Developmental status of preschool children receiving cART: a descriptive cohort study

Maternal depression and infant social withdrawal as predictors of behaviour and development in vertically HIV-infected children at 3.5 years

BACKGROUND

In low- and middle-income countries, there is a high prevalence of post-partum depression and it is often associated with HIV status. Maternal depression negatively affects mothering and can lead to social withdrawal in infants. Maternal depression and infant social withdrawal can have deleterious long-term effects on children's behaviour and neurodevelopmental trajectories.

AIM

To investigate whether maternal depression and infant social withdrawal at 10-12 months post-partum were significant predictors of child behaviour and development at 42 months.

METHOD

Seventy-four mother-infant dyads living with HIV were followed in a prospective, longitudinal design. Mothers were assessed for depression using the Center for Epidemiologic Studies Depression scale (CES-D). Infant social withdrawal was assessed by the modified Alarm Distress Baby Scale (m-ADBB), and development and behaviour were evaluated by the Griffiths Mental Development Scales (GMDS) and the Child Behavior Checklist (CBCL), respectively.

RESULTS

Maternal depression  explained 4.8% of the variance in child behaviour (β = 0.98, t = 2.05, p < 0.05) and 10.3% of the variance in development   (β = -0.30, t = -2.66, p < 0.05). Infant social withdrawal   was not a significant predictor of behaviour   (β = 3.27, t = 1.36, p = 0.18), but it did uniquely explain 7% of the variance in development (β = -1.32, t = -2.48, p < 0.05).

CONCLUSION

In the context of HIV, screening for maternal depression and the quality of mother-infant interactions are important (especially in the 1st year post-partum), given the significant long-term impact they have on behaviour and neurodevelopment.

ABBREVIATIONS

ANOVA: analysis of variance; ART: antiretroviral therapy; CBCL: Child Behavioral Checklist; CES-D: Center for Epidemiologic Studies Depression Scale; CHEI: children HIV-exposed and infected; CHER: Children with HIV Early Antiretroviral Treatment Trial; CHEU: children HIV-exposed and uninfected; CHUU: children HIV-unexposed and -uninfected; GMDS: Griffiths Mental Development Scales; HIV: human immunodeficiency virus; LMIC: low- and middle-income countries; m-ADBB: modified Alarm Distress Baby Scale; NRF: National Research Foundation; SAMRC: South African Medical Research Council; WHO: World Health Organization.

Cognitive outcomes at ages seven and nine years in South African children from the children with HIV early antiretroviral (CHER) trial: a longitudinal investigation

INTRODUCTION

Many children living with HIV (CLWH) display impaired cognition. Although early combination antiretroviral therapy (ART) produces improved cognitive outcomes, more long-term outcome data are needed. After concluding the Children with HIV Early antiRetroviral (CHER) trial in 2011, we investigated cognitive performance, at seven and nine years of age. Participants had been randomized to deferred ART (ART-Def; n = 22); immediate time-limited ART for 40 weeks (ART-40W; n = 30) and immediate time-limited ART for 96 weeks (ART-96W; n = 18). We also recruited HIV-exposed uninfected (CHEU; n = 28) and HIV-unexposed (CHU; n = 35) children.

METHODS

Data were collected between May 2012 and December 2017. Mixed-model repeated-measures ANOVAs assessed differences over time between CLWH (ART-40W, ART-96W and ART-Def) and CHIV- CHEU and CHU between ART-Early (ART-40W and ART-96W), ART-Def, CHEU and CHU; and between ART-40W, ART-96W, ART-Def, CHEU and CHU.

RESULTS

All comparisons found significant effects of Time for most outcome variables (better scores at nine than at seven years; ps < 0.05). The first ANOVAs found that for (a) motor dexterity, CLWH performed worse than CHIV- at seven years (p < 0.001) but improved to equivalence at nine years, (b) visual-spatial processing and problem solving, only CLWH (p < 0.04) showed significant performance improvement over time and (c) working memory and executive function, CLWH performed worse than CHIV- at both seven and nine years (p = 0.03 and 0.04). The second ANOVAs found that for (a) working memory, CHU performed better than ART-Early and CHEU (p < 0.01 and <0.04), and (b) motor dexterity, ART-Def performed worse than ART-Early, CHEU and CHU at seven years (p = 0.02, <0.001 and <0.001 respectively) but improved to equivalence at nine years (ps > 0.17). Similarly, for motor dexterity, ART-Def performed worse than ART-96W, CHEU and CHU at seven years (p < 0.04, <0.001 and <0.001) but improved to equivalence at nine years (ps > 0.20).

CONCLUSIONS

Although neurocognitive developmental trajectories for treatment groups and controls were largely similar (i.e. performance improvements from 7 to 9), all ART-treated children, regardless of treatment arm, remain at risk for cognitive deficits over early school ages. Although the nature of these deficits may change as cognitive development proceeds, there are potential negative consequences for these children's future learning, reasoning and adaptive functioning.

Play profiles of children with HIV/Aids: A comparative study

INTRODUCTION

Despite play being widely used in occupational therapy practice as a means and ends in intervention, no research has explored how the play of children with HIV/AIDS is affected. Therefore, the specific processes through which play can be used in therapy with children with HIV/AIDS remains underexplored, especially in low resourced settings. This study aims to compare the level of playfulness of children with HIV/AIDS to that of age and gender matched typically developing children living in the same low resourced community.

METHODS

The Test of Playfulness (ToP) was used to examine the differences and similarities of play between children aged 4-7 years who are typically developing children (n = 52) and children with HIV/AIDS who receive antiretroviral treatment (n = 44). Each child was video recorded playing with a familiar playmate both indoors and outdoors. The videos were scored by two independent raters who were blinded to all aspects of the study. Scores were subjected to Rasch analysis to calculate interval level measure scores. Independent t-tests were used to compare differences between the means of the groups.

RESULTS

Typically developing children scored significantly higher when playing outdoors, as compared to children with HIV [t (94) = 3.57, p = .001]. There was no significant difference between mean measure scores for indoor play when comparing typically developing children and children with HIV. Children who are HIV positive scored significantly lower than typically developing children on items related to the ability to suspend reality and framing in both indoor and outdoor environments.

CONCLUSIONS

Children with HIV/AIDS exhibited lower levels of playfulness when compared to typically developing children. This study provides insight on the play profiles of children with HIV/AIDS, highlighting play deficits and differences between indoor and outdoor play. Occupational therapy can play a significant role in promoting playfulness in children with HIV/AIDS.

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.

Neurodevelopment at 11 months after starting antiretroviral therapy within 3 weeks of life

BACKGROUND

Antiretroviral therapy (ART) started between 7 and 12 weeks of age improves neurodevelopmental outcomes in HIV-infected (HIV+) infants, but the impact of even earlier initiation is not yet described.

OBJECTIVES

We assessed the early neurodevelopment of HIV+ infants who started ART within 21 days of life.

METHOD

Participants were enrolled from the public sector birth HIV-diagnosis programme. Inclusion criteria included the following: birth weight > 2000 g, infant commencing ART < 6 weeks and no infant cytomegalovirus disease. Antiretroviral therapy included Zidovudine/Lamivudine/Nevirapine for the first 2 weeks, the latter then replaced by Lopinavir/Ritonavir. Once body weight > 3 kg and gestational age > 44 weeks, Abacavir replaced Zidovudine. The Griffiths mental development scales (GMDS) were administered at 10-12 months.

RESULTS

Of 29 infants assessed, 23 (79%) were girls. Mean birth weight was 3002 ± 501 g. Twenty-four mothers (83%) received ART during pregnancy. Seven (24%) infants were diagnosed HIV+ within 48 h of birth. Median [interquartile range] viral load (VL) at diagnosis was 3904 [259-16 922] copies/mL, age starting ART was 6.0 [3-10] days and age at VL suppression was 19.1 [15-36] weeks. At the GMDS assessment, nine (31%) participants had detectable VL and 26 (90%) had World Health Organization (WHO) clinical stage I disease. The GMDS was performed at a mean age of 11.5 ± 0.8 months. Mean quotients were within the average range: Global Griffiths score was 103.6 ± 10.9 and mean quotients on the subscales ranged from lowest 95.9 ± 13.4 for locomotor to highest 112.8 ± 11.3 for hearing-and-language.

CONCLUSION

Preliminary findings in this small group suggest that early neurodevelopmental scores are within the normal range in infants with perinatal HIV infection who started ART at a median of 6 days.

Value of the Goodenough Drawing Test as a research tool to detect developmental delay in South African preschool children

There is a need for simple, cost-effective research tools to detect developmental delay in preschool children in low- and middle-income countries where insufficient resources are often a barrier to detection and management. The Goodenough Draw-a-Person test is freely available, easily administered, and requires limited language ability and equipment; it is thus potentially useful in resource-constrained settings. We aimed to determine the diagnostic accuracy of the Draw-a-Person test to identify developmental delay in 5-year-old preschool children using the Griffiths Mental Developmental Scales-Extended Revised eye-hand coordination subquotient as the gold standard. This was a cross-sectional analysis of drawings by South African preschool children from low-income families, whose Griffiths Mental Developmental Scales-Extended Revised assessments included a human figure drawing. Draw-a-Person test quotients were estimated independently by a developmental paediatrician and two medical officers to calculate inter-rater agreement. The paediatrician’s scores were used to determine the diagnostic accuracy of the Draw-a-Person test quotient (<85) to predict developmental delay with the eye-hand coordination subquotient (<75). A total of 125 children were included, with a mean age of 60.8 months (range 59–66 months) of which 48.8% were boys. The mean Draw-a-Person test score was 94 (standard deviation 15) with 28 Draw-a-Person test scores below 85. Applying the Draw-a-Person test cut-off of 85, sensitivity of the Draw-a-Person test to the eye-hand coordination subquotient was 80% and specificity 89%. The area under the receiver operator characteristic curve was 0.87 (95% confidence interval [0.78–0.96]). The Goodenough Draw-a-Person test could thus be a useful research tool for detecting fine motor and visuoperceptual delay in South African preschool children.

A Feasibility RCT Evaluating a Play-Informed, Caregiver-Implemented, Home-Based Intervention to Improve the Play of Children Who Are HIV Positive

Background/aim

In South Africa, contextual factors have been identified as barriers to outdoor, unstructured play. The human immunodeficiency virus (HIV) and resulting progressive HIV encephalopathy (PHE) is a pandemic in this area, associated with development delays that are not addressed by highly active antiretroviral treatment (HAART). This study aimed to describe the playfulness in children with HIV and PHE on HAART living in challenging socioeconomic areas in South Africa aged 6 months to 8 years and to evaluate the feasibility and preliminary effectiveness of a play-informed, caregiver-implemented, home-based intervention (PICIHBI) for improving play.

Methods

A feasibility randomized control trial allowed for comparison of PICIHBI and conventional one-on-one occupational therapy interventions. Children were filmed playing pre-, mid-, and postintervention, using the Test of Playfulness (ToP) to assess playfulness. The PICIHBI comprised of 10 monthly sessions facilitated by an occupational therapist, involving group discussions with caregivers and periods of experiential play.

Results

Twenty-four children with HIV and/or PHE were randomized into one of the two intervention groups. Overall, the group (n = 24) had a median score of 0 (lowest item score) on nine of 24 ToP items and only had a median score of 3 (highest score) on two items. Pre- to postintervention overall ToP scores improved marginally for the PICIHBI group (n = 12) and the conventional group (n = 12). Between-group differences were not significant. The PICIHBI group demonstrated a significant increase in one ToP item score at midassessment. No significant ToP item changes were found in the conventional group.

Conclusion

Children with HIV were found to have the most difficulty on ToP items relating to the play elements of internal control and freedom from constraints of reality. The PICIHBI did not significantly improve children's play and was not more effective than the conventional intervention. Considerations for feasibility and effectiveness, including barriers to attendance, are discussed.

Absence of neurocognitive disadvantage associated with paediatric HIV subtype A infection in children on antiretroviral therapy

Introduction

Infection with HIV subtype A has been associated with poorer neurocognitive outcomes compared to HIV subtype D in Ugandan children not eligible for antiretroviral therapy (ART). In this study, we sought to determine whether subtype‐specific differences are also observed among children receiving ART.

Materials and Methods

Children were recruited from a clinical trial in which they were randomized to receive either lopinavir (LPV)‐ or non‐nucleoside reverse transcriptase inhibitor (NNRTI)‐ based ART (NCT00978068). Age at initiation of ART ranged from six months to six years. HIV subtype was determined by PCR amplification and population sequencing of the pol region derived from peripheral blood mononuclear cell DNA, followed by application of the REGA and Recombinant Identification Programme algorithms. General cognition was assessed using the Kaufman Assessment Battery for Children (Second Edition), attention using the Test of Variables of Attention, and motor skills using the Bruininks‐Oseretsky Test of Motor Proficiency (Second Edition). Home environment was assessed using the Home Observation for the Measurement of the Environment (HOME). Age‐adjusted test z‐scores were entered into a regression model that adjusted for sex, socio‐economic status score, HOME score, years of schooling, and ART treatment type.

Results

One hundred and five children were tested; median (interquartile range) age was 7.05 years (6.30 to 8.44), CD4 count was 867.7 cells/mm³ (416.0 to 1203.5), and duration on ART was 4.03 years (3.55 to 4.23). Seventy‐eight children had HIV subtype A and 27 had subtype D; the groups had comparable home and socio‐economic status, except that there were more males among children infected with subtype A than D (64.7% vs. 35.3%, p = 0.02). There were no differences between the subtypes in general cognition (estimated mean difference: 0.20; 95% CI: −0.11 to 0.50); p = 0.21), attention (−0.18, 95% CI: −0.60 to 0.24, p = 0.41) and motor skills (1.60, 95% CI: −0.84 to 4.04, p = 0.20).

Conclusions

Our results imply that ART may diminish the neurocognitive disadvantage seen in treatment‐naïve HIV‐infected children with subtype A.