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

HIV status disclosure and antiretroviral therapy adherence among children in Masaka region, Uganda

HIV-infected children are now living into adolescence and early adulthood in large numbers due to the availability and increased use of antiretroviral therapy (ART). However, receipt of HIV status disclosure among children remains low. We assessed the association between disclosure of HIV status and adherence to ART among children in the Masaka region of Uganda using multivariable logistic regression with generalised linear models with Poisson log-link function and robust variance in Stata software version 15.1. Data were collected from 524 assenting children aged 12-17 years between March and December 2020. Results show that, although not statistically significant, children who received disclosure of their HIV status reported improved ART adherence compared to children with no disclosure. Out-of-school children with post-primary education and children on first-line ART regimens were significantly more likely to report improved ART in both crude and adjusted analyses. Innovative interventions to promote progressive disclosure of HIV status to children on ART, in school, are needed to improve their ART adherence. There is also a need to evaluate the suitability of current counselling interventions provided to children being switched to second-line ART regimens to delay the need for third-line ART regimens.

Pediatrics HIV-positive status disclosure and its predictors in Ethiopia: a systematic review and meta-analysis

Introduction

HIV-positive status disclosure for children is challenging for family members, guardians, and healthcare professionals. Disclosure is very challenging, particularly for children, yet no systematic synthesis of evidence accurately measures HIV-positive status disclosure in children. This systematic review and meta-analysis study aimed to quantify the national prevalence of pediatric HIV-positive status disclosure in Ethiopia and identify factors associated with HIV-positive status disclosure.

Method

We systematically searched PubMed, EMBASE, Web of Science databases, and google scholar for relevant published studies. Studies published in the English language and conducted with cohort, case-control, and cross-sectional designs were eligible for the review. The primary and secondary outcomes of the study were HIV-positive status disclosure and factors associated with HIV-positive status disclosure, respectively. The quality of the included studies was assessed using the Joanna Briggs Institute critical appraisal tools. A random effect- model was used to estimate the pooled prevalence of HIV-positive status disclosure. Heterogeneity and publication bias of included studies was determined using I² and Egger's test, respectively.

Result

From 601 records screened, nine relevant studies consisting of 2,442 HIV-positive children were included in the analysis. The overall pooled prevalence of HIV-positive status disclosure among children living with HIV/AIDS in Ethiopia was 31.2% (95% CI [23.9-38.5]). HIV-negative status of caregivers (AOR: 2.01; 95% CI [1.28-3.18]), long duration on ART (greater than 5 years) (AOR: 3.2; 95% CI [1.77-5.78]) and older age of the child (>10 years) (AOR: 7.2; 95% CI [4.37-11.88]) were significantly associated with HIV-positive status disclosure.

Conclusion

Low prevalence of pediatric HIV-positive status disclosure was observed in Ethiopia. The longer duration of ART, the HIV-negative status of the caregiver, and older age greater than 10 years were the predictors of pediatric HIV-positive status disclosure. Health system leaders and policymakers shall design training and counseling programs for healthcare professionals and caregivers to enhance their awareness about HIV-positive status disclosure.

Trial registration

This review was registered under PROSPERO and received a unique registration number, CRD42019119049.

Living With a Stigmatized Identity; Perceptions of Disclosure, Coping, and Medication Adherence Among Adolescent Boys and Young Men in Chiredzi-Zimbabwe

There is limited research on adolescent boys and young men (ABYM)'s initial and onward HIV seropositive status disclosure, coping strategies and treatment adherence journeys especially in Zimbabwe. This qualitative exploratory study employed in-depth individual interviews at Chiredzi General Hospital in Zimbabwe to explore the dynamics of disclosure, coping and treatment adherence among ABYM. Twenty-one HIV positive ABYM with ages ranging from 14 to 21 were recruited from their scheduled visit to collect medication at the hospital. Findings indicate that ABYM disclosure journeys began with shock, confusion or misunderstanding and ended in a positive life outlook. Treatment adherence among ABYM was very poor due to poverty, erratic food supply, feeling sick after taking medication, forgetfulness and the public nature of medication collection centers. The study concluded that ABYM maintained secrecy in order to be accepted by their peers but also to protect themselves from stigma and isolation.

Telling Children with Perinatal HIV About Their HIV Serostatus: Healthcare Workers' Practices and Barriers to Disclosing in a South African Rural Health District

In South Africa, caregivers and healthcare workers (HCWs) lack confidence and skills to disclose to children with perinatal HIV (PHIV). Moreover, existing disclosure guidelines do not provide strategies on how to approach disclosure. Although the caregiver has been endorsed as a responsible person to disclose to the child, the involvement of HCWs in the process is critical. Yet research suggests that many HCWs are reluctant to perform disclosure. This study examines the involvement in, practices of, and barriers against HCWs’ disclosing to children with PHIV.

Truth, Deception, and Coercion; Communication Strategies Used by Caregivers of Children with Perinatally Acquired HIV During the Pre-Disclosure and Post-Disclosure Period in Rural Communities in South Africa

Typically, children with perinatal HIV (PHIV) receive antiretroviral treatment (ART) for a long time prior to receiving disclosure. Communication with children about HIV and treatment is critical for monitoring adherence and retention in care. However, there is a dearth of information on communication between caregivers and their children. This study examines what and how caregivers tell their their children about their illness and medication in the pre-disclosure and post-disclosure period. A qualitative study using semi-structured one-on-one interviews and focus group discussions was conducted with caregivers recruited via purposive sampling from a rural sub-district in South Africa. The interviews were analyzed using thematic analysis. The sample consisted of 38 caregivers, 24 of whom were the children's biological mothers, 20 had disclosed to the children and 18 had not done so. Caregivers who had disclosed had told their children the truth and named the disease as HIV, but communication about HIV was infrequent and focused on pill taking. Those who had not disclosed had lied, deflected illness-related information, and attributed the children's ill health to co-morbid conditions. To enforce adherence, most caregivers used coercion and threats of the grave consequences of non-adherence as a communication strategy. Those who had not disclosed used deception, deflecting, and coercion as strategies for coping through the pre-disclosure period. There is a need for healthcare workers to prepare, support, and empower caregivers to develop appropriate responses to children's questions and to understand the implications of deception on future full disclosure and children's acceptance of their HIV status.

Impact of Friendship Bench problem-solving therapy on adherence to ART in young people living with HIV in Zimbabwe: A qualitative study

BACKGROUND

Adolescents and young people globally are highly vulnerable to poor mental health especially depression, and they account for 36% of new HIV infections in Eastern and Southern Africa. HIV services remain inadequate for this population and their adherence to ART is low. The Friendship Bench (FB), an evidence-based model developed in Zimbabwe to bridge the mental health gap, is a brief psychological intervention delivered on benches in primary care facilities by lay health workers ("grandmothers") trained in problem-solving therapy. This study explored the experience of young people living with HIV attending FB, and their perception of how problem-solving therapy impacted their adherence to ART.

METHODS

Semi-structured interviews were conducted in July 2019 with 10 young people living with HIV aged 18-24 years, who had recently completed FB counselling in Harare. Participants were purposively sampled and recruited from three primary care facilities. Interviews were conducted in Shona, audio-recorded, transcribed verbatim and translated into English. Transcripts were analysed in NVivo12 using inductive thematic analysis.

RESULTS

Study findings revealed a clear emotional denial towards HIV, particularly for young people infected perinatally, and a resulting low adherence to ART. The study also unpacked the issues of internal stigma and how young people living with perinatally acquired HIV are informed of their HIV status. Participants reported that FB had a critical role in helping them accept their HIV status. Grandmothers' empathic attitude was key during counselling on adherence to ART, to demystify the disease and treatment, normalize the reality of living with HIV, encourage young people to socialize with peers and free them of guilt. Interviewees unanimously reported improved ART adherence following FB counselling, and many described enhanced health and wellbeing.

CONCLUSION

Participants saw FB as a strong contributor to their general well-being, evident in decreased symptoms of depression and improved adherence to ART. FB problem-solving therapy should be rolled out to further support young people after post-test counselling or HIV serostatus disclosure for perinatally acquired HIV, for acceptance of HIV status and adherence to ART.

The Consequences of Delaying Telling Children with Perinatal HIV About Their Diagnosis as Perceived by Healthcare Workers in the Eastern Cape; A Qualitative Study

Although the benefits of disclosure are considerable, informing children with perinatal HIV of their own HIV status is often delayed to late adolescence. This study examined the social and contextual challenges that influence delaying disclosure to children and assessed the outcomes of delayed disclosure on the psychosocial health of children as perceived by the healthcare workers (HCWs) providing care to these children. Data were collected from HCWs via focus group discussions. Nurses, lay counsellors, social workers, and dieticians were selected from facilities in a rural South African health district. Thematic analysis was performed. The caregivers’ social context was the main barrier against informing children timely about their HIV diagnosis. The extent of the internalised HIV stigma influenced the delay in disclosing to the children. Delaying disclosure contributes to children’s refusing to take their medication, leads to the accidental disclosure of HIV, give rise to anger and resentment towards the caregiver, increase the risk of secondary transmitting of HIV, and poor health outcomes. It is essential to train HCWs to support caregivers and children through the disclosure process to ensure that caregivers realise the benefits of disclosure. Strategies to encourage caregivers to disclose early should be sensitive to their concerns about the negative impacts of disclosure.

Pain, Anger, and the Fear of Being Discovered Persist Long after the Disclosure of HIV Serostatus among Adolescents with Perinatal HIV in Rural Communities in South Africa

Informing adolescents of their HIV serostatus forms part of their HIV care and is a critical step in the transition to adult clinical care services. This article describes the experiences of adolescents with perinatal HIV in regard to disclosure, and examines the impact disclosure has on their emotional health and behaviors. We used a qualitative design to conduct interviews with 21 adolescents aged 12-19 years recruited from a rural district in South Africa. NVivo 10 computer software was used for thematic analyses. All adolescents were aware of their HIV-serostatus. The findings show that delayed disclosure, was a one-time event, and was unplanned. Disclosure occurred at the clinic rather than the adolescent's home. For most adolescents, feelings of anger, pain, sadness, negative perceptions of self, internalized stigma, and denial persisted long after disclosure occurred. They lived in constant fear of having their serostatus being discovered, and they developed a sense of fear of self-disclosure. Their negative emotions undermined treatment adherence. In contrast, other adolescents that described disclosure as a positive event, had accepted their HIV status, and lived similar to other adolescents. The prolonged negative reactions underscore the importance of ongoing post-disclosure interventions for adolescents in rural settings where psychosocial support services are insufficient to address their emotional wellbeing.

Child-Centred Care in HIV Service Provision for Children in Resource Constrained Settings: A Narrative Review of Literature

INTRODUCTION

Child-centred care approaches are increasingly gaining traction in healthcare; and are being applied in the delivery of HIV care for children in resource constrained settings. However, very little is known about their potential benefits.

METHODS

We synthesised literature from primary and secondary publications exploring the philosophical underpinnings of the concept of child-centred care, and its application to HIV service delivery for children in resource constrained settings. We concluded the review by suggesting a conceptual framework for mainstreaming and integrating child-centred care approaches in the management of HIV in resource constrained settings.

RESULTS

The philosophical underpinnings of child-centred care stem from human rights (child-rights), holism, the ecological model, and life-cycle approaches. Although there is no standard definition of child-centred care in the context of HIV, the literature review highlighted several phrases used to describe the "child-centredness" of HIV care for children. These phrases include: (i) Respect for child-healthcare rights. (ii) Using the lifecycle approach to accommodate children of different ages. (iii) Provision of age-appropriate HIV services. (iv) Meaningful participation and inclusion of the child in the healthcare consultation process. (v) Using age-appropriate language to increase the child's understanding during healthcare consultations. (vi) Age-appropriate disclosure. (vii) Primary caregiver (PCG) participation and preparation (equipping the PCGs with information on how to support their children). (viii) Creation of a child-friendly healthcare environment. (ix) Consideration of the child ecological systems to have a holistic understanding of the child. (x) Partnership and collaborative approach between children, PCGs, and healthcare workers (HCWs).

CONCLUSION

Child-centred care approaches can potentially increase child-participation, promote positive health outcomes and resilience in children living with a communicable, highly stigmatised and chronic condition such as HIV. More evidence from controlled studies is required to provide concrete results to support the application of child-centred care approaches in HIV care services.

Child, Caregiver, and Health Care Provider Perspectives and Experiences Regarding Disclosure of HIV Status to Perinatally Infected Children in Lima, Peru

BACKGROUND

Despite recommendations for disclosure of HIV status to children living with HIV (CLHIV), fewer than half of CLHIV at the Instituto Nacional de Salud del Niño (INSN) in Lima, Peru, have had disclosure. How and when the disclosure process for CLHIV should take place in Peru has not been studied.

METHODS

We conducted a qualitative study at INSN to explore perceptions and experiences of 6 health care providers (HCPs), 14 disclosed and nondisclosed CLHIV (8-17 years), and their 14 caregivers regarding knowledge of illness, disclosure of HIV status, and appropriate disclosure approaches.

RESULTS

Disclosed children wanted to be told their diagnosis earlier. Nondisclosed children expressed frustration taking medications. Caregivers and HCPs discussed motivations to disclose, including educating, honesty, improving medication adherence, and preventing secondary transmission.

CONCLUSION

Culturally appropriate guidelines and training for HCPs and caregivers are needed to support disclosure of children's HIV status and ongoing support for CLHIV.

Disclosure of human immunodeficiency virus status to children in South Africa: A comprehensive analysis

Background

The extent of disclosure of HIV status to children and adolescents and the context facilitating their disclosure process have received little attention.

Objectives

To assess disclosure and provide a comprehensive analysis of characteristics associated with disclosure to children (3–14 years) receiving antiretroviral treatment in a South African semi-urban clinic.

Methods

This cross-sectional study used structured interview administered questionnaires which were supplemented with medical record data. Predictors included child, caregiver, clinical and socio-economic characteristics, viral suppression, immune response, adherence, health-related quality of life and family functioning.

Results

We included 190 children of whom 45 (23.7%) received disclosure about their HIV status, of whom 28 (14.7%) were partially disclosed and 17 (8.9%) were fully disclosed. Older age of the child and higher education of the caregiver were strongly associated with disclosure. Female caregivers, detectable viral load, syrup formulation, protease inhibitor (PI) regimens with stavudine and didanosine, and self-reported non-adherence were strongly associated with non-disclosure.

Conclusion

When children do well on treatment, caregivers feel less stringent need to disclose. Well-functioning families, higher educated caregivers and better socio-economic status enabled and promoted disclosure. Non-disclosure can indicate a sub-optimal social structure which could negatively affect adherence and viral suppression. There is an urgent need to address disclosure thoughtfully and proactively in the long-term disease management. For the disclosure process to be beneficial, an enabling supportive context is important, which will provide a great opportunity for future interventions.

Socio-demographic, clinical, and psychosocial factors associated with primary caregivers' decisions regarding HIV disclosure to their child aged between 6 and 12 years living with HIV in Malawi

The World Health Organisation (WHO) recommends that children living with HIV should be informed about their HIV status within the ages of 6 to 12 years using age-appropriate resources. The aim of this study was to assess the socio-demographic, clinical and psychosocial factors associated with primary caregivers’ decisions to disclose HIV to children living with HIV aged 6 to 12 years in Malawi. A cross-sectional study of 429 primary caregivers of children living with HIV were systematically recruited from all regions of the country. Information on HIV disclosure, family and child socio-demographic characteristics, child clinical characteristics, and child and family psychosocial characteristics was collected using validated instruments. Logistic regression was used to analyse data. The prevalence of non-disclosure of HIV status to children was 64 per cent. Concerns about the child’s inability to cope with the news (29%), a lack of knowledge on how to disclose HIV status (19%), and fear of stigma and discrimination (17%) were the main reasons for non-disclosure. On multivariate analysis, the odds of non-disclosure were higher among primary caregivers who were farmers (aOR 3.0; 95% CI: 1.1–8.4), in younger children (6–8 years) (aOR 4.1; 95% CI: 2.3–7.4), in children who were in WHO HIV clinical stage one (aOR 3.8; 95% CI: 1.4–10.2), and in children who were not asking why they were taking ARVs (aOR 2.9; 95% CI: 1.8–4.8). On the other hand, nondisclosure of HIV status was less likely in underweight children (aOR 0.6; 95% CI: 0.3–0.9). Many children living with HIV in Malawi are unaware of their HIV status. Non-disclosure is associated with a number of clinical and demographic characteristics. The findings highlight the need to provide guidance and support to primary caregivers to help them to effectively disclose HIV status to their children.

HIV diagnosis disclosure to infected children and adolescents; challenges of family caregivers in the Central Region of Ghana

BACKGROUND

Disclosure of Human Immunodeficiency Virus (HIV) to infected older children and adolescents is essential for both personal health maintenance and HIV prevention within the larger population. Non-disclosure of HIV status has been identified as one of the potential barriers to optimum adherence especially in children and adolescents. Like many other countries in the SSA region, Ghana has significant number of children and adolescents infected by HIV, who have increased survival times, due to increased access to ART. However, both family caregivers and healthcare workers face an array of challenges with the disclosure process, including the timing, what information about the child's HIV status should be shared with him/her and how to go about it. The aim of the study was to identify family caregiver factors associated with non-disclosure of HIV status to infected children and adolescents accessing Antiretroviral Therapy (ART) at the three main ART sites within the Central Region of Ghana.

METHODS

A quantitative analytical survey was conducted among 103 family caregivers of HIV infected children (aged 6-17 years) assessing ART services in the Central Region of Ghana. Data were analyzed using SSPS version 21.

RESULTS

The age range of caregivers was 20-69 years. The study found a low disclosure rate (23.3%) among caregivers. Majority of the caregivers (80.6%) lacked knowledge on the process of disclosure (how and what to tell child), and majority (64%) also had never received guidance about the disclosure process from their healthcare providers. The main barriers to disclosure were caregiver lack of knowledge regarding the disclosure process and when to disclose, the fear of child's reaction, and fear of stigmatization and associated negative social consequences.

CONCLUSION

These findings suggest a lesser involvement of health care providers in preparing caregivers for the disclosure process. This therefore highlight the need for the National HIV/AIDS/STI Control Program to strengthen the involvement and training of healthcare providers in HIV diagnosis disclosure to infected children, based on context-specific policy guidelines informed by the WHO recommendations.

Breaking Down Barriers to Tell: A Mixed Methods Study of Health Worker Involvement in Disclosing to Children That They Are Living with HIV in Rural South Africa

Disclosing to a child that s/he is living with HIV is necessary to promote adherence to treatment and improve health outcomes. Facilitating disclosure between caregivers and children remains a challenge for health workers. Understanding how health workers are involved in and perceive the disclosure process is integral to engaging with such challenges. We held group discussions with and surveyed 73 physicians, nurses, and counselors across 16 randomly selected facilities in two rural South African health districts, exploring their experiences of supporting disclosure between caregivers and children. Ninety percent of those surveyed agreed that children should be informed of their HIV status. Differences between categories of health workers regarding training, involvement in the disclosure process, and perceived responsibility for disclosure support led to inconsistent disclosure practices within facilities. Disclosure-strengthening interventions must consider the composition of the health worker team and the role that each category of health worker performs in their local settings.

Adolescents' Experiences and Their Suggestions for HIV Serostatus Disclosure in Zambia: A Mixed-Methods Study

Background

HIV serostatus disclosure is an immense challenge for adolescents living with HIV, their caregivers, and health workers. In Zambia, however, little guidance is available from the adolescents’ point of view on the HIV disclosure process.

Objective

This study aimed to examine the setting of HIV serostatus disclosure for adolescents, its impacts on them, and their suggestions on the best practice of HIV disclosure.

Methods

We conducted a mixed-methods study at the University Teaching Hospital in Zambia from April to July 2014. We recruited 200 adolescents living with HIV, aged 15–19 years. We collected data using a structured questionnaire including two open-ended questions. We excluded two adolescents due to withdrawal during the survey, and eight from the data set due to out-of-eligibility criteria in age. Eventually, we included 190 in the analysis. We performed descriptive analysis to calculate the distributions of basic characteristics of the adolescents, their experience and preference on HIV serostatus disclosure, its emotional and behavioral impacts, and health education topics they had ever learned at hospital. We performed thematic analysis with open-ended data to explain first impressions upon disclosure in detail and to determine perceived advantages of HIV serostatus disclosure.

Results

The majority of adolescents recommended the age of 12 as appropriate for adolescents to learn about their HIV serostatus and preferred disclosure by both parents. Out of 190 adolescents, 73.2% had negative or mixed feelings about HIV serostatus disclosure, while 86.2% reported that disclosure was beneficial. Thematic analyses showed that the adolescents reacted emotionally due to an unexpected disclosure and a belief of imminent death from HIV. However, they improved adherence to treatment (84.7%), limited self-disclosure of their HIV serostatus to others (81.1%), and felt more comfortable in talking about HIV with their caregivers (54.2%). Thematic analysis identified perceived benefits of disclosure as follows: better understanding of their sickness and treatment, and improved self-care and treatment adherence. Lower percentage of the adolescents have learned about psychosocial well-being, compared to facts about HIV and treatment.

Conclusion

Despite initial emotional distress experienced after the disclosure, knowing one’s own HIV serostatus was found to be a crucial turning point for adolescents to improve motivation for self-care. HIV serostatus disclosure to adolescents requires follow-up support involving parents/primary caregivers, health workers, and peers.

Caregivers Lack of Disclosure Skills Delays Disclosure to Children with Perinatal HIV in Resource-Limited Communities: Multicenter Qualitative Data from South Africa and Botswana

To promote the appropriate implementation of procedures for health disclosure to children, it is important to understand the reasons why caregivers delay the disclosure of healthcare information to children. This paper explored the views of caregivers on what makes disclosure to children with perinatal acquired HIV (PAH) difficult and what could make disclosure in these cases easier. Data were collected using focus group interviews with caregivers who were purposely selected from a multicenter study conducted in Botswana and South Africa. Forty-seven nondisclosed caregivers of children between 5 and 18 years who were receiving ART were interviewed. Caregivers felt that children should be told of their HIV-positive status despite the fact that none had disclosed this information to the children. The caregivers reported lack of disclosure skills but believed they were primarily responsible for disclosure to children and required support from healthcare workers (HCWs) during the disclosure process. They believed that counseling on how to approach disclosure and training on when and how to disclose will make the disclosure process easier. HCWs have a crucial role to play in promoting disclosure to perinatally infected children. The development of appropriate disclosure guidelines and training for HCWs will facilitate disclosure to children.

"Experiences with disclosure of HIV-positive status to the infected child": Perspectives of healthcare providers in Dar es Salaam, Tanzania

Background

The specific age to which an HIV infected child can be disclosed to is stipulated to begin between ages 4 and 6 years. It has also been documented that before disclosure of HIV positive status to the infected child. Health care providers should consider children’s cognitive-developmental ability. However, observation and situation analysis show that, health care providers still feel uncomfortable disclosing the HIV positive status to the infected child. The aim of the study was to explore healthcare providers’ experiences in disclosure of HIV-positive status to the infected child.

Methods

A qualitative study involving 20 health care providers who attend HIV-positive children was conducted in September, 2014 in Dar es Salaam, Tanzania. Participants were selected from ten HIV care and treatment clinics (CTC) by purposive sampling. An interview guide, translated into participants’ national language (Kiswahili) was used during in-depth interviews. Sampling followed the principle of data saturation. The interviews focused on perspectives of health-care providers regarding their experience with paediatric HIV disclosure. Data from in-depth interviews were transcribed into text; data analysis followed qualitative content analysis.

Results

The results show how complex the process of disclosure to children living with HIV can be to healthcare providers. Confusion was noted among healthcare providers about their role and responsibility in the process of disclosing to the HIV infected child. This was reported to be largely due to unclear guidelines and lack of standardized training in paediatric HIV disclosure. Furthermore, healthcare providers were concerned about parental hesitancy to disclose early to the child due to lack of disclosure skills and fear of stigma. In order to improve the disclosure process in HIV infected children, healthcare providers recommended further standardized training on paediatric HIV disclosure with more emphasis on practical skills and inclusion of disclosure content that is age appropriate for children with HIV.

Discussion

The disclosure process was found to be a complex process. Perspectives regarding disclosure in children infected with HIV varied among healthcare providers in terms of their role in the process, clear national guidelines and appropriate standardized training for paediatric disclosure. Consistent with other studies, healthcare providers reported difficulties during disclosure because parents /guardians largely fear blame, social stigma, child's negative emotional reaction when disclosed to and have concerns about the child being too young and immature to understand the HIV condition.

Conclusions

In order to prevent inconsistencies during the disclosure process, it is important to have in place clear guidelines and standardized paediatric HIV disclosure training for healthcare providers. This would help improve their skills in paediatric disclosure, leading to positive health outcomes for children infected with HIV.

Caring for HIV-positive orphans in the context of HIV and AIDS: perspectives of Botswana grandmothers

BACKGROUND

Botswana has a human immunodeficiency virus (HIV) prevalence of 18.6% and an estimated 137 805 orphans in a population of approximately two million people. Many of these orphans are cared for by their grandmothers, who struggle with caring for orphans suffering from a disease they know very little about.

METHODS

The purpose of this exploratory qualitative study was to explore experiences of grandmothers caring for HIV-positive orphan grandchildren.

RESULTS

The ages of the grandmothers interviewed ranged from 60 to 80 years, while the number of orphans under their care ranged from one to nine. The themes that emerged included the following: challenges of HIV treatment, HIV-related stigma, disclosure of HIV status, communication of sexuality issues and the adolescent pregnancies. Cultural beliefs prevented them from talking about sexuality and in some cases, accepting HIV as the cause of death.

CONCLUSIONS

Grandmothers were challenged by HIV treatment of orphans and their supportive role as caregivers. The lack of knowledge of the disease must be addressed to improve adherence and communication about HIV. HIV programs need to address older persons' dynamic and diverse needs as individuals. Community home-based care nurses need to support grandmothers caring for HIV-positive grandchildren and refer them to relevant professionals who can assist with the care responsibilities.

IMPLICATIONS FOR PRACTICE

Nurses working with older people caring for HIV positive orphans need to develop culturally sensitive HIV education programs that address needs specific to.

A model of caregiver paediatric HIV disclosure decision-making

Many of the over 3 million HIV-positive children will only be told of their status as adolescents. Knowing one's status may increase treatment adherence, reduce onward HIV transmission, increase trust in caregivers and maximise available support. Yet deciding whether, what, how and when to tell HIV-positive children about their condition is challenging for caregivers. We systematically review HIV disclosure theories before presenting a process model of caregiver paediatric HIV disclosure decision-making. The model, consisting of both a pre-intention and a post-intention stage, integrates individual and contextual determinants. It aims to be situationally specific, broadly applicable and consistent with the empirical literature. Research and practice implications are discussed.

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

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

"I don't feel shy because I will be among others who are just like me…": The role of support groups for children perinatally infected with HIV in Zimbabwe

As access to paediatric antiretroviral therapy (ART) continues to improve in sub-Saharan Africa, a new historically specific cohort of HIV-perinatally infected children surviving into adolescent has emerged. Although remarkable successes have been made clinically in keeping this cohort alive and in reasonable health, their social support experiences are still unknown. The research being reported here sought to explore peer social support experiences of HIV-perinatally infected children in Harare, Zimbabwe. In this article, we draw on 56 repeat in-depth interviews (IDIs) conducted in three phases and two focus group discussions (FGDs) with HIV-infected children (11-13 years). Additional interviews were held with 10 carers. Study findings suggested that both children and carers perceive support groups as a safe social space for learning and acquiring HIV information as well as gaining confidence. Additionally, findings highlighted the importance of consistency of participation. Structural and personal barriers to access and participation in support group were also identified. We conclude that support groups are a useful resource for HIV-infected children and therefore should be supported by stable funding.

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

Background

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

Methods

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

Results

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

Conclusions

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