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

Leveraging qualitative approaches to guide sustainable international research collaborations

Qualitative research approaches were used to launch an international research collaboration between the U. S. and Cambodia. Cambodian officials requested assistance in learning qualitative approaches to complement the research skills of Cambodian mental health providers. This article provides a description of how U. S. researchers responded to that request and engaged with Cambodian psychiatrists to explore mental health needs and interventions in both countries and initiate a sustainable relationship. The early focus on qualitative research methodologies may be an avenue that mitigates some of the challenges that can characterize international research. In this study, early communications involved developing a plan to teach qualitative methods while also collecting and analyzing data in both countries that would address the mental health concerns experienced by respective care providers. A case study exemplar was embedded with a scripted focus group guide to collect data from U. S. focus groups, then share with Cambodian psychiatrists. Components of hermeneutic phenomenological interviewing and descriptive content analysis were used to simultaneously teach and enact the research methods, gather data in both countries to analyze, and inspire participants to replicate the methods in their ongoing work. Cambodian psychiatrists were able to demonstrate competence in facilitating focus groups after being participant-observers. Researcher/practitioners from both U. S. and Cambodian teams gained new understandings about the mental health needs of their patients. The mutual engagement of a research focus is an effective way to establish cross-cultural relationships. The challenges of staying with stable teams over times remain, but the content shared and learned in a participatory structure yields understandings that cross cultural boundaries. Anticipated and unexpected challenges may be offset by an intention of reciprocity and mutual engagement. The use of qualitative methodologies, early and repeatedly, can facilitate relational understanding.

Resilience of adolescents living with HIV in the Cape Metropole of the Western Cape

Resilience shapes the experiences of adolescents living with HIV (ALWH), enabling them to come to terms with their diagnosis, have hope for the future and maintain meaningful relationships. Yet, little is known about contextual factors associated with resilience resources in South Africa. We aimed to describe individual, relational and community resilience resources, and identify contextual factors associated with resilience. We recruited 385 adolescents, aged 13-18, over a period of 5 months from 11 different public health HIV clinics. The Child and Youth Resilience Measure (CYRM-12) was used to measure resilience resources. Data on demographic variables, psychological attributes, and environmental factors such as HIV-related stigma and stressful life events were collected. ALWH lacked resilience in some aspects of the individual, relational and community domains. For every one-unit increase in the HIV-related stigma and stressful life events scores, resilience decreased by 0.29 (p = 0.01) and 0.37 (p = 0.04) units, respectively. Higher levels of resilience were associated with being virally suppressed (Mann-Whitney U, p = 0.028) although this association was no longer present in the regression model. Efforts to improve resilience amongst ALWH should be focused on fostering individual coping skills, interconnectedness, and positive relationships, to mitigate adverse environmental factors.

Resilience from childhood to young adulthood: retrospective perspectives of deaf and hard of hearing people who studied in regular schools

OBJECTIVE

Most deaf and hard of hearing (DHH) youth grow up in hearing familial and educational environments, posing unique risks for their socio-emotional well-being. The study's objective was to explore protective processes contributing to resilience among DHH individuals in different life periods.

DESIGN

We conducted semi-structured interviews with 23 DHH young adults on their life-long coping with having a hearing loss (HL).

MAIN OUTCOME MEASURES

Thematic analysis identified, according to participants' retrospective perceptions, processes that supported their positive adjustment from childhood up to early adulthood.

RESULTS

Themes were organised at three ecological levels: individual, including five subthemes (e.g. certain attitudes to HL); family, including various types of parental support; and community, including four subthemes (e.g. extra-curricular activities). Family and community level resources enabled and nurtured personal attitudes and coping abilities. The perceptions of which personal attitudes and contextual resources were helpful changed from childhood to young adulthood.

CONCLUSIONS

Findings show how resilience is heterogeneously promoted in the unique context of DHH individuals living in hearing environments. They also show interactions between the individual, family and wider society and the dynamics of coping resources across time. Findings indicate the important of considering DHH individuals' coping choices in their specific life context.

Measuring resilience in children: a review of recent literature and recommendations for future research

PURPOSE OF REVIEW

Understanding variability in developmental outcomes following exposure to early life adversity (ELA) has been an area of increasing interest in psychiatry, as resilient outcomes are just as prevalent as negative ones. However, resilient individuals are understudied in most cohorts and even when studied, resilience is typically defined as an absence of psychopathology. This review examines current approaches to resilience and proposes more comprehensive and objective ways of defining resilience.

RECENT FINDINGS

Of the 36 studies reviewed, the most commonly used measure was the Strengths and Difficulties Questionnaire (n = 6), followed by the Child Behavior Checklist (n = 5), the Resilience Scale for Chinese Adolescents (n = 5), the Rosenberg Self-Esteem Scale (n = 4), and the Child and Youth Resilience Scale (n = 3).

SUMMARY

This review reveals that studies tend to rely on self-report methods to capture resilience which poses some challenges. We propose a complementary measure of child resilience that relies on more proactive behavioral and observational indicators; some of our preliminary findings are presented. Additionally, concerns about the way ELA is characterized as well as the influence of genetics on resilient outcomes prompts further considerations about how to proceed with resiliency research.

Disclosure, Social Support, and Mental Health are Modifiable Factors Affecting Engagement in Care of Perinatally-HIV Infected Adolescents: A Qualitative Dyadic Analysis

Adolescents living with perinatally acquired HIV in South Africa face significant barriers to successful transition from pediatric to adult care. We performed in-depth qualitative interviews with 41 adolescents living with HIV and 18 of their caregivers to investigate modifiable factors to improve engagement in care prior to transition to adult care. Based on dyadic, inductive content analysis, findings suggest that HIV status disclosure, social support, and mental health are targets for improvement in engagement in care. Early disclosure and a sense of belonging facilitated engagement in care, while barriers included delayed or inadequate disclosure, denial, and lack of disclosure to others. Adherence support improved by having a biological mother as a direct supervisor. Barriers to care included changing caregivers, abandonment, undiagnosed mental health problems and learning difficulties. Despite these factors, the majority of adolescents showed resilience and remained engaged in care despite difficult circumstances.

State of the Mind: Growing up with HIV

Human immunodeficiency virus (HIV) is a neurotropic virus that has a detrimental impact on the developing central nervous system (CNS) of children growing up with perinatal HIV (PHIV) due to a combination of pathophysiological processes related to direct viral cytopathic effects and immune activation. This leads to a spectrum of neurocognitive impairment ranging from severe encephalopathy to subtle domain-specific cognitive impairments, as well as psychological disorders that are compounded by HIV-related stigma and sociodemographic factors that disproportionately affect PHIV children. Early commencement and consistent use of combination antiretroviral therapy (cART) has resulted in a dramatic improvement in neuropsychological outcomes for PHIV children; however, they remain vulnerable to cognitive impairment and psychological disorders, as evidenced by imaging findings, randomised clinical trials and observational studies. An optimal neuroprotective cART regimen remains elusive in children, but systemic viral suppression, regular neurocognitive and psychological screening and ready access to neuropsychological management strategies are key components for optimising neuropsychological outcomes. However, a lack of standardised and validated screening tools, particularly in resource-limited settings, hinders a precise understanding of the nature, prevalence and associations between neuropsychological symptomatology and HIV health. This article reviews the natural history, cellular pathophysiology and structural and functional imaging findings for children growing up with HIV, as well as summarising management strategies related to antiretroviral therapy, screening tools and specific interventions for neurocognitive impairments and psychological disorders.

Increased Risk of Executive Function and Emotional Behavioral Problems Among Virologically Well-Controlled Perinatally HIV-Infected Adolescents in Thailand and Cambodia

BACKGROUND

Large numbers of perinatally HIV-infected (PHIV) children are aging into adolescence. We examined cognitive and behavioral outcomes in a longitudinal cohort of Asian youth.

METHODS

We followed up 231 PHIV, 125 perinatally HIV-exposed, uninfected (HEU), and 138 HIV-unexposed, uninfected (HUU) adolescents (aged 10 years and older), matched by age/sex, in Thailand and Cambodia for 3 years. Executive function was assessed with Children's Color Trails Tests 1 and 2 (CCTT-1 and -2), the design fluency test, and the verbal fluency test. Working memory (Freedom from Distractibility Index) and processing speed index were assessed using WISC-III. Visual memory was assessed by design memory and design recognition subtests of the Wide Range Assessment of Memory and Learning (WRAML-2) and behavioral problems using the Child Behavior Checklist (CBCL). Generalized estimating equations examined adjusted odds ratios of cognitive impairment (Z-scores ≥2 SD below age-adjusted means of the HUU group) and CBCL T-scores in the borderline-clinical range (T-Scores ≥60) in PHIV and HEU versus HUU youth, adjusting for ethnicity, household income, and caregiver characteristics.

RESULTS

The median age at enrollment was 13.8 years, with 58% women and 63% Thai participants. PHIV youth had >86% virological suppression and significantly higher impairment rates on CCTT-1 and -2 tests, design fluency test, verbal fluency tests, design memory, and CBCL internalizing and externalizing problems. Results were mostly similar between HEU and HUU groups, apart from higher impairment rates on CCTT-1 and internalizing problems in HEU.

CONCLUSION

Asian adolescents with PHIV remain at risk of cognitive and mental health problems despite HIV treatment. Selective risks are observed among HEU youth.

Machine-learning classification of neurocognitive performance in children with perinatal HIV initiating de novo antiretroviral therapy

OBJECTIVE

To develop a predictive model of neurocognitive trajectories in children with perinatal HIV (pHIV).

DESIGN

Machine learning analysis of baseline and longitudinal predictors derived from clinical measures utilized in pediatric HIV.

METHODS

Two hundred and eighty-five children (ages 2-14 years at baseline; Mage = 6.4 years) with pHIV in Southeast Asia underwent neurocognitive assessment at study enrollment and twice annually thereafter for an average of 5.4 years. Neurocognitive slopes were modeled to establish two subgroups [above (n = 145) and below average (n = 140) trajectories). Gradient-boosted multivariate regressions (GBM) with five-fold cross validation were conducted to examine baseline (pre-ART) and longitudinal predictive features derived from demographic, HIV disease, immune, mental health, and physical health indices (i.e. complete blood count [CBC]).

RESULTS

The baseline GBM established a classifier of neurocognitive group designation with an average AUC of 79% built from HIV disease severity and immune markers. GBM analysis of longitudinal predictors with and without interactions improved the average AUC to 87 and 90%, respectively. Mental health problems and hematocrit levels also emerged as salient features in the longitudinal models, with novel interactions between mental health problems and both CD4 cell count and hematocrit levels. Average AUCs derived from each GBM model were higher than results obtained using logistic regression.

CONCLUSION

Our findings support the feasibility of machine learning to identify children with pHIV at risk for suboptimal neurocognitive development. Results also suggest that interactions between HIV disease and mental health problems are early antecedents to neurocognitive difficulties in later childhood among youth with pHIV.

Experiences with stigma and discrimination among adolescents and young adults living with HIV in Bangkok, Thailand

Thailand has identified stigma and discrimination as barriers to controlling their HIV epidemic. We aimed to explore the perspectives of young adults living with HIV in Bangkok regarding the influence of stigma and discrimination in education, employment, health care, personal relationships, and perceptions of self. Participants aged 15-24 years were conveniently and purposively sampled from local HIV clinics in Bangkok. Twenty-three individuals (14 female, 9 male; median age 20) were enrolled into the study between May and June 2017. Semi-structured qualitative interviews were conducted in Thai. Interview transcripts were translated into English and analyzed with Dedoose software (v7.6.12) using a framework analysis approach. Participants reported varied experiences with and beliefs about HIV-related stigma as they related to family, employment, education, and society. While few experienced discrimination, such as losing opportunities at work or school, all reported anticipating potential stigma and fearing negative repercussions from disclosure. Many participants reported that fear of disclosure negatively impacted their medication adherence. For the individuals interviewed, fear of stigma was a daily consideration. Many experienced HIV-related stigma in school, at work, within their communities, and in their inter-personal relationships. Anti-stigma efforts should include strategies that address the needs of young adults.

From surviving to thriving: the role of resilience in meeting global HIV goals

: Advances in HIV treatment and pioneering public health strategies have yielded remarkable successes in the global fight against HIV. However, attaining UNAIDS Fast Track 90-90-90 global targets will require a renewed focus on the psychosocial aspects of HIV that too often prevent vulnerable individuals from engaging in prevention, testing, and treatment. Each step along the HIV Care Continuum can be viewed as an opportunity for positive adaptation or 'resilience', and the scientific study of resilience among HIV populations continues to grow. This AIDS supplement aims to draw attention to current conceptualizations of resilience among HIV-affected populations and to delineate factors that people living with HIV identify as critical for their ability to cope with HIV-related challenges. We also highlight innovative resilience-based interventions that are designed to help people living with HIV not only survive - but also thrive - across psychological, social, and health-related domains.

Efavirenz

Treatment of HIV infection is typically carried out using a combination of at least three drugs. Efavirenz is a non-nucleoside reverse transcriptase inhibitor that acts by non-competitive inhibition of the viral enzyme. Efavirenz-based regimens have performed favorably compared with protease inhibitor-based therapies either in naive patients or as simplification strategies in pretreated subjects. Efavirenz is administered once-daily and its simple dosing schedule improves adherence to therapy allowing for durability of the virologic and clinical responses. In the case of viral rebound, K103N is the most commonly efavirenz-selected viral mutation. As non-nucleoside reverse transcriptase inhibitors have a distinctive adverse-event profile, protease inhibitor-sparing regimens may reduce the risk of metabolic complications, insulin resistance and peripheral fat redistribution.