The effects of caregiver and household HIV on child development: a community-based longitudinal study of young children

Co-occurring Intimate Partner Violence, Mental Health, Human Immunodeficiency Virus, and Parenting Among Women: A Scoping Review

Little research exists on the human immunodeficiency virus (HIV)-intimate partner violence (IPV)-mental health (MH) syndemic impact on parenting. The objective of this scoping review is to identify and summarize the available evidence regarding the syndemic relationship between HIV or Acquired Immune Deficiency Syndrome (AIDS), IPV, and poor MH among mothers and caregivers who identify as women. We conducted the review according to the Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and meta-analyses extension for scoping reviews guidelines, a comprehensive search was conducted from 2001 to September 2023. The inclusion criteria targeted studies examining at least two of the HIV, IPV, or MH epidemics among participants and their syndemic impact on parenting. Both qualitative and quantitative studies were included. Covidence software was used to screen and extract data. Twenty-three studies were included in the analysis. Most of the studies were conducted in the United States. Furthermore, all the studies used quantitative research designs, with most being longitudinal. Most of the research was concentrated on the IPV-MH syndemic with no research found on the HIV-IPV syndemic impact on parenting. Research on the HIV-IPV-MH syndemic found that an HIV diagnosis exacerbated the negative impacts of IPV-MH on parenting. Research on IPV-MH showed that this syndemic significantly influences parenting, leading to less nurturing and more punitive behaviors. Studies did not find a direct association between IPV and harsh parenting practices, the relationship was mediated by poor MH. Studies examining the HIV-MH syndemic found that anxiety and maternal depression were the most frequent MH disorders. The review revealed that living with the different syndemics, (IPV-MH-HIV, HIV-MH, and IPV-MH) adversely affects parenting practices, resulting in harsher parenting.

"I've accepted it because at the end of the day there is nothing, I can do about it": A qualitative study exploring the experiences of women living with the HIV, intimate partner violence and mental health syndemic in Mpumalanga, South Africa

In South Africa, Mental Health (MH), HIV, and Intimate Partner Violence (IPV) form a syndemic, that disproportionately affects women. These challenges are often co-occurring and create complex adversities for women. Recognising these intersections and the broader socio-cultural dynamics at play is crucial to understanding the layered experiences of these women and developing effective interventions. This research explores the experiences of the women living with at least two of the epidemics (HIV, IPV and or MH) and how they cope. A qualitative study design was used and 20 women (22-60 years) were recruited from Mpumalanga, South Africa. To be eligible for the study the women had to have experienced at least two of the epidemics. Data were collected through home-based interviews, arts-based activities, and analysed thematically using MAXQDA (2022) software. MH challenges were prevalent among all the participants and were linked to both IPV and HIV, resulting in symptoms such as anxiety, depression, and suicidal thoughts. In relation to the HIV-MH link, MH challenges in this combination included feelings of denial, sadness and anxiety related to participant's HIV diagnosis. A bidirectional relationship also existed in the IPV-MH group where pre-existing MH challenges among women increased their vulnerability of having violent partners, whilst IPV also increased MH challenges. In the IPV-MH-HIV group early childhood violence exposure was linked with MH challenges and later victimization and vulnerability to HIV. Participants primarily used religion, acceptance, occasional alcohol, and family support as coping strategies. Particularly in IPV situations, alcohol use/misuse was the most prevalent coping strategies. The study highlights the syndemic relationship between HIV, IPV and MH challenges among South African women living in a peri-urban community, with a central emphasis on MH challenges. Interventions should holistically address these challenges, with particular focus on MH challenges, cultural sensitivity, and promotion of healthy coping strategies.

Perinatal HIV exposure and infection and caregiver depressive symptoms

Survival is possible for children perinatally exposed to or infected by HIV in the post-combined antiretroviral therapy era and identifying factors affecting children's ability to thrive has public health significance. Caregiver mental health is one such factor to consider given its impact on child development, but previous work has not included a full complement of HIV exposure/infection groups within HIV-endemic settings. We compared depressive symptoms among caregivers of 3 groups of 6-10-year-olds in Uganda: children with perinatally acquired HIV infection (CPHIV, n = 102), children with perinatal HIV exposure, but no infection (CPHEU, n = 101), and children without perinatal HIV exposure or infection (CHUU, n = 103). The Hopkins Symptom Checklist was used to assess caregiver depressive symptoms. Generalized linear models were used to estimate group mean differences. Adjusted models included caregiver demographics, social support, and lifetime trauma. Depression symptoms were higher among CPHEU compared to CPHIV caregivers (model coefficient [B] = -3.5, 95%CI -5.3, -1.8). This finding was minimally attenuated following adjustment for covariates (B = -2.2, 95%CI -4.1, -0.4) and among biological mothers. At lower levels of social support and wealth, CPHEU caregivers reported higher levels of depression symptoms than CPHIV caregivers. Our findings point to unmet mental health needs among CPHEU caregivers.

Emotional and Behavior Difficulties and the Mental Health of Caregivers of Adolescents Living with HIV

This study examined the relationship between child emotional and behavioral difficulties, parenting stress and the mental health of caregivers of adolescents living with HIV. Caregiver data from a two-year pilot study for adolescents and their caregivers (N = 89 dyads) in Uganda, were analyzed. Ordinary Least Square regression models were conducted to examine the association between child difficulties reported by caregivers using the Strengths and Difficulties Questionnaire on parenting stress (measured by Parenting Stress Index) and caregiver mental health (measured by the Brief Symptoms Inventory). Results indicate that 12.36% of caregivers reported child difficulty scores within the borderline range and 8.99% reported scores within the abnormal range. Child difficulties (b = 0.52, 95% CI: 0.18, 0.85) were associated with parenting stress. Similarly, the perceived impact of child difficulties was associated with both parenting stress (b = 0.89, 95% CI: 0.24, 1.54) and caregiver mental health (b = 1.73, 95% CI: 1.09, 2.37). Study findings have important implications for developing effective psychosocial interventions targeting children and adolescents living with HIV and their caregivers.

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.

Depression-Mediating Pathways From Household Adversity to Antiretroviral Therapy Nonadherence Among Children and Adolescents Living With HIV in Zambia: A Structural Equation Modeling Approach

BACKGROUND

In Zambia, half of children and adolescents living with HIV (CALWH) on antiretroviral therapy (ART) are virologically unsuppressed. Depressive symptoms are associated with ART nonadherence but have received insufficient attention as mediating factors in the relationship between HIV self-management and household-level adversities. We aimed to quantify theorized pathways from indicators of household adversity to ART adherence, partially mediated by depressive symptoms, among CALWH in 2 Zambian provinces.

SETTING

In July-September 2017, we enrolled 544 CALWH aged 5-17 years and their adult caregivers into a year-long prospective cohort study.

METHODS

At baseline, CALWH-caregiver dyads completed an interviewer-administered questionnaire, which included validated measures of recent (past 6 months) depressive symptomatology and self-reported past-month ART adherence (never versus sometimes or often missing medication doses). We used structural equation modeling with theta parameterization to identify statistically significant ( P < 0.05) pathways from household adversities (past-month food insecurity and caregiver self-reported health) to depression (modeled latently), ART adherence, and poor physical health in the past 2 weeks.

RESULTS

Most CALWH (mean age: 11 years, 59% female) exhibited depressive symptomatology (81%). In our structural equation model, food insecurity significantly predicted elevated depressive symptomatology ( ß = 0.128), which was associated inversely with daily ART adherence ( ß = -0.249) and positively with poor physical health ( ß = 0.359). Neither food insecurity nor poor caregiver health was directly associated with ART nonadherence or poor physical health.

CONCLUSIONS

Using structural equation modeling, we found that depressive symptomatology fully mediated the relationship between food insecurity, ART nonadherence, and poor health among CALWH.

Understanding the experiences of caregivers of HIV-exposed children under five: A phenomenological inquiry

Background

Children born to mothers with HIV require special care from the womb to the postnatal period, and caregivers involved in their care face several challenges.

Objective

This study aimed to explore caregivers' experiences providing care for HIV-exposed children under five.

Methods

This study employed a phenomenological approach. Ten caregivers of HIV-exposed children living in Jakarta, Indonesia, were selected using snowball techniques. Online in-depth interviews were conducted to collect data from September 2021 to July 2022, and thematic analysis using Colaizzi's method was performed for data analysis.

Results

The study involved ten caregivers (nine females and one male) aged between 23 and 42 years. Seven of them were mothers who tested HIV-positive, while one was an adoptive father, one was a mother's sister, and one was an aunt of HIV-exposed children. The majority of them were housewives and had a low educational background. Three themes were generated: (i) disease-transmission foreboding, (ii) prejudice against mothers and children exposed to HIV, and (iii) seeking support.

Conclusion

Caring for HIV-exposed children poses emotional and physical challenges for caregivers, necessitating support from health professionals and peer groups. Nurses play essential roles in improving caregiver well-being and supporting optimal growth and development in HIV-exposed children under five by designing intervention programs. Furthermore, to enhance home-based HIV care in Indonesia, the government must implement social interventions that target families with limited resources.

Explaining external economic support inequality among households affected by HIV/AIDS in Tanzania: an Oaxaca Blinder decomposition analysis

BACKGROUND

HIV/AIDS remains the leading cause of death in sub-Saharan Africa. Due to multiple constraints experienced by households that seem to be disproportionally affected, families generally seek assistance from the community and external economic support. Previous researchers studied socioeconomic and gender inequality in HIV/AIDS prevalence in sub-Saharan African countries. However, very few researchers have paid attention to the external economic support for HIV/AIDS affected households in Tanzania. This study investigates the difference in economic support among households affected or not affected by the HIV/AIDS epidemic in Tanzania.

METHODS

Data used stemmed from the Tanzania HIV Impact Survey 2016-2017 (THIS) of the Population-based HIV Impact Assessment (PHIA) project, collected between 2016 and 2017 in Tanzania. The study population were the heads of households (adults) with age greater than 15. The dependent variable for the study was economic support. This consisted of both material and non-material assistance obtained from outside the household. Socio-demographic (economics) characteristics constituted the predictors of the study. Descriptive statistics and econometric modelling were used to analyse determinants associated with external economic support. Oaxaca-Blinder decomposition method was also performed to investigate the difference in economic support depending on households' serological status in Tanzania.

RESULTS

A total of 12,008 households were included. Almost 11% of the household heads indicated that their households received economic support. HIV/AIDS affected 7% of households. The mean age of the household heads was 45 years (SD ± 15) with a range of 16-80. The majority of household heads were men (72%). Being a household head affected by HIV/AIDS increases the probability to receive external economic support (p < 0.05). The difference in external economic support between the two groups (HIV/AIDS and no- HIV/AIDS households) was - 0.032 (p < 0.01). This gap was observed to favour households affected by HIV/AIDS. Almost 72% (- 0.023/- 0.032) of this difference was explained by characteristics such as the wealth index (p < 0.01), residence area (urban) (p < 0.01), marital status (widowed (p < 0.05) and divorced or separated) (p < 0.1) and age (p < 0.01).

CONCLUSION

The difference in economic support across households affected or not affected by HIV/AIDS was explained by wealth index, residence area, marital status and age. These findings represent important implications for health policy regarding future economic support strategies for HIV/AIDS-affected households.

A situational analysis of child and adolescent mental health services and systems in the Western Cape Province of South Africa

BACKGROUND

Even though child and adolescent mental health is a global health priority, services are very limited, particularly in low- and middle-income countries (LMIC), and therefore need comprehensive strengthening. This requires knowledge of the hardware elements of the system (human resources, financing, medicines, technology, organisational structure, service infrastructure, and information systems). This study sought to examine these elements of child and adolescent mental health (CAMH) services and systems in the Western Cape Province of South Africa.

METHODS

The World Health Organization Assessment Instrument of Mental Health Systems (WHO-AIMS) version 2.2 of 2005 was adapted to identify key variables of interest in CAMH. Data were collected for the calendar year 2016 and focused on the public health sector. We outlined findings based on best available data across the six domains of the WHO-AIMS.

RESULTS

In domain 1, we found no provincial CAMH policy or implementation plans to support the national CAMH policy and were unable to identify a CAMH-specific budget. In domain 2, there was no dedicated provincial leadership structure for CAMH, and no dedicated or 'child- and adolescent-friendly' mental health services at primary or secondary care levels. At tertiary level, there were only three specialist CAMH teams. The majority of CAMH resources were based in the City of Cape Town, with limited resources in the rural districts. Essential medicines were available in all facilities, and the majority of children and adolescents had access to free services. In domain 3, data were limited about the extent of training offered to primary healthcare staff, and little or no psychosocial interventions were available in primary care. Domain 4 identified a small and variable CAMH workforce across all levels of care. In domain 5, few public health campaigns focused on CAMH, and little evidence of formal intersectoral collaboration on CAMH was identified. Domain 6 identified significant limitations in health information systems for CAMH, including lack of child- and adolescent-specific and disaggregated data to establish baselines for policy development, monitoring, evaluation and CAMH research.

CONCLUSIONS

This study identified significant structural weaknesses in CAMH and presents a clear call for action to strengthen services and systems in the province and in South Africa. it would be important to expand research also to include provider and user perspectives for service strengthening.

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.

Quality-of-Life (QoL) of Indonesian Children Living with HIV: The Role of Caregiver Stigma, Burden of Care, and Coping

Background

Treatment of children with HIV infection has increased rapidly by increasing the life span of HIV patients from baby to adult. Improving the quality-of-life (QoL) in children living with HIV is a priority of HIV management in children and caregivers of children living with HIV have important roles. Caregiver stigma, caregiver burden, and caregiver coping affect caregivers in treating children living with HIV.

Objective

Analyzing the association of caregiver stigma, caregiver burden, and caregiver coping on QoL of Indonesian children living with HIV.

Methods

Participants in this study were caregivers of Indonesian children living with HIV. Participants were measured for caregiver stigma, caregiver burden, caregiver coping, and QoL of Indonesian children living with HIV. The instrument used in measuring caregiver stigma was people living with HIV/AIDS and caregiver questionnaire, caregiver burden used Zarit Burden questionnaire, caregiver coping used F-COPES questionnaire, and QoL used PedsQL for children aged 2-18 years old. Measurement data were analyzed using logistic regression and independent t tests with P<0.05.

Results

Indonesian children living with HIV in this study had an average age of 7.7±3.68 years and average participant age of 40.2±11.26 years. All participants stated that Indonesian children living with HIV tend to keep their health status confidential. Most QoL of Indonesian children living with HIV was good (71.7%), caregiver stigma value was 21.7±2.06, and caregiver burden level was moderate, of 50.9%. However, there was no significant association between caregiver stigma (β=0.064; P=0.548) and burden level (β=0.058; P=0.593) on QoL. On the other hand, caregiver coping value was 77.2±7.30, and there was a significant association of caregiver coping on QoL (β=-0.196; P=0.049).

Conclusion

There is an association of caregiver coping on QoL of Indonesian children living with HIV, in which the higher the caregiver coping, the lower the QoL. Meanwhile, there is no significant association of caregiver stigma and burden on QoL of Indonesian children living with HIV.

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.

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..

Agricultural and Finance Intervention Increased Dietary Intake and Weight of Children Living in HIV-Affected Households in Western Kenya

We tested whether a multisectoral household agricultural and finance intervention increased the dietary intake and improved the nutritional status of HIV-affected children. Two hospitals in rural Kenya were randomly assigned to be either the intervention or the control arm. The intervention comprised a human-powered water pump, microfinance loan for farm commodities, and training in sustainable farming practices and financial management. In each arm, 100 children (0-59 mo of age) were enrolled from households with HIV-infected adults 18-49 y old. Children were assessed beginning in April 2012 and every 3 mo for 1 y for dietary intake and anthropometry. Children in the intervention arm had a larger increase in weight (β: 0.025 kg/mo, P = 0.030), overall frequency of food consumption (β: 0.610 times · wk-1 · mo-1, P = 0.048), and intakes of staples (β: 0.222, P = 0.024), fruits and vegetables (β: 0.425, P = 0.005), meat (β: 0.074, P < 0.001), and fat (β: 0.057, P = 0.041). Livelihood interventions have potential to improve the nutrition of HIV-affected children. This trial was registered at clinicaltrials.gov as NCT01548599.

Associations between young children's exposure to household violence and behavioural problems: Evidence from a rural Kenyan sample

Little is known about how young children in low- and middle-income countries (LMICs) experience violence in their homes, and how different types of household violence may affect child development. This study reports on levels of exposure to household violence and associations with child behavioural outcomes in preschool-aged children in western Kenya. A sample of 465 caregivers, whose children (n = 497) attended early learning centres supported by an international NGO, were enrolled in the study. Caregivers reported on exposure to intimate partner violence (IPV), household discipline practices, attitudes about gender roles, and child behavioural outcomes. Multivariable analysis showed significant predictive effects of IPV (regression coefficient = 1.35, SE = 0.54, p = 0.01) and harsh psychological child discipline (regression coefficient = 0.74, SE = 0.22, p = 0.001), but not physical discipline (regression coefficient = 0.42, SE = 0.24, p = 0.08), on worse child behavioural problems. These findings indicate that child exposure to violence in different forms is highly prevalent, and associated with poorer outcomes in young children. Community-based programmes focused on parenting and early child development are well-positioned to address household violence in LMIC settings, but must be supported to provide a broader understanding of violence and its immediate and long-term consequences.

Neurodevelopmental and behavioural outcomes of HIV-exposed uninfected and HIV-unexposed children at 2-3 years of age in Cape Town, South Africa

Successful vertical HIV transmission prevention programmes (VTP) have resulted in an expanding population of HIV-exposed uninfected (HEU) infants whose growth, health and neurodevelopmental outcomes could have consequences for future resource allocation. We compared neurodevelopmental and behavioural outcomes in a prospective cohort of 2-3 year old HEU and HIV-unexposed uninfected (HU) children.Women living with and without HIV and their infants were enrolled within three days of birth from a low-risk midwife obstetric unit in Cape Town, South Africa during 2012 and 2013, under WHO Option A VTP guidelines. HIV-uninfected children aged 30-42 months were assessed using the Bayley scales of Infant Development-Third edition (BSID) and Strengths and Difficulties questionnaire (SDQ).Thirty-two HEU and 27 HU children (mean birth weight 3048g vs 3096g) were assessed. HEU children performed as well as HU children on BSID cognitive, language and motor domains. Mean scores fell within the low average range. Mothers of HEU children reported fewer conduct problems but stunting was associated with increased total difficulties on the SDQ.HEU and HU children's performance on the BSID was similar. In this low-risk cohort, HIV exposure did not confer additional risk. Stunting was associated with increased behavioural problems irrespective of HIV exposure.

The effect of the Hambisela programme on stress levels and quality of life of primary caregivers of children with cerebral palsy: A pilot study

BACKGROUND

Caregivers of children with cerebral palsy (CP) are at risk of having high stress levels and poor quality of life (QOL) which could have a detrimental effect on themselves and their children. Taking caregivers' well-being into consideration is therefore important when providing rehabilitation to children with CP. Interventions to mediate primary caregiver stress and QOL using an educational tool have not been tested in this population in South Africa.

OBJECTIVES

The aim of this study was to determine the effect of a group-based educational intervention, Hambisela, on stress levels and QOL of primary caregivers of children with CP in Mamelodi, a township in Gauteng, South Africa.

METHOD

Eighteen primary caregivers of children with CP participated in a quasi-experimental pretest-post-test pilot study. Hambisela, a group-based educational intervention, was carried out once a week over 8 consecutive weeks. Caregiver stress and QOL were assessed before and after the intervention using the Parenting Stress Index-Short Form (PSI-SF) and the Paediatric Quality of Life-Family Impact Module (PedsQL^TM-FIM). Sociodemographic information was assessed using a demographic questionnaire. The Gross Motor Function Classification System (GMFCS) was used to assess the gross motor level of severity of CP in the children.

RESULTS

Data were collected for 18 participants at baseline and 16 participants at follow-up. At baseline, 14 (87.5%) participants had clinically significant stress which reduced to 11 (68.8%) at follow-up. There was no significant change in primary caregiver's stress levels (p = 0.72) and QOL (p = 0.85) after the Hambisela programme. Higher levels of education were moderately associated with lower levels of primary caregiver stress (r = -0.50; p = 0.03).

CONCLUSION

Most primary caregivers in this pilot study suffered from clinically significant stress levels. Hambisela, as an educational intervention, was not effective in reducing the stress or improving the QOL in these primary caregivers of children with CP. Future studies with a larger sample size are needed to investigate the high stress levels of primary caregivers of children with CP.

CLINICAL IMPLICATIONS

Rehabilitation services for children with disabilities should include assessments to identify caregivers with high stress levels. Holistic management programmes should also include care for the carers.

Prevalence and factors associated with emotional and behavioural difficulties among children living with HIV in Malawi: a cross-sectional study

BACKGROUND

Approximately 84,000 children under the age of 15 years are living with HIV in Malawi. Although the survival rate of children living with HIV in Malawi has improved due to the increased availability of antiretroviral medications, these children continue to experience numerous challenges negatively impacting on their mental health. The aim of this study was to investigate the prevalence of, and factors associated with, emotional and behavioural difficulties in children aged between 6 and 12 years living with HIV in Malawi.

METHODS

A random sample of 429 primary caregivers of children living with HIV drawn from the three main administrative regions of Malawi was recruited in a cross-sectional study. They completed a questionnaire about family socio-demographic characteristics, HIV disclosure, and child demographic and clinical characteristics, as well as the Strengths and Difficulties Questionnaire, Life Stress Scale, Support Function Scale, and Impact on Family Scale which were pre-tested and translated into the local Chichewa language. Data were analysed using descriptive statistics and logistic regression.

FINDINGS

Using the newer band categorisations of the Strengths and Difficulties Questionnaire, parent version, 31% of primary caregivers reported that their child had a slightly raised to very high level of total difficulties. Factors that were associated with difficulties were: primary caregivers' young age (adjusted odds ratio [aOR] 3.6; 95% confidence interval [CI]: 1.4-9.5); low level of education (aOR 2.6; 95% CI: 1.2-5.7); lack of employment (aOR 2.7; 95% CI: 1.2-5.9); the report of a substantial impact of the child's illness on the family (3.1; 95% CI: 1.5-6.5); and a low level of family functional support (aOR 2.0; 95% CI: 1.1-4.1). Neither non-disclosure of HIV status nor any of the child demographic or clinical factors were significant in multivariate analysis (p > .0.05).

CONCLUSION

Close to one-third of children living with HIV in this study had high scores indicative of emotional and behavioural difficulties. Emotional and behavioural difficulties in children living with HIV were associated with family demographic and psychosocial factors, but not HIV disclosure. Effective policies and programs that promote the mental wellbeing of children living with HIV in Malawi are indicated.

Predictors of treatment failure, time to switch and reasons for switching to second line antiretroviral therapy in HIV infected children receiving first line anti-retroviral therapy at a Tertiary Care Hospital in Ethiopia

Background

Treatment failure and delay in switching to second line regimen are major concerns in the treatment of HIV infected children in a resource limited setting. The aim of this study was to determine the prevalence and predictors of first line antiretroviral therapy (ART) regimen failure, reasons and time taken to switch to second line antiretroviral (ARV) medications after treatment failure among HIV-infected children.

Methods

A retrospective cohort study was conducted February 2003 to May 2018 in HIV-clinic at Tikur Anbessa Specialized Hospital (TASH), Ethiopia. All HIV infected children ≤15 years of age and who were taking first line ART for at least 6 months were included. Data abstraction format was used to collect the data from patients’ chart and registry. Binary and multivariable logistic regression statistics were used.

Results

Out of 318 enrolled HIV-infected children, the prevalence of treatment failure was found to be 22.6% (72/318), among these 37 (51.4%) had only immunologic failure, 6 (8.3%) had only virologic failure and 24 (33.3%) had both clinical and immunological failure. The mean time taken to modify combination antiretroviral therapy (cART) regimen was 12.67 (4.96) weeks after treatment failure was confirmed. WHO Stage 3 and 4 [Adjusted Odds Ratio (AOR), 3.64, 95% CI 1.76–7.56], not having both parents as primary caretakers [AOR, 2.72 95% CI, 1.05–7.06], negative serology of care takers [AOR, 2.69 95% CI, 1.03–7.03], and cART initiation at 11 month or younger were predicting factors of treatment failure. Of the 141 (47.9%) children who had regimen switching or substitution, treatment failure (44.4%) and replacement of stavudine (d4T) (30.8%) were major reasons. Only 6.6% patients had received PMTCT service.

Conclusion

One fifth of the patients had experienced treatment failure. Advanced WHO stage at baseline, not being taken care of by mother and father, negative sero-status caretakers, and younger age at initiation of cART were the predictors of treatment failure. PMTCT service uptake was very low. There was a significant time gap between detection of treatment failure and initiation of second line cART. Half of the patients encountered regimen switching or substitution of cART due to treatment failure and replacement of stavudine (d4T).

Validation of an HIV/AIDS Stigma Measure for Children Living with HIV and Their Families

BACKGROUND

There are few validated tools to measure stigma, particularly among children living with HIV and their families.

METHODS

This study was nested within a larger study that followed 240 child-caregiver dyads (children aged 10-15 years) at 8 clinics in western Kenya. The stigma instrument was administered to all child-caregiver dyads at 2 time points 6 months apart. The primary end point was to construct validity assessed by comparison to criterion constructs using generalized estimating equation models.

RESULTS

Mean age of child participants was 12.3 years and 52% were female. Generally, caregivers reported experiencing higher levels of HIV stigma compared to their children. Children (9%) and caregivers (14%) reported that HIV stigma made them feel stressed, anxious, and depressed. Child and caregiver stigma items showed high construct validity by emotional and behavioral outcomes.

CONCLUSIONS

The stigma instrument showed high validity when compared to emotional and behavioral outcomes.

Early Childhood Development in Children Born to HIV-Infected Mothers: Perspectives From Kenyan Clinical Providers and Caregivers

Objective. To understand the perspectives of clinical providers and caregivers regarding early childhood development (ECD) in children born to HIV-infected mothers in Kenya. Methods. This was a qualitative study of provider and caregiver perspectives on ECD at 5 Kenyan HIV clinics, using semistructured interviews and focus group discussions. Constant comparison and triangulation methods were employed to elucidate the concepts of ECD. Results. Twenty-five providers and 67 caregivers participated. While providers understood ECD in terms of milestones, caregivers strongly equated ECD with physical growth. Factors affecting ECD, such as nutrition, perinatal effects, and illness, were perceived differently by providers and caregivers. Both groups generally believed that HIV-infected children would have typical ECD if adherent to their HIV treatment. Conclusions. Important considerations regarding ECD in this population were uncovered. Understanding provider and caregiver perspectives’ on ECD in HIV-exposed children is critical for promoting ECD in this community.

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).

The Strengths and Difficulties Questionnaire (SDQ) in Africa: a scoping review of its application and validation

BACKGROUND

Child and adolescent mental health in Africa remains largely neglected. Quick and cost-effective ways for early detection may aid early intervention. The Strengths and Difficulties Questionnaire (SDQ) is globally used to screen for mental health problems, but little is known about its use in Africa. We set out to perform a scoping review to examine existing studies that have used the SDQ in Africa.

METHODS

A comprehensive scoping review methodology was used to identify all peer-reviewed studies ever published that have used the SDQ in Africa. Data were extracted and analysed to assess the countries, languages and SDQ versions used, the purpose of the SDQ studies, psychometric properties of the SDQ, and to consider knowledge gaps for future in-country and cross-country studies.

RESULTS

Fifty-four studies from 12 African countries were identified, most from South Africa. Many different languages were used, but authorized SDQs in those languages were not always available on the SDQinfo website. Authors frequently commented on challenges in the translation and backtranslation of mental health terminology in African languages. The SDQ was typically used to investigate internalisation/externalization disorders in different clinical populations, and was most frequently used in the evaluation of children and adolescents affected by HIV/AIDS. Sixteen studies (29.6%) administered the SDQ to participants outside the intended age range, only 4 (7.4%) used triangulation of all versions to generate assessments, and eight studies (14.8%) used only subscales of the SDQ. Only one study conducted thorough psychometric validation of the SDQ, including examination of internal consistency and factor analysis. Where 'caseness' was defined in studies, UK cut-off scores were used in all but one of the studies.

CONCLUSIONS

The SDQ may be a very useful tool in an African setting, but the scoping review suggested that, where it was used in Africa researchers did not always follow instrument guidelines, and highlighted that very little is known about the psychometric properties of the SDQ in Africa. We recommend comprehensive evaluation of the psychometric properties of the SDQ in various African languages, including internal consistency, factor structure, need for local cut-off values and ensuring cultural equivalence of the instrument.