Black South Africans are disproportionately affected by HIV compared with White counterparts. In their unique social context, South African families affected by HIV are vulnerable to adverse psychosocial effects. U.S.-based and emerging South African research suggests mothers living with HIV may experience compromised parenting. In the United States, mother-child relationship quality has been associated with internalizing (anxiety, depression) and externalizing (delinquency, acting out) child behaviors. This study adds to South African research with emphasis on the role of the mother-child relationship among HIV-affected South Africans from multiple communities. Structural equation modeling examined relationships between maternal health and child adjustment, operating through mother-child relationship. The best-fitting model suggested maternal health influences youth externalizing behaviors through the mother-child relationship, but that maternal health is directly related to child internalizing problems. Findings support and extend previous results. Further research would benefit from investigating ways the unique South African context influences these variables and their interactions.