Pediatric HIV disease. The newest chronic illness of childhood

Mental Health and Functional Competence in the Cape Town Adolescent Antiretroviral Cohort

BACKGROUND

The impact of HIV and antiretrovirals (ART) on long-term mental health in perinatally infected children has not been well studied in sub-Saharan Africa where HIV is most prevalent.

SETTING

Cape Town, South Africa.

METHODS

We investigated mental health measures, including depression, anxiety, attention-deficit hyperactivity disorder, motivation, disruptive behavior, and functioning in perinatally infected adolescents (PHIV+) stable on ART within the Cape Town Adolescent Antiretroviral Cohort. Two hundred four adolescents living with HIV (median age 10 years; mean CD4 953) and a sample of 44 uninfected adolescents were enrolled. The Beck Youth Inventories, Children's Motivation Scale, Conner's Parent's Rating Scale, and Child Behavior Checklist were administered. Among PHIV+, we explored independent associations between HIV-related stigma, recent life stressors, sociodemographic, clinical, and caregiver-related variables, and mental health measures.

RESULTS

PHIV+ had poorer functional competence, self-concept and motivation, higher levels of disruptive behavior, depression and attention-deficit hyperactivity disorder symptoms and clinically significant anger and disruptive behavior. Within the PHIV+ group, the loss of both biological parents was associated with higher levels of disruptive behavior. Within the PHIV+, factors associated with mental health symptoms and poorer functioning were mostly sociodemographic factors, HIV-related stigma, and life stressors. Age of initiation of ART was associated with self-concept, and failing first-line ART with internalizing and externalizing behavior problems.

CONCLUSIONS

PHIV+ are likely to face future physical and psychological health consequences related to the functional competence challenges they face if mental health care is not made a priority in the fight against HIV.

Healthcare workers' perspectives and practices regarding the disclosure of HIV status to children in Malawi: a cross-sectional study

Background

In 2011 the World Health Organisation recommended that children with a diagnosis of HIV be gradually informed about their HIV status between the ages of 6 and 12 years. However, to date, literature has focused mainly on primary caregiver and child experiences with HIV disclosure, little is known about healthcare workers’ perspectives and practices of HIV status disclosure to children. The aim of this study was to assess healthcare workers’ perspectives and practices regarding the disclosure of HIV status to children aged between 6 and 12 years in Malawi.

Methods

A cross-sectional survey was used to collect data from 168 healthcare providers working in antiretroviral clinics in all government District and Tertiary Hospitals in Malawi. Participants were asked questions regarding their knowledge, practice, and barriers to HIV disclosure. Data were analysed using binary logistic regression.

Results

Almost all healthcare workers (98%) reported that it was important to disclose HIV status to children. A significant proportion (37%) reported that they had never disclosed HIV status to a child and about half estimated that the rate of HIV disclosure at their facility was 25% or less. The main barriers to disclosure were lack of training on disclosure (85%) and lack of a standard tool for disclosure (84%). Female healthcare workers (aOR) 2.4; 95% CI: 1.1–5.5) and lack of training on disclosure (aOR 7.7; 95% CI: 3.4–10.7) were independently associated with never having disclosed HIV status to a child.

Conclusions

This study highlights the need for providing appropriate training in HIV disclosure for healthcare workers and the provision of standardised disclosure materials.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3354-9) contains supplementary material, which is available to authorized users.

NeuroAIDS in children

The human immunodeficiency virus-1 (HIV-1) enters the central nervous system compartment within the first few weeks of systemic HIV infection and may cause a spectrum of neurologic complications. Without combination antiretroviral therapy (cART), 50-90% of all HIV-infected infants and children develop some form of neuroAIDS. Of the estimated 2.3 million children less than 15 years of age who were living in sub-Saharan Africa at the end of 2014, only 30% were receiving cART, suggesting that there is a large burden of neuroAIDS among HIV-infected children in sub-Saharan Africa. There is complex interplay between the disease process itself, the child's immune reaction to the disease, the secondary complications, the side-effects of antiretroviral drugs, and inadequate antiretroviral drug uptake into the central nervous system. In addition there is the layering effect from the multiple socioeconomic challenges for children living in low- and middle-income countries. Adolescents may manifest with a range of neurocognitive sequelae from mild neurocognitive disorder through to severe neurocognitive impairment. Neuroimaging studies on white-matter tracts have identified dysfunction, especially in the frontostriatal networks needed for executive function. Psychiatric symptoms of depression, attention deficit hyperactivity disorder, and behavioral problems are also commonly reported in this age group. Antiretroviral drugs may cause treatment-limiting neurologic and neuropsychiatric adverse reactions. The following chapter addresses the neurologic complications known to be, and suspected of being, associated with HIV infection in children and adolescents.

Paediatric HIV/AIDS disclosure: towards a developmental and process-oriented approach

As antiretroviral therapy becomes more widely available in low-resource settings and children with HIV/AIDS live for longer periods, disclosure of HIV diagnosis to infected children is becoming increasingly important. This article reviews the current literature on HIV-related disclosure in light of theories of cognitive development, and argues for the adoption of a process-oriented approach to discussing HIV with infected children. Disclosure presents unique challenges to healthcare workers and caregivers of children with HIV/AIDS that include controlling the flow of information about the child's HIV status to him/her and deciding on what is in his/her best interest. Health care workers' and caregivers' views regarding disclosure to children may often be contradictory, with healthcare workers likely to support disclosing the diagnosis of HIV/AIDS to children and caregivers more reluctant to discuss the disease with them. There is a clear need for practical interventions to support paediatric HIV disclosure which provide children with age-appropriate information about the disease.

The role of nutrition in pediatric HIV/AIDS: a review of micronutrient research

It is becoming increasingly evident that nutrition is not only an important component of health but also that levels of specific nutrients can affect disease expression. This is particularly apparent in the realm of HIV disease. Despite this knowledge, research in this area, especially pertaining to the pediatric population, has been limited. This report presents a narrative review and critique of the work that has been conducted in the area of micronutrients including descriptive, correlational, and intervention studies. Gaps in knowledge, recommendations for future research, and nursing implications are highlighted. Current information suggests a role for micronutrients in the treatment of HIV disease, and further research will help develop these adjunct therapies that can affect the overall outcomes and quality of life of these patients.

[Social and family characteristics in children born to women infected by the human immunodeficiency virus]

OBJECTIVES

To evaluate the social and family characteristics of children born to women infected by the human immunodeficiency virus (HIV). As secondary objectives, to analyse their schooling and the number of hospital admissions and lengths of stay that these children required.

DESIGN

A prospective observation study.

SETTING

HIV unit in a children's hospital.

PARTICIPANTS

INCLUSION CRITERIA

all the children recruited from the HIV unit who had their infection status defined during the study period, understood as between the first known case in 1985 and April 1994. The sample included 177 children (62 HIV-infected and 115 not infected).

MEASUREMENTS AND MAIN RESULTS

Through an interview the social, family and school variables were collected. On comparison between infected and non-infected children, there were no important differences as to the lack of protection of the new-born (8.1% vs 13%), scant mother-child relationship (31.2% vs 36.5%) or people responsible for the custody of these children. Less schooling and greater problems of school integration were detected in infected cases, with odds ratios of 2.68 (p = 0.004) and 11.36 (p = 0.004), respectively. Children infected also needed more admissions (4.3 +/- 5.7) than the non-infected (1.7 +/- 0.9) (p = 0.001), and more days of hospital stay (75.1 +/- 110.3 vs 23.3 +/- 19.6) (p = 0.0003).

CONCLUSIONS

Infected children and non-infected children had similar social and family characteristics. However, less schooling, problems of school integration, and more and longer hospital admissions were related to HIV infection in children, and not so much to their status as children of seropositive mothers.

Diagnosis disclosure by family caregivers to children who have perinatally acquired HIV disease: when the time comes

BACKGROUND

Children with perinatally acquired HIV disease (PAHD) can be relatively symptom-free and live to school age and older. These children often confront their caregivers with questions about the illness and complex treatments; however, caregivers may try to avoid disclosing the diagnosis of PAHD to the child.

PURPOSE

To generate a substantive theory that describes and explains how family caregivers manage diagnosis disclosure to a child who has PAHD.

METHOD

Using grounded theory, a substantive theory was constructed based on the accounts of 18 ethnically diverse families. Eight families had 10 children with PAHD who had been told their diagnosis. Ten families had 10 children with PAHD who had not been told their diagnosis.

RESULTS

The basic social psychological problem was identified as caregiver readiness to disclose the diagnosis. When the Time Comes was identified as the central phenomenon linked to the problem of caregiver readiness. Causal conditions, intervening conditions, and strategic responses of caregivers and children were discovered and are inextricably linked to the central phenomenon.

CONCLUSIONS

The process by which family caregivers respond to diagnosis disclosure to children with PAHD is based on the perceived self-readiness of the caregiver to disclose the diagnosis and illness-related information to their child.

The treatment of non-HIV-related conditions in newborns at risk for HIV: a survey of neonatologists

OBJECTIVES

The purpose of this study was to examine attitudes of neonatologists about treatment of conditions unrelated to the human immunodeficiency virus (HIV) for critically ill newborns at risk for HIV.

METHODS

Questionnaires were mailed to the 1508 members of the Section on Perinatal Medicine of the American Academy of Pediatrics; 63% completed the survey (n = 951). The survey included structured questions about treatment for hypothetical cases and open-ended questions eliciting reasons for decisions.

RESULTS

Differences in recommendations for treatment by both maternal and infant HIV status were substantial and statistically reliable. For example, 98% of respondents recommended life-saving cardiac surgery for a neonate with no risk for HIV, but only 93% recommended such surgery for a child of an HIV-positive mother; only 50% recommended the same surgery for a newborn known to be infected. The corresponding figures for chronic dialysis were 91%, 61%, and 26%. Most expected diminished quality of life for both infected and uninfected children of HIV-positive mothers.

CONCLUSIONS

Recommendations about life-sustaining treatment for non-HIV-related conditions varied by HIV status. These data on physician attitudes raise the possibility that infants labeled as HIV positive, whether infected or not, may suffer discrimination.

Psychosocial needs expressed by the natural caregivers of HIV infected children

The presence in a family of a young child with AIDS, with the exception of a small number of transfusion-infected children, implies almost necessarily the presence of an infected adult, usually the mother. The problem in such a situation is not that of a child with a fatal illness but that of an entire family. Our study included a sample of thirty natural caregivers. These were mostly mothers but others responsible for the care of a seropositive child, such as fathers, aunts and grandmothers, were also included. The aim of the project was to describe their perceptions of their own psycho-social needs. Our results reveal that these caregivers are economically disadvantaged. They need help in coping with stress and their life situation. Their need to confide in others is frequently not met. However, the need to learn how to protect themselves and other members of the family against both HIV and other infections and to know the course and the treatments associated with this disease are seen by them, both as being very important and as being well met, particularly by the health professionals who care for them.