The influence of disclosure of HIV diagnosis on time to disease progression in a cohort of Romanian children and teens

An mHealth Intervention for Gay and Bisexual Men's Mental, Behavioral, and Sexual Health in a High-Stigma, Low-Resource Context (Project Comunică): Protocol for a Randomized Controlled Trial

BACKGROUND

The World Health Organization reported that 80% of new HIV diagnoses in Europe in 2014 occurred in Central and Eastern Europe. Romania has a particularly high HIV incidence, AIDS prevalence, and number of related deaths. HIV incidence in Romania is largely attributed to sexual contact among gay and bisexual men. However, homophobic stigma in Romania serves as a risk factor for HIV infection for gay and bisexual men. The Comunică intervention aims to provide a much-needed HIV risk reduction strategy, and it entails the delivery of motivational interviewing and cognitive behavioral therapy skills across 8 live text-based counseling sessions on a mobile platform to gay and bisexual men at risk of HIV. The intervention is based on the information-motivation-behavior and minority stress models. There is preliminary evidence suggesting that Comunică holds promise for reducing gay and bisexual men's co-occurring sexual (eg, HIV transmission risk behavior), behavioral (eg, heavy alcohol use), and mental (eg, depression) health risks in Romania.

OBJECTIVE

This paper describes the protocol for a randomized controlled trial designed to test the efficacy of Comunică in a national trial.

METHODS

To test Comunică's efficacy, 305 gay and bisexual men were randomized to receive Comunică or a content-matched education attention control condition. The control condition consisted of 8 time-matched educational modules that present information regarding gay and bisexual men's identity development, information about HIV transmission and prevention, the importance of HIV and sexually transmitted infection testing and treatment, heavy alcohol use and its associations with HIV transmission risk behavior, sexual health communication, finding social support, and creating sexual health goals. Participants undergo rapid HIV and syphilis testing and 3-site chlamydia and gonorrhea testing at baseline and the 12-month follow-up. Outcomes are measured before the intervention (baseline) and at the 4-, 8-, and 12-month follow-ups.

RESULTS

The study was funded in September 2018, and data collection began in May 2019. The last participant follow-up was in January 2024. Currently, the data analyst is cleaning data sets in preparation for data analyses, which are scheduled to begin in April 2024. Data analysis meetings are scheduled regularly to establish timelines and examine the results as analyses are gradually being conducted. Upon completion, a list of manuscripts will be reviewed and prioritized, and the team will begin preparing them for publication.

CONCLUSIONS

This study is the first to test the efficacy of an intervention with the potential to simultaneously support the sexual, behavioral, and mental health of gay and bisexual men in Central and Eastern Europe using motivational interviewing support and sensitivity to the high-stigma context of the region. If efficacious, Comunică presents a scalable platform to provide support to gay and bisexual men living in Romania and similar high-stigma, low-resource countries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03912753; https://clinicaltrials.gov/study/NCT03912753.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52853.

Disclosure of HIV status and associated clinical outcomes of children and adolescents living with HIV in Asia

Disclosure of HIV status is an important part of pediatric care. We studied disclosure and clinical outcomes in a multi-country Asian cohort of children and adolescents with HIV. Those 6-19 years of age who initiated combination antiretroviral therapy (cART) between 2008 and 2018, and who had at least one follow-up clinic visit were included. Data up to December 2019 were analyzed. Cox and competing risk regression analyses were used to assess the effect of disclosure on disease progression (WHO clinical stage 3 or 4), loss to follow-up (LTFU; > 12 months), and death. Of 1913 children and adolescents (48% female; median [IQR] age 11.5 [9.2-14.7] years at last clinic visit), 795 (42%) were disclosed to about their HIV status at a median age of 12.9 years (IQR: 11.8-14.1). During follow-up, 207 (11%) experienced disease progression, 75 (3.9%) were LTFU, and 59 (3.1%) died. There were lower hazards of disease progression (adjusted hazard ratio [aHR] 0.43 [0.28-0.66]) and death (aHR 0.36 [0.17-0.79]) for those disclosed to compared with those who were not. Disclosure and its appropriate implementation should be promoted in pediatric HIV clinics in resource-limited settings.

Pediatric HIV Disclosure Intervention Improves Immunologic Outcome at 48 Weeks: The Sankofa Trial Experience

BACKGROUND

The World Health Organization recommends disclosure of HIV status to children and adolescents living with HIV (CALWH). HIV disclosure improves adherence to antiretroviral therapy and immunologic and virologic outcomes. However, the prevalence of HIV disclosure is low in sub-Saharan Africa. We assessed the longitudinal effect of the Sankofa Pediatric HIV disclosure intervention on immunologic and virologic outcomes among CALWH in Ghana.

METHODS

We conducted a secondary analysis of a two-arm site-randomized clinical trial among CALWH aged 7-18 years. Data were collected at baseline, 24, and 48 weeks. Generalized linear mixed models were used to compare immunologic (CD4) and virologic (viral load) outcomes as both continuous and categorical variables by disclosure status and by intervention group.

RESULTS

Among participants who had their HIV status disclosed during this study, the proportion with CD4 percent >25% increased from 56.5% at baseline to 75.4% at week 48 ( P = 0.03), with a slight increase in the undisclosed group (69.5% vs. 74.3%, P = 0.56). In the intervention arm, there was a steady increase in proportion with CD4 percent >25% from 47.1% at baseline to 67.8% at week 48 ( P = 0.01) while it remained unchanged in the control arm (80.5% vs. 81.3% [ P = 0.89]). Concurrently, declines in detectable viral load were observed in both disclosed (63.3% vs. 51.5%, P = 0.16) and undisclosed (69.9% vs. 62.0%, P = 0.17) groups while the intervention group experienced a meaningful drop from 72.9% to 57.6% at 24 weeks ( P = 0.04), which was maintained at 48 weeks.

CONCLUSIONS

A structured, culturally relevant disclosure intervention can improve clinical outcomes.

A randomized controlled trial of an mHealth intervention for gay and bisexual men's mental, behavioral, and sexual health in a high-stigma, low-resource context: Project Comunică protocol

Background

The World Health Organization (WHO) reported that 80% of new HIV diagnoses in 2014 in Europe occurred in Central and Eastern Europe (CEE). Romania has particularly high HIV incidence, AIDS prevalence, and AIDS-related deaths. HIV incidence today in Romania is largely attributed to sexual contact among gay and bisexual men (GBM). However, homophobic stigma in Romania keeps GBM out of reach of the scant available prevention services and serves as a risk factor for HIV. The Comunică intervention delivers motivational interviewing and cognitive-behavioral therapy skills across eight live text-based counseling sessions. Preliminary evidence suggests that Comunică possesses promise for reducing GBM's co-occurring mental (e.g., depression), behavioral (e.g., heavy alcohol use), and sexual (e.g., HIV-transmission-risk behavior) health risks in Romania and perhaps other similar high-stigma national contexts. This paper describes a randomized controlled trial (RCT) designed to test the efficacy of Comunică.

Methods

To test Comunică's efficacy, 305 GBM were randomized to receive Comunică or a content-matched education attention control condition. The control condition consists of eight time-matched educational modules that present information regarding GBM identity development, information about HIV transmission and prevention, the importance of HIV/STI testing and treatment, heavy alcohol use and its associations with HIV-transmission-risk behavior, sexual health communication, finding social support, and creating sexual health goals. Outcomes are measured pre-intervention (baseline), and at 4-, 8-, and 12-month follow-ups. The primary outcome is frequency of condomless anal sex acts with HIV-positive or unknown-status partners outside of the context of one's own adherent PrEP use or primary partner's adherent PrEP use or undetectable viral load in the past 30 days at each follow-up. Secondary outcomes include depression, anxiety, suicidal thoughts, heavy alcohol use, and HIV/STI testing; motivational and stigma-related mechanisms of intervention efficacy will also be examined.

Discussion

If found to be efficacious, Comunică presents a scalable platform to provide mental, behavioral, and sexual health support to GBM living in Romania and similar high-stigma, low-resource areas within the CEE region and beyond.

Trial registration

Registered April 11, 2019 to ClinicalTrials.gov Identifier: NCT03912753.

Socio-Cultural Influencers of Disclosure of HIV Status to Children on Antiretroviral Therapy in the Masaka Region, Uganda: A Qualitative Study

This study explored sociocultural influencers of disclosure of HIV status to children taking daily antiretroviral therapy (ART) in the Masaka region, Uganda using data collected from 26 key informant interviews with caregivers between October 2020 and July 2021. The findings revealed both positive and negative sociocultural influencers of disclosure. Beliefs that disclosure cultivates responsibility in the child to improve ART adherence and the culture of routine sexual health education conversations with children were positive socio-cultural influencers. Beliefs that disclosure increases children's loss of hope in life and breaks confidentiality with children inadvertently disclosing their HIV status to others leading to discrimination and social rejection, were key negative sociocultural influencers. These findings suggest a need for socio-culturally informed interventions that target caregiver negative socio-cultural disclosure influencers in this setting through contextualized sensitization and training to prepare children taking daily ART to receive disclosure progressively.

Incidence and predictors of mortality among adolescents on antiretroviral therapy in Amhara Region, Ethiopia: a retrospective cohort analysis

OBJECTIVE

This study aimed to assess the incidence and predictors of mortality in adolescents receiving antiretroviral therapy (ART) in Ethiopia's Amhara Region.

DESIGN

We conducted an institution-based retrospective follow-up study.

SETTINGS

The study was conducted at Amhara Region's comprehensive specialised hospitals in Ethiopia.

PARTICIPANTS

We included 961 randomly selected medical records of adolescents receiving ART between January 2005 and June 2020.

PRIMARY AND SECONDARY OUTCOMES

The incidence of mortality since ART treatment initiation served as the primary outcome, and predictors of mortality served as secondary outcomes. We used Cox proportional hazard regression to examine the relationship between mortality and its predictors. Variables with p values<0.05 in the multivariable analysis were considered statistically significant mortality predictors. Adjusted HR (aHR) with 95% CI was used to measure the strength of association.

RESULTS

More than half (n=496, 53.5%) of the adolescents living with HIV (ALHIV) were girls. The adolescent mortality rate was 1.52 (95% CI: 1.04 to 1.53) per 100 person-years throughout the follow-up period of 81 583 adolescent months. Mortality was higher for ALHIV who had not received formal education (aHR: 3.27, 95% CI: 1.36 to 7.87), had widowed parents (aHR: 1.85, CI: 95% 1.01 to 3.56) or received no social support (aHR: 2.81, 95% CI: 1.69 to 4.67). Adolescents who had opportunistic infections (OIs) at ART initiation (aHR: 1.94, 95% CI: 1.19 to 3.14), low haemoglobin (Hgb/g/l) levels (aHR: 2.17, 95% CI: 1.08 to 4.18), a bedridden functional status (aHR: 3.11, 95% CI: 1.64 to 5.72), stage IV clinical staging (aHR: 3.03, 95% CI: 1.46 to 6.30), non-disclosing status (aHR: 2.24, 95% CI:1.36 to 3.69) and CD4 count 200-350 cells/mm³ (aHR: 2.17, 95% CI: 1.08 to 4.18) also had a higher risk of death. Not receiving cotrimoxazole preventive therapy (aHR: 1.85, 95% CI: 1.07 to 3.22) and poor adherence to ART (aHR: 2.24, 95% CI: 1.27 to 3.95), compared with adherent, was associated with higher mortality risk. Changed treatment regimens were associated with lower mortality (aHR: 0.59, 95% CI: 0.35 to 0.98).

CONCLUSIONS

Our study found a lower mortality rate for adolescents with HIV than previous Ethiopian studies, but our significant mortality predictors were similar to those found in earlier studies of adults and adolescents. Our findings reveal a potential point for health service improvement in Ethiopia: incorporating monitoring of Hgb levels into patient follow-up care, supporting recommendations that clinicians emphasise managing OIs and providing counselling services to improve adherence.

HIV status disclosure and antiretroviral therapy adherence among children in Masaka region, Uganda

HIV-infected children are now living into adolescence and early adulthood in large numbers due to the availability and increased use of antiretroviral therapy (ART). However, receipt of HIV status disclosure among children remains low. We assessed the association between disclosure of HIV status and adherence to ART among children in the Masaka region of Uganda using multivariable logistic regression with generalised linear models with Poisson log-link function and robust variance in Stata software version 15.1. Data were collected from 524 assenting children aged 12-17 years between March and December 2020. Results show that, although not statistically significant, children who received disclosure of their HIV status reported improved ART adherence compared to children with no disclosure. Out-of-school children with post-primary education and children on first-line ART regimens were significantly more likely to report improved ART in both crude and adjusted analyses. Innovative interventions to promote progressive disclosure of HIV status to children on ART, in school, are needed to improve their ART adherence. There is also a need to evaluate the suitability of current counselling interventions provided to children being switched to second-line ART regimens to delay the need for third-line ART regimens.

Determinants of Disclosure, Adherence and Viral Suppression in Children and Adolescents Living With HIV in Ecuador: A Cross-Sectional Study

BACKGROUND

Studies on HIV disclosure and adherence among children performed in Latin America are anecdotal. We aimed to assess the factors associated with HIV disclosure, adherence and viral suppression among Ecuadorian children and compare the psychologic consequences and the impact on adherence and viral suppression of early against late disclosure age.

METHODS

Cross-sectional study using a questionnaire and collected data on medical records of HIV-infected children between 6 and 21 years of age in Ecuador.

RESULTS

In 250 children included, HIV diagnosis was revealed at a median age of 11 years (p25-p75 9-12). Children 12 years old or older (P < 0.0001), 10 or more years since HIV diagnosis (P = 0.001), antiretroviral initiation above 3 years of age (P = 0.018) and decease of the mother (P = 0.048) were significantly associated with total disclosure in multivariate analysis. Profound sadness or anxiety was significantly more common when diagnosis was disclosed after 12 years of age (28.4%) than before (15.4%, P = 0.047). According to the simplified medication adherence questionnaire, 194 children (78.2%) were adherent to antiretroviral therapy and HIV-RNA viral load was undetectable in 168 (67.7%). In multivariate analysis, variables associated with nonadherence were age ≥14 years (P < 0.001), taking ≥3 daily antiretroviral pills (P = 0.013) and the presence of adverse effects (P < 0.001), whereas nonadherence (P = 0.001) was the only variable significantly associated with an unsuppressed HIV-RNA viral load.

CONCLUSIONS

Although we failed to show that an earlier disclosure age is followed by better adherence outcomes, psychological outcomes did seem to improve, supporting disclosure before 12 years of age.

Clinic-Based Pediatric Disclosure Intervention Trial Improves Pediatric HIV Status Disclosure in Ghana

BACKGROUND

Disclosing HIV status to HIV-positive children is a major challenge facing families and health care providers. Despite recommendations for disclosure, rates remain low. We tested whether a pediatric HIV disclosure intervention delivered as an integral component of routine HIV health care in Ghana would improve disclosure to children.

METHODS

Dyads of HIV-infected children aged 7-18 years and their caregivers were enrolled from 2 HIV clinics in Accra and Kumasi, Ghana. The sites were randomly assigned to one of the 2 intervention arms to avoid treatment contamination between intervention and control participants. Trained interventionist used theory-guided therapeutic communication and personalized interaction to promote disclosure. Disclosure outcomes were measured at 12-week intervals. All analyses were completed using a modified intention-to-treat approach.

RESULTS

We enrolled 446 child-caregiver dyads (N = 240 intervention group; N = 206 control group); 52% of the children were boys, mean age 9.78 (±2.27) years. For disclosure at 1 year, a better overall treatment effect was observed (P < 0.001). Children in the treatment group had greater disclosure at each time point (P < 0.001) and a higher proportion of them had been disclosed to by 1 year (51.4% vs. 16.2%; P < 0.001; un-adjusted hazard ratio = 3.98: 95% confidence interval: 2.63 to 6.03) and 3 years (71.3% vs. 34.0%; unadjusted hazard ratio = 4.21: 95% confidence interval: 3.09 to 5.72). In the multivariate Cox model, factors associated with disclosure were treatment group (P < 0.001), children <11 years of age (P < 0.001), HIV-infected caregivers (P = 0.015), and caregiver's with greater education (P = 0.022).

CONCLUSIONS

This practical clinic-based disclosure intervention shows excellent promise as a means of improving HIV pediatric disclosure outcomes.

Trends in HIV Treatment Adherence Before and After HIV Status Disclosure to Adolescents in Botswana

PURPOSE

This study aimed to determine if disclosure of HIV status to adolescents impacted their medication adherence and how medication autonomy might explain observed effects.

METHODS

Three hundred adolescents on HIV treatment using electronic medication monitors were followed for 24 months while undergoing routine care. One hundred six of the adolescents were HIV disclosure-naïve and HIV status disclosure in this group was assessed quarterly. Analyses included data from the 75 adolescents who experienced disclosure during the study providing adherence and autonomy data both predisclosure and postdisclosure. Segmented generalized estimating equations were used to examine the trend of adherence and autonomy predisclosure and postdisclosure. Covariates assessed include age at disclosure, sex, and orphan status.

RESULTS

Median age at study entry was 12.2 years (interquartile range 11.6-12.9). Incident disclosure occurred in 75 (71%) of the adolescents at a median age of 13.1 years (interquartile range 12.5-13.9). Adherence decreased by 11% (95% confidence interval [CI] 7-15, p < .001) during the predisclosure period and by 22% (95% CI 9-36, p = .001) during the postdisclosure period. Adolescents' autonomy over their medication-taking increased over time, but disclosure did not impact the rate of increase in measured medication-taking autonomy. On a scale of 1-4 assessing autonomy (1 = receiving directly observed therapy and 4 = taking medicines mostly without supervision), autonomy increased by an average of .03 units/month (95% CI .02-.03, p < .001) predisclosure and by .05 units/month (95% CI -.01 to .11, p = .42) postdisclosure.

CONCLUSIONS

The findings suggest that, among perinatally HIV infected adolescents, HIV status disclosure may adversely impact treatment adherence. Postdisclosure support to HIV infected adolescents should be intensified.

HIV positive status disclosure and associated factor among HIV infected children in pediatric ART clinics in Gondar town public health facilities, North West Ethiopia, 2018

BACKGROUND

Due to the increasing availability of antiretroviral treatment, HIV infected children are living longer which points out the necessity of disclosure. And which is important to support the uptake and adherence to treatment. Disclosure is an important measure to prevent secondary transmission when children are sexually active.

OBJECTIVE

The aim of this study was to determine the prevalence of HIV positive status disclosure and associated factors among human immune virus-infected children in pediatric antiretroviral treatment clinics in Gondar town public health facilities.

METHOD

An institution based cross-sectional study was conducted among 449 primary caregivers of children aged 6-15years in regular follow-up at pediatric ART clinics in Gondar town public health facilities between March 3, 2018, to April 25, 2018. All subjects in the study area were included in the study. Data was collected in 5 pediatric ART clinics in Gondar town by structured questionnaires through face to face interview and supplemented by chart review to obtain some clinical factors. The variables which have an association with disclosure were identified on the basis of AOR, with 95%CI and p-value <0. 05. Model fitness was checked using Hosmer and Lemeshow goodness of fit test.

RESULT

Out of 449 participants, 418 were interviewed with response rate of 93%. The prevalence of HIV positive status disclosure found to be 44%. Age of child >10years [AOR=5.88, (95% CI: 3.52, 9.81)], duration on ART [AOR=2.67 (95% CI: 1.59, 4.51)], place of follow-up [AOR=2.23 (95% CI: 1.27, 5.01)] and educational status of caregiver [AOR=3.00 (95% CI: 1.62, 5.56)] were identified variables.

CONCLUSION

The prevalence of disclosure found to be low. Therefore appropriate measure should be taken to promote disclosure.

Courage and confidence to stop lying: caregiver perspectives on a video to support paediatric HIV disclosure in Kampala, Uganda

The World Health Organization (WHO) recommends that HIV-positive children are told their diagnosis by age 12 years. However, most perinatally-infected children reach adolescence without being told their HIV status. Effective strategies are needed to promote disclosure, and optimise children's health outcomes as they transition to adolescence and adulthood. This qualitative study explored how caregivers of HIV-positive children aged 7-12 years perceived and related to a video used as part of a larger behavioural intervention to promote full disclosure to children by age 12 years. Eight semi-structured interviews and 3 group reflection sessions with 28 caregivers were analysed thematically. Five themes were generated: courage and confidence; reasoning and empathy; child- caregiver relationship; foreign but relatable; and not reaching everyone. The video was found acceptable and appropriate for fostering readiness to disclose. Through watching it, participants reported they could see people similar to themselves prevail despite challenges, which gave them courage.

Communication with children and adolescents about the diagnosis of their own life-threatening condition

When a child is diagnosed with a life-threatening condition, one of the most challenging tasks facing health-care professionals is how to communicate this to the child, and to their parents or caregivers. Evidence-based guidelines are urgently needed for all health-care settings, from tertiary referral centres in high-income countries to resource limited environments in low-income and middle-income countries, where rates of child mortality are high. We place this Review in the context of children's developing understanding of illness and death. We review the effect of communication on children's emotional, behavioural, and social functioning, as well as treatment adherence, disease progression, and wider family relationships. We consider the factors that influence the process of communication and the preferences of children, families, and health-care professionals about how to convey the diagnosis. Critically, the barriers and challenges to effective communication are explored. Finally, we outline principles for communicating with children, parents, and caregivers, generated from a workshop of international experts.

Disclosure and Clinical Outcomes Among Young Adolescents Living With HIV in Kenya

PURPOSE

Informing adolescents of their own HIV infection is critical as the number of adolescents living with HIV increases. We assessed the association between HIV disclosure and retention in care and mortality among adolescents aged 10-14 years in Kenya's national program.

METHODS

We abstracted routinely collected patient-level data for adolescents enrolled into HIV care in 50 health facilities from November 1, 2004, through March 31, 2010. We defined disclosure as any documentation that the adolescent had been fully or partially made aware of his or her HIV status. We compared weighted proportions for categorical variables using χ2 and weighted logistic regression to identify predictors of HIV disclosure; we estimated the probability of LTFU using Kaplan-Meier methods and dying using Cox regression-based test for equality of survival curves.

RESULTS

Of the 710 adolescents aged 10-14 years analyzed; 51.3% had severe immunosuppression, 60.3% were in WHO stage 3 or 4, and 36.6% were aware of their HIV status. Adolescents with HIV-infected parents, histories of opportunistic infections (OIs), and enrolled in support groups were more likely to be disclosed to. At 36 months, disclosure was associated with lower mortality [1.5% (95% CI .6%-4.1%) versus 5.4% (95% CI 3.6.6%-8.0%, p < .001)] and lower LTFU [6.2% (95% CI 3.0%-12.6%) versus 33.9% (95% CI 27.3%-41.1%) p < .001].

CONCLUSIONS

Only one third of HIV-infected Kenyan adolescents in treatment programs had been told they were infected, and knowing their HIV status was associated with reduced LTFU and mortality. The disclosure process should be systematically encouraged and organized for HIV-infected adolescents.

Socio-demographic, clinical, and psychosocial factors associated with primary caregivers' decisions regarding HIV disclosure to their child aged between 6 and 12 years living with HIV in Malawi

The World Health Organisation (WHO) recommends that children living with HIV should be informed about their HIV status within the ages of 6 to 12 years using age-appropriate resources. The aim of this study was to assess the socio-demographic, clinical and psychosocial factors associated with primary caregivers’ decisions to disclose HIV to children living with HIV aged 6 to 12 years in Malawi. A cross-sectional study of 429 primary caregivers of children living with HIV were systematically recruited from all regions of the country. Information on HIV disclosure, family and child socio-demographic characteristics, child clinical characteristics, and child and family psychosocial characteristics was collected using validated instruments. Logistic regression was used to analyse data. The prevalence of non-disclosure of HIV status to children was 64 per cent. Concerns about the child’s inability to cope with the news (29%), a lack of knowledge on how to disclose HIV status (19%), and fear of stigma and discrimination (17%) were the main reasons for non-disclosure. On multivariate analysis, the odds of non-disclosure were higher among primary caregivers who were farmers (aOR 3.0; 95% CI: 1.1–8.4), in younger children (6–8 years) (aOR 4.1; 95% CI: 2.3–7.4), in children who were in WHO HIV clinical stage one (aOR 3.8; 95% CI: 1.4–10.2), and in children who were not asking why they were taking ARVs (aOR 2.9; 95% CI: 1.8–4.8). On the other hand, nondisclosure of HIV status was less likely in underweight children (aOR 0.6; 95% CI: 0.3–0.9). Many children living with HIV in Malawi are unaware of their HIV status. Non-disclosure is associated with a number of clinical and demographic characteristics. The findings highlight the need to provide guidance and support to primary caregivers to help them to effectively disclose HIV status to their children.

HIV diagnosis disclosure to infected children and adolescents; challenges of family caregivers in the Central Region of Ghana

BACKGROUND

Disclosure of Human Immunodeficiency Virus (HIV) to infected older children and adolescents is essential for both personal health maintenance and HIV prevention within the larger population. Non-disclosure of HIV status has been identified as one of the potential barriers to optimum adherence especially in children and adolescents. Like many other countries in the SSA region, Ghana has significant number of children and adolescents infected by HIV, who have increased survival times, due to increased access to ART. However, both family caregivers and healthcare workers face an array of challenges with the disclosure process, including the timing, what information about the child's HIV status should be shared with him/her and how to go about it. The aim of the study was to identify family caregiver factors associated with non-disclosure of HIV status to infected children and adolescents accessing Antiretroviral Therapy (ART) at the three main ART sites within the Central Region of Ghana.

METHODS

A quantitative analytical survey was conducted among 103 family caregivers of HIV infected children (aged 6-17 years) assessing ART services in the Central Region of Ghana. Data were analyzed using SSPS version 21.

RESULTS

The age range of caregivers was 20-69 years. The study found a low disclosure rate (23.3%) among caregivers. Majority of the caregivers (80.6%) lacked knowledge on the process of disclosure (how and what to tell child), and majority (64%) also had never received guidance about the disclosure process from their healthcare providers. The main barriers to disclosure were caregiver lack of knowledge regarding the disclosure process and when to disclose, the fear of child's reaction, and fear of stigmatization and associated negative social consequences.

CONCLUSION

These findings suggest a lesser involvement of health care providers in preparing caregivers for the disclosure process. This therefore highlight the need for the National HIV/AIDS/STI Control Program to strengthen the involvement and training of healthcare providers in HIV diagnosis disclosure to infected children, based on context-specific policy guidelines informed by the WHO recommendations.

Pediatric HIV Disclosure in Northern India: Evaluation of Its Prevalence, Perceptions amongst Caregivers, and Its Impact on CLHIV

Background

With improving standards of care of children living with HIV (CLHIV), pediatric HIV related mortality rates are declining. New challenges like HIV status disclosure are emerging which need to be addressed to ensure their smooth transition into adulthood. Poor disease disclosure rates are observed in CLHIV globally.

Aims

This study was done to assess the prevalence of HIV disclosure in North Indian CLHIV, know the perceptions of caregivers regarding disclosure, and evaluate the impact of disclosure on CLHIV.

Methods

It was a questionnaire based cross-sectional study carried out amongst 144 caregivers of CLHIV aged 6-16 years attending the pediatric HIV clinic of a tertiary care teaching hospital.

Results

Though the majority (93.8%) caregivers felt that it is important to disclose but only 33% of the children were actually disclosed. Eighty five percent felt that disclosure must be done by one of the family members and correspondingly 73% of the disclosed children were actually disclosed by their parents. Forty seven percent believed that the most appropriate age for disclosure is 10-12 years. The mean age at which disclosure was actually done was 11.06 ± 1.62 years. Comparison of the disclosed and undisclosed CLHIV revealed that the disclosed group had significantly higher age, longer duration of taking ART, and higher proportion of paternal orphans. Age of the CLHIV was the only significant factor for disclosure. Several reasons were cited by the caregivers for nondisclosure. The caregivers observed improved drug adherence in 47.9% of the children following disclosure.

Conclusions

There is a need to develop region specific pediatric HIV disclosure guidelines keeping in mind the caregivers' perceptions. The guidelines must be age appropriate, systematic, and socioculturally acceptable. The most suitable age for disclosure appears to be 10-12 years. Involvement of caregivers and health care providers in the process is a must.

Disclosure to HIV-seropositive children in rural Zambia

Background

Care of children living with HIV comprises various issues, some considered challenging. One of the challenging areas is the serostatus disclosure to HIV-positive children. This study describes the current situation of HIV disclosure among rural children in Zambia and examines the socio-demographic factors promoting disclosure.

Methods

We used a mixed method approach applying both quantitative and qualitative methods to obtain comprehensive picture of HIV serostatus disclosure for children. Data were collected in Mumbwa district, Zambia (2010–2012), included 57 clinical records of children older than 5 years old. We examined children’s age, gender, and cohabitation status with their parents, caregivers’ level of education and income, and the relation between children and caregivers. Logistic regression model was applied to examine associations between disclosure and socio-demographic characteristics. Semi-structured interviews with 50 caregivers and 22 HIV-positive children were conducted to qualitatively investigate attitude towards disclosure and support needed.

Results

Full disclosure was completed in 17 out of 57 (29.8%) patients. Median ages of patients in disclosed group and non-disclosed group were 10 and 9, respectively (IQR 8.0–13.0, 7.0–11.25). In univariate analyses, older age and male gender has positive relation to the completion of serostatus disclosure. In logistic regression models, cohabitation status with patients’ mothers showed positive correlation to the completion of serostatus disclosure. In the interviews with caregivers, all caregivers said that disclosure of serostatus is a necessary process and good for their children, while actual serostatus disclosure rate was low.

Conclusion

Serostatus disclosure to HIV-seropositive children is not prevalent in Rural Zambia. Although further researches would be desirable, increased support to caregivers would be beneficial.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1252-2) contains supplementary material, which is available to authorized users.

Characteristics of HIV-infected adolescents enrolled in a disclosure intervention trial in western Kenya

Knowledge of one's own HIV status is essential for long-term disease management, but there are few data on how disclosure of HIV status to infected children and adolescents in sub-Saharan Africa is associated with clinical and psychosocial health outcomes. We conducted a detailed baseline assessment of the disclosure status, medication adherence, HIV stigma, depression, emotional and behavioral difficulties, and quality of life among a cohort of Kenyan children enrolled in an intervention study to promote disclosure of HIV status. Among 285 caregiver-child dyads enrolled in the study, children's mean age was 12.3 years. Caregivers were more likely to report that the child knew his/her diagnosis (41%) compared to self-reported disclosure by children (31%). Caregivers of disclosed children reported significantly more positive views about disclosure compared to caregivers of non-disclosed children, who expressed fears of disclosure related to the child being too young to understand (75%), potential psychological trauma for the child (64%), and stigma and discrimination if the child told others (56%). Overall, the vast majority of children scored within normal ranges on screenings for behavioral and emotional difficulties, depression, and quality of life, and did not differ by whether or not the child knew his/her HIV status. A number of factors were associated with a child's knowledge of his/her HIV diagnosis in multivariate regression, including older age (OR 1.8, 95% CI 1.5-2.1), better WHO disease stage (OR 2.5, 95% CI 1.4-4.4), and fewer reported caregiver-level adherence barriers (OR 1.9, 95% CI 1.1-3.4). While a minority of children in this cohort knew their HIV status and caregivers reported significant barriers to disclosure including fears about negative emotional impacts, we found that disclosure was not associated with worse psychosocial outcomes.

HIV knowledge, stigma, and illness beliefs among pediatric caregivers in Ghana who have not disclosed their child's HIV status

The majority of HIV-infected children in sub-Saharan Africa have not been informed of their HIV status. Caregivers are reluctant to disclose HIV status to their children because of concern about the child’s ability to understand, parental sense of guilt, and fear of social rejection and isolation. We hypothesized that the low prevalence of pediatric HIV disclosure in Ghana is due to lack of accurate HIV information and high HIV stigma among caregivers. This is a preliminary analysis of baseline data of an HIV pediatric disclosure intervention study in Ghana (“Sankofa”). “Sankofa” – is a two-arm randomized controlled clinical trial comparing disclosure intervention plus usual care (intervention arm) vs usual care (control arm) at Korle-Bu Teaching Hospital (KBTH; control arm) and Komfo-Anokye Teaching Hospital (KATH; intervention arm). We enrolled HIV-infected children, ages 7–18 years who do not know their HIV status, and their caregivers. Baseline data of caregivers included demographic characteristics; Brief HIV Knowledge Questionnaire (HIV-KQ-18); Brief Illness Perception Questionnaire; and HIV Stigma Scale. Simple and multivariable linear regression analyses were used to assess the relationship between caregiver characteristics and HIV knowledge, stigma, and illness perception. Two hundred and ninety-eight caregivers were enrolled between January 2013 and July 2014 at the two study sites; KBTH (n = 167) and KATH (n = 131). The median age of caregivers was 41 years; 80.5% of them were female and about 60% of caregivers were HIV-positive. Seventy-eight percent of caregivers were self-employed with low household income. In both unadjusted and adjusted analyses, HIV negative status and lower level of education were associated with poor scores on HIV-KQ. HIV positive status remained significant for higher level of stigma in the adjusted analyses. None of the caregiver’s characteristics predicted caregiver’s illness perception. Intensification of HIV education in schools and targeted community campaigns are needed.

Adolescents' Experiences and Their Suggestions for HIV Serostatus Disclosure in Zambia: A Mixed-Methods Study

Background

HIV serostatus disclosure is an immense challenge for adolescents living with HIV, their caregivers, and health workers. In Zambia, however, little guidance is available from the adolescents’ point of view on the HIV disclosure process.

Objective

This study aimed to examine the setting of HIV serostatus disclosure for adolescents, its impacts on them, and their suggestions on the best practice of HIV disclosure.

Methods

We conducted a mixed-methods study at the University Teaching Hospital in Zambia from April to July 2014. We recruited 200 adolescents living with HIV, aged 15–19 years. We collected data using a structured questionnaire including two open-ended questions. We excluded two adolescents due to withdrawal during the survey, and eight from the data set due to out-of-eligibility criteria in age. Eventually, we included 190 in the analysis. We performed descriptive analysis to calculate the distributions of basic characteristics of the adolescents, their experience and preference on HIV serostatus disclosure, its emotional and behavioral impacts, and health education topics they had ever learned at hospital. We performed thematic analysis with open-ended data to explain first impressions upon disclosure in detail and to determine perceived advantages of HIV serostatus disclosure.

Results

The majority of adolescents recommended the age of 12 as appropriate for adolescents to learn about their HIV serostatus and preferred disclosure by both parents. Out of 190 adolescents, 73.2% had negative or mixed feelings about HIV serostatus disclosure, while 86.2% reported that disclosure was beneficial. Thematic analyses showed that the adolescents reacted emotionally due to an unexpected disclosure and a belief of imminent death from HIV. However, they improved adherence to treatment (84.7%), limited self-disclosure of their HIV serostatus to others (81.1%), and felt more comfortable in talking about HIV with their caregivers (54.2%). Thematic analysis identified perceived benefits of disclosure as follows: better understanding of their sickness and treatment, and improved self-care and treatment adherence. Lower percentage of the adolescents have learned about psychosocial well-being, compared to facts about HIV and treatment.

Conclusion

Despite initial emotional distress experienced after the disclosure, knowing one’s own HIV serostatus was found to be a crucial turning point for adolescents to improve motivation for self-care. HIV serostatus disclosure to adolescents requires follow-up support involving parents/primary caregivers, health workers, and peers.

Adolescents with HIV and transition to adult care in the Caribbean, Central America and South America, Eastern Europe and Asia and Pacific regions

INTRODUCTION

The HIV epidemics in the Caribbean, Central America and South America (CCASA), Eastern Europe (EE) and Asia and Pacific (AP) regions are diverse epidemics affecting different key populations in predominantly middle-income countries. This narrative review describes the populations of HIV-positive youth approaching adolescence and adulthood in CCASA, EE and AP, what is known of their outcomes in paediatric and adult care to date, ongoing research efforts and future research priorities.

METHODS

We searched PubMed and abstracts from recent conferences and workshops using keywords including HIV, transition and adolescents, to identify published data on transition outcomes in CCASA, EE and AP. We also searched within our regional clinical/research networks for work conducted in this area and presented at local or national meetings. To give insight into future research priorities, we describe published data on characteristics and health status of young people as they approach age of transition, as a key determinant of health in early adulthood, and information available on current transition processes.

RESULTS AND DISCUSSION

The perinatally HIV-infected populations in these three regions face a range of challenges including parental death and loss of family support; HIV-related stigma and socio-economic disparities; exposure to maternal injecting drug use; and late disclosure of HIV status. Behaviourally HIV-infected youth often belong to marginalized sub-groups, with particular challenges accessing services and care. Differences between and within countries in characteristics of HIV-positive youth and models of care need to be considered in comparisons of outcomes in young adulthood. The very little data published to date on transition outcomes across these three regions highlight some emerging issues around adherence, virological failure and loss to follow-up, alongside examples of programmes which have successfully supported adolescents to remain engaged with services and virologically suppressed.

CONCLUSIONS

Limited data available indicate uneven outcomes in paediatric services and some shared challenges for adolescent transition including retention in care and adherence. The impact of issues specific to low prevalence, concentrated epidemic settings are poorly understood to date. Outcome data are urgently needed to guide management strategies and advocate for service provision in these regions.

Diagnosis disclosure to adolescents living with HIV in rural Kenya improves antiretroviral therapy adherence and immunologic outcomes: A retrospective cohort study

Background & aims

Emphasis on adolescent HIV has increased worldwide as antiretroviral treatment has greatly extended life expectancies of HIV-positive children. Few evidence-based guidelines exist on the optimal time to disclose to an adolescent living with HIV (ALHIV); little is known about the medical effects of disclosure. This study looked to determine whether disclosure is associated with improved medical outcomes in ALHIV. Prior work has tended to be qualitative, cross-sectional, and with an emphasis on psychosocial outcomes. This paper addresses the adolescent cohort retrospectively (longitudinally), building upon what is already known about disclosure.

Methods

Retrospective, longitudinal clinical record reviews of ALHIV seen at Kericho District Hospital between April 2004 and November 2012 were performed. Patient demographics and clinical outcomes were systematically extracted. The student’s t-test was used to calculate changes in mean CD4 count, antiretroviral therapy (ART), and cotrimoxazole adherence pre- vs. post-disclosure. Linear regression modelling assessed for trends in those clinical outcomes associated with age of disclosure.

Results

Ninety-six ALHIV (54 female, 42 male) were included; most (73%) entered care through the outpatient department. Nearly half were cared for by parents, and 20% experienced a change in their primary caregiver. The mean time in the study was 2.47 years; mean number of visits 10.97 per patient over the mean time in the study. Mean disclosure age was 12.34 years. An increase in mean ART adherence percentage was found with disclosure (0.802 vs. 0.917; p = 0.0015). Younger disclosure age was associated with significantly higher mean CD4 counts over the course of the study (p = 0.001), and a nonsignificant trend toward a higher mean ART adherence percentage (p = 0.055).

Conclusion

ART adherence and improved immunologic status are both associated with disclosure of HIV infection to adolescent patients. Disclosure of an HIV diagnosis to an adolescent is an important means to improve HIV care.

The Impact of Disclosure on Health and Related Outcomes in Human Immunodeficiency Virus-Infected Children: A Literature Review

This review explores the association between pediatric human immunodeficiency virus (HIV) disclosure and health and related outcomes among children living with HIV. A multi-stage process was used to search for relevant articles on the ISI Web of Knowledge database. Fifteen articles met the inclusion criteria. Five major outcomes emerged from children’s knowledge of their HIV-seropositive status: physical/physiological outcomes; adherence to antiretroviral therapy; psychosocial outcomes; sexual and reproductive health, including HIV prevention outcomes; and disclosure of status by the children. Disclosure of a child’s HIV status to the child has value in terms of positive health outcomes for the child, such as better adherence and slower disease progression—albeit the different studies did not always reach the same conclusions, and some suggest negative health outcomes, such as increased psychiatric hospitalization. Yet, there does not seem to be a systematic or coherent system for child disclosure. One recommendation from this review, therefore, is for government and program policies and guidelines that will promote child HIV disclosure in order to address the current low rates of disclosure in sub-Saharan Africa (SSA). More rigorous and longitudinal studies on the outcomes of disclosure, with larger sample sizes, and in SSA, are also needed.

Pediatric HIV Disclosure Intervention Improves Knowledge and Clinical Outcomes in HIV-Infected Children in Namibia

Objectives:

Using routinely collected data, we evaluated a nationally implemented intervention to assist health care workers and caregivers with HIV disclosure to children. We assessed the impact of the intervention on child's knowledge and health outcomes.

Methods:

Data were abstracted from national databases and patient charts for HIV-infected children aged 7–15 years attending 4 high-volume HIV clinics in Namibia. Disclosure rates, time to disclosure, and HIV knowledge in 314 children participating in the intervention were analyzed. Logistic regression was used to identify correlates of partial vs. full disclosure. Paired t-tests and McNemar tests were used to compare adherence and viral load (VL) before versus after intervention enrollment.

Results:

Among children who participated in the disclosure intervention, 11% knew their HIV status at enrollment and an additional 38% reached full disclosure after enrollment. The average time to full disclosure was 2.5 years (interquartile range: 1.2–3 years). Children who achieved full disclosure were more likely to be older, have lower VLs, and have been enrolled in the intervention longer. Among children who reported incorrect knowledge regarding why they take their medicine, 83% showed improved knowledge after the intervention, defined as knowledge of HIV status or adopting intervention-specific language. On comparing 0–12 months before vs. 12–24 months after enrollment in the intervention, VL decreased by 0.5 log₁₀ copies per milliliter (N = 42, P = 0.004), whereas mean adherence scores increased by 10% (N = 88, P value < 0.001).

Conclusions:

This HIV disclosure intervention demonstrated improved viral suppression, adherence, and HIV knowledge and should be considered for translation to other settings.

Sexual and reproductive health knowledge and behavior among adolescents living with HIV in Zambia: a case study

Introduction

As HIV infected adolescents mature into adulthood, they are confronted with issues related to sexuality and sexual reproductive health (SRH). An estimated 68,000 adolescents aged 10-19 years are living with HIV in Zambia. The current study explores their sexuality and SRH experience and needs.

Methods

This was a mixed method analytical cross-sectional study. Adolescents at a tertiary hospital were surveyed on their sexuality and SRH experiences. Bivariate analyses on SPSS were used to assess factors associated with selected behaviors. Emerging themes from open-ended questions qualitative data were explored using content analysis.

Results

A total of 148 adolescents (63.5% females) aged 15-19 years were surveyed. Majority (77.0%) had secondary education; 77.2% currently in school; 40.1 % had a boy or girlfriend; 15.1% have ever had sex, of whom only 61.1 % reported consistent condom use. About 68.9 % expressed intention to have children; 2.1% of girls had been pregnant before. Of 52 respondents, 19.2% had a sexually transmitted infection (STI) before. Not being in school was a significant predictor, for knowing where to access information about sex (OR= 2.53; 95% CI:1.10-5.82; p=0.02), and also for ever gone there (OR=2.61; 95% CI:1.04-6.58; p=0.03).

Conclusion

The survey of HIV infected adolescents attending a tertiary hospital in Zambia found that their sexuality and SRH needs remain similar to those of the general adolescent population in terms of counseling in sexual matters, family planning and STI services. More efforts are needed to provide for adolescent health care needs, especially those living with HIV.

Talking to children about their HIV status: a review of available resources, tools, and models for improving and promoting pediatric disclosure

As children living with HIV (CLHIV) grow into adolescence and adulthood, caregivers and healthcare providers are faced with the sensitive challenge of when to disclose to a CLHIV his or her HIV status. Despite WHO recommendations for CLHIV to know their status, in countries most affected by HIV, effective resources are often limited, and national guidance on disclosure is often lacking. To address the need for effective resources, gray and scientific literature was searched to identify existing tools and resources that can aid in the disclosure process. From peer-reviewed literature, seven disclosure models from six different countries were identified. From the gray literature, 23 resources were identified including children's books (15), job aides to assist healthcare providers (5), and videos (3). While these existing resources can be tailored to reflect local norms and used to aid in the disclosure process, careful consideration must be taken in order to avoid damaging disclosure practices.

Impact of HIV-Status Disclosure on Adherence to Antiretroviral Therapy Among HIV-Infected Children in Resource-Limited Settings: A Systematic Review

Pediatric HIV remains a significant global health dilemma, especially in resource-constrained nations. As access to ART increases around the world, areas of concern in pediatric HIV treatment include age-appropriate disclosure of HIV status to children and development of adherence habits over time. This review was conducted to synthesize quantitative associations reported between disclosure and adherence among children living with HIV in resource-limited settings. An electronic database search of PubMed, MEDLINE and Cochrane returned 1348 results after removal of duplicates, 14 of which were found to meet inclusion criteria. Review of these reports showed conflicting results regarding the impact of disclosure on adherence, with 5 showing no association, 4 showing a negative impact of disclosure on adherence, and 5 showing positive benefits of disclosure for adherence habits. Thus, there was no clear consensus on the effect, if any, that disclosure has on medication adherence. Longitudinal, prospective research needs to be conducted to evaluate further impacts that disclosure may have on adherence habits over time, and interventions must be structured to link the two processes together in order to maximize health benefit to the child or adolescent.

Parental concerns on disclosure of HIV status to children living with HIV: children's perspective

Disclosure is an important component of comprehensive management of children living with HIV infection (CLHIV). Many parental concerns are barriers for disclosure in children and only few studies addresses children's perspective on these concerns. Our study aims to understand children's perspective on parental concerns for disclosure and assess the knowledge of HIV. A questionnaire-based cross-sectional study involving CLHIV between 10 and 18 years attending HIV clinic in southern India, was conducted. Data were collected by directly interviewing only the children after obtaining consent from parents/caregivers. Initial open-ended questions were asked to assess the disclosure status and only fully disclosed children were included. Out of 362 enrolled eligible children, the prevalence of full and partial disclosure was 36.7% and 24%, respectively. The mean age of disclosure was 10.4 years (SD ± 2.6) and non-parental family members in an informal setting were the most common source of disclosure (38.3%). Forty-six percentages of parents were unaware of their child's disclosure status. Only 2% had disclosed their status to others who were not part of their care. Among disclosed children, 33.8% became upset or sad upon knowing their status, 12% faced discrimination and 41.4% had complete knowledge about their illness. Though the prevalence of disclosure among CLHIV was high, a majority of them had incomplete knowledge about HIV infection. The parental concerns as reported in literature like the child is too young to disclose, concerns about coping, fear of stigma and discrimination and child disclosing to others were not expressed by children.

Determinants and processes of HIV status disclosure to HIV--infected children aged 4 to 17 years receiving HIV care services at Baylor College of Medicine Children's Foundation Tanzania, Centre of Excellence (COE) in Mbeya: a cross-sectional study

BACKGROUND

Disclosure of HIV sero-status to HIV-infected children is associated with reduced risk of death and better adherence to antiretroviral drugs. However, caregivers find it difficult to determine when and how they should disclose the HIV sero-positive status to HIV-infected children. In this study, we assessed the determinants and processes of HIV status disclosure to HIV-infected children aged 4 to 17 years receiving HIV care services at the Baylor College of Medicine Children's Foundation Tanzania, Centre of Excellence (COE) in Mbeya.

METHODS

This was a cross-sectional study conducted among 334 caregivers of HIV positive children attending the Baylor COE in Mbeya, Tanzania. Data were collected using quantitative and qualitative research methods. Quantitative data were collected on socio-demographic characteristics of children and caregivers using an interviewer-administered questionnaire. Data were entered into Epi-Info version 3.5.1 and analyzed using STATA version 10. Univariable and multivariable logistic regression analyses were conducted to obtain odds ratios (OR) and 95% confidence intervals (95% CI) associated with disclosing HIV positive status to HIV-infected children. Qualitative data were collected on the processes used in accomplishing the HIV status disclosure event using case histories and key informant interviews and analyzed manually using latent analysis techniques.

RESULTS

About one-third of the caregivers (32.6%) disclosed the children's HIV sero-positive status to them. Disclosure was more likely among children 10 years or older (adjusted OR [AOR] = 8.8; 95% CI: 4.7, 16.5), caregivers with knowledge about HIV disclosure (AOR = 5.7; 95% CI: 2.3, 13.7) and those earning more than Tsh 99,999 (US $62.5) per month (AOR = 2.4; 95% CI: 1.3, 4.5). Qualitative findings showed that caregivers used a diversity of approaches to complete the HIV status disclosure event including direct, third-party, event-driven and use of drawings.

CONCLUSIONS

Our study shows that disclosure is common among older children and is largely driven by the caregivers' knowledge about HIV status disclosure and monthly earnings. HIV status disclosure was accomplished through a variety of approaches. These findings suggest a need to provide caregivers with knowledge about HIV status disclosure approaches to improve HIV status disclosure to HIV-infected children.

Cross Sectional Characterization of Factors Associated with Pediatric HIV Status Disclosure in Southern Ethiopia

Background

Disclosure of HIV positive status to children and adolescents is a complex process. However, disclosure has been found to be associated with improved outcomes. The objective of the current study was to identify the predictors that facilitate disclosure of HIV status to children and adolescents and to study the reasons for non-disclosure.

Methods

Interviews of caregivers and reviews of records were done to collect data on caregiver and child information and details regarding the disclosure status of children. Bivariate analysis was done to test the association between HIV status disclosure and different caregiver and child factors. To identify the independent predictors of disclosure, we did multivariable logistic regression.

Results

A total of 177 children attending an HIV clinic were included. The mean age of the participants was 10.1 years (SD = 2.8), and about half (50.8%) were female. Most caregivers, 137 (77.8%) stated that disclosure of HIV status to children is important and should be done. However, disclosure had only been made to 59 (33.3%) of the participants. Child age more than 10 years [AOR = 6.7; 95%CI: 1.73–26.01], duration of HIV diagnosis of 5 years or more [AOR = 4.4; 95%CI: 1.26–15.06] and taking a zidovudin (AZT) based regimen [AOR = 3.5; 95%CI: 1.31–9.53] predicted HIV positive status disclosure. Additionally, length of treatment of caregivers of more than 14 years [AOR = 3.9; 95%CI: 1.07–14.61], disclosure of caregiver’s HIV status to children and/or others [AOR = 4.7; 95%CI: 1.19–18.74], and the child’s inquiry about their condition [AOR = 4.5; 95%CI: 1.16–17.43] increased the odds of disclosure.

Conclusion

The rate of disclosure among HIV infected children in southern Ethiopia is low. Primarily time-based factors were associated with the probability of HIV positive status disclosure and a specific regimen which has not been found previously. Further qualitative research may elucidate more on these factors; educational strategies may address some of these determinants.

Disclosure of their HIV status to perinatally infected youth using the adapted Blasini disclosure model in Haiti and the Dominican Republic: preliminary results

OBJECTIVES

To assess the safety, acceptability, and preliminary efficacy of a culturally-adapted disclosure intervention for perinatally HIV-infected combined antiretroviral therapy patients in Haiti and the Dominican Republic.

DESIGN

A quasi-experimental trial was conducted comparing caregiver-youth pairs who completed the intervention [adapted Blasini disclosure model (aBDM)] to pairs who discontinued aBDM participation before disclosure. aBDM consists of five components: structured healthcare worker training; one-on one pre-disclosure intervention/education sessions for youth (describing pediatric chronic diseases including cancer, diabetes and HIV) and for caregivers (strengthening capacity for disclosure); a scheduled supportive disclosure session; and one-on-one postdisclosure support for caregivers and youth.

METHODS

Caregivers of nondisclosed combined antiretroviral therapy patients aged 10.0-17.8 years were invited to participate. Data were collected by separate one-on-one face-to-face interviews of caregivers and youth by study staff and medical record review by pediatricians at enrollment and 3 months after disclosure or after intervention discontinuation.

RESULTS

To date, 65 Dominican Republic and 27 Haiti caregiver-youth pairs have enrolled. At enrollment, only 46.4% of youth had viral suppression and 43.4% of caregivers had clinically significant depressive symptomatology. To date, two serious study-related adverse events have occurred. Seven of the 92 (7.6%, 6 in the Dominican Republic) enrolled pairs discontinued participation before disclosure and 39 had completed postdisclosure participation. Median plasma HIV-RNA concentration was lower in youth who completed aBDM than in youth who discontinued participation before aBDM disclosure (<40 versus 8673 copies/ml; P = 0.027). Completers expressed considerable satisfaction with aBDM.

CONCLUSION

Preliminary results suggest safety, acceptability, and possible effectiveness of the aBDM.

Growing-up just like everyone else: key components of a successful pediatric HIV disclosure intervention in Namibia

OBJECTIVES

To facilitate replication and adaptation of pediatric HIV disclosure interventions, we identified key components of a child-friendly cartoon book used to guide Namibian caregivers and healthcare workers (HCWs) through a gradual, structured disclosure process.

DESIGN

Qualitative interviews were conducted with caregivers and HCWs from four high-volume pediatric HIV clinics in Namibia.

METHODS

Semi-structured in-depth interviews with 35 HCWs and 64 caregivers of HIV+ children aged 7-15 were analyzed using constant comparative and modified grounded theory analysis. Major barriers to disclosure were compared to accounts of intervention success, and themes related to key components were identified.

RESULTS

The disclosure book overcomes barriers to disclosure by reducing caregiver resistance, increasing HIV and disclosure knowledge, and providing a gradual, structured framework for disclosure. The delayed mention of HIV-specific terminology overcomes caregiver fears associated with HIV stigma, thus encouraging earlier uptake of disclosure initiation. Caregivers value the book's focus on staying healthy, keeping the body strong, and having a future 'like other kids', thus capitalizing on evidence of the positive benefits of resilience and hopefulness rather than the negative consequences of HIV. The book's concepts and images resonate with children who readily adopt the language of 'body soldiers' and 'bad guys' in describing how important it is for them to take their medicine. Discussion cues ease communication between HCWs, caregivers, and pediatric patients.

CONCLUSION

Given the urgent need for available pediatric HIV disclosure interventions, easily implementable tools like the Namibian disclosure book should be evaluated for utility in similar settings.

Factors affecting disclosure of serostatus to children attending Jinja Hospital Paediatric HIV clinic, Uganda

BACKGROUND

Disclosure of HIV status is important for optimal adherence to antiretroviral therapy in children. Identifying factors that affect disclosure of sero-status to children will help improve the process of disclosure. The purpose of the study was to determine the rate of HIV disclosure by the parents/caretakers to their children and other factors affecting disclosure.

METHODS

A cross sectional study among 174 caretakers of children age 5-8 years, twenty children and all (ten) health workers at Jinja Hospital paediatric HIV clinic. Data was collected with standardized questionnaires on socio-demographic factors, disclosure status, health facility factors, fears and perceived benefits of disclosure.

RESULTS

We found disclosure rates in 56% of the children. Among those not disclosed to, non-disclosure was 19% and deception 25%. Factors associated with disclosure of sero-status to a child were age of child (X2 37.4 df 1 p< 0.001), child being on antiretroviral therapy (OR 2.0 CI 1.1-3.6 p=0.024) and child attending psychosocial support group (OR 7.4 CI 3.6-15.3 p < 0.001). There were no appropriate guidelines on disclosure and only half of health providers had training on disclosure of HIV serostatus to children.

CONCLUSION

The overall prevalence of disclosure was low. Psychosocial support groups promoted disclosure.

Antiretroviral treatment failure, drug resistance, and subtype diversity in the only pediatric HIV clinic in Rhode Island

BACKGROUND

Drug resistance development in the human immunodeficiency virus (HIV)-infected pediatric population in the United States can impact long-term antiretroviral therapy (ART) efficacy. Limited formularies and adherence constraints in children jeopardize lifelong-needed ART.

METHODS

We examined treatment failure, drug resistance, and their correlates in ART-naive and ART-experienced children attending the pediatric HIV clinic in Rhode Island between 1991 and 2012. Pol sequences were obtained for phylogenetic, subtype, and resistance analyses. Associations between selected covariates and virologic failure and resistance were evaluated using generalized additive models and Fisher exact tests.

RESULTS

Data were available for all 56 clinic-attending children. At diagnosis, 33% were aged <1 year, 31% aged 1-4 years, and 37% aged ≥ 5 years; 54% were male, 73% black or Hispanic, 55% US-born, 20% refugees, and 64% perinatally infected. Of 44 ART-experienced children, 57% had virologic failure, most never virologically suppressed. Failure was associated with missed appointments (P = .05) and missed doses (P < .01). Of 40 children with available genotypes, 35% were infected with non-B subtypes; 6% of ART-naive children had resistance; and 73% of ART-experienced children had ≥ 1 major mutation: (16% conferring triple-class, 47% dual-class, and 37% single-class resistance). An epidemiologically confirmed resistance transmission from a perinatally infected teenage male to a newly infected teenage female was demonstrated.

CONCLUSIONS

We report high HIV type 1 diversity, extensive drug resistance among ART-experienced children, and horizontal transmission of resistance in the Rh ode Island pediatric HIV clinic. As HIV-infected children mature into adulthood, close monitoring of ART, adherence, and diagnosis disclosure are essential to optimize patient care.

Disclosure of their status to youth with human immunodeficiency virus infection in the Dominican Republic: a mixed-methods study

A mixed-methods study was conducted to determine the proportion of HIV-infected children who knew their status, identify characteristics associated with children's knowledge of their status, and describe caregivers' and adolescents' experiences relevant to disclosure in the Dominican Republic (DR). Of 327 patients aged 6-18 years treated in the principal DR pediatric HIV facilities, 74 (22.6 %) knew their status. Patients aged 13 years or older and/or who had participated in non-clinical activities for HIV-infected children were more likely to know their status. Caregivers who had disclosed cited healthcare providers' advice, children's desire to know and concerns that children might initiate sexual activity before knowing or discover their status by accidental or malicious disclosure. Non-disclosing caregivers worried that children would be traumatized by disclosure and/or stigmatized if they revealed it to others. Adolescents supported disclosure by 10-12 years of age, considered withholding of children's HIV diagnosis ill-advised, and recommended a disclosure process focused initially on promoting non-stigmatizing attitudes about HIV.

Knowledge and disclosure of HIV status among adolescents and young adults attending an adolescent HIV clinic in Accra, Ghana

BACKGROUND

In Ghana it is estimated that 1.2% of HIV infections occur in young people aged 15-24 but the representation in our clinics is small. Adherence to treatment, appointment keeping and knowledge of HIV status remains a challenge. Disclosure has been shown to result in better adherence to therapy, good clinical outcomes, psychological adjustment and reduction in the risk of HIV transmission when the young person becomes sexually active. A baseline study was conducted to ascertain if adolescents and young adults knew their HIV status and their knowledge on HIV. Informed consent and assent were obtained from willing participants. Self-administered questionnaires on general knowledge of HIV, HIV treatment and disclosure were collected and analyzed.

RESULTS

Thirty-four young persons participated in the study. The mean age was 16.9±SD 2.5 and 62% (21/32) were female. All of them were still in school. Eighty-five percent were aware that young people their age could fall sick, 91% had heard of HIV, 70% knew someone with HIV and 45% thought that adolescents were not at risk of HIV. On modes of HIV transmission, 66.7% knew HIV was transmitted through sex and 63.6% knew about mother to child transmission. Fifty three percent (18/34) knew their HIV status, 50% (17/34) were on antiretroviral and 35% (6/17) of them admitted to missing ARV doses. One person who said he was HIV negative and another who did not know his status were both on ARVs.

CONCLUSION

Disclosure of HIV status to adolescents and young people is dependent on a complex mix of factors and most practitioners recommend an age and developmentally appropriate disclosure. Thus it is highly individualized. The knowledge and awareness of HIV was 91% compared to 97% of adults in the most recent Ghana Demographic and Health Survey however only about two thirds had acceptable in depth knowledge on HIV. Only half knew their HIV status which was not the best considering their ages. There is the need to strengthen education to young persons with HIV, support adhere to ARVs for better outcomes and assist care givers to disclose HIV status to them.

Using health provider insights to inform pediatric HIV disclosure: a qualitative study and practice framework from Kenya

Optimal pediatric HIV disclosure impacts illness and developmental experiences while improving access to timely treatment. However, disclosure rates in high HIV prevalence countries remain low and there are limited data on best practices. We conducted a qualitative study of disclosure practices and interviewed healthcare providers from five pediatric HIV clinics in Kenya. We identified themes central to disclosure practices, rationale for approaches, barriers to implementing disclosure, and creative strategies to overcome challenges. We used these insights to develop a practice-based framework for disclosure that is sensitive to practical challenges. Overall, providers had limited training but extensive experience in disclosure, endorsed individualized disclosure practices, invested substantial time on disclosure despite clinical burden, and noted adverse outcomes associated with unplanned or abrupt disclosure. Providers advocated for an approach to disclosure that is child-centered but respects caregiver fears and values. Caregiver support was provided to enable caregivers to be the person who ultimately disclosed HIV status to children. Unplanned or abrupt disclosure to children was reported to have severe and persistent adverse impact and was a stimulus to accelerate disclosure in scenarios when providers believed children may be suspecting their diagnosis. Based on these expert insights, the framework we developed incorporates concurrent evaluation of child and caregiver readiness, identifies cues to prompt disclosure discussions, includes caregiver education and support, and utilizes a gradual approach of unveiling HIV diagnosis to the child.

Caregivers' intentions to disclose HIV diagnosis to children living with HIV in South Africa: a theory-based approach

When children know their HIV serostatus, they are more likely to cooperate with steps to manage their health and the risk of transmitting HIV to others. Mounting evidence indicates that caregivers often do not disclose to HIV-positive children that the children are living with HIV, but little is known about the modifiable determinants of pediatric HIV disclosure. The present study examined theory-of-planned-behavior predictors of the intention to disclose to children their HIV diagnosis. The participants were 100 caregivers of HIV-positive children in Eastern Cape Province, South Africa. Proportional-odds logistic regression analysis revealed that normative support for disclosure and caregiver-child communication predicted the intention to disclose, whereas behavioral beliefs regarding the consequences of disclosing and self-efficacy to disclose did not. The results suggest that interventions to increase pediatric HIV disclosure in South Africa should help caregivers enlist support for disclosure among important referents and improve communication with their HIV-infected children.

HIV disclosure and its effect on treatment outcomes in perinatal HIV-infected Thai children

The World Health Organization guideline recommends informing children of their HIV status between the ages of 6-12 years. Primary caregivers of perinatal HIV-infected Thai children ≥6 years were interviewed in order to assess the HIV status disclosure rate. In addition, pill counts of antiretroviral therapy (ART) were performed every three months. CD4 and HIV-RNA were performed every six months. Of the 260 children/adolescents included, the median age of disclosure was 14.8 years. The disclosure rate among those from 6 to 12 years was 21% and for those greater than 12 years of age was 84%. When comparing children aged 6-12 years whose HIV status had been disclosed to them, to children whose HIV had yet to be disclosed, no difference was noted in median ART adherence by pill count, CD4 count, or proportion of HIV-RNA <50 copies/ml (p > 0.05). Factors associated with HIV disclosure were an age of ≥12 years (OR 17.8, 95% CI 8.86-35.79) and a current CD4 ≤ 30% (OR 2.09, 95% CI 1.20-3.62). In conclusion, although the majority of adolescents ≥12 years were aware of their HIV status only one-fifth of children aged 6-12 years were aware. Moreover, the child's/adolescent's disclosure status had no bearing on ART adherence by pill count or immunological and virological outcomes.

Adolescent HIV disclosure in Zambia: barriers, facilitators and outcomes

INTRODUCTION

As adolescents living with HIV gain autonomy over their self-care and begin to engage in sexual relationships, their experiences of being informed about their HIV status and of telling others about their HIV status may affect their ability to cope with having the disease.

METHODS

In 2010, we conducted a qualitative study among adolescents aged 10-19 living with HIV in Zambia, and with their parents and health care providers. Through interviews and focus group discussions, we explored the disclosure of HIV status to adolescents living with HIV; adolescents' disclosure of their status to others; and the impact of both forms of disclosure on adolescents.

RESULTS

Our study identified three main barriers to disclosure of HIV status: local norms that deter parents from communicating with their children about sexuality; fear of HIV stigma; and an underlying presumption that adolescents would not understand the consequences of a HIV diagnosis on their lives and relationships. With regard to adolescents' disclosure of their HIV status to their sexual partners, our study identified fear of rejection as a common barrier. In rare cases, open family conversations about HIV helped adolescents come to terms with a HIV diagnosis. Findings indicated that disclosure had various outcomes at the individual and interpersonal levels. At the individual level, some adolescents described being anxious, depressed and blaming themselves after being told they had HIV. At the interpersonal level, disclosure created opportunities for adolescents to access adherence support and other forms of psychosocial support from family members and peers. At the same time, it occasionally strained adolescents' sexual relationships, although it did not always lead to rejection.

CONCLUSIONS

There is a need for public health interventions that guide adolescents living with HIV, their parents and families through the disclosure process. Such interventions should help parents to assess and understand the evolving cognitive capacity and maturity of their adolescents in order to determine the appropriate time to inform them of their HIV-positive status. Such interventions should also mitigate the risk of HIV stigma, as well as local norms that may prevent discussions of sexuality within families. Adolescents who have been informed of their HIV status should be provided with on-going support to prevent disclosure from negatively affecting their psychological and sexual wellbeing. Further research is needed to explore the potential role of trusted family members in contributing to the disclosure process.

A cross-sectional study of disclosure of HIV status to children and adolescents in western Kenya

Introduction

Disclosure of HIV status to children is essential for disease management but is not well characterized in resource-limited settings. This study aimed to describe the prevalence of disclosure and associated factors among a cohort of HIV-infected children and adolescents in Kenya.

Methods

We conducted a cross-sectional study, randomly sampling HIV-infected children ages 6–14 years attending 4 HIV clinics in western Kenya. Data were collected from questionnaires administered by clinicians to children and their caregivers, supplemented with chart review. Descriptive statistics and disclosure prevalence were calculated. Univariate analyses and multivariate logistic regression were performed to assess the association between disclosure and key child-level demographic, clinical and psychosocial characteristics.

Results

Among 792 caregiver-child dyads, mean age of the children was 9.7 years (SD = 2.6) and 51% were female. Prevalence of disclosure was 26% and varied significantly by age; while 62% of 14-year-olds knew their status, only 42% of 11-year-olds and 21% of 8-year-olds knew. In multivariate regression, older age (OR 1.49, 95%CI 1.35–1.63), taking antiretroviral drugs (OR 2.27, 95%CI 1.29–3.97), and caregiver-reported depression symptoms (OR 2.63, 95%CI 1.12–6.20) were significantly associated with knowing one’s status. Treatment site was associated with disclosure for children attending one of the rural clinics compared to the urban clinic (OR 3.44, 95%CI 1.75–6.76).

Conclusions

Few HIV-infected children in Kenya know their HIV status. The likelihood of disclosure is associated with clinical and psychosocial factors. More data are needed on the process of disclosure and its impact on children.

Perinatally acquired HIV infection in adolescents from sub-Saharan Africa: a review of emerging challenges

Worldwide, more than three million children are infected with HIV, 90% of whom live in sub-Saharan Africa. As the HIV epidemic matures and antiretroviral treatment is scaled up, children with HIV are reaching adolescence in large numbers. The growing population of adolescents with perinatally acquired HIV infection living within this region presents not only unprecedented challenges but also opportunities to learn about the pathogenesis of HIV infection. In this Review, we discuss the changing epidemiology of paediatric HIV and the particular features of HIV infection in adolescents in sub-Saharan Africa. Longstanding HIV infection acquired when the immune system is not developed results in distinctive chronic clinical complications that cause severe morbidity. As well as dealing with chronic illness, HIV-infected adolescents have to confront psychosocial issues, maintain adherence to drugs, and learn to negotiate sexual relationships, while undergoing rapid physical and psychological development. Context-specific strategies for early identification of HIV infection in children and prompt linkage to care need to be developed. Clinical HIV care should integrate age-appropriate sexual and reproductive health and psychological, educational, and social services. Health-care workers will need to be trained to recognise and manage the needs of these young people so that the increasing numbers of children surviving to adolescence can access quality care beyond specialist services at low-level health-care facilities.

'You're HIV positive': perinatally infected young people's accounts of the critical moment of finding out their diagnosis

This paper presents the recollections of 28 young people (15-24 years old) of formally learning that they had acquired HIV perinatally. Prior to the naming of their illness, many participants had experienced repeated biographical disruption through ill health and other major life events. However, the critical moment in their HIV trajectory was when they were told their diagnosis. How information about their diagnosis was managed previously, often disguised, combined with the ways in which the disclosure process was handled communicated to young people the inherent dangers and stigma associated with revealing their HIV status to others. The formal disclosure occasion also signalled to most participants the route of their HIV infection as well as previously hidden health information about family members. Although some young people discovered their diagnosis in an unplanned way, most described the disclosure of their HIV status as a structured event, usually a formal telling with those in authority naming the condition. This even applied to those for whom the discovery that they were HIV positive was a process that happened over time. This paper describes their memories of the disclosure event which for half took place over the age of 12. They received messages conveying the imperative to keep this information a secret to avoid being stigmatised and to protect themselves and their families. They described subsequent feelings of isolation and distress. Policy-makers and clinicians need to consider the WHO disclosure recommendations whilst taking into account individual circumstances.

Disclosure of HIV status to children in resource-limited settings: a systematic review

Introduction

Informing children of their own HIV status is an important aspect of long-term disease management, yet there is little evidence of how and when this type of disclosure takes place in resource-limited settings and its impact.

Methods

MEDLINE, EMBASE and Cochrane Databases were searched for the terms hiv AND disclos* AND (child* OR adolesc*). We reviewed 934 article citations and the references of relevant articles to find articles describing disclosure to children and adolescents in resource-limited settings. Data were extracted regarding prevalence of disclosure, factors influencing disclosure, process of disclosure and impact of disclosure on children and caregivers.

Results

Thirty-two articles met the inclusion criteria, with 16 reporting prevalence of disclosure. Of these 16 studies, proportions of disclosed children ranged from 0 to 69.2%. Important factors influencing disclosure included the child's age and perceived ability to understand the meaning of HIV infection and factors related to caregivers, such as education level, openness about their own HIV status and beliefs about children's capacities. Common barriers to disclosure were fear that the child would disclose HIV status to others, fear of stigma and concerns for children's emotional or physical health. Disclosure was mostly led by caregivers and conceptualized as a one-time event, while others described it as a gradual process. Few studies measured the impact of disclosure on children. Findings suggested adherence to antiretroviral therapy (ART) improved post-disclosure but the emotional and psychological effects of disclosure were variable.

Conclusions

Most studies show that a minority of HIV-infected children in resource-limited settings know his/her HIV status. While caregivers identify many factors that influence disclosure, studies suggest both positive and negative effects for children. More research is needed to implement age- and culture-appropriate disclosure in resource-limited settings.

Disclosure of their HIV status to infected children: a review of the literature

Since the introduction of highly active antiretroviral therapy (ART) in 1996, HIV-infected children often survive beyond adolescence. To assess worldwide trends in disclosure since ART was introduced, we reviewed articles that refer to disclosure of their status to HIV-infected children, and which described patient, health care provider and/or caregiver opinions about disclosure and/or reported the proportion of children who knew their diagnosis. Most studies (17 [55%]) were performed in low- or middle-income (LMI) countries. In the 21 articles that included information on whether the children knew their status, the proportion who knew ranged from 1.2 to 75.0% and was lower in LMI (median = 20.4%) than industrialized countries (43%; p = 0.04). LMI country study participants who knew their status tended to have learned it at older ages (median = 9.6 years) than industrialized country participants (median = 8.3 years; p = 0.09). The most commonly reported anticipated risks (i.e. emotional trauma to child and child divulging status to others) and benefits (i.e. improved ART adherence) of disclosure did not vary by the country's economic development. Only one article described and evaluated a disclosure process. Despite recommendations, most HIV-infected children worldwide do not know their status. Disclosure strategies addressing caregiver concerns are urgently needed.

Prevalence, perceptions, and correlates of pediatric HIV disclosure in an HIV treatment program in Kenya

Disclosure to HIV-infected children regarding their diagnosis is important as expanding numbers of HIV-infected children attain adolescence and may become sexually active. In order to define correlates of pediatric disclosure and facilitate development of models for disclosure, we conducted a cross-sectional survey of primary caregivers of HIV-1 infected children aged 6-16 years attending a pediatric HIV treatment program in Nairobi, Kenya. We conducted focus group discussions with a subset of caregivers to further refine perceptions of disclosure. Among 271 caregiver/child dyads in the cross-sectional survey, median child age was 9 years (interquartile range: 7-12 years). Although 79% of caregivers believed children should know their HIV status, the prevalence of disclosure to the child was only 19%. Disclosure had been done primarily by health workers (52%) and caregivers (33%). Caregivers reported that 5 of the 52 (10%) who knew their status were accidentally disclosed to. Caregivers of older children (13 vs. 8 years; p<0.001), who were HIV-infected and had disclosed their own HIV status to the child (36% vs. 4%; p=0.003), or who traveled frequently (29% vs. 16%, p=0.03) were more likely to have disclosed. Children who had been recently hospitalized (25% vs. 44%, p=0.03) were less likely to know their status, and caregivers with HIV were less likely to have disclosed (p=0.03). Reasons for disclosure included medication adherence, curiosity or illness while reasons for nondisclosure included age and fear of inadvertent disclosure. Our study found that disclosure rates in this Kenyan setting are lower than observed rates in the USA and Europe but consistent with rates from other resource-limited settings. Given these low rates of disclosure and the potential benefits of disclosure, strategies promoting health worker trainings and caregiver support systems for disclosure may benefit children with HIV.

The impact of fear, secrecy, and stigma on parental disclosure of HIV status to children: a qualitative exploration with HIV positive parents attending an ART clinic in South Africa

South Africa is one of the sub Saharan countries where considerable progress in providing antiretroviral treatment (ART) has been made. The increased access to ART contributes to improvements in the prognosis of HIV and parents are more likely to raise their children than ever before. The study examined the social context influencing disclosure of parental HIV status to children from the perspectives of fathers and mothers accessing ART from an academic hospital in South Africa. Three focus group interviews were conducted with 26 non-disclosed biological parents of children aged between 7 and 18 years. Their ages ranged between 20-60 years and they cared for a total of 60 children. Parental decision not to disclose their HIV status to children was influenced by the fear of death and dying, the influence of television and media, stigma and discrimination. Parents delayed disclosure of their HIV status to children because children believed that AIDS kills. Parents also feared that the child may not be able to keep the parent's HIV status secret and might result in the family being subjected to stigma, discrimination, and isolation. Fear of stigma and discrimination were also responsible for the continuous efforts by parents to protect their HIV status from their children, family and neighbour's. Parents also delayed disclosure to children because they lacked disclosure skills and needed support for disclosure from health care providers. Healthcare providers are in a unique position to provide such support and guidance and assist parents to disclose and children to cope with parental HIV infection.

HIV status disclosure and retention in care in HIV-infected adolescents on antiretroviral therapy (ART) in West Africa

OBJECTIVE

We assessed the effect of HIV status disclosure on retention in care from initiation of antiretroviral therapy (ART) among HIV-infected children aged 10 years or more in Cote d'Ivoire, Mali and Sénégal.

METHODS

Multi-centre cohort study within five paediatric clinics participating in the IeDEA West Africa collaboration. HIV-infected patients were included in this study if they met the following inclusion criteria: aged 10-21 years while on ART; having initiated ART ≥ 200 days before the closure date of the clinic database; followed ≥ 15 days from ART initiation in clinics with ≥ 10 adolescents enrolled. Routine follow-up data were merged with those collected through a standardized ad hoc questionnaire on awareness of HIV status. Probability of retention (no death or loss-to-follow-up) was estimated with Kaplan-Meier method. Cox proportional hazard model with date of ART initiation as origin and a delayed entry at date of 10th birthday was used to identify factors associated with death or loss-to-follow-up.

RESULTS

650 adolescents were available for this analysis. Characteristics at ART initiation were: median age of 10.4 years; median CD4 count of 224 cells/mm³ (47% with severe immunosuppression), 48% CDC stage C/WHO stage 3/4. The median follow-up on ART after the age of 10 was 23.3 months; 187 adolescents (28.8%) knew their HIV status. The overall probability of retention at 36 months after ART initiation was 74.6% (95% confidence interval [CI]: 70.5-79.0) and was higher for those disclosed compared to those not: adjusted hazard ratio for the risk of being death or loss-to-follow-up = 0.23 (95% CI: 0.13-0.39).

CONCLUSION

About 2/3 of HIV-infected adolescents on ART were not aware of their HIV status in these ART clinics in West Africa but disclosed HIV status improved retention in care. The disclosure process should be thus systematically encouraged and organized in adolescent populations.

Disclosure of diagnosis by parents and caregivers to children infected with HIV: prevalence associated factors and perceived barriers in Addis Ababa, Ethiopia

Vertical transmission of HIV from infected mothers to children is a common phenomenon. After the introduction of highly active antiretroviral treatment (HAART), most children live longer than before. Recently, HAART has become widely available to children living in sub-Saharan African countries, and this makes disclosure of HIV status an important issue. We conducted a cross-sectional survey involving 172 parents/caregivers of HIV-infected school-age children who had follow-up at the Pediatric Infectious Disease Clinic of the Yekatit 12 Hospital, Addis Ababa. Only 16.3% of HIV-infected schoolchildren knew their diagnosis. The child's age was the main predictor of disclosure (OR: -0.25; 95% CI: -0.35, -0.09; p<0.05). The main reason for nondisclosure was fear of negative emotional consequences for the child. More than half of the parent/caregivers agreed that they need to tell the children their diagnosis, but 86% reported that they needed health care providers to help them at the event. The low rate of disclosure found in this study shows the need for awareness creation and training of health professionals, and this should be supported by appropriate guidelines to be followed by health professionals working in pediatric ART clinics. Caregivers need to be provided with the necessary knowledge and skills on how to look after children who know their HIV status.