Disclosing HIV/AIDS to children: The paths families take to truthtelling

Dilemmas when talking about Huntington's disease: A qualitative study of offspring and caregiver experiences in Norway

Research provides a compelling list of reasons why offspring should be included in honest conversations about disease when the disease affects their caregivers. Despite this, we lack in-depth knowledge about how families affected by the severe and complex genetic condition Huntington's disease (HD) experience talking about the many aspects of how this disease affects their lives. This study aimed to provide an in-depth exploration of how offspring with a caregiver with HD and caregivers with a partner with HD experienced talking about disease throughout childhood. Thematic analysis was conducted with semistructured interviews of both caregivers (n = 14) and offspring (n = 36) from families affected by HD, reflecting both current and past experiences. In addition to highlighting the many needs offspring have for knowledge and conversation about the disease with their caregivers, our findings also show that a variety of dilemmas can follow these conversations, including when to talk, what to say, how often HD should be talked about on a day-to-day basis, and whether to share disease-related information with others outside the family. The findings show the complexity of talking with offspring about HD. A difficult task for both offspring and caregivers seemed to be finding out how to balance the many dilemmas that arise in conversations and how to use dialogue to best help offspring adapt and cope with the many challenges that can come with HD. The findings can assist health care professionals, such as genetic counselors, prepare, and guide families affected by HD in the many and complex conversations that arise about the disease, in turn helping offspring adjust and cope with their current lives or future lives affected by HD.

Talking to children about their HIV diagnosis: a discussion rooted in different global perspectives

An online meeting was arranged with four professionals representing four countries to debate current practices and future steps in naming HIV to children (disclosing HIV status). This article considers the evidence and reports on the commentary and debate from the meeting. Naming HIV to children remains a challenge. Although studies identify some of the facilitators and barriers to informing children of their HIV diagnosis, further review of practice is required. This article presents a global perspective of naming practices from different settings. The article comprises commentary and a report of the online debate, along with supporting evidence. The four participating authors concluded that health professionals must work in collaboration with families to support early naming of HIV to children or having an open discussion about HIV in clinics. Naming when a child is younger reduces self-stigma and empowers children and young people to adhere to their medication, make informed decisions and share their own diagnosis appropriately. The authors concluded that health professionals play a key role in educating colleagues and the public to reduce stigma and discrimination. Professionals working with children and families living with HIV require support and resources to instil confidence in naming and facilitate naming of HIV status to a child.

Modality of Primary HIV Disclosure and Association with Mental Health, Stigma, and Antiretroviral Therapy Adherence in Tanzanian Youth Living with HIV

Disclosing HIV status to children before adolescence is a major challenge facing families and healthcare providers. This study used a mixed methods approach to explore the youth perspective of how youth living with HIV (YLHIV) found out their status and to quantify the association of disclosure modality with mental health, stigma, adherence, and HIV outcomes in adolescence. Youth 11-24 years of age attending adolescent HIV clinic in Moshi, Tanzania were included. Adolescents answered questions, including when and how they found out they had HIV, mental health surveys (nine-item Patient Health Questionnaire, Strengths and Difficulties Questionnaire, and modified University of California Los Angeles trauma screen), modified Berger's stigma scale, and self-reported adherence. HIV-1 RNA and latest CD4 were obtained. In-depth interviews were conducted using a convenience sample. The majority of youth reported that they found out their HIV status on their own (80%). Youth attending the government site were less likely to be purposefully told their HIV status compared with those attending the referral site (p < 0.01). Depressive and emotional/behavioral symptoms, internal stigma, and incomplete adherence were significantly more likely among those who figured out their HIV status on their own as compared with those who were purposefully told. Youth discussed how they figured out their HIV status on their own during in-depth interviews. These findings demonstrated that youth who figured out their HIV status on their own had increased mental health symptoms and worse adherence to antiretroviral therapy (ART). It is imperative to implement disclosure protocols in early childhood to reduce mental health difficulties, internal stigma, and promote ART adherence in YLHIV.

Families Living with Blood-Borne Viruses: The Case for Extending the Concept of "Serodiscordance"

The concept of “serodiscordance” (mixed infection status) is primarily associated with epidemiological concerns about HIV transmission risk in couples. We make the case for extending this concept to include families with mixed HIV and viral hepatitis status. Social research on couples with mixed HIV and hepatitis C status has laid an important foundation for illuminating how experiences of serodiscordance within intimate partnerships are much broader than concerns about risk. This body of work attests to serodiscordance holding promise as a valuable concept for understanding viral infections as socially situated and intensely relational phenomena. However, serodiscordance is still limited as a concept because of its near universal focus on couples. It is rarely applied to wider relationships, including family networks beyond the couple. Despite evidence in the literature that families are affected by blood-borne viruses in multiple social, emotional, financial, and generational ways, the concept of serodiscordance does not capture these broader dynamics. Making serodiscordance more inclusive is an important step in recognising the diverse ways families' everyday lives, relationships, and futures can be entangled with HIV, hepatitis C, and hepatitis B, and for understanding how today's era of effective treatment options might shape the “family life” of viral infections.

Challenges faced by caregivers of children on antiretroviral therapy at Mutale Municipality selected healthcare facilities, Vhembe District, Limpopo Province

BACKGROUND

Children depend solely on caregivers who can be either parents or guardians for drug administration to enhance adherence to antiretroviral treatment (ART), which might pose any number of challenges.

PURPOSE

The purpose of this study was to explore and describe the challenges faced by caregivers of children on ART at Mutale Municipality, Vhembe District, Limpopo Province.

RESEARCH DESIGN AND METHOD

The research design was qualitative, explorative, descriptive and contextual in nature. The population consisted of 16 caregivers who were 18 years of age and above, and mentally capable, irrespective of educational qualifications, caring for children aged between 0 and 15 years who were on ART between April 2013 and October 2014. Non-probability, purposive sampling was used to select the 16 caregivers. Required permission, approval and ethical clearance were obtained from the University of Venda Higher Degree Committee, Limpopo Provincial Health Department and relevant institutions. An in-depth, individual, unstructured interview method was used to collect data. One central question was asked: 'What are the challenges you experience when caring for a child on antiretroviral treatment?' Subsequent questions were based on the participants' responses to the central question. Qualitative data were analysed by means of Tesch's open-coding method.

RESULTS

The findings of this study revealed that participants, that is, caregivers of children on ART, experienced financial burdens because of transport costs needed to comply with follow-up dates and insufficient of money for food, clothing the child in need of care, pocket money for lunch boxes during school hours and time lost while waiting for consultations. Participants reported some level of stigmatisation against children on ART by family members, especially the husbands or in-laws of the secondary caregivers. Many primary and secondary caregivers seemed to have given up seeking support from government and community structures.

CONCLUSION

The conclusions drawn from this research are that caregivers hardly receive any support from family members or the community. Fear of disclosing the HIV-positive status of children resulted in the delay of financial support from the government, thus leading to serious financial burden on the caregivers.

Factors influencing the decision-making of parental HIV disclosure: a socio-ecological approach

OBJECTIVES

Using the socio-ecological approach, the current study aims to identify facilitators and barriers to decision-making regarding parental HIV disclosure or nondisclosure at intrapersonal, interpersonal, and sociocultural levels; and examine the unique contribution of factors at different level of influences to the decision of disclosure or nondisclosure.

DESIGN

A cross-sectional survey was conducted among people living with HIV in Guangxi, China. A sub-sample of 1254 participants, who had children aged 5-16 years, was included in the data analysis in the current study.

METHODS

Multivariate models using hierarchical logistic regression were employed to assess the association of parental decision regarding HIV disclosure to children with various factors at intrapersonal, interpersonal, and sociocultural levels controlling background characteristics, and detect the level-specific influence on disclosure decision.

RESULTS

Positive coping with HIV infection and a good parent-child relationship facilitated parental HIV disclosure; whereas high level of resilience and fears of parental HIV disclosure impeded their decisions to talk about HIV status to their children. In addition, the current study recognized specific contribution of multiple ecological levels to parental decisions regarding disclosure to children.

CONCLUSION

The socio-ecological model is a promising theoretical framework to guide further studies and interventions related to parental HIV disclosure. Directions for further studies using socio-ecological approach were also discussed.

Health care workers' perspectives about disclosure to HIV-infected children; cross-sectional survey of health facilities in Gauteng and Mpumalanga provinces, South Africa

The perspectives and practices of health care workers (HCWs) regarding disclosure to HIV-infected children have not been adequately investigated ten years after the roll-out of pediatrics antiretroviral therapy (ART). The aim of the study was to examine the opinions of HCWs about disclosure to HIV-infected children and determine their role in disclosure to children accessing ART in health centers in South Africa. This was a cross-sectional survey using a semi-structured questionnaire among HCWs in ART centers at three hospitals and 48 primary health facilities in two provinces in South Africa. Of the 206 HCWs, 140 (68.2%) were nurses, 44 (21.5%) were lay counsellors, and 4 (2%) were doctors. The majority (n = 183, 89.3%) felt that disclosure benefits children and they should be told about their HIV status. Over half (n = 93, 51.4%) recommended 11–18 years as the appropriate age to disclose. Half (n = 99, 48.5%) said that caregivers should take the lead to disclose, 87 (42.7%) said that disclosure is a shared responsibility of caregivers and HCWs, and 18 (8.8%) said HCWs should lead disclosure. HCWs perceived their role as that of preparing the caregiver for disclosure and the child to understand the disease. However, the lack of guidelines and training on disclosure counselling for children affects their ability to fully participate in disclosure to children. There is a need to adopt the World Health Organizations’ disclosure guidelines for children and adapt them to the local cultural and community contexts and train HCWs to guide, support, and assist caregivers in their disclosure to HIV-infected children.

Practice and perception of parental HIV disclosure to children in Beijing, China

To explore parental disclosure practices and perceptions among HIV-positive parents in urban China, we conducted in-depth interviews with 29 HIV-positive parents in Beijing in 2011. The disclosure rate was low (17%), and unplanned disclosure was common. Most parents chose not to disclose because of concerns regarding their children's young age, concerns about potentially negative psychological impacts on the children, potential secondary disclosure by the children to others, and perceived stigma associated with HIV infection and the causes of such infection (e.g., homosexual behaviors). Parents considered that an appropriate disclosure should be well-planned, cautious, and a gradual process conducted in a comfortable and relaxed environment when both parents and children were calm. We concluded that it was important to (a) provide professional guidance and services about disclosure to children for HIV-positive parents in China, (b) reduce or eliminate HIV-related stigma, (c) set up support groups among HIV-positive parents, and (d) tailor disclosure strategies for different populations of various demographic and socioeconomic characteristics.

Caregiver perceptions and motivation for disclosing or concealing the diagnosis of HIV infection to children receiving HIV care in Mbarara, Uganda: a qualitative study

Background

Disclosure of the diagnosis of HIV to HIV-infected children is challenging for caregivers. Despite current recommendations, data suggest that levels of disclosure of HIV status to HIV-infected children receiving care in resource-limited settings are very low. Few studies describe the disclosure process for children in these settings, particularly the motivators, antecedent goals, and immediate outcomes of disclosure to HIV-infected children. This study examined caregivers' perception of the disclosure concept prior to disclosure, their motivation towards or away from disclosure, and their short- and long-term intentions for disclosure to their HIV-infected children.

Methods

In-depth interviews were conducted with primary caregivers of 40 HIV-infected children (ages 5–15 years) who were receiving HIV care but did not know their HIV status.

Results

Caregivers of HIV-infected children mainly perceived disclosure as a single event rather than a process of gradual delivery of information about the child's illness. They viewed disclosure as potentially beneficial both to children and themselves, as well as an opportunity to explain the parents' role in the transmission of HIV to the children. Caregivers desired to personally conduct the disclosure; however, most reported being over-whelmed with fear of negative outcomes and revealed a lack of self-efficacy towards managing the disclosure process. Consequently, most cope by deception to avoid or delay disclosure until they perceive their own readiness to disclose.

Conclusions

Interventions for HIV disclosure should consider that caregivers may desire to be directly responsible for disclosure to children under their care. They, however, need to be empowered with practical skills to recognize opportunities to initiate the disclosure process early, as well as supported to manage it in a phased, developmentally appropriate manner. The potential role for peer counselors in the disclosure process deserves further study.

'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.

Maternal HIV disclosure to HIV-uninfected children in rural South Africa: a pilot study of a family-based intervention

Background

As access to treatment increases, large numbers of HIV-positive parents are raising HIV-negative children. Maternal HIV disclosure has been shown to have benefits for mothers and children, however, disclosure rates remain low with between 30-45% of mothers reporting HIV disclosure to their children in both observational and intervention studies. Disclosure of HIV status by parent to an HIV-uninfected child is a complex and challenging psychological and social process. No intervention studies have been designed and tested in Southern Africa to support HIV-positive parents to disclose their status, despite this region being one of the most heavily affected by the HIV epidemic.

Method

This paper describes the development of a family-centred, structured intervention to support mothers to disclose their HIV status to their HIV-negative school-aged children in rural South Africa, an area with high HIV prevalence. The intervention package includes printed materials, therapeutic tools and child-friendly activities and games to support age-appropriate maternal HIV disclosure, and has three main aims: (1) to benefit family relationships by increasing maternal HIV disclosure; (2) to increase children’s knowledge about HIV and health; (3) to improve the quality of custody planning for children with HIV-positive mothers. We provide the theoretical framework for the intervention design and report the results of a small pilot study undertaken to test its acceptability in the local context.

Results

The intervention was piloted with 24 Zulu families, all mothers were HIV-positive and had an HIV-negative child aged 6–9 years. Lay counsellors delivered the six session intervention over a six to eight week period. Qualitative data were collected on the acceptability, feasibility and the effectiveness of the intervention in increasing disclosure, health promotion and custody planning. All mothers disclosed something to their children: 11/24 disclosed fully using the words "HIV" while 13/24 disclosed partially using the word "virus".

Conclusion

The pilot study found the intervention was feasible and acceptable to mothers and counsellors, and provides preliminary evidence that participation in the intervention encouraged disclosure and health promotion. The pilot methodology and small sample size has limitations and further research is required to test the potential of this intervention. A larger demonstration project with 300 families is currently underway.

Disclosure of parental HIV infection to children: a systematic review of global literature

This review examines the global empirical literature regarding disclosure of parental HIV infection to children. Thirty-eight articles published in English-language journals prior to 2011 were retrieved and reviewed regarding disclosure process, reasons for disclosure/non-disclosure and impacts of disclosure/non-disclosure. Disclosure rate was relatively low worldwide. The decision making of disclosure or non-disclosure was mainly affected by children's development level, stigma, consideration of children's benefits, and parenting practices. Unintentional and forced disclosures were common. Findings regarding the impacts of disclosure/non-disclosure were mixed but disclosure tended to have long-term positive impacts on the well-being of children, parents and family in general. This review underscores the importance of developing evidence-informed developmentally and culturally appropriate interventions to assist HIV-positive parents to disclose their HIV status to children, particularly in low-resource settings.

Caregivers' Barriers to Disclosing the HIV Diagnosis to Infected Children on Antiretroviral Therapy in a Resource-Limited District in South Africa: A Grounded Theory Study

We used a grounded theory approach to explore how a sample of caregivers of children on antiretroviral treatment (ART) experience HIV disclosure to their infected children. This paper explores caregivers' barriers to disclosing HIV to infected children. Caregivers of children aged 6-13 years who were receiving ART participated in four focus-group interviews. Three main themes, caregiver readiness to tell, right time to tell, and the context of disclosure, emerged. Disclosure was delayed because caregivers had to first deal with personal fears which influenced their readiness to disclose; disclosure was also delayed because caregivers did not know how to tell. Caregivers lacked disclosure skills because they had not been trained on how to tell their children about their diagnosis, on how to talk to their children about HIV, and on how to deal with a child who reacts negatively to the disclosure. Caregivers feared that the child might tell others about the diagnosis and would be discriminated and socially rejected and that children would live in fear of death and dying. Health care providers have a critical role to play in HIV disclosure to infected children, considering the caregivers' expressed desire to be trained and prepared for the disclosure.

Disclosure of maternal HIV status to children: considerations for research and practice in sub-Saharan Africa

An estimated 2.8 million children are born to HIV-infected mothers each year, 2.5 million of whom are likely to be HIV-exposed but uninfected. In sub-Saharan Africa up to 40% of pregnant women are HIV-infected, resulting in large numbers of HIV-uninfected children living with at least one HIV-infected parent. These parents face many challenges, including the dilemma of when and how to disclose their HIV status to their children, particularly those who are pre-adolescent. This article summarizes the current evidence on maternal HIV disclosure to their HIV-uninfected children, explores the reported benefits of disclosure to children and mothers, highlights the gaps in knowledge and areas for future research, and discusses possible future intervention models focusing on primary school-aged children in sub-Saharan Africa.

Disclosing HIV diagnosis to children in Odi district, South Africa: Reasons for disclosure and non-disclosure

Background

The increasing access to antiretroviral therapy (ART) and survival of HIV-infected children has posed challenges to caregivers on disclosing the HIV diagnosis to children.

Objectives

The objectives of this study was to determine the reasons of caregivers for the disclosure and non-disclosure of the HIV diagnosis to children on ART and to determine the caregivers’ perceptions of children's reaction to disclosure.

Method

A cross-sectional study was conducted amongst 149 caregivers of children between 4–17 years who receive ART from a district hospital in South Africa. Descriptive and inferential statistics were used in the analysis of data.

Results

The prevalence of disclosure was 40% and the mean age of disclosure was 9.3 years. Reasons for disclosure included that the child was not adhering to treatment (n = 59; 39%); the child was consistently asking questions about the treatment and nature of the disease (n = 59; 39%). Reasons for non-disclosure were that the child was too young (n = 90; 72%); the child would tell others about diagnosis (n = 90; 21.1%); the child would be socially rejected (n = 90; 18.6%); fear of negative consequences for the child (n = 90; 13.3%); and caregivers do not know how to tell or approach disclosure (n = 90; 8.9%).

Conclusion

Caregivers disclosed the diagnosis so that their child would adhere to ART medication; non-disclosing caregivers delayed disclosure because their children were too young to understand the HIV diagnosis. Disclosure of HIV to children should be integrated into regular discussions with caregivers of children in ART settings to improve their knowledge and skills to manage disclosure.

Theoretical models of parental HIV disclosure: a critical review

This study critically examined three major theoretical models related to parental HIV disclosure (i.e., the Four-Phase Model [FPM], the Disclosure Decision Making Model [DDMM], and the Disclosure Process Model [DPM]), and the existing studies that could provide empirical support to these models or their components. For each model, we briefly reviewed its theoretical background, described its components and/or mechanisms, and discussed its strengths and limitations. The existing empirical studies supported most theoretical components in these models. However, hypotheses related to the mechanisms proposed in the models have not yet tested due to a lack of empirical evidence. This study also synthesized alternative theoretical perspectives and new issues in disclosure research and clinical practice that may challenge the existing models. The current study underscores the importance of including components related to social and cultural contexts in theoretical frameworks, and calls for more adequately designed empirical studies in order to test and refine existing theories and to develop new ones.

Patterns of disclosure of HIV status to infected children in a Sub-Saharan African setting

OBJECTIVE

Adult caregivers provide children living with HIV with varying amounts and types of information about their health status that may affect their coping and health care behaviors. We aimed to describe patterns of information sharing with children and thoughts around disclosure among caregivers in the Democratic Republic of the Congo.

METHODS

A total of 259 primary caregivers of children aged 5 to 17 years in an HIV pediatric care and treatment program were screened; 8 adult caregivers (3%) had informed their child of the child's HIV status. We conducted structured interviews with 201 caregivers whose children had not yet been told their HIV status.

RESULTS

Nearly 50% of caregivers had provided no information to their child about their health; 15% had given partial information without mentioning HIV, and 33% provided information that deflected attention from HIV, whether deliberately so or otherwise. Almost all caregivers said that the child should be told their status some day, and three-fourths reported having ever thought about what might lead them to tell. However, nearly one-third of caregivers saw no benefits to informing the child of her/his HIV status. A majority of caregivers felt that they themselves were the best to eventually disclose to the child but some wanted support from health care providers.

CONCLUSIONS

HIV-infected children are given limited information about their health. Health care providers may serve as important sources of support to caregivers as they decide when and how to talk candidly with their children about their health.

Medical decisional capacity among children with HIV

Medical decisional capacity (DC) refers to the ability to understand, appreciate, and make meaningful decisions about one's health. This is an important construct for children living with HIV whose involvement in their medical care has important implications for disease management. In this study, we assessed the relationship among DC, developmental stage, intellectual ability, and social-emotional functioning of children with and without HIV infection (n=50). We hypothesized a positive correlation between variables, but did not expect to find a difference in DC between groups. Results provided partial support for our hypotheses. There was a positive relationship between developmental stage and understanding, which is but one dimension of DC. Children with HIV infection obtained significantly lower scores on measures of intellectual and adaptive functioning, but there was no significant difference in DC between groups. Findings suggest that children living with HIV have the capacity to meaningfully participate in their healthcare despite lower intellectual and adaptive functioning.

Telling children they have HIV: lessons learned from findings of a qualitative study in sub-Saharan Africa

HIV-infected children in developing countries are living longer lives as they gain access to antiretroviral treatment programs. As they grow older, their parents/guardians are faced with the difficult decision of if, when, and how to inform their child of his/her HIV status. Both negative and positive social, psychological, and behavioral impacts of disclosure to children have been reported, including improved adherence to medication regimens. Understanding the disclosure process from the perspective of HIV positive children, therefore, is critical to developing these interventions. Through children's experiences we can learn about what works well, what needs to be strengthened, and what is missing in current disclosure practices. We conducted in-depth interviews with eight caregiver-child dyads in Kinshasa, Democratic Republic of the Congo. The children were in a comprehensive HIV pediatric care and treatment program and had already been told their HIV diagnosis. For the analysis we placed particular emphasis on children's reports of communication with their caregivers and health care providers about their illness. Patterns emerged of limited communication between children and their caregivers as well as their providers, before, during, and after disclosure. From the perspective of children in this study, disclosure was largely a discrete event rather than a process. Sociocultural contexts surrounding HIV/AIDS, as well as health status, variations in parent-child communication and the relationships between health providers and children under their care, should inform psychosocial interventions delivered alongside treatment programs.

How should risk be communicated to children: a cross-sectional study comparing different formats of probability information

BACKGROUND

Newborn screening, which identifies inherited disorders and sometimes carrier status, will increasingly involve health professionals in the provision of appropriate information and support to children and their families. The ability to understand carrier results relies on an understanding of probabilistic terms. However, little is known about how best to convey probabilistic medical information to children. Research with adult populations suggests information format significantly affects comprehension. This study aimed to explore which presentation format is most effective in conveying probabilistic information to children.

METHODS

A probabilistic task based on the cup game was used to measure which of five different formats was associated with greatest understanding in children aged 7-11 years old (n = 106). Formats used were verbal labels (e.g. rarely, sometimes), percentages, proportion-word (e.g. 1 in X), proportion-notation (e.g. 1:X) and pie charts. There was also an additional mixed format condition. In each trial a picture was presented of three cups, each with a different probability depicted beneath it, and the child was asked to select which cup was most likely to contain the ball. Three trials were presented per format. Children also rated how certain they were that they had answered correctly.

RESULTS

There was a significant relationship between format and comprehension scores. Post hoc tests showed children performed significantly better when probability was presented as a pie chart, in comparison to percentages, proportion-notation, proportion-word and mixed format trials. Furthermore, most children (84%) got all trials correct for this format and children were significantly more certain that their response was correct in the pie chart trials compared to all the other formats (p < 0.001). Significant positive correlations were found between self-ratings of certainty and comprehension of verbal labels, percentages and pie charts. Older age was also associated with better performance on all formats except percentages. Overall comprehension was calculated by summing the scores for the individual trials and this was independently associated with older age and higher IQ.

CONCLUSION

The results suggest that 7-11 year olds can understand probability information, but that the format used will significantly affect the accuracy and confidence with which children in this age group make judgements about the likelihood of an event. Of the formats studied, pie charts appear to be the optimal method of presenting probabilistic information to children in this age group. Health professionals and designers of health messages should be cognisant of this when communicating medical information to children aged 7-11 years old.

Reasons for and against maternal HIV disclosure to children and perceived child reaction

This study explores the decision making of 66 HIV-positive women regarding disclosing their serostatus to their children and the child's perceived immediate and long-term reactions. Data came from a larger investigation of the disclosure process of HIV-infected women. Children included 27 boys and 39 girls between the ages 5 and 18 years. Forty-one children knew of their mother's diagnosis and 32 were disclosed to by their mother. Results suggest that women are interested in taking a leading role in disclosing to their children and make the decision based on the child's ability to handle the information and not be psychologically harmed.

Mental health and disclosure of HIV status in Zambian adolescents with HIV infection: implications for peer-support programs

OBJECTIVES

To examine emotional and behavioural difficulties in HIV positive Zambian adolescents and to determine the relationship between disclosure of HIV status and mental health.

DESIGN

A cross-sectional survey.

METHODS

Participants were 127 HIV positive adolescents aged 11 to 15 years recruited through clinics in the Lusaka region. Mental health was assessed using the youth report version of the Strengths and Difficulties Questionnaire (SDQ). Caregivers completed the parent SDQ. Sixty-two participants were invited for a semi-structured interview which probed views on attending a peer support group.

RESULTS

Compared to a British community sample participants had increased mental health problems (OR, 2.1), particularly emotional symptoms (OR = 3.6) and peer problems (OR = 7.1). The majority of children (n = 94) were receiving antiretroviral (ARV) treatment, but only 48 children (37.8%) had their HIV status disclosed. Those who had not had their HIV status disclosed were younger (P < 0.001) and less likely to be receiving ARV treatment (P < 0.001). Controlling for these factors they were also more likely to score in the abnormal range of the emotional difficulties subscale (OR = 2.63, 95% CI: 1.11 to 6.26). Of 38 interviews transcribed, content analysis showed that only 3 children were opposed to participation in a peer-group program, with the majority (23/38) expressing reasoned and positive responses, regardless of disclosure status.

CONCLUSION

High rates of emotional and peer problems were found in this sample but disclosure of HIV status did not have a negative effect on mental health. Interventions to promote disclosure could facilitate access to emotional and peer support.

HIV-positive mothers' disclosure of their serostatus to their young children: a review

One challenge faced by mothers living with HIV (MLWHs) is the decision about whether or not to disclose their HIV status to their young children, and how best to carry out the disclosure. Disclosure of their serostatus has emerged as one of the main concerns MLWHs have, and that decision can result in high levels of psychological distress. Concerns are exacerbated among MLWHs with younger children, due to the fact that they face additional worries, such as whether the child is old enough to understand, or will be able to keep the information confidential. A great deal of recent research--within approximately the past decade--has been conducted to investigate maternal disclosure of HIV, and the outcomes on children. This article reviews the current state of the research literature, focusing on factors that appear to influence whether or not mothers chose to disclose; characteristics of children who have been made aware of their mothers' serostatus relative to children who remain unaware; factors that appear to influence children's reactions to maternal disclosure; and implications of this research as well as future research directions.