Evidence of impact: health, psychological and social effects of adult HIV on children

How do new crises impact HIV risk behaviour - exploring HIV risk behaviour according to COVID-19-related orphanhood status in South Africa?

The COVID-19 pandemic resulted in high death rates globally, and over 10.5 million children lost a parent or primary caregiver. Because HIV-related orphanhood has been associated with elevated HIV risk, we sought to examine HIV risk in children affected by COVID-19 orphanhood. Four hundred and twenty-one children and adolescents were interviewed, measuring seven HIV risk behaviours: condom use, age-disparate sex, transactional sex, multiple partners, sex associated with drugs/alcohol, mental health and social risks. Approximately 50% (211/421) experienced orphanhood due to COVID-19, 4.8% (20/421) reported living in an HIV-affected household, and 48.2% (203/421) did not know the HIV status of their household. The mean age of the sample was 12.7 years (SD:2.30), of whom 1.2% (5/421) were living with HIV. Eighty percent (337/421) reported at least one HIV risk behaviour. HIV sexual risk behaviours were more common among children living in HIV-affected households compared to those not living in HIV-affected households and those with unknown household status (35.0% vs. 13.6% vs.10.8%, X2 = 9.25, p = 0.01). Children living in HIV-affected households had poorer mental health and elevated substance use (70.0% vs. 48.5%, X2 = 6.21, p = 0.05; 35.0% vs. 19.9%, X2 = 4.02, p = 0.1306, respectively). HIV-affected households may require specific interventions to support the health and well-being of children and adolescents.

A community-based child health and parenting intervention to improve child HIV testing, health, and development in rural Lesotho (Early Morning Star): a cluster-randomised, controlled trial

BACKGROUND

When caregivers live in remote settings characterised by extreme poverty, poor access to health services, and high rates of HIV/AIDS, their caregiving ability and children's development might be compromised. We aimed to test the effectiveness of a community-based child health and parenting intervention to improve child HIV testing, health, and development in rural Lesotho.

METHODS

We implemented a matched cluster-randomised, controlled trial in the Mokhotlong district in northeastern Lesotho with 34 community clusters randomly assigned to intervention or wait-list control groups within a pair. Eligible clusters were villages with non-governmental organisation partner presence and an active preschool. Participants were caregiver-child dyads, where the child was 12-60 months old at baseline. The intervention consisted of eight group sessions delivered at informal preschools to all children in each village. Mobile health events were hosted for all intervention (n=17) and control (n=17) clusters, offering HIV testing and other health services to all community members. Primary outcomes were caregiver-reported child HIV testing, child language development, and child attention. Assessments were done at baseline, immediately post-intervention (3 months post-baseline), and 12 months post-intervention. We assessed child language by means of one caregiver-report measure (MacArthur-Bates Communicative Development Inventory [CDI]) and used two observational assessments of receptive language (the Mullen Scales of Early Learning receptive language subscale, and the Peabody Picture Vocabulary Test 4th edn). Child attention was assessed by means of the Early Childhood Vigilance Task. Assessors were masked to group assignment. Analysis was by intention to treat. This trial was registered with ISRCTN.com, ISRCTN16654287 and is completed.

FINDINGS

Between Aug 8, 2015, and Dec 10, 2017, 1040 children (531 intervention; 509 control) and their caregivers were enrolled in 34 clusters (17 intervention; 17 control). Compared with controls, the intervention group reported significantly higher child HIV testing at the 12-month follow-up (relative risk [RR] 1·46, 95% CI 1·29 to 1·65, p<0·0001), but not immediately post-intervention. The intervention group showed significantly higher child receptive language on the caregiver report (CDI) at immediate (effect size 3·79, 95% CI 0·78 to 6·79, p=0·028) but not at 12-month follow-up (effect size 2·96, 95% CI -0·10 to 5·98, p=0·056). There were no significant group differences for the direct assessments of receptive language. Child expressive language and child attention did not differ significantly between groups.

INTERPRETATION

Integrated child health and parenting interventions, delivered by trained and supervised lay health workers, can improve both child HIV testing and child development.

FUNDING

United States Agency for International Development (USAID) and the President's Emergency Plan for AIDS Relief (PEPFAR).

Neurodevelopment among children exposed to HIV and uninfected in sub-Saharan Africa

INTRODUCTION

The population of 16 million children exposed to HIV and uninfected (CHEU) under 15 years of age continues to expand rapidly, and the estimated prevalence of CHEU exceeds 20% in several countries in sub-Saharan Africa with high HIV prevalence. Some evidence suggests that CHEU experience suboptimal neurodevelopmental outcomes compared to children born to women without HIV. In this commentary, we discuss the latest research on biologic and socio-behavioural factors associated with neurodevelopmental outcomes among CHEU.

DISCUSSION

Some but not all studies have noted that CHEU are at risk of poorer neurodevelopment across multiple cognitive domains, most notably in language and motor skills, in diverse settings, ages and using varied assessment tools. Foetal HIV exposure can adversely influence infant immune function, structural brain integrity and growth trajectories. Foetal exposure to antiretrovirals may also influence outcomes. Moreover, general, non-CHEU-specific risk factors for poor neurodevelopment, such as preterm birth, food insecurity, growth faltering and household violence, are amplified among CHEU; addressing these factors will require multi-factorial solutions. There is a need for rigorous harmonised approaches to identify children at the highest risk of delay. In high-burden HIV settings, existing maternal child health programmes serving the general population could adopt structured early child development programmes that educate healthcare workers on CHEU-specific risk factors and train them to conduct rapid neurodevelopmental screening tests. Community-based interventions targeting parent knowledge of optimal caregiving practices have shown to be successful in improving neurodevelopmental outcomes in children and should be adapted for CHEU.

CONCLUSIONS

CHEU in sub-Saharan Africa have biologic and socio-behavioural factors that may influence their neurodevelopment, brain maturation, immune system and overall health and wellbeing. Multidisciplinary research is needed to disentangle complex interactions between contributing factors. Common environmental and social risk factors for suboptimal neurodevelopment in the general population are disproportionately magnified within the CHEU population, and it is, therefore, important to draw on existing knowledge when considering the socio-behavioural pathways through which HIV exposure could impact CHEU neurodevelopment. Approaches to identify children at greatest risk for poor outcomes and multisectoral interventions are needed to ensure optimal outcomes for CHEU in sub-Saharan Africa.

Child maltreatment mediates the relationship between HIV/AIDS family dysfunction trajectories and psychosocial problems among adolescents

The relationship between parental HIV/AIDS status or death and child mental health is well known, although the role of child maltreatment as a confounder or mediator in this relationship remains uncertain. This study examined the potential path mechanism through child maltreatment mediating the link between HIV/AIDS family dysfunction trajectories and psychosocial problems. A cross-sectional survey was conducted in the Lower Manya Municipal Assembly of Ghana. A questionnaire which consisted of the Strengths and Difficulties Questionnaire (SDQ), Social and Health Assessment (SAHA), Rosenberg Self-Esteem Scale (RSES) and the Conflict Tactics Scale (CTS) was completed by 291 adolescents. Controlling for relevant sociodemographic confounders, mediation analyses using linear regression were fitted to examine whether the association between family dysfunction and psychosocial problems is mediated by child maltreatment. The results indicate that, among adolescents, child maltreatment fully mediated the association between being orphaned by AIDS and self-esteem (b = .59 [95%CI .32, .91]), delinquency and risky behaviours (b = .56 [95%CI .31, .86]) and peer problems (b = .74 [95%CI .48, 1.03]). Similarly, child maltreatment fully mediated the association between living with an HIV/AIDS-infected parent and self-esteem (b = .78 [95%CI .43, 1.23]), delinquency and risky behaviours (b = .76 [95%CI .45, 1.11]), depression/emotional problems (b = .64 [95%CI .40, .92]) and peer problems (b = .94 [95%CI .66, 1.26]). Partial mediation was found for hyperactivity. Child maltreatment mediates the association between the family dysfunction trajectories of parental HIV/AIDS or death and psychosocial problems among adolescents. This implies that efforts to address child maltreatment among families affected by HIV/AIDS may be helpful in the prevention of psychosocial problems among these children, thus enhancing their wellbeing. The findings therefore underscore the need for comprehensive psychosocial interventions that addresses both the unique negative exposures of HIV/AIDS and maltreatment for children affected by HIV.

Child maltreatment and associated sociodemographic factors among children affected by HIV/AIDS in Ghana: a multi-informant perspective

ABSTRACTChild maltreatment is considered a major public health concern among children because they can cause significant physical and psychological problems. Child maltreatment is widespread but often underestimated. Surprisingly, there is hardly any data on child maltreatment and any associated sociodemographic factors children affected by HIV/AIDS in low-income countries. This study employed cross-sectional, quantitative survey that involved 291 children aged 10-17 years and their caregivers in the Lower Manya Krobo District, Ghana and examined their exposure to and experience of child maltreatment. The results show that at least one form of maltreatment was reported by approximately 90% of the children, and it was significantly higher among orphans and vulnerable children (OVC) as compared with comparison children. Older age, frequent changes in residence, non-schooling and living with many siblings are associated with child maltreatment. The results demonstrate that maltreatment among children affected by HIV/AIDS are not rare, and that the dysfunction family conditions that they find themselves bear systemic risks for maltreatment. It is important that culturally appropriate and evidence-based interventions are implemented to address the maltreatment.

Pre-exposure prophylaxis as an opportunity for engagement in HIV prevention among South African adolescents

Pre-exposure prophylaxis (PrEP) offers a potential biomedical strategy to reduce HIV incidence among adolescent populations disproportionately affected by HIV. There is limited evidence on the social and clinical implications, including engagement in HIV prevention efforts, of PrEP for South African adolescents, who face high HIV risk. We conducted a mixed-methods study in Western Cape, South Africa from 2015 to 2016. Adolescents (N = 35) aged 16-17 and clinical service providers working with adolescents (N = 25) were recruited from community and clinic settings. Adolescents and service providers completed a survey about their overall perceptions of PrEP and completed interviews guided by semi-structured protocols. We performed descriptive analysis of quantitative data using SPSS and thematic analysis of qualitative data using NVivo. The majority of adolescents endorsed future PrEP use for themselves and partners, and all clinical service providers endorsed future PrEP use for sexually active adolescents. Both adolescents and service providers identified PrEP as an opportunity to engage youth as active participants in HIV prevention. Service providers also viewed PrEP as a potential mechanism for shifting life trajectories. Findings from this study enhance our understanding of the considerations needed to engage adolescents and clinical service providers in the roll-out of oral PrEP in South Africa.

From surviving to thriving: integrating mental health care into HIV, community, and family services for adolescents living with HIV

Adolescents are a crucial generation, with the potential to bring future social and economic success for themselves and their countries. More than 90% of adolescents living with HIV reside in sub-Saharan Africa, where their mental health is set against a background of poverty, familial stress, service gaps, and an HIV epidemic that is now intertwined with the COVID-19 pandemic. In this Series paper, we review systematic reviews, randomised trials, and cohort studies of adolescents living with and affected by HIV. We provide a detailed overview of mental health provision and collate evidence for future approaches. We find that the mental health burden for adolescents living with HIV is high, contributing to low quality of life and challenges with adherence to antiretroviral therapy. Mental health provision is scarce, infrastructure and skilled providers are missing, and leadership is needed. Evidence of effective interventions is emerging, including specific provisions for mental health (eg, cognitive behavioural therapy, problem-solving, mindfulness, and parenting programmes) and broader provisions to prevent drivers of poor mental health (eg, social protection and violence prevention). We provide evidence of longitudinal associations between unconditional government grants and improved mental health. Combinations of economic and social interventions (known as cash plus care) could increase mental health benefits. Scalable delivery models include task sharing, primary care integration, strengthening families, and a pyramid of provision that differentiates between levels of need, from prevention to the care of severe disorders. A turning point has now been reached, from which complacency cannot persist. We conclude that there is substantial need, available frameworks, and a growing evidence base for action while infrastructure and skill acquisition is built.

Association Between Maternal HIV Stigma Among South Indian Mothers Living with HIV and the CD4 Count of Children Living with HIV

HIV stigma takes a multidimensional toll on a mother’s ability to care for herself and subsequently may impact her ability to care for her child, particularly when mother and child are seroconcordant. A cross-sectional analysis was conducted to examine the association between maternal HIV stigma and child CD4 count in rural India. We assessed 108 mother–child dyads and found that a one-unit increase in community stigma fear decreased child CD4 count by 352 cells (95% CI = − 603, − 102), highlighting the need to develop a better understanding of the consequences of HIV-related stigma on the compounded burden of care in households where mother and child both live with HIV.

Adolescent parenthood and HIV-infection in South Africa-Associations with child cognitive development

HIV, both directly and indirectly, impacts child development outcomes. The most severe impacts are for children infected with HIV, and those exposed but uninfected are also shown to have challenges-though less severe. However, little is known regarding the development of children born to adolescent mothers affected by HIV. This study aims to examine cognitive development for children born to adolescent mothers, comparing those children living with HIV, those HIV exposed and uninfected (HEU) and those HIV unexposed (HU). Analyses utilise cross-sectional data from 920 adolescent mother (10-19 years)-first born child dyads residing in the Eastern Cape Province, South Africa. Participants completed detailed study questionnaires inclusive of validated and study specific measures relating to sociodemographic characteristics, HIV, and maternal and child health. Trained assessors administered standardised child development assessments (using the Mullen Scales of Early Learning) with all children. Chi-square tests and ANOVA tests were used to explore maternal and child characteristics according to child HIV status (HIV, HEU, HU) on cognitive development. Linear regression models were used to explore the cross-sectional associations between child HIV status and child cognitive development. 1.2% of children were living with HIV, 20.5% were classified as being HEU and, 78.3% were classified as HU. Overall, children living with HIV were found to perform lower across developmental domains compared to both HEU and HU groups (composite score of early learning: 73.0 vs 91.2 vs. 94.1, respectively: F = 6.45, p = 0.001). HEU children on average scored lower on all developmental domains compared to HU children, reaching significance on the gross motor domain (p<0.05). Exploratory analyses identified maternal education interruption as a potential risk factor for lower child cognitive development scores and, higher maternal age to be protective of child cognitive development scores. These exploratory findings address a critical evidence gap regarding the cognitive development of children born to adolescent mothers affected by HIV in South Africa. Analyses identify stepwise differences in the average scoring on child cognitive development domains according to child HIV status among children born to adolescent mothers affected by HIV; with children living with HIV performing worse overall. Young mothers and their children may benefit from adapted interventions aimed at bolstering child development outcomes. Targeted programming particularly among younger adolescent mothers and those experiencing education interruption may identify those families, particularly in need. Attention to maternal continuity of education and age of conception may be interventions to consider.

Predicting neurodevelopmental risk in children born to mothers living with HIV in Kenya: protocol for a prospective cohort study (Tabiri Study)

INTRODUCTION

For the growing number of children with in utero and postpartum exposure to HIV and/or antiretrovirals, it is unclear which exposures or risk factors play a significant role in predicting worse neurodevelopmental outcomes. This protocol describes a prospective longitudinal cohort study of infants born to mothers living with HIV and those born to mothers without HIV. We will determine which risk factors are most predictive of child neurodevelopment at 24 months. We aim to create a risk assessment tool to help predict which children are at risk for worse neurodevelopment outcomes.

METHODS AND ANALYSIS

This study leverages an existing Kenyan cohort to prospectively enrol 500 children born to mothers living with HIV and 500 to those without HIV (n=1000 total) and follow them from birth to age 24 months. The following factors will be measured every 6 months: infectious morbidity and biological/sociodemographic/psychosocial risk factors. We will compare these factors between the two groups. We will then measure and compare neurodevelopment within children in both groups at 24 months of age using the Child Behaviour Checklist and the Bayley Scales of Infant and Toddler Development, third edition. Finally, we will use generalised linear mixed modelling to quantify associations with neurodevelopment and create a risk assessment tool for children ≤24 months.

ETHICS AND DISSEMINATION

The study is approved by the Moi University's Institutional Research and Ethics Committee (IREC/2021/55; Approval #0003892), Kenya's National Commission for Science, Technology and Innovation (NACOSTI, Reference #700244) and Indiana University's Institutional Review Board (IRB Protocol #110990). This study carries minimal risk to the children and their mothers, and all mothers will provide written consent for participation in the study. Results will be disseminated to maternal child health clinics within Uasin Gishu County, Kenya and via papers submitted to peer-reviewed journals and presentation at international conferences.

A model to understand HIV-related stigma and the psychosocial well-being of children orphaned by AIDS: a theory generative approach

HIV-related stigma has negatively impacted the psychosocial well-being of children who have been orphaned by AIDS-related causes. Response to reducing stigma and ensuring child well-being is hindered by the limited understanding of HIV-related stigma and how it affects the psychosocial well-being of children. Due to the call for a comprehensive understanding of HIV-related stigma, this study aimed to develop a model to understand the manner in which HIV-related stigma affects the psychosocial well-being of children orphaned by AIDS. The study implemented a mixed method, exploratory, sequential design within a theory generative approach that included concept development, statement development, model description, and model evaluation. The developed model indicated that HIV-related stigma is embedded in social interaction and mediated by children orphaned by AIDS response to stigma. HIV-related stigma and maladaptive coping strategies collectively affect several domains of child psychosocial well-being and elevate psychosocial distress. This is the first model to provide a child-centred understanding of HIV-related stigma and its consequences for psychosocial well-being. The model may be used to guide future research and inform the development of appropriate interventions.

Adolescent health series: Adolescent neurocognitive development in Western and Sub-Saharan African contexts

The transitional period of adolescence has long been associated with physical, social and behavioural change. During this time, adolescents start to develop their own self-identity, make important life decisions and acquire the necessary skills to successfully transition to adulthood. More recently, advances in brain imaging technology have enabled increased understanding of structural and functional changes in the human brain during this developmental period, and how they relate to social, emotional, motivational and cognitive development. The ability to integrate these developing cognitive processes in increasingly complex social contexts is a key aspect of mature decision-making, which has implications for adolescent health, educational, economic and social outcomes. Insights from the field of developmental cognitive neuroscience could increase our understanding of this influential stage of life and thus inform potential interventions to promote adolescent health, a critical goal for global health research. Many social changes occur during adolescence and the social environment shapes both brain and cognitive development and the decisions adolescents make. Thus, it is important to study adolescent neurocognitive development in socio-cultural context. Yet, despite evidence from Western studies that socio-cultural and economic factors impact on adolescent neurocognitive development, existing studies of adolescent neurocognitive development in sub-Saharan Africa are relatively scarce. We summarise research findings from Western and sub-Saharan African contexts and highlight areas where research is lacking. Longitudinal studies from more diverse global samples will be needed to build a comprehensive model of adolescent development, that characterises both commonalities in developmental trajectories, as well as the way these can meaningfully differ between both individuals and contexts.

School functioning of children with perinatal HIV-infection in high-income countries: A systematic review

INTRODUCTION

Since the introduction of combination antiretroviral therapy, human immunodeficiency virus (HIV) infection is a manageable chronic disease. However, school-age children (4-18 years) living with HIV could still experience problems with functioning at school, due to the impact of the virus itself, medication, comorbidities and social stigma. School functioning covers academic achievement, school attendance, and social relationships and is of utmost importance to optimize normal participation.

METHODS

To gain insight in school functioning problems of perinatally HIV-infected children, we performed a systematic review of the literature in multiple databases from January 1997 up to February 2019. Studies were included if they described outcomes of school functioning of school-age children perinatally infected with HIV, in high-income countries. Meta-analyses were performed for sufficiently comparable studies.

RESULTS AND DISCUSSION

Results from 32 studies show that HIV-infected children experience more problems in various areas of school functioning in comparison with national norms, matched healthy controls, siblings and HIV-exposed uninfected (HEU) children. The most pronounced differences concerned the usage of special educational services, general learning problems, and mathematics and reading performance scores. Comparisons with both national norms and siblings/HEU children show that the differences between HIV-infected children and siblings/HEU children were less pronounced. Moreover, siblings/HEU children also reported significantly worse outcomes compared to national norms. This suggests that problems in school functioning cannot be solely attributed to the HIV-infection, but that multiple socio-economic and cultural factors may play a role herein.

CONCLUSION

Perinatally HIV-infected children seem vulnerable to problems in various areas of school functioning. Therefore, monitoring of school functioning should be an important aspect in the care for these children. A family-focused approach with special attention to a child's socio-environmental context and additional attention for siblings and HEU children, is therefore recommended.

Associations between caregiver mental health and young children's behaviour in a rural Kenyan sample

Background: Research shows that caregiver mental health problems have direct, significant effects on child behaviour. While these risks are amplified in low-resource settings, limited evidence exists from these places, especially sub-Saharan Africa.

Objective: We measured associations between caregiver mental health and child behaviour in a rural Kenyan sample, hypothesizing that higher rates of caregiver mental health would be associated with increased child behavioural problems. We also sought to provide an overview of caregiver mental health symptoms in our sample.

Method: Cross-sectional data were collected from caregivers of children ages 4–5 years old enrolled in a community-based early child development programme in western Kenya. 465 caregivers were recruited and assessed at baseline, and answered questions about child behaviour, mental health symptoms (depression, anxiety, stress), and help-seeking. A multivariate linear regression model was used to assess significance of each mental health factor.

Results: Caregiver anxiety (p = 0.01) and parenting stress (p < 0.001) were significantly associated with child behavioural problems. 245 caregivers (52.9%) had high levels of symptoms of depression, anxiety, or both; furthermore, 101 caregivers (21.7%) scored above the cut-off for both of these scales. A high proportion of our sample (60.6%) reported seeking some formal or informal psychosocial support services; however, less than one-third of these caregivers were symptomatic (30.9%).

Conclusion: Anxiety and stress were associated with poorer child behavioural outcomes. Our sample reflected a higher prevalence of caregiving adults with mental health symptomology than previous estimates from Kenya, with few high-symptom caregivers seeking support. We discuss further implications for programming and health services delivery.

Double benefit? Integrating an early childhood development programme into HIV PMTCT Option B+ services in Malawi

KEY MESSAGES

Benefits for mothers and children can be achieved through the successful integration of an early childhood development programme into PMTCT Option B+ services in Malawi.Our study based on in-depth interviews with 62 mothers indicated that such an approach is feasible and acceptable.Participating mothers reported that the integration of the early childhood development component improved their confidence and they believed it improved their parenting;led to improved relationships with health care providers;increased the engagement of fathers and support from others in the family;helped mothers build a new social network and support system through the peer engagement components;reduced the risk of stigmatization in the health care setting.

Mental health of women living with HIV and its impact on child development in Andhra Pradesh, India

Global literature examining the association between mental health of women living with HIV (WLWH) and child development is scarce. In this study, we examined the relationship between mothers' mental health and their children's social development outcomes 6 months later. Data for these analyses come from several waves of interviews of 600 WLWH in the South Indian state of Andhra Pradesh, India. These women were enrolled in a 2×2 factorial clinical trial designed to assess the impact of food supplementation and nutrition education, both in addition to ASHA support, on adherence to ART and improved health outcomes for the women and one of their children. They were assessed on food security, stigma, social support, quality of life, depressive symptoms and child development outcomes. Results of longitudinal GEE regression analysis indicate that mother's depressive symptoms were significantly negatively associated with child's social quotient 6 months later. These findings have important implications for targeted health interventions, integrating mental health, both for WLWH and their children in India.

Poor linkage to care for HIV-positive OVC with disabled caregivers: a longitudinal study in Tanzania

Background

Despite extensive efforts to scale up counseling and testing services and care and treatment clinics (CTCs) in Tanzania, linkage between points of diagnosis and CTCs remains low. Studies have looked at barriers such as lack of trained health providers, poor referral system, economic costs or distance to health facilities, but fewer assessed the association between caregivers’ vulnerability such as disability and linkage of orphans and vulnerable children (OVCs) in their care to health facilities. This study describes the magnitude of caregivers’ disability and assesses its relationship with successful linkage to care of their OVC living with HIV/AIDS in Tanzania.

Methods

Data for this analysis came from the USAID Kizazi Kipya project in 79 councils of Tanzania. Data on HIV risk, service use and ART adherence among OVC aged 0–19 years were collected during the project’s quarterly routine data collection (Oct 2017-Sep 2018). Characteristics of caregivers were collected during the project beneficiary screening and enrollment process. Generalized estimating equation models were used to analyze the factors that are associated with linkage of 14,538 HIV positive OVC to CTC, who were taken care of by 11,834 caregivers.

Results

The majority of caregivers (70%) were females, had completed primary education (67%), 54% were married or cohabiting. Of all the OVC, 3% were living with disabled caregivers; of whom 89% were physically disabled while 11% were mentally disabled. OVCs living with disabled caregivers were less likely to be linked to care (OR 0.76, 95% CI 0.58, 0.99). Factors positively associated with OVC linkage to care were high caregivers’ education level (OR 1.99, 95% CI 1.51, 2.63) and OVC living with a HIV positive caregivers (OR 1.25, 95% CI 1.12, 1.41). OVC living in household with high socio-economic status were less likely to be linked to care (OR 0.76, 95% CI 0.67, 0.86) than those in low-SES households.

Conclusion

These results suggest HIV positive OVC living with disabled caregivers had poor linkage to care. The findings highlighted the need to focus attention to the disabilities-led household to promote inclusion and improve access to the HIV services.

Patterns of emotional and behavioural challenges in children living with HIV: results from a hyperendemic South African setting

This study examined the patterns of emotional and behavioural problems in children from an HIV hyperendemic sub-Saharan Africa setting. A cross-sectional questionnaire survey was administered to 198 parents/caregivers of children living with HIV aged 2-12 years, attending a paediatric HIV out-patient service at a public sector hospital in KwaZulu-Natal Province, South Africa. The parent version of the Strengths and Difficulties Questionnaire (SDQ) which consists of five sub-scales (i.e. emotional difficulties, conduct problems, hyperactivity/inattention symptoms, peer problems and prosocial behaviours) were used to capture data on emotional and behavioural problems in children. The results indicated that over half of sampled children (n = 115, 58.1%) had abnormal levels of problems in at least one sub-scale, with adjusted regression indicating that academic difficulties and delayed milestones were significantly associated (i.e. greater total SDQ score as a continuous measure). Lower parental/caregiver educational attainment (i.e. not having tertiary education) was the only parent/caregiver characteristic associated with greater emotional and behavioural problems. Given the high prevalence of emotional and behavioural problems and its link to academic difficulties and delayed milestones, the need for screening and developmental support for children living with HIV may be warranted.

Assessment of Health-Related Quality of Life Among Patients Infected With HIV Receiving Care in a Nigerian Tertiary Hospital

OBJECTIVES

Globally, an appropriate estimate of the health-related quality of life (HRQoL) of people living with HIV/AIDS (PLWHA) is essential for the economic evaluation of antiretroviral therapy (ART) programs to ensure optimal value for money. Therefore, this article aimed to evaluate the HRQoL of PLWHA on ART and to explore its predictors.

METHODS

A cross-sectional study was conducted among PLWHA in an ART clinic of a Nigerian tertiary hospital. The participants were selected through a computer-based simple random sampling technique. The study instrument used for data collection was the English-language version of the European Quality of Life (EQ-5D-5L). The participants completed the questionnaire in the waiting room of the clinic, and the patients' clinical data were retrieved from their medical records. Descriptive statistics and multivariate linear regression were used for data analysis. P<.05 was considered statistically significant.

RESULTS

Out of the 352 participants, the majority were female (66.5%), and more than half (56.2%) had a CD4 count fewer than 500 cells/mm³. The EQ-5D index and utility score of the study population were 0.72 ± 4.18 and 73.05 ± 10.36, respectively. The significant predictors of EQ-5D index were the number of children (β = -0.215, P=.026), CD4 count (β = 0.171, P=.030), and duration on ART (β = -0.144, P=.011).

CONCLUSIONS

Our findings suggest that PLWHA receiving ART in Nigeria had good HRQoL. However, concerted efforts targeted at improving CD4 cell count and reducing the family burden of PLWHA would enhance their HRQoL.

Parenting the child with HIV in limited resource communities in South Africa: mothers with HIV's emotional vulnerability and hope for the future

Introduction:

A diagnosis of HIV does not affect the well-being of mothers alone but also affects how they care for their children. The aim of this study was to explore how mothers who were diagnosed with HIV when pregnant or when their children became ill experience raising children living with HIV. The purpose was to understand how a diagnosis of HIV impacts mothering their children at different points on the mothering journey.

Methods:

Using descriptive phenomenological enquiry, interviews were conducted with 28 mothers recruited via purposeful sampling from clinics in health district in South Africa. The interviews were audiotaped, transcribed verbatim, and analysed following the thematic approach.

Results:

The mothers found mothering a child living with HIV stressful and associated with constant thoughts of death. The burden of mothering was increased for mothers who had to confront emotions of self-blame and guilt for unintentionally infecting the child. They used secrecy to protect their children from the social consequences of a diagnosis of HIV. The thought of living with HIV weighed on them every day and they expressed their experience of intense feelings of chronic worry, anxiety, and sadness. The findings identified high levels of stress, with the mothers expressing emotions suggestive of depression. With time, they accepted living with HIV and embraced motherhood, and became better mothers.

Conclusion:

The negative coping strategies used to deal with the child’s HIV diagnosis and high levels of stress and anxiety identified in the study underscore the need to address the psychosocial needs of mothers living with HIV. There is need to provide psychosocial support and continuous counselling for these mothers post diagnosis and upon a positive HIV diagnosis of the child to women enrolled in the prevention of mother to child transmission of HIV programme.

Trends in the prevalence and incidence of orphanhood in children and adolescents <20 years in rural KwaZulu-Natal South Africa, 2000-2014

BACKGROUND

In South Africa, large increases in early adult mortality during the 1990s and early 2000s have reversed since public HIV treatment rollout in 2004. In a rural population in KwaZulu-Natal, we investigate trends in parental mortality and orphanhood from 2000-2014.

METHODS

Using longitudinal demographic surveillance data for a population of approximately 90,000, we calculated annual incidence and prevalence of maternal, paternal and double orphanhood in children and adolescents (<20 years) and, overall and cause-specific mortality of parents by age.

RESULTS

The proportion of children and adolescents (<20 years) for whom one or both parents had died rose from 26% in 2000 to peak at 36% in 2010, followed by a decline to 32% in 2014. The burden of orphanhood remains high especially in the oldest age group: in 2014, 53% of adolescents 15-19 years had experienced the death of one or both parents. In all age groups and years, paternal orphan prevalence was three-five times higher than maternal orphan prevalence. Maternal and paternal orphan incidence peaked in 2005 at 17 and 27 per 1,000 person years respectively (<20 years) before declining by half through 2014. The leading cause of parental death throughout the period, HIV/AIDS and TB cause-specific mortality rates declined substantially in mothers and fathers from 2007 and 2009 respectively.

CONCLUSIONS

The survival of parents with children and adolescents <20 years has improved in tandem with earlier initiation and higher coverage of HIV treatment. However, comparatively high levels of parental deaths persist in this rural population in KwaZulu-Natal, particularly among fathers. Community-level surveillance to estimate levels of orphanhood remains important for monitoring and evaluation of targeted state welfare support for orphans and their guardians.

In utero exposure to protease inhibitor-based antiretroviral regimens delays growth and developmental milestones in mice

Antiretroviral therapy (ART) in pregnancy has dramatically reduced HIV vertical transmission rates. Consequently, there is a growing number of children that are HIV exposed uninfected (CHEUs). Studies suggest that CHEUs exposed in utero to ART may experience developmental delays compared to their peers. We investigated the effects of in utero ART exposure on perinatal neurodevelopment in mice, through assessment of developmental milestones. Developmental milestone tests (parallel to reflex testing in human infants) are reflective of brain maturity and useful in predicting later behavioral outcomes. We hypothesized that ART in pregnancy alters the in utero environment and thereby alters developmental milestone outcomes in pups. Throughout pregnancy, dams were treated with boosted-atazanavir combined with either abacavir/lamivudine (ATV/r/ABC/3TC), or tenofovir/emtricitabine (ATV/r/TDF/FTC), or water as control. Pups were assessed daily for general somatic growth and on a battery of tests for primitive reflexes including surface-righting, negative-geotaxis, cliff-aversion, rooting, ear-twitch, auditory-reflex, forelimb-grasp, air-righting, behaviors in the neonatal open field, and olfactory test. In utero exposure to either ART regimen delayed somatic growth in offspring and evoked significant delays in the development of negative geotaxis, cliff-aversion, and ear-twitch reflexes. Exposure to ATV/r/ABC/3TC was also associated with olfactory deficits in male and forelimb grasp deficits in female pups. To explore whether delays persisted into adulthood we assessed performance in the open field test. We observed no significant differences between treatment arm for males. In females, ATV/r/TDF/FTC exposure was associated with lower total distance travelled and less ambulatory time in the centre, while ATV/r/ABC/3TC exposure was associated with higher resting times compared to controls. In utero PI-based ART exposure delays the appearance of primitive reflexes that involve vestibular and sensory-motor pathways in a mouse model. Our findings suggest that ART could be disrupting the normal progress/maturation of the underlying neurocircuits and encourage further investigation for underlying mechanisms.

Depressive symptoms among children attending community based support in South Africa - pathways for disrupting risk factors

Children in Southern Africa are exposed to high rates of structural and family adversities. This study tests whether services from Community Based Organisations (CBOs) in South Africa can promote children's resilience against depression exposed to such adversities. Two linked longitudinal studies were conducted, comprising n = 1848 children aged 9 to 13 years. One group received CBO services, whilst the other (quasi-control) did not. Analyses used interaction terms in regression models to test for potential moderation effects of CBO attendance, and marginal effects models to interpret significant interactions. Two interaction effects were shown, demonstrating moderation effects of CBO attendance on common structural disadvantages. First, children exposed to community violence showed increased depression (contrast = 0.62 [95%CI 0.43, 0.82], p < .001), but this association was removed by CBO access (contrast = 0.07 [95%CI -0.28, 0.43], p = .682). Second, children living in informal housing showed increased depression (contrast = 0.63 [95%CI 0.42, 0.85], p < .001), however, this association was removed by CBO access (contrast = 0.01 [95%CI -0.55, 0.56], p = .977). CBO attendance is associated with fewer depressive symptoms, and can buffer against important structural adversities of poor housing and violence that are common in high HIV-prevalence areas. However, CBO attendance was not able to remove the increased psychosocial distress associated with some family-level vulnerabilities such as orphanhood and abuse. These findings highlight the centrality of CBO-provided psychosocial support for children in Southern Africa, and suggest areas for bolstering provision.

Adaptation of the WHO group interpersonal therapy for people living with HIV/AIDS in Northwest Ethiopia: A qualitative study

BACKGROUND

Psychological treatments improve depressive symptoms in people living with HIV/AIDS (PLWHA). Adaptation of treatments should be based on explanatory models of depression and other elements within the given context.

AIM

This study aimed to examine explanatory models of depression and acceptable approaches for implementation of group IPT in Northwest Ethiopia.

METHODS

Qualitative data were collected from April to May 2019 from case managers, adherence supporters and service users using focus group discussion and analysed thematically.

RESULTS

PLWHA attributed depression to psychosocial problems, spiritual factors and biological factors. Depression had several impacts at individual and family level. Group-based interpersonal therapy (IPT) was acceptable if provided by trained peer counselors.

CONCLUSION

The current study findings informed how to conduct feasibility and acceptability trials of group IPT in the HIV population in Ethiopia.

Child functioning and disability in children living with human immunodeficiency virus in a semi-rural healthcare setting in South Africa

Background

Children living with HIV (CLHIV) often experience HIV-related impairment and disability.

Aim

The study sought to understand the level of child functioning and access to rehabilitative care in the context of South African healthcare in order to inform an integrated rehabilitative framework.

Setting

District level semi-rural healthcare facility in KwaZulu-Natal.

Methods

The Washington Group/United Nations International Children’s Emergency Fund Module on Child Functioning, was administered to carers of CLHIV aged between 5 and 10 years, and accessing care at the study setting.

Results

Forty-four caregivers of children receiving treatment from June 2018 to March 2019, at the facility, participated. Four (9.1%) children had difficulty with seeing, 13 (29.5%) children had difficulty with hearing and 10 (22.7%) children had difficulty with walking. In the cognitive and behavioural domains, 17 (38.6%) children reported difficulties in communication and concentration, with 16 (36.4%) children experiencing difficulties in learning and remembering. Difficulties reported in accepting change and controlling behaviour were both experienced by 23 (52.3%) children. Although many children experiencing impairments were referred for rehabilitation, many caregivers did not follow-up after the initial assessment, because of financial constraints, lack of time and transport restrictions.

Conclusion

Functional difficulties were frequently experienced by children living with HIV. Disability screening would be beneficial at various points of care to promote early identification and timely referral to healthcare professionals. Decentralising rehabilitative care to homes and communities could offer a solution to some of the reported barriers to accessing care.

Empowering parents for human immunodeficiency virus prevention: Health and sex education at home

BACKGROUND

Improving health literacy amongst human immunodeficiency virus (HIV)-positive mothers could strengthen child and adolescent HIV prevention. The Amagugu intervention included health literacy materials to strengthen maternal communication and has demonstrated success in low-resource HIV-endemic settings.

OBJECTIVES

Our aims were to (1) evaluate whether Amagugu materials improved health literacy leading to changes in parental behaviour towards communicating on topics such as HIV, health behaviours and sex education, and (2) explore what additional information and materials mothers would find helpful.

METHOD

The Amagugu evaluation included 281 HIV-positive mothers and their HIV-uninfected children (6-10 years). Process evaluation data from exit interviews were analysed using content analysis and logistic regression techniques.

RESULTS

Of 281 mothers, 276 (98.0%) requested more educational storybooks: 99 (35.2%) on moral development/future aspirations, 92 (32.7%) on general health, safety and health promotion, and 67 (23.8%) on HIV and disease management. Compared to baseline, mothers reported that the materials increased discussion on the risks of bullying from friends (150; 53.4%), teacher problems (142; 50.5%), physical abuse (147; 52.3%) and sexual abuse (126; 44.8%). Most mothers used the 'HIV Body Map' for health (274; 97.5%) and sex education (267; 95.0%). The use of a low-cost doll was reported to enhance mother-child communication by increasing mother-child play (264; 94.3%) and maternal attentiveness to the child's feelings (262; 93.6%).

CONCLUSION

Parent-led health education in the home seems feasible, acceptable and effective and should be capitalised on in HIV prevention strategies. Further testing in controlled studies is recommended.

Multisystem Resilience for Children and Youth in Disaster: Reflections in the Context of COVID-19

In the context of rising disasters worldwide and the challenges of the COVID-19 pandemic, this commentary considers the implications of findings in resilience science on children and youth for disaster preparation and response. The multisystem challenges posed by disasters are illustrated by the COVID-19 pandemic. We discuss the significance of disasters in the history of resilience science and the emergence of a unifying systems definition of resilience. Principles of a multisystem perspective on resilience and major findings on what matters for young people in disasters are delineated with reference to the pandemic. Striking parallels are noted in the psychosocial resilience factors identified at the level of individual children, families, schools, and communities. These parallels suggest that adaptive capacities associated with resilience in these interacting systems reflect interconnected networks and processes that co-evolved and may operate in concert. As resilience science moves toward integrated theory, knowledge, and applications in practice, particularly in disaster risk reduction and resilience promotion, more focus will be needed on multisystem and multidisciplinary research, communication, training, and planning.

The impact of common mental disorders among caregivers living with HIV on child cognitive development in Zimbabwe

This paper aimed to assess the impact of maternal common mental disorders (CMD) among caregivers living with HIV on the cognitive functioning of their child. Data were collected at baseline and 12 months follow-up from mother-child dyads recruited as part of an ongoing trial in Zimbabwe. Symptoms of CMD were assessed using the Shona Symptom Questionnaire. Mixed-effects linear regression was used to assess child cognitive scores at follow-up (using the Mullen Scales of Early Learning) in relation to caregiver CMD prevalence over 12 months. At baseline, caregivers reporting CMD (n = 230; 40.1%) were less likely to have completed higher education (46.9% vs. 56.9%; p = 0.02), more likely to be unmarried (27.8% vs. 16.0%; p < 0.01), and experience food insecurity (50.0% vs. 29.4%; p < 0.01) compared to the group without CMD (n = 344). There were 4 CMD patterns over time: (i) Emerging CMD (n = 101; 19.7% of caregivers) defined as those who were below the cut-off at baseline, and above it at 12 months; (ii) Improving CMD (n = 76; 14.8%) defined as those who reported CMD at baseline, and were below the cut-off by follow-up; (iii) No CMD (n = 206; 40.1%) defined as those who did not report CMD symptoms at either time point; and (iv) Chronic CMD (n = 131; 25.5%) defined as those who reported CMD above the cut-off at both time points. Children of caregivers with chronic CMD (n = 131, 25.5%) had lower receptive language scores (aMD:-2.81, 95%CI -5.1 to -0.6; p = 0.05) compared to the reference group with no CMD (n = 206, 40.1%). Exposure to caregiver CMD over a prolonged period may affect child receptive vocabulary skills.

Modelling the impact of maternal HIV on uninfected children: correcting current estimates

A mathematical model, populated primarily with data from South Africa, was developed to model the numbers of children affected by maternal HIV, and the number who will experience long-term negative developmental consequences. A micro-simulation model generated two scenarios. The first simulated a cohort of women whose HIV status mimicked that of a target population, and mother-child dyads by way of age- and disease-specific fertility rates. Factors defining risk were used to characterize the simulated environment. The second scenario simulated mother-child dyads without maternal HIV. In the first scenario an estimated 26% of children are orphaned, compared to 10% in the absence of HIV. And a further 19% of children whose mother is alive when they turn 18 are affected by maternal HIV. School drop-out among all children increased by 4 percentage points because of maternal HIV, similarly population level estimates of abuse and negative mental health outcomes are elevated. Relative to HIV unaffected children, HIV affected have elevated risk of poor outcomes, however not all will suffer long-term negative consequences. Interventions to protect children should target the proportion of children at risk, while interventions to mitigate harm should target the smaller proportion of children who experience long-term negative outcomes..

Rural South African Community Perceptions of Antibiotic Access and Use: Qualitative Evidence from a Health and Demographic Surveillance System Site

Knowledge and practices of rural South African populations with regard to antibiotic access and use (ABACUS) remain understudied. By using the case of four villages in the north east of the country, our aim was to investigate popular notions and social practices related to antibiotics to inform patient-level social interventions for appropriate antibiotic use. To achieve this, we investigated where community members (village residents) were accessing and sourcing medication, and what they understood antibiotics and antibiotic resistance (ABR) to be. Embedded within the multicountry ABACUS project, this qualitative study uses interviews and focus group discussions. A sample of 60 community members was recruited from the Agincourt Health and Demographic Surveillance System, situated in Mpumalanga Province, from April to August, 2017. We used the five abilities of seek, reach, pay, perceive, and engage in access to healthcare as proposed by Levesque’s “Access to Healthcare” framework. Respondents reported accessing antibiotics prescribed from legal sources: by nurses at the government primary healthcare clinics or by private doctors dispensed by private pharmacists. No account of the illegal purchasing of antibiotics was described. There was a mix of people who finished their prescription according to the instructions and those who did not. Some people kept antibiotics for future episodes of infection. The concept of “ABR” was understood by some community members when translated into related Xitsonga words because of knowledge tuberculosis and HIV/AIDS treatment regimens. Our findings indicate that regulation around the sale of antibiotics is enforced. Safer use of antibiotics and why resistance is necessary to understand need to be instilled. Therefore, context-specific educational campaigns, drawing on people’s understandings of antibiotics and informed by the experiences of other diseases, may be an important and deployable means of promoting the safe use of antibiotics.

Growth and Neurodevelopment of HIV-Exposed Uninfected Children: a Conceptual Framework

PURPOSE OF REVIEW

The population of HIV-exposed uninfected (HEU) children is expanding rapidly, and over one million HEU infants are born each year globally. Several recent studies have reported that HEU children, particularly in low- and middle-income countries, are at risk of poor outcomes, including impaired growth and neurodevelopment. However, the reasons for poor clinical outcomes amongst HEU children remain unclear.

RECENT FINDINGS

We summarise the findings from recent large studies that have characterised growth and neurodevelopment in HEU children, identified risk factors and explored underlying mechanistic pathways. We propose a conceptual framework to explain how exposure to HIV and antiretroviral therapy (ART) may lead to adverse growth and neurodevelopment in uninfected children, and review the available evidence and research gaps. We propose that HEU children are affected both indirectly, through the augmentation of universal risk factors underlying poor growth and neurodevelopment, and directly through HIV/ART-specific pathways, which ultimately may converge through a series of common pathogenic mechanisms. In the era of universal ART, a better understanding of these pathways is crucial to inform future prevention and intervention strategies.

Parenting and discipline in post-conflict Sierra Leone

BACKGROUND

While the literature on physical punishment concludes that it has negative effects on children, the practice remains common in many countries. In post-conflict countries with nongovernmental organizations (NGO) operating in child protection, traditional disciplinary practices may conflict with international child rights agendas. The country of Sierra Leone has a unique history of conflict, abject poverty, low literacy, and weak governance - often, NGO agents are responsible for providing social services that the government is unable to consistently provide.

OBJECTIVE

We examined how Sierra Leonean caregivers think about appropriate discipline for children, and whether they perceived any changes in their attitudes toward disciplinary practices since the end of the war.

PARTICIPANTS AND SETTING

We collected data from parents and caregivers in urban, peri-urban, and rural areas of Sierra Leone's four districts.

METHODS

We used focus groups (12 groups, n = 92) and individual interviews (n = 21) to collect data in 2013. Focus groups and interviews were conducted by research assistants fluent in Krio and English. We used a thematic content analysis approach.

RESULTS

We found that physical discipline-"beating"-was widely acceptable and common. A few parents mentioned other means of discipline, such as withholding food. Parents widely agreed that parenting had changed since the war, and reported that child rights movements supported by NGOs had made it more difficult to discipline their children in traditional ways.

CONCLUSIONS

Discipline was seen a central component of child-rearing and a means of ensuring safe and proper development. This may be a protective mechanism in the precarious, high poverty environment of post-war Sierra Leone. The negative responses of parents to NGO efforts to reduce physical punishment and other forms of child abuse suggest that grassroots approaches are needed to address this pervasive problem.

Sustainable Survival for adolescents living with HIV: do SDG-aligned provisions reduce potential mortality risk?

Introduction

The Sustainable Development Goals (SDGs) present a groundbreaking global development agenda to protect the most vulnerable. Adolescents living with HIV in Sub‐Saharan Africa continue to experience extreme health vulnerabilities, but we know little about the impacts of SDG‐aligned provisions on their health. This study tests associations of provisions aligned with five SDGs with potential mortality risks.

Methods

Clinical and interview data were gathered from N = 1060 adolescents living with HIV in rural and urban South Africa in 2014 to 2015. All ART‐initiated adolescents from 53 government health facilities were identified, and traced in their communities to include those defaulting and lost‐to‐follow‐up. Potential mortality risk was assessed as either: viral suppression failure (1000+ copies/ml) using patient file records, or adolescent self‐report of diagnosed but untreated tuberculosis or symptomatic pulmonary tuberculosis. SDG‐aligned provisions were measured through adolescent interviews. Provisions aligned with SDGs 1&2 (no poverty and zero hunger) were operationalized as access to basic necessities, social protection and food security; An SDG 3‐aligned provision (ensure healthy lives) was having a healthy primary caregiver; An SDG 8‐aligned provision (employment for all) was employment of a household member; An SDG 16‐aligned provision (protection from violence) was protection from physical, sexual or emotional abuse. Research partners included the South African national government, UNICEF and Pediatric and Adolescent Treatment for Africa.

Results

20.8% of adolescents living with HIV had potential mortality risk – i.e. viral suppression failure, symptomatic untreated TB, or both. All SDG‐aligned provisions were significantly associated with reduced potential mortality risk: SDG 1&2 (OR 0.599 CI 0.361 to 0.994); SDG 3 (OR 0.577 CI 0.411 to 0.808); SDG 8 (OR 0.602 CI 0.440 to 0.823) and SDG 16 (OR 0.686 CI 0.505 to 0.933). Access to multiple SDG‐aligned provisions showed a strongly graded reduction in potential mortality risk: Among adolescents living with HIV, potential mortality risk was 38.5% with access to no SDG‐aligned provisions, and 9.3% with access to all four.

Conclusions

SDG‐aligned provisions across a range of SDGs were associated with reduced potential mortality risk among adolescents living with HIV. Access to multiple provisions has the potential to substantially improve survival, suggesting the value of connecting and combining SDGs in our response to paediatric and adolescent HIV.

Psychiatric disorders and young adult milestones in HIV-exposed, uninfected youth

The global population of perinatally HIV-exposed but uninfected (HEU) children is growing, with relatively little known about their psychosocial outcomes, particularly across adolescence and young adulthood. Using data from a longitudinal cohort study of HEU youth in New York City (N = 134), we examine rates of substance use disorders (SUD) and non-SUD psychiatric disorders (mood, anxiety, and behavioral) at five time-points during adolescence and young adulthood, as well as associated demographic and environmental factors and the association of ever having a disorder with young adult developmental milestones. HEU participants in this study experienced high rates of psychiatric disorders, particularly SUD in young adulthood. During the entire study period (2003-2018), over one third were diagnosed at least once with a SUD, and 69% were diagnosed with a non-SUD psychiatric disorder. Older age and female gender were associated with higher rates of non-SUD diagnoses. A history of meeting criteria for any disorder at any time point was associated with reduced odds in young adulthood of working or being in school and increased odds of reporting incarceration, homelessness, and recent condomless sex. There is an urgent need to develop systems to follow HEU youth and provide services to intervene and treat psychiatric disorders, including substance use.

Emotional and behavioral resilience among children with perinatally acquired HIV in Thailand and Cambodia

OBJECTIVES

Psychosocial challenges associated with perinatally acquired HIV (PHIV) infection are well known, yet many children infected with HIV since birth demonstrate positive outcomes, referred to as resilience. The purpose of this study was to evaluate emotional-behavioral development and identify salient predictors of resilience among long-term survivors of PHIV.

DESIGN

Prospective investigation of children with PHIV compared with demographically similar perinatally HIV-exposed but uninfected (PHEU) and HIV-unexposed, uninfected (HUU) children, all from Thailand and Cambodia.

METHODS

The Child Behavior Checklist (CBCL; parent version) was administered at baseline and annual follow-up visits (median follow-up of 3 years) to children age 6-14. Resilience was defined as consistent CBCL scores on the Internalizing, Externalizing or Total Problem T scales within normative ranges (T-scores <60) at every time point. Generalized estimating equations examined CBCL scores over time and logistic models examined demographic, socioeconomic, and cultural predictors of resilience.

RESULTS

Participants included 448 children (236 PHIV, 98 PHEU, 114 HUU), with median (interquartile range) age at first evaluation of 7 (6-9) years. Children with PHIV exhibited similar rates of resilience as PHEU and HUU on the Externalizing and Total Problems scales. Resilience on the Internalizing scale was more likely in PHEU (71%) compared with PHIV (59%) or HUU (56%), P = 0.049. Factors associated with resilience in adjusted models included: HIV-exposed but uninfected status, higher household income, Cambodian nationality, female sex, and caregiver type.

CONCLUSION

Despite biopsychosocial risks, resilience is observed among PHIV and PHEU children. Further study is needed to understand mechanisms underlying associated factors and intervention priorities.

Emotional and behavioral problems and associated factors among children and adolescents on highly active anti-retroviral therapy in public hospitals of West Gojjam zone, Amhara regional state of Ethiopia, 2018: a cross-sectional study

Background

Children and adolescents with HIV/AIDS are more likely to have emotional and behavioral problems than the general population. This can result in a continuing negative influence on the quality of life, school performance, immunity and co-morbidity of children and adolescents with HIV/AIDS.

Objective

To assess the prevalence and associated factors of Emotional and Behavioral Problems among children and adolescents on Highly Active Anti-Retroviral Therapy in the public hospitals of West Gojjam Zone, Amhara regional state of Ethiopia.

Methods

An institutional based cross sectional study was conducted by screening 411 children and adolescents for emotional and behavioral problems using Pediatric Symptomatology Check List (PSCL). Systematic random sampling technique was used to select the study participants. Data analysis was done using SPSS version 23. Bivariable and multivariable logistic regression analysis were fitted to identify factors associated with Emotional and Behavioral Problems. Odds ratio (OR) with 95% confidence interval (CI) was computed to determine the level of significance.

Result

Out of the total 411 participants, 43.6% were screened positive for Emotional and Behavioral Problems. Lower age (AOR = 5.33, 95%CI: 2.56–11.04), having non-kin care giver (AOR = 4.64, 95%CI: 1.20–17.90), parental loss (AOR = 2.15, 95%CI: 1.03–4.49), non self -disclosure of HIV sero status (AOR = 1.99, 95% CI: 1.16–3.41) and having distressed care giver (AOR = 1.64, 95%CI: 1.04–2.57) had statistically significant association with EBPs.

Conclusion

The prevalence of Emotional and Behavioral Problems is high among children and adolescents on HAART. Lower age, care giver’s mental distress, non-self disclosure status, having non-kin care giver and parental loss were variables significantly associated with EBPs. This demonstrates a need for the integration of Mental Health and Psycho Social Support (MHPSS) service with HIV/AIDS care.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1453-3) contains supplementary material, which is available to authorized users.

Parenting self-efficacy in the context of poverty and HIV in Eastern Uganda: A qualitative study

We sought to understand social representations of effective parenting and parenting self-efficacy among female HIV-affected caregivers in rural Eastern Uganda. We conducted in-depth interviews (n = 21) to describe parenting experiences and caregivers' perceptions of their own parenting abilities and to create vignettes for use in directed focus groups. We carried out open focus groups (n = 2) to gain social perspectives on parenting, and directed focus groups (n = 2) concentrated on parenting self-efficacy. Analysis involved memoing and inductive and deductive coding of transcripts. Caregivers' perceptions of their own parenting were grounded in parenting values such as providing children with basic needs, having well-behaved children, and having good relationships with children. Caregivers' perceptions were influenced by challenges, including single parenthood, living with HIV, limited family resources, and mental health problems. When facing challenges, caregivers relied on social support and faith as well as their own parenting confidence. Caregivers' perceptions of their parenting abilities were influenced by how they felt others perceived them, their satisfaction in the parenting role, their perseverance despite challenges, and the extent to which they had a vision for their family. Our findings contextualize parenting self-efficacy within parenting values, challenges, and social perceptions among HIV-affected caregivers in rural Uganda.

Neurodevelopmental outcomes in HIV-infected and uninfected African children

OBJECTIVE

HIV infection is associated with cognitive impairments, but outcomes are poorly explored in children starting antiretroviral therapy (ART) early or in those exposed but uninfected.

DESIGN

Nested cross-sectional evaluation of the neurocognitive and behavioural outcomes of HIV-infected, HIV-exposed uninfected (HEU) and HIV-unexposed (HUU) Cameroonian children at age 4-9 years prospectively followed.

METHODS

Cognitive development was assessed in 127 HIV-infected, 101 HEU, 110 HUU children using the KABC-II, neurologic dysfunction using the Touwen examination and behavioural difficulties using the Strength and Difficulties Questionnaire (SDQ). Analyses were adjusted for children age, sex and primary language. Contextual factors were included in a second step to assess their effects on outcomes.

RESULTS

All HIV-infected children were treated before 12 months. There was a negative linear gradient in KABC-II scores from HUU children to HEU and HIV-infected children [gradient: -6.0 (-7.7; -4.3) for nonverbal index, NVI, and -8.8 (-10.7; -6.8) for mental processing index, MPI]. After adjusting for contextual factors, scores of HEU children were not significantly different from those of HUU children (all P > 0.1) and differences between HIV-uninfected and HUU children reduced [NVI: from -11.9 (-15.3; -8.5) to -3.4 (-6.8; -0.01), MPI: from -17.6 (-21.3; -13.8) to -5.5 (-9.3; -1.7)]. Compared with uninfected children, HIV-infected children had more neurological dysfunctions and higher SDQ scores (P = 0.002).

CONCLUSION

Despite early ART, perinatal-HIV infection is associated with poorer neurocognitive scores and increased behavioural difficulties during childhood. Contextual factors play an important role in this association, which emphasizes the need for early nutritional and developmental interventions targeting both HIV-affected infants and their relatives.

Health risk behavior among perinatally HIV exposed uninfected adolescents: A systematic review

Background: Perinatally HIV exposed uninfected (PHEU) adolescents are an increasing sub-population, especially in high HIV epidemic settings. HIV exposure may have some lasting implications for adolescents’ development, however, longer term health outcomes such as health risk behavior (HRB) are so far not well understood in this adolescent sub-population. Methods: In this systematic review, we identify the prevalent forms, burden, and underlying risk factors for HRB of PHEU adolescents. We searched in PubMed, PsycINFO and Applied Social Sciences Index & Abstracts for peer reviewed empirical studies published between 1980 and August 2018 on HRB among PHEU adolescents aged 10 – 19 years. Results: Eleven eligible studies, all conducted in North America were identified and they showed that sexual risk behavior such as lifetime unprotected sex increased drastically especially in mid-adolescence. PHEU adolescents’ substance use (especially alcohol and marijuana) was high and increased over time. In a significant minority (10-18%) substance use disorder was screened. Some intra and interpersonal risk factors such as caregiver and PHEU adolescents’ mental health problems, age and HIV status were shared across the two forms of HRB. However, other risk factors like race, gender and experience of traumatic life events were behavior specific. Conclusion: Overall, there is need to conduct similar research in other settings especially those with high HIV burden where the PHEU adolescent sub-population is rising. Future research in this area could benefit from examining more forms of HRB and exploring the clustering of HRB among PHEU adolescents.

Population-level Mortality Associated with HIV Exposure in HIV-uninfected Infants in Botswana and South Africa: A Model-based Evaluation

We aimed to quantify the contribution of excess mortality in HIV-exposed uninfected (HEU) infants to total mortality in HIV-uninfected infants in Botswana and South Africa in 2013. Population attributable fractions (PAFs) and excess infant deaths associated with HIV exposure in HIV-uninfected infants were estimated. Additionally, the Thembisa South African demographic model estimated the proportion of all infant mortality associated with excess mortality in HEU infants from 1990 to 2013. The PAF (lower bound; upper bound) of mortality associated with HIV exposure in HIV-uninfected infants was 16.8% (2.5; 31.2) in Botswana and 15.1% (2.2; 28.2) in South Africa. Excess infant deaths (lower bound; upper bound) associated with HIV exposure in 2013 were estimated to be 5.6 (0.5; 16.6)/1000 and 4.9 (0.6; 11.2)/1000 HIV-uninfected infants in Botswana and South Africa, respectively. In South Africa, the proportion of all infant (HIV-infected and HIV-uninfected) mortality associated with excess HEU infant mortality increased from 0.4% in 1990 to 13.8% in 2013.

Health Capability Deprivations in a Rural Swazi Community: Understanding Complexity With Theoretically Informed, Qualitatively Driven, Mixed-Method Design, Participatory Action Research

Comprehensive theories of health justice can supplement rights-based approaches like primary health care, by conceptualizing key terms, and systematizing knowledge about structural factors that influence health. Our aim was to use "health capability" as a theoretical lens for understanding how primary health care approaches might address structural factors impeding health in a rural Swazi community. We conducted abductive, interpretive, analysis of a mixed-method (QUAL+quan) data set about "health capability deprivations," generated through participatory action research. Four themes are discussed: illness and disease, unhealthy daily living environments, inability to move freely, and gendered expectations and norms. The analysis demonstrates that there were complex interrelationships between health capability deprivations, material and ideological deprivation prevented community members from aspiring to or securing their right to health, health capability theory can augment primary health care approaches and vice versa, and qualitatively driven, mixed-method research can generate unique insights about structural factors that influence health.

Parental Bereavement in Young Children Living in South Africa and Malawi: Understanding Mental Health Resilience

BACKGROUND

Parental loss is a major stressful event found to increase risk of mental health problems in childhood. Yet, some children show resilient adaptation in the face of adversity across time.

SETTING

This study explores predictors of mental health resilience among parentally bereaved children in South Africa and Malawi and their cumulative effect. The study also explores whether predictors of resilience differed between orphaned and nonorphaned children.

METHODS

Consecutive attenders of community-based organizations (children; 4-13 years, and their caregivers) were interviewed at baseline and 15- to 18-month follow-up (n = 833). Interviews comprising inventories on demographic information, family data, child mental health, bereavement experience, and community characteristics. Mental health screens were used to operationalize resilience as the absence of symptoms of depression, suicidality, trauma, emotional, and behavioral problems.

RESULTS

Almost 60% of children experienced parental loss. One-quarter of orphaned children showed no mental health problems at either wave and were classified as resilient. There were equal proportions of children classified as resilient within the orphaned (25%) versus nonorphaned group (22%). Being a quick learner, aiding ill family members, positive caregiving, household employment, higher community support, and lower exposure to domestic violence, physical punishment, or stigma at baseline predicted sustained resilience. There were cumulative influences of resilience predictors among orphaned children. Predictors of resilience did not vary by child age, sex, country of residence or between orphaned and nonorphaned children.

CONCLUSIONS

This study enhances understanding of resilience in younger children and identifies a number of potential environmental and psychosocial factors for bolstering resilience in orphaned children.

Evaluating the effectiveness of a multi-component intervention on early childhood development in paediatric HIV care and treatment programmes: a randomised controlled trial

BACKGROUND

HIV infection in a family may affect optimum child development. Our hypothesis is that child development outcomes among HIV-exposed infants will be improved through a complex early childhood stimulation (ECS) programme, and income and loans saving programme for HIV positive parents.

METHODS

The study was a cluster-randomized controlled trial in 30 clinic sites in two districts in Zimbabwe. Clinics were randomised in a 1:1 allocation ratio to the Child Health Intervention for Development Outcomes (CHIDO) intervention or Ministry of Health standard care. The CHIDO intervention comprises three elements: a group ECS parenting programme, an internal savings and lending scheme (ISALS) and case-management home visits by village health workers. The intervention was aimed at caregiver-child dyads (child aged 0-24 months) where the infant was HIV exposed or infected. The primary outcomes were cognitive development (assessed by the Mullen Scales of Early Learning) and retention of the child in HIV care, at 12 months after enrolment. A comprehensive process evaluation was conducted.

DISCUSSION

The results of this cluster-randomised trial will provide important information regarding the effects of multi-component interventions in mitigating developmental delays in HIV-exposed infants living in resource-limited environments.

TRIAL REGISTRATION

This trial is registered with the Pan African Clinical Trials Registry ( www.pactr.org ), registration number PACTR201701001387209; the trial was registered on 16th January 2017 (retrospectively registered).

Measuring Symptoms of Psychopathology in Zambian Orphans and Vulnerable Children: Scale Validation and Psychometric Evaluation

There is a paucity of validated mental health measures for assessing psychological well-being among HIV-affected youth. We sought to explore the psychometric properties and validity of the Achenbach Youth Self-Report and Child Posttraumatic Stress Disorder Symptom Scale among orphans and vulnerable children (OVC) living in Lusaka, Zambia. These scales were administered to 210 OVC aged 13 to 17 years via audio computer-assisted self-interview. Confirmatory factor analysis was used to assess scale structure, Cronbach's alpha for internal consistency, and correlations between scales related to mental or psychosocial health for construct validity. A known-groups validation was conducted using local identifications of youth with and without significant psychosocial problems, and test-retest reliability was assessed. Scales exhibited good internal reliability (α > .80), adequate criterion validity (area under the curve > .70), and moderate test-retest reliability (.62-.68). Findings support the utility of these symptom scales for identifying OVC experiencing significant psychosocial problems in Zambia.

Mental health among adolescents living with HIV in Namibia: the role of poverty, orphanhood and social support

The mental health needs of children and adolescents living with HIV (ALHIV) in Namibia are poorly understood, despite the dramatic improvement in their survival. ALHIV in resource poor contexts face particular risk factors, such as poverty, orphanhood, and poor social support. This study examines the mental health of ALHIV in Namibia, and the factors that contribute to mental health problems. A case-control design assessed emotional and behavioural symptoms of distress, risk and protective factors among adolescents aged 12-18 years. Case participants were 99 HIV-positive adolescents. Case controls were 159 adolescents from the same community who were not known to be HIV seropositive at the time of the study. Control group participants were selected from schools using a stratified random sampling. A larger proportion of HIV-positive adolescents were orphaned (62.6% vs. 20.8%, p < .001); the groups showed no differences in poverty factors. HIV-positive adolescents scored lower than the control group on total perceived social support (p < .05) and caregiver support (p < .05), but no differences in perceived friend support and support from a self-selected person were present. HIV-positive adolescents reported significantly more total emotional and behavioural difficulties (p = .027) and conduct problems (p = .025), even after controlling for socio-demographic factors. However, after controlling for the effects of orphanhood, group differences in mental health outcomes were no longer significant. Furthermore, mediation analysis suggested that social support completely mediated the relationship between HIV status and mental health (standardised pathway coefficients = .05, p = .021). Policies and programmes that aim to strengthen social support and take orphanhood status into consideration may improve the mental health of adolescents living with HIV.

Gendered childcare norms - evidence from rural Swaziland to inform innovative structural HIV prevention approaches for young women

Addressing discriminatory gender norms is a prerequisite for preventing HIV in women, including young women. However, the gendered expectation that women will perform unpaid childcare-related labour is rarely conceptualised as influencing their HIV risk. Our aim was to learn from members of a rural Swazi community about how gendered childcare norms. We performed sequential, interpretive analysis of focus group discussion and demographic survey data, generated through participatory action research. The results showed that gendered childcare norms were firmly entrenched and intertwined with discriminatory norms regarding sexual behaviour. Participants perceived that caring for children constrained young women's educational opportunities and providing for children's material needs increased their economic requirements. Some young women were perceived to engage in "transactional sex" and depend financially on men, including "sugar daddies", to provide basic necessities like food for the children they cared for. Our results suggested that men were no longer fulfilling their traditional role of caring for children's material needs, despite women's traditional role of caring for their physical and emotional needs remaining firmly entrenched. The results indicate that innovative approaches to prevent HIV in young women should incorporate structural approaches that aim to transform gendered norms, economically empower women and implement policies guaranteeing women equal rights.