HIV-positive mothers' disclosure of their serostatus to their young children: a review

Chinese Mothers' Intent to Disclose Their HIV Status to Their Children: The Role of Positive Outcome Expectations and Reward Responsiveness

Objective: The current study investigated the role of positive outcome expectations and reward responsiveness in intention to disclose HIV status to children among women living with HIV in China. The moderating role of reward responsiveness was also explored. Method: A 1-year longitudinal survey was conducted. 269 women living with HIV who had at least one child aged >5 years and had not yet disclosed their HIV status to their oldest child were selected from a larger sample of women living with HIV at baseline, with a total of 261 respondents completing the follow-up survey. Results: After adjusting for significant socio-demographic and medical variables, positive outcome expectations positively predicted mothers' intention to disclose HIV, while reward responsiveness had a negative effect. A moderation effect of reward responsiveness was found, with further analysis showing that reward responsiveness has strengthened the relationship between positive outcome expectations and intention to disclose HIV. Conclusion: Findings support the relevance of positive outcome expectations and reward responsiveness to intention of disclosure among women living with HIV in China.

Motivators and Barriers for Parents to Disclose their HIV Status to Children

Disclosure to children has been identified as one of the main challenges for parents living with HIV (PLH). The aim of this study was to qualitatively explore motivators, barriers, and the process of parental disclosure in a Zimbabwean community with high HIV prevalence. A total of 28 PLH participated in three focus groups comprising PLH who had disclosed their HIV status to their children (n = 11), PLH who had not disclosed to their children (n = 7), and the third group contained PLH who both had and had not disclosed their status (n = 10). Full, partial and indirect disclosure approaches were used by parents. Barriers to disclosing included the children being "too young" and lacking understanding of HIV as well as inability to maintain confidentiality around parents' status, 2) causing the child to worry, 3) being embarrassed, and 4) fearing that disclosure would prompt a child to treat a parent with disrespect. Motivators included 1) support of various kinds from their children, 2) educating their children around HIV risk, and 3) facilitating discussions about parental illness and death. Our findings suggest that understanding the barriers to disclosure is likely insufficient for supporting and promoting parental disclosure. The motivation for disclosure, support for the disclosure process, and culturally relevant interventions are needed to promote and support parental disclosure.

Psychosocial interventions for improving engagement in care and health and behavioural outcomes for adolescents and young people living with HIV: a systematic review and meta-analysis

INTRODUCTION

Adolescents and young people comprise a growing proportion of new HIV infections globally, yet current approaches do not effectively engage this group, and adolescent HIV-related outcomes are the poorest among all age groups. Providing psychosocial interventions incorporating psychological, social, and/or behavioural approaches offer a potential pathway to improve engagement in care and health and behavioural outcomes among adolescents and young people living with HIV (AYPLHIV).

METHODS

A systematic search of all peer-reviewed papers published between January 2000 and July 2020 was conducted through four electronic databases (Cochrane Library, PsycINFO, PubMed and Scopus). We included randomized controlled trials evaluating psychosocial interventions aimed at improving engagement in care and health and behavioural outcomes of AYPLHIV aged 10 to 24 years.

RESULTS AND DISCUSSION

Thirty relevant studies were identified. Studies took place in the United States (n = 18, 60%), sub-Saharan Africa (Nigeria, South Africa, Uganda, Zambia, Zimbabwe) and Southeast Asia (Thailand). Outcomes of interest included adherence to antiretroviral therapy (ART), ART knowledge, viral load data, sexual risk behaviours, sexual risk knowledge, retention in care and linkage to care. Overall, psychosocial interventions for AYPLHIV showed important, small-to-moderate effects on adherence to ART (SMD = 0.3907, 95% CI: 0.1059 to 0.6754, 21 studies, n = 2647) and viral load (SMD = -0.2607, 95% CI -04518 to -0.0696, 12 studies, n = 1566). The psychosocial interventions reviewed did not demonstrate significant impacts on retention in care (n = 8), sexual risk behaviours and knowledge (n = 13), viral suppression (n = 4), undetectable viral load (n = 5) or linkage to care (n = 1) among AYPLHIV. No studies measured transition to adult services. Effective interventions employed various approaches, including digital and lay health worker delivery, which hold promise for scaling interventions in the context of COVID-19.

CONCLUSIONS

This review highlights the potential of psychosocial interventions in improving health outcomes in AYPLHIV. However, more research needs to be conducted on interventions that can effectively reduce sexual risk behaviours of AYPLHIV, as well as those that can strengthen engagement in care. Further investment is needed to ensure that these interventions are cost-effective, sustainable and resilient in the face of resource constraints and global challenges such as the COVID-19 pandemic.

Chinese mothers' intent to disclose the HIV status to their children: the role of outcome expectations and self-efficacy

The present study examined the association between outcome expectations, self-efficacy, and intention to disclose HIV status to children among HIV-positive women in China, and the moderating and mediating role of self-efficacy on the association between outcome expectations and intention to disclose. A cross-sectional survey was conducted among 179 HIV-positive mothers who had at least one living child aged >5 years and had not yet disclosed their HIV status to her oldest child. Results from hierarchical regressions revealed that after adjusting for socio-demographic and medical variables, negative outcome expectations had a negative association (β = -0.22), while disclosure self-efficacy had a positive association (β = 0.43) with an intention to disclose HIV. The moderation effect of self-efficacy on the association between outcome expectations and intention to disclose HIV was not significant. Results from structural equation modeling showed that self-efficacy mediated the association between negative/positive outcome expectations and intention to disclose HIV. Findings support the importance of outcome expectations and self-efficacy and also the mediating role of self-efficacy in HIV disclosure among HIV-positive mothers in the Chinese context.

Personal and Network-Related Factors Associated to Diagnosis Disclosure Reactions for Children and Adolescents Living with HIV

The process of human immunodeficiency virus (HIV) diagnosis disclosure for vertically infected young people living with HIV has proven decisive for acceptance/adherence to treatment. Herein, we present a cross-sectional study aiming at evaluating how individual and network related variables are associated with reactions to HIV disclosure among them. We used the egocentric approach with a structured questionnaire applied to individuals aged 15-25 years in an HIV referral center in Rio de Janeiro, Brazil. Outcome variable referred to adoption or not of risk behavior after diagnostic disclosure, was classified as "good"/"bad" reactions. Results showed that, of the 80 study participants, 25% reported a "bad reaction" to diagnostic disclosure, an outcome that was more common for patients with at least one friend in their social support network (OR 4.81; 95%CI [1.05-22.07]). In conclusion, a "bad reaction" to HIV serological disclosure may be associated with inadequate structure of the individual's social support network.

A Mixed-Methods Longitudinal Investigation of Mothers' Disclosure of HIV to Their Children

Mothers living with HIV (MLH) must navigate disclosing their serostatus to their children, but the longitudinal impact on families remains unknown. This study examined HIV disclosure, parenting, parenting stress, and child adjustment among 174 MLH-child dyads (aged 6-14; 35% Latinx; 57% Black/African American). Quantitative data were collected over four waves spanning 15 months. Qualitative data were collected with 14 families in which disclosure had occurred. Latent change score modeling revealed that disclosure led to improvements in parenting stress, communication, and relationship quality. Disclosure did not predict child adjustment. Qualitative themes contextualized these findings, revealing stability and improvements in family functioning. MLH should be supported in disclosing their serostatus to their children to minimize parenting stress and bolster parenting skills.

HIV-positive status disclosure and associated factors among children in public health facilities in Dire Dawa, Eastern Ethiopia: A cross-sectional study

INTRODUCTION

HIV status disclosure in children is one of acontroversial issue in current health. Over 44,000 children in Ethiopia were living with HIV in the year 2019 with a variable level of disclosure, which ranges from 16.3% to 49%. Therefore, this study aimed to assess HIV-positive status disclosure and associated factors among HIV-infected children.

METHODS

A cross-sectional study was conducted in ten public health facilities providing pediatric antiretroviral therapy services. Systematic random sampling was used to select 221 caregivers of children aged 6-15 years. Face-to-face interviews were employed to generate the data. Binary logistic regression was used to analyze the association between HIV-positive status disclosure to children and independent variables with statistical significance set at p-value <0.05.

RESULTS

Out of the total, 134 (60.6%) of HIV-infected children knew about their HIV status. The mean age at disclosure was 10.71 years. Children aged older than 10 years [AOR = 22, 95% CI: 5.3-79.2], female children [AOR = 3; 95% CI = 1.2-8.7], children lost their family member by HIV [AOR = 3.5, 95% CI: 1.2-10], caregiver's perception of child did not get stigmatized [AOR = 4, 95% CI: 1.6-11], and children's responsible for anti-retroviral therapy [AOR = 16, 95% CI: 5-50] were significantly associated with HIV positive status disclosure compared to their counterpart respectively. Children who stayed on anti-retroviral for 10-15 years were [AOR = 7; 95% CI: 2-27] more likely to know their HIV positive status compared to those staying on anti-retroviral therapy for <6 years.

CONCLUSION

The proportion of disclosure of HIV-positive status among HIV-infected children was low. Factors associated were the age of the child, sex, existence of parent, stigma, ART duration, and responsibility of the child for his/her drugs. HIV care providers should consider these factors while supporting disclosure.

Preventing mental health conditions in adolescents living with HIV: an urgent need for evidence

INTRODUCTION

As adolescents transition from childhood to adulthood, they experience major physical, social and psychological changes, and are at heightened risk for developing mental health conditions and engaging in health-related risk behaviours. For adolescents living with HIV (ALHIV), these risks may be even more pronounced. Research shows that this population may face additional mental health challenges related to the biological impact of the disease and its treatment, the psychosocial burdens of living with HIV and HIV-related social and environmental stressors.

DISCUSSION

Psychosocial interventions delivered to adolescents can promote positive mental health, prevent mental health problems and strengthen young people's capacity to navigate challenges and protect themselves from risk. It is likely that these interventions can also benefit at-risk populations, such as ALHIV, yet there is little research on this. There is an urgent need for more research evaluating the effects of interventions designed to improve the mental health of ALHIV. We highlight four priorities moving forward. These include: generating more evidence about preventive mental health interventions for ALHIV; including mental health outcomes in research on psychosocial interventions for ALHIV; conducting intervention research that is sensitive to differences among ALHIV populations and involving adolescents in intervention design and testing.

CONCLUSIONS

More robust research on promotive and preventive mental health interventions is needed for ALHIV. Programmes should be informed by adolescent priorities and preferences and responsive to the specific needs of these groups.

An Integrated Approach to HIV Disclosure for HIV-Affected Families in Thailand

Disclosure of HIV status to family members could improve communication, relationship, and cohesion. We evaluated the impact of a family-centered program designed to increase the readiness/willingness of parents to disclose HIV status to their children. People living with HIV (PLWH) with children ≥8 years were surveyed regarding HIV knowledge, family relationship, attitudes, willingness/readiness to disclose, and they were then invited to participate in group education and family camps. Of 367 PLWH surveyed, 0.8% had disclosed, 14.7% had not yet disclosed but were willing/ready to disclose, 50.4% were willing but not ready, and 33.2% did not wish to disclose. The educational sessions and camps led to significant improvements of HIV knowledge and disclosure techniques, and readiness/willingness to disclose. Given the benefits of group education and family camps in supporting PLWH to improve their communication with their families and disclose their HIV status, these supporting activities should be included in HIV programs.

Using Social Media and Technology to Communicate in Pediatric HIV Research: Qualitative Study With Young Adults Living With or Exposed to Perinatal HIV

BACKGROUND

As young adults living with perinatal HIV (PHIV) or perinatal HIV exposure but uninfected (PHEU) grow older and manage the challenges and competing demands of young adulthood, new approaches are needed to facilitate their retention in longitudinal research and clinical care beyond in-person clinic visits. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel virus that causes coronavirus disease (COVID-19), emerged in the United States in January 2020 and has underscored this need; studies are adapting to remote communication with and data collection from participants. However, there are limited data on communication preferences among young adults who are living with PHIV or PHEU.

OBJECTIVE

The objectives of this qualitative study were to describe participants' perceptions and use of social media and technology in their personal lives and in the context of participating in longitudinal pediatric HIV research and to describe the implications of the use of technology and social media for communication and retention purposes within a longitudinal pediatric study about HIV.

METHODS

We conducted 6 focus group discussions with 31 young adults living with PHIV and 13 in-depth interviews with 6 young adults living with PHIV and 7 living with PHEU. We asked about their preferences for the use of social media and digital technology in the Adolescent Master Protocol, a US-based longitudinal cohort study of youth affected by HIV.

RESULTS

Participants' willingness to use social media platforms, telephone calls, SMS text messages, and video calls within the context of HIV research varied due to fears of HIV stigma and inadvertent disclosure. However, trusting relationships with clinical staff positively impacted their willingness to use these platforms.

CONCLUSIONS

Our findings offer insight into how pediatric studies and clinics can communicate with participants as they age, even as new technologies and social media platforms emerge and replace old ones. For optimal retention, pediatric clinical staff should consider communication approaches offering flexible and tailored options for young adults participating in HIV research.

Maternal HIV status disclosure to young uninfected children: psychological variables of the mother

Mothers living with HIV are faced with the dilemma of when and how to disclose their HIV-positive status to their young uninfected children. In this study, a South African sample of mothers living with HIV, with young uninfected children (6-10 years) in the city of Tshwane was studied. In the sample of 406 mothers, 11.6% reported that they disclosed their HIV status to their young uninfected children. The research compared 47 mothers who disclosed (29 full disclosure and 18 partial disclosure) and a random sample of 50 mothers who did not disclose to their children, in terms of depression symptoms, parenting stress and coping strategies. The results showed that single and widowed mothers disclosed significantly more to their uninfected young children than mothers who had partners or were married. Mothers in the three disclosure groups did not differ in their experience of depression symptoms, parental distress and coping styles. Mothers who disclosed partially reported less parent-child dysfunctional interaction. Time since disclosure did not influence level of disclosure and was not significantly related to psychological outcome of mothers. Mothers who disclosed reported significantly more emotional and instrumental support as coping strategies than mothers who did not disclose. Mothers thus mostly disclose their status to their children to gain support and family closeness. Mothers who disclosed and had not disclosed did not differ in terms of psychological variables. Some mothers perceived partial disclosure as age-appropriate for young children. It is recommended that HIV-positive mothers receive psychosocial support services to equip them to disclose their health status in an age-appropriate way to their children, as it is documented that maternal disclosure benefits both mother and child.

iCOPE, a multi-level, cluster randomized, 36-month, parallel-group study to assess the efficacy of HIV disclosure intervention in HIV parental disclosure among parents living with HIV in China

Objectives:

Parents living with HIV who disclose their HIV status to their children could benefit from the parental HIV disclosure. However, it is also very challenging because of persistent stigma and discrimination against HIV. This report describes the study design and protocol of the “Interactive Communication with Openness, Passion, and Empowerment (iCOPE)” randomized controlled trial aimed at assisting parents living with HIV in conducting culturally and developmentally appropriate disclosure to their uninfected children in China through trainings among both parents living with HIV and healthcare providers.

Methods:

A total of 791 parents living with HIV with children aged between 6 and 15 years and 357 healthcare providers were randomized into either the intervention group or control group. Intervention package for parents consisted of five 2-h sessions focusing on positive coping, disclosure decision making, developing a developmentally appropriate disclosure plan, and accessing social support and post-disclosure counseling. The intervention for healthcare providers was made up of two 45-min sessions organized around two primary themes: knowledge of child cognitive development and effective parent–child communication skills in the context of parental disclosure. The control group received nutritional education of either five 2-h sessions (parents) or two 45-min sessions (healthcare providers). The outcome assessments were conducted at baseline, 6, 12, 18, 24, 30, and 36 months.

Conclusion:

The iCOPE study is among the first efforts to develop and evaluate a theory-based and multi-level intervention to promote culturally and developmentally appropriate parental HIV disclosure in China. It has implications for healthcare providers, social workers, and policy makers as it will provide efficacy data on how to enhance appropriate parental HIV disclosure and will shed light on developing a clinical guideline regarding parental HIV disclosure in China and other low- and middle-income countries.

Disclosure of maternal HIV infection to children among Chinese women with HIV: The application of the Theory of Planned Behaviour and the role of various norms

Maternal HIV disclosure to children has numerous benefits for both mothers and children. However, the prevalence of maternal HIV disclosure to children remains low in many countries. The present study examined factors associated with intention to disclose maternal HIV status to children among Chinese HIV+ women who have not disclosed their HIV status to their child. Factors from the Theory of Planned Behavior and various norms (injunctive, descriptive and moral norm) were examined. Findings from 179 HIV+ women revealed that only 16.8% intended to disclose their HIV status to their child in the future. Adjusted for significant background variables, all factors from the TPB and various norms (i.e. attitude, injunctive norm, descriptive norm, moral norm, perceived behavioural control) were associated with intention to disclose HIV status (adjusted odds ratios ranged from 3.22, 15.85). Stepwise logistic regression showed that attitude (ORm = 6.96) and injunctive norm (ORm = 6.81) were associated with intention to disclose HIV status. Interventions to promote maternal HIV disclosure were warranted to promote attitude, perceived behavioural control, and various norms associated with HIV disclosure.

Important Roles of Health Professionals in Maternal HIV Disclosure Among HIV-Infected Women in China

Maternal HIV disclosure to children is beneficial for both mothers and children. A cross-sectional survey was conducted to investigate the prevalence of maternal HIV disclosure to at least one living child aged > 5 years among 292 HIV-infected mothers in Guangxi Province, China. Among all participants, 45.2% had self-disclosed their HIV positive sero-status to at least one living child aged > 5 years. After adjusting for the significant background variables, participants self-reported health professionals in governmental antenatal care clinics had discussed with them about maternal HIV disclosure (adjusted odds ratios, aOR: 5.85), had received counseling services (aOR: 7.84) or support (aOR: 8.75) from these health professionals when making decision on maternal HIV, and perceived higher empathy of these health professionals (aOR: 1.09) were more likely to have reported maternal HIV disclosure. Instrumental and affective interactions between health professionals and HIV-infected mothers were important facilitators of maternal HIV disclosure.

Communication with children and adolescents about the diagnosis of a life-threatening condition in their parent

Many adults diagnosed with a life-threatening condition have children living at home; they and their partners face the dual challenge of coping with the diagnosis while trying to maintain a parenting role. Parents are often uncertain about how, when, and what to tell their children about the condition, and are fearful of the effect on their family. There is evidence that children are often aware that something is seriously wrong and want honest information. Health-care professionals have a key role in supporting and guiding parents and caregivers to communicate with their children about the diagnosis. However, the practical and emotional challenges of communicating with families are compounded by a scarcity of evidence-based guidelines. This Review considers children's awareness and understanding of their parents' condition, the effect of communication around parental life-threatening condition on their wellbeing, factors that influence communication, and the challenges to achieving effective communication. Children's and parents' preferences about communication are outlined. An expert workshop was convened to generate principles for health-care professionals, intended as practical guidance in the current absence of empirically derived guidelines.

The birds and the bees: do Puerto Rican mothers and daughters talk about sex?

Introduction

Effective communication skills that foster responsible sexual decisions are known to have the potential to reduce the risky adolescent sexual behavior. It is well understood that maternal communication is a key element in modifying the adolescent sexual behavior. The objective of this qualitative study was to explore if Puerto Rican mothers of adolescent girls have conversations about sexuality with their daughters and the content of such conversations.

Methods

A total of 22 HIV-seropositive mothers and 22 HIV-seronegative mothers were enrolled. Six focus groups were conducted, sessions were transcribed ad-verbum and coded for specific topics. All qualitative analysis was incorporated into Atlas.ti.

Results

Participants in both groups had a similar average age (mean=41 years old); but, the HIV-seropositive mothers were more likely single, less educated and unemployed. Regarding having engaged in conversations about sexuality and the topics covered, however, there were no differences revealed among HIV-seropositive mothers and seronegative mothers. In both groups, mothers understood the importance of these conversations, but most said they were difficult and uncomfortable.

Conclusion

These findings reinforce the importance of communication between mothers and daughters for the prevention of STIs, HIV/AIDS, and teenage pregnancy in minority populations.Interventions are needed for mother and daughter to improve communication skills, communication about sexuality, and addressing prevention.

A Systematic Review and Narrative Synthesis of Interventions for Parental Human Immunodeficiency Virus Disclosure

INTRODUCTION

Disclosure of parental human immunodeficiency virus (HIV) infection to their children remains a difficult process for parents living with HIV (PLWH). In order to identify the best strategies to facilitate parental HIV disclosure, it is necessary to examine the efficacy of existing interventions designed to help PLWH parents with the disclosure process to their children.

OBJECTIVES

To systematically review the efficacy of interventions designed to assist PLWH disclose their HIV status to their children.

METHODS

We conducted a systematic review and narrative synthesis of interventions designed to assist PLWH disclose their HIV status to their children. MEDLINE/PubMed, PsycINFO, Embase, Global Health, and Web of Science were searched.

RESULTS

Studies were eligible for inclusion if they evaluated an intervention for parental HIV disclosure. Five studies published between 2001 and 2015 met the inclusion criteria. The interventions were conducted in South Africa, China, and the United States. Three of the studies used two-arm randomized controlled trials, in which the intervention group was given enhanced care while the control group received standard care. Four of the five studies included a theoretically informed intervention and three were limited to mothers. Results showed that four of the interventions increased parental HIV disclosure.

CONCLUSION

The findings suggest that parental HIV disclosure interventions are successful in assisting parents with the disclosure process and can be adapted in different cultural context. Future parental HIV disclosure interventions should include fathers in order to assist men with parental HIV disclosure.

Predictors of Disclosure of Maternal HIV Status by Caregivers to their Children in an Inner-City Community in the United States

Disclosure of HIV status to children is a challenge parents living with HIV face. To evaluate predictors of maternal HIV disclosure in a low-income clinic in the U.S. that serves an African American, Hispanic and immigrant population with high HIV prevalence, 172 caregivers with 608 children completed a standardized survey. Caregivers were 93 % female, 84 % biological mothers, and 34 % foreign born. Sixty-two (36 %) caregivers had at least one disclosed child, 42 of whom also had other nondisclosed children. Of all children, 581 (96 %) were uninfected and 181 (30 %) were disclosed. Caregiver's U.S. birth (OR: 2.32, 95 % CI 1.20-4.52), child's age (OR: 1.2/year, 95 % CI 1.16-1.24), and increased HIV-stigma perception by caregiver (1.06/point increase, 95 % CI 1.04-1.09) predicted disclosure. Children were more often disclosed if their caregiver was born in the U.S. or reported higher HIV-related stigma. These findings suggest that complex family context may complicate disclosure, particularly among immigrants.

The Amagugu Intervention: A Conceptual Framework for Increasing HIV Disclosure and Parent-Led Communication about Health among HIV-Infected Parents with HIV-Uninfected Primary School-Aged Children

Advances in access to HIV prevention and treatment have reduced vertical transmission of HIV, with most children born to HIV-infected parents being HIV-uninfected themselves. A major challenge that HIV-infected parents face is disclosure of their HIV status to their predominantly HIV-uninfected children. Their children enter middle childhood and early adolescence facing many challenges associated with parental illness and hospitalization, often exacerbated by stigma and a lack of access to health education and support. Increasingly, evidence suggests that primary school-aged children have the developmental capacity to grasp concepts of health and illness, including HIV, and that in the absence of parent-led communication and education about these issues, HIV-exposed children may be at increased risk of psychological and social problems. The Amagugu intervention is a six-session home-based intervention, delivered by lay counselors, which aims to increase parenting capacity to disclose their HIV status and offer health education to their primary school-aged children. The intervention includes information and activities on disclosure, health care engagement, and custody planning. An uncontrolled pre-post-evaluation study with 281 families showed that the intervention was feasible, acceptable, and effective in increasing maternal disclosure. The aim of this paper is to describe the conceptual model of the Amagugu intervention, as developed post-evaluation, showing the proposed pathways of risk that Amagugu aims to disrupt through its intervention targets, mechanisms, and activities; and to present a summary of results from the large-scale evaluation study of Amagugu to demonstrate the acceptability and feasibility of the intervention model. This relatively low-intensity home-based intervention led to: increased HIV disclosure to children, improvements in mental health for mother and child, and improved health care engagement and custody planning for the child. The intervention model demonstrates the potential for disclosure interventions to include pre-adolescent HIV education and prevention for primary school-aged children.

Taking HIV Testing to Families: Designing a Family-Based Intervention to Facilitate HIV Testing, Disclosure, and Intergenerational Communication

INTRODUCTION

Facility-based HIV testing does not capture many adults and children who are at risk of HIV in South Africa. This underscores the need to provide targeted, age-appropriate HIV testing for children, adolescents, and adults who are not accessing health facilities. While home-based counseling and testing has been successfully delivered in multiple settings, it also often fails to engage adolescents. To date, the full potential for testing entire families and linking them to treatment has not been evaluated.

METHODS

The steps to expand a successful home-based counseling and testing model to a family-based counseling and testing approach in a high HIV prevalence context in rural South Africa are described. The primary aim of this family-based model is to increase uptake of HIV testing and linkage to care for all family members, through promoting family cohesion and intergenerational communication, increasing HIV disclosure in the family, and improving antiretroviral treatment uptake, adherence, and retention. We discuss the three-phased research approach that led to the development of the family-based counseling and testing intervention.

RESULTS

The family-based intervention is designed with a maximum of five sessions, depending on the configuration of the family (young, mixed, and older families). There is an optional additional session for high-risk or vulnerable family situations. These sessions encourage HIV testing of adults, children, and adolescents and disclosure of HIV status. Families with adolescents receive an intensive training session on intergenerational communication, identified as the key causal pathway to improve testing, linkage to care, disclosure, and reduced stigma for this group. The rationale for the focus on intergenerational communication is described in relation to our formative work as well as previous literature, and potential challenges with pilot testing the intervention are explored.

CONCLUSION

This paper maps the process for adapting a novel and largely successful home-based counseling and testing intervention for use with families. Expanding the successful home-based counseling and testing model to capture children, adolescents, and men could have significant impact, if the pilot is successful and scaled-up.

Parenting Among Adolescents and Young Adults with Human Immunodeficiency Virus Infection in the United States: Challenges, Unmet Needs, and Opportunities

Given the realistic expectations of HIV-infected adolescents and young adults (AYA) to have children and start families, steps must be taken to ensure that youth are prepared to deal with the challenges associated with their HIV and parenting. Literature reviews were conducted to identify published research and practice guidelines addressing parenting or becoming parents among HIV-infected AYA in the United States. Research articles or practice guidelines on this topic were not identified. Given the paucity of information available on this topic, this article provides a framework for the development of appropriate interventions and guidelines for use in clinical and community-based settings. First, the social, economic, and sexual and reproductive health challenges facing HIV-infected AYA in the United States are summarized. Next, family planning considerations, including age-appropriate disclosure of HIV status to those who are perinatally infected, and contraceptive and preconception counseling are described. The impact of early childbearing on young parents is discussed and considerations are outlined during the preconception, antenatal, and postnatal periods with regard to antiretroviral medications and clinical care guidelines. The importance of transitioning AYA from pediatric or adolescent to adult-centered medical care is highlighted. Finally, a comprehensive approach is suggested that addresses not only medical needs but also emphasizes ways to mitigate the impact of social and economic factors on the health and well-being of these young parents and their children.

HIV Status Disclosure through Family-Based Intervention Supports Parenting and Child Mental Health in Rwanda

INTRODUCTION

Few evidence-based interventions exist to support parenting and child mental health during the process of caregiver HIV status disclosure in sub-Saharan Africa. A secondary analysis of a randomized-controlled trial was conducted to examine the role of family-based intervention versus usual social work care (care as usual) in supporting HIV status disclosure within families in Rwanda.

METHOD

Approximately 40 households were randomized to family-based intervention and 40 households to care as usual. Parenting, family unity, and child mental health during the process of disclosure were studied using quantitative and qualitative research methods.

RESULTS

Many of the families had at least one caregiver who had not disclosed their HIV status at baseline. Immediately post-intervention, children reported lower parenting and family unity scores compared with those in the usual-care group. These changes resolved at 3-month follow-up. Qualitative reports from clinical counselor intervention sessions described supported parenting during disclosure. Overall findings suggest adjustments in parenting, family unity, and trust surrounding the disclosure process.

CONCLUSION

Family-based intervention may support parenting and promote child mental health during adjustment to caregiver HIV status disclosure. Further investigation is required to examine the role of family-based intervention in supporting parenting and promoting child mental health in HIV status disclosure.

A Parent-Based Intervention to Prevent HIV Among Adolescent Children of Mothers Living with HIV: The Ms. Now! Program

One group often overlooked by HIV prevention efforts is adolescent children of mothers living with HIV (MLH). Despite their potential vulnerability, very few evidence-based prevention programs exist for this population in the United States (U.S.) and elsewhere. The current study introduces a parent-based program adapted for families affected by HIV for the purpose of preventing adolescent HIV infection. Following a structured process of adaptation, 12 African American MLH-adolescent dyads were recruited from HIV clinics and non-governmental organizations in a southeastern U.S. city to participate in a feasibility pilot evaluation of the adapted program (Moms Stopping It Now! [Ms. Now]). The intervention consisted of group and individual sessions implemented in a university setting and at participants' homes, respectively. We determined feasibility through assessing participant acceptability and signs of intervention efficacy. Quantitative and qualitative process data revealed high levels of acceptability, as participants were largely satisfied and engaged with Ms. Now, and were willing to attend most sessions. In addition, positive intervention effects approaching medium to large effect sizes were observed for some protective parenting outcomes, including increases in parent-child relationship quality, parental monitoring, maternal HIV disclosure self-efficacy, and communication about maternal HIV infection. Other outcomes, namely communication about sex topics, did not show positive shifts due to ceiling effects and may be indicative of the pre-existing strengths these MLH possess. Ms. Now's approach and further refinement is discussed in the context of strengthening families affected by HIV. Moreover, we recommend that policy aimed at program development consider jointly targeting these populations (MLH and adolescents) due to the unique benefits of family intervention.

A Mixed-Methods Study Supporting a Model of Chinese Parental HIV Disclosure

Parents who are HIV-positive confront difficult decisions regarding whether, when, and how to disclose their HIV status to their children. In China, a setting of acute HIV stigma where family harmony is culturally valued, limited research has been conducted on parental disclosure. We aimed to develop a model of parental disclosure that accounts for the cultural context in China based on a mixed-methods study. In our individual, in-depth interviews (N = 24) as well as survey data (N = 84) collected from parents living with HIV in Shanghai and Beijing, we found the primary barriers to disclosure were stigma, fear of exposing the mode by which they acquired HIV, psychologically burdening the child, rejection by the child, and negative social consequences for the family. Parents concurrently cited many motivations for disclosure, such as disease progression, ensuring safety of the child, gaining assistance, and fulfilling their parental responsibility. Most parents had not actively disclosed their HIV status (68 %); many parents reported some form of partial disclosure (e.g., sharing they have a blood disease but not labeling it HIV), unplanned disclosure, or unintentional disclosure to their children by other people. Findings informed the development of a Chinese Parental HIV Disclosure Model, with primary components accounting for distal cultural factors, decision-making (balancing approach and avoid motivations), the disclosure event, and outcomes resulting from the disclosure. This model highlights the cultural context of the Chinese parental disclosure process, and may be useful in guiding future observational research and intervention work.

Disclosure and impact of maternal HIV+ serostatus on mothers and children in rural Haiti

Mothers living with HIV (MLWHs) in the United States have reported that one of their main challenges is the decision to disclose their HIV serostatus to their children and the potential consequences of their disclosure. Little is known about the experiences of MLWHs regarding disclosing their HIV serostatus to their children and the impact of maternal HIV serostatus disclosure in the island nations of the Caribbean. Study objectives were to identify the factors influencing maternal HIV serostatus disclosure, examine the breadth of maternal HIV serostatus, and understand the impact of disclosure on mothers and the children. Baseline interviews were conducted between 2006 and 2007 with 25 HIV-positive mothers and 26 children ages 10-17 participating in a pilot psychosocial support intervention for HIV-affected youth and their caregivers in Haiti. Interviews were transcribed verbatim and coded for topical themes by two investigators. Analysis of the interviews yielded several themes relevant to reasons for disclosure, including children's experience of HIV stigma in the community, social support and encouragement from psychosocial intervention workers. The main themes related to breadth of disclosure were brief disclosure and explicit disclosure with some mothers sharing information about how they learned about their illness diagnosis and their medication. Themes related to impacts of disclosure included emotional reactions of children and mothers, and children's desire to assist mothers with illness and become involved. These findings suggest the need to provide more psychosocial support to HIV-affected families in the Caribbean region.

A rapid assessment of post-disclosure experiences of urban HIV-positive and HIV-negative school-aged children in Kenya

There has been limited involvement of HIV-negative children in HIV disclosure studies; most studies conducted on the effects of disclosure on children have been with HIV-positive children and HIV-positive mother-child dyads. Seven HIV-positive and five HIV-negative children participated in a larger study conducted to understand the lived experiences of HIV-positive parents and their children during the disclosure process in Kenya. In this study, the experiences of these 12 children after receiving disclosure of their own and their parents' illnesses respectively are presented. Each child underwent an in-depth qualitative semi-structured digitally recorded interview. The recorded interviews were transcribed and loaded into NVivo8 for phenomenological data analysis. Five themes emerged from the data, indicating that HIV-positive and negative children appear to have differing post-disclosure experiences revolving around acceptance of illness, stigma and discrimination, medication consumption, sexual awareness, and use of coping mechanisms. Following disclosure, HIV-negative children accepted their parents' illnesses within a few hours to a few weeks; HIV-positive children took weeks to months to accept their own illnesses. HIV-negative children knew of high levels of stigma and discrimination within the community; HIV-positive children reported experiencing indirect incidences of stigma and discrimination. HIV-negative children wanted their parents to take their medications, stay healthy, and pay their school fees so they could have a better life in the future; HIV-positive children viewed medication consumption as an ordeal necessary to keep them healthy. HIV-negative children wanted their parents to speak to them about sexual-related matters; HIV-positive children had lingering questions about relationships, use of condoms, marriage, and childbearing options. All but one preadolescent HIV-positive child had self-identified a person to speak with for social support. When feeling overwhelmed by their circumstances, the children self-withdrew and performed positive activities (e.g., praying, watching TV, listening to the radio, singing, dancing) to help themselves feel better. Many HIV-affected families have a combination of HIV-positive and negative siblings within the household. Pending further studies conducted with larger sample sizes, the results of this study should assist healthcare professionals to better facilitate disclosure between HIV-positive parents and their children of mixed HIV statuses.

Nurse-delivered counselling intervention for parental HIV disclosure: results from a pilot randomized controlled trial in China

OBJECTIVE

The objective of this study was to design and conduct a preliminary evaluation of an intervention to assist parents in decision-making about disclosure of their HIV diagnosis to their children.

DESIGN

This was a pilot randomized controlled trial (RCT) with blinded assessment. Participants were randomized to intervention or treatment-as-usual (TAU) arms.

SETTING

The study occurred at an outpatient HIV primary care centre in Shanghai, China.

PARTICIPANTS

Participants were 20 HIV-positive outpatients with at least one child (13-25 years old) who was unaware of the parent's HIV diagnosis.

INTERVENTION

The nurse-delivered intervention involved three, hour-long, individual sessions over 4 weeks. Intervention content comprised family assessment, discussion of advantages and disadvantages of disclosure, psycho-education about cognitive, social and emotional abilities of children at different developmental stages, and disclosure planning and practicing via role-plays.

MAIN OUTCOME MEASURE(S)

Primary study outcomes for intervention versus TAU arms were self-reported disclosure distress, self-efficacy, and behaviours along a continuum from no disclosure to full disclosure and open communication about HIV.

RESULTS

In all cross-sectional (Wald tests) and longitudinal (general estimating equations) analyses, at both postintervention (4 weeks) and follow-up (13 weeks), effects were in the hypothesized directions. Despite the small sample size, most of these between-arm comparisons were statistically significant, with at least one result for each outcome indicating a 'large' effect size.

CONCLUSION

Our results suggest that nurses are able to deliver a counselling intervention in a clinic setting with the potential to alleviate parental distress around HIV disclosure to their children. Findings warrant future trials powered for efficacy.

Maternal and child psychological outcomes of HIV disclosure to young children in rural South Africa: the Amagugu intervention

OBJECTIVES

Increasingly, HIV-infected parents are surviving to nurture their children. Parental HIV disclosure is beneficial, but disclosure rates to younger children remain low. Previously, we demonstrated that the 'Amagugu' intervention increased disclosure to young children; however, effects on psychological outcomes have not been examined in detail. This study investigates the impact of the intervention on the maternal and child psychological outcomes.

METHOD

This pre-post evaluation design enrolled 281 HIV-infected women and their HIV-uninfected children (6-10 years) at the Africa Centre for Health and Population Studies, in rural South Africa. The intervention included six home-based counselling sessions delivered by lay-counsellors. Psychological outcomes included maternal psychological functioning (General Health Questionnaire, GHQ12 using 0,1,2,3 scoring); parenting stress (Parenting Stress Index, PSI36); and child emotional and behavioural functioning (Child Behaviour Checklist, CBCL).

RESULTS

The proportions of mothers with psychological distress reduced after intervention: GHQ threshold at least 12 (from 41.3 to 24.9%, P < 0.001) and GHQ threshold at least 20 (from 17.8 to 11.7%, P = 0.040). Parenting stress scores also reduced (Pre M = 79.8; Post M = 76.2, P < 0.001): two subscales, parental distress and parent-child relationship, showed significant improvement, while mothers' perception of 'child as difficult' was not significantly improved. Reductions in scores were not moderated by disclosure level (full/partial). There was a significant reduction in child emotional and behavioural problems (CBCL Pre M = 56.1; Post M = 48.9, P < 0.001).

CONCLUSION

Amagugu led to improvements in mothers' and children's mental health and parenting stress, irrespective of disclosure level, suggesting general nonspecific positive effects on family relationships. Findings require validation in a randomized control trial.

Increasing HIV serostatus disclosure in low and middle-income countries: a systematic review of intervention evaluations

OBJECTIVE

To review the effectiveness of interventions to increase HIV serostatus disclosure in low and middle-income countries.

DESIGN

Systematic review of peer-reviewed articles providing prepost or multiarm evaluations of disclosure interventions, defined broadly as any intervention with the goal of increasing rates of voluntary disclosure of HIV serostatus through self-disclosure or partner notification.

METHODS

Articles were included if they reported postintervention evaluation results and were published between 1 January 1990 and 1 August 2014. Searching was conducted through five electronic databases, secondary searching of four journals, and hand searching reference lists of included articles. Systematic methods were used for screening and data abstraction, which was conducted in duplicate. Study quality (rigor) was assessed with eight items.

RESULTS

Fourteen articles evaluating 13 interventions met the inclusion criteria, all from sub-Saharan Africa. Most interventions focused on people living with HIV and used cognitive-behavioral group sessions or peer/community health worker support to encourage disclosure to sexual partners, family members, or friends. One focused on maternal disclosure to HIV-uninfected children, whereas two examined voluntary partner notification interventions. Several studies had limitations due to weak designs, small sample sizes, or high attrition. Findings on disclosure were mixed, with most effect sizes being relatively small, and some more rigorous studies showing no effect. Partner notification interventions had the strongest evidence of impact.

CONCLUSION

The existing evidence base for interventions to increase disclosure is limited and shows variable results. Further research is needed to determine whether current approaches to increasing disclosure are effective or whether new approaches should be considered.

National Institutes of Health investment in studies of HIV disclosure to children

The goals of this manuscript will be to review current and past National Institutes of Health (NIH) funding on maternal and child HIV disclosure research and lay out current research gaps in these areas. Examples of work funded by NIH will highlight how the disclosure needs of families affected by HIV have changed over the past 30 years as well as highlight what we have learned. The review will include the recent NICHD RFA that focused specifically on disclosure of HIV status to children in low and middle-income country settings. A brief description of findings from these NIH-funded grants will be provided. The authors will then describe current research gaps and challenges as they relate to research on HIV disclosure both in the U.S. and internationally.

Children affected by maternal HIV/AIDS: feasibility and acceptability trial of the Children United with Buddies (CUB) intervention

Past research has shown that young children affected by maternal HIV present with elevated stress/anxiety and negative well-being. This pilot intervention for children aged 7-14 affected by maternal HIV targeted improving positive child-mother communication, improving HIV/AIDS knowledge and reducing anxiety (especially related to transmission), and lessening feelings of stigma. Each of the three child intervention sessions included behavioral skills training and a themed craft exercise; mothers attended an open discussion group while the children attended their sessions. Study participants were 37 child-mother pairs. The study design was a randomized two-group pretest-posttest experimental design. The intervention sessions were audiotaped for transcription. Results showed significant decreases in anxiety and worry for children in the intervention group, and increases in happiness and knowledge regarding HIV/AIDS transmission. Intervention group mothers reported greater social support. Qualitative findings for the intervention group children and mothers also support these findings. Early intervention reduces child stress, and may affect longer-term outcomes.

Psychosocial challenges of young people affected by HIV: experiences from Hamilton County, Chattanooga, Tennessee

The number of young people affected by HIV and AIDS in Tennessee has steadily grown over the last few years. As a response to this situation, several organizations are working hard to address the needs of families impacted by HIV and AIDS. However, a close examination of some of the services provided suggests that young people within these families are ignored. Most of the services are geared toward HIV and AIDS-infected adult members of these families. Young people within these household are not targeted, and little is known about psychosocial challenges they experience in living with HIV-positive parents or guardians. In an attempt to address this gap, this small-scale qualitative study investigated the psychosocial challenges of young people affected by HIV and AIDS as a result of living with HIV-positive parents or guardians. Perceived sense of depression, experiencing stigma, self-blame, and lack of communication and loneliness were challenges that young people faced regularly.

To tell or not to tell: disclosure to children and family amongst Thai women living with HIV/AIDS

HIV disclosure is a complex phenomenon. The choice of disclosure or non-disclosure is a reflection of how each HIV-positive person experiences and deals with HIV/AIDS in their everyday life. In this study, we qualitatively explore the experiences of disclosing HIV status to family members and children among HIV-positive women living in Thailand. Due to fear of stigma and discrimination, the women decided to tell only a few people, usually their significant others including parents and children. Although most women received good support from their family members, some were rejected and discriminated against by their family members. This stems from lack of knowledge about HIV/AIDS among family members. Women found disclosure to their children a difficult decision to make. Only some women told their children about their HIV status. They wished to protect their children from emotional burden. This protection also appeared in their attempts to prepare their children for dealing with HIV/AIDS. Support from family members played a major role in the lives of HIV-positive women. Although disclosure has been promoted as a means of ending stigma and discrimination, our data suggested that disclosure may not be positive for some women. This has implications for health promotion in HIV health care. Healthcare providers need to appreciate the ramifications of promoting disclosure to HIV-positive women who are mothers.

Maternal HIV disclosure to young HIV-uninfected children: an evaluation of a family-centred intervention in South Africa

OBJECTIVES

Sub-Saharan Africa has large populations of HIV-infected parents who need support to raise their HIV-uninfected children. This research evaluates the 'Amagugu Intervention' aimed at supporting mothers to disclose their own HIV diagnosis to their HIV-uninfected children.

DESIGN

Uncontrolled pre and post-intervention evaluation.

SETTING

Africa Centre for Health and Population Studies, South Africa.

PARTICIPANTS

Two hundred and eighty-one HIV-infected women and their HIV-uninfected children aged 6-10 years.

INTERVENTION

This lay counsellor-led intervention included six sessions conducted with mothers at home, providing printed materials and child-friendly activities to support disclosure of their diagnosis.

MAIN OUTCOME MEASURE

The primary outcome was disclosure to the child (full, partial, none). The secondary outcomes included maternal mental health (General Health Questionnaire) and child mental health (Child Behaviour Checklist).

RESULTS

One hundred and seventy-one (60%) women 'fully' disclosed and 110 (40%) women 'partially' disclosed their HIV status to their child. Women who perceived their health to be excellent were less likely to 'fully' disclose compared to those considering their health to be poorer [adjusted odds ratio 0.50 (0.26-0.98), P = 0.042]. [corrected]. Compared to those not in a current partnership, those with a current partner were almost three times more likely to 'fully' disclose [adjusted odds ratio 2.92 (1.33-6.40), P = 0.008]. Mothers reported that most children reacted calmly to 'full' (79%) or 'partial' disclosure (83%). Compared to 'partial' disclosure, 'full' disclosure was associated with more children asking questions about maternal death (18 versus 8%).

CONCLUSIONS

This intervention is acceptable in resource-limited settings and shows promise. Further research using a controlled design is needed to test this intervention.

Telling adolescents a parent is dying

BACKGROUND

When a parent is terminally ill, one of the major challenges facing families is informing children of the parent's condition and prognosis. This study describes four ways in which parents disclose information about a parent's life-threatening illness to their adolescent children.

METHODS

We audio-recorded and transcribed 61 individual interviews with hospice patients who were recruited from a large hospice in northeastern Ohio, their spouses/partners, and their adolescent children. The interviews were coded and analyzed using a constant comparison approach.

RESULTS AND CONCLUSIONS

Families inform adolescents about the progression of a parent's terminal illness in characteristic ways that remain fairly consistent throughout the illness, and are aimed at easing the adolescents' burden and distress. The families engaged in the process of disclosure in one of four ways: measured telling, skirted telling, matter-of-fact telling, and inconsistent telling. These results will inform the development of interventions that assist families with disclosure and are tailored to each family's communication style.

A Five Step Process for Interactive Parent-Adolescent Communication About HIV Prevention: Advice from Parents Living With HIV/AIDS

AIM

This study investigated how parents living with HIV communicated about HIV prevention with their 10-18 year old children.

METHODS

Interviews with 76 mothers and fathers were analyzed for (1) their experiences discussing HIV prevention with adolescents, and (2) advice on how to best broach HIV-related topics.

RESULTS

Interactive conversations, where both parents and adolescents participated, were regarded as effective. Parents emphasized that adolescents should have a "voice" (be able to voice their concerns) and a "choice" (have a variety of effective prevention strategies to choose from) during HIV-related talks.

DISCUSSION

A five step process for interactive communication emerged as a result of these discussions.

IMPLICATIONS

Health care professionals can facilitate adolescent sexual health by encouraging parents to actively involve their children in discussions about HIV prevention.

CONCLUSION

Future HIV prevention programs could benefit by providing parents with appropriate tools to foster interactive discussions about sexual health with adolescents.

Promoting a combination approach to paediatric HIV psychosocial support

Ninety percent of the 3.4 million HIV-infected children live in sub-Saharan Africa. Their psychosocial well being is fundamental to establishing and maintaining successful treatment outcomes and overall quality of life. With the increased roll-out of antiretroviral treatment, HIV infection is shifting from a life-threatening to a chronic disease. However, even for paediatric patients enrolled in care and treatment, HIV can still be devastating due to the interaction of complex factors, particularly in the context of other household illness and overextended healthcare systems in sub-Saharan Africa.This article explores the negative effect of several interrelated HIV-specific factors on the psychosocial well being of HIV-infected children: disclosure, stigma and discrimination, and bereavement. However, drawing on clinical studies of resilience, it stresses the need to move beyond a focus on the individual as a full response to the needs of a sick child requires support for the individual child, caregiver-child dyads, extended families, communities, and institutions. This means providing early and progressive age appropriate interventions aimed at increasing the self-reliance and self-acceptance in children and their caregivers and promoting timely health-seeking behaviours. Critical barriers that cause poorer biomedical and psychosocial outcomes among children and caregiver must also be addressed as should the causes and consequences of stigma and associated gender and social norms.This article reviews interventions at different levels of the ecological model: individual-centred programs, family-centred interventions, programs that support or train healthcare providers, community interventions for HIV-infected children, and initiatives that improve the capacity of schools to provide more supportive environments for HIV-infected children. Although experience is increasing in approaches that address the psychosocial needs of vulnerable and HIV-infected children, there is still limited evidence demonstrating which interventions have positive effects on the well being of HIV-infected children. Interventions that improve the psychosocial well being of children living with HIV must be replicable in resource-limited settings, avoiding dependence on specialized staff for implementation.This paper advocates for combination approaches that strengthen the capacity of service providers, expand the availability of age appropriate and family-centred support and equip schools to be more protective and supportive of children living with HIV. The coordination of care with other community-based interventions is also needed to foster more supportive and less stigmatizing environments. To ensure effective, feasible, and scalable interventions, improving the evidence base to document improved outcomes and longer term impact as well as implementation of operational studies to document delivery approaches are needed.

Do Chinese parents with HIV tell their children the truth? A qualitative preliminary study of parental HIV disclosure in China

BACKGROUND

With the extended lifespan of people living with human immunodeficiency virus (HIV) due to the advent of antiretroviral therapy, the disclosure of HIV serostatus to their uninfected children is becoming more critical. However, limited data are available regarding parental HIV disclosure to children in China. We explore patterns of parental HIV disclosure and the reasons for disclosure or non-disclosure to children.

METHODS

A preliminary study was conducted using open-ended questions in Guangxi, China in 2011 with 39 parents living with HIV.

RESULTS

A majority of participants (77%) had not disclosed their HIV serostatus to their children. Participants who voluntarily disclosed tended to be older and were more likely to disclose to their adult children. Among parents who disclosed, reasons included a need for emotional and financial support, as well as feelings of obligation to their children. Among non-disclosing parents, primary reasons included concerns that children were too young to understand, fear of being stigmatized, and fear of increased psychological burden to children.

CONCLUSIONS

Few parents with HIV disclosed their HIV status to their children. These data indicate the need for future research to explore disclosure issues in relation to children's age and the implementation of developmentally appropriate interventions and support systems for parents and children affected by HIV in China.

Disclosure of parental HIV infection to children and psychosocial impact on children in China: a qualitative study

This qualitative study aims to investigate parental HIV disclosure and psychological impact from the perspectives of their children. In-depth individual interviews with 47 children who had lost one or both parents to AIDS were conducted in China. All transcripts were coded using the software ATLAS.ti 5. Results showed that few of children knew of parental HIV status before the death of their parents. The main disclosers were the children's current caregivers. Some children knew about their parent's HIV infection based on their own observations or through overheard conversation, or their interactions with villagers. Both positive and negative psychological outcomes related to parental HIV disclosure were reported. Psychological counseling is needed for both parents and children to dealing with the parental HIV infection.

Parental HIV disclosure in Burkina Faso: experiences and challenges in the era of HAART

Increasingly parents living with HIV will have to confront the dilemmas of concealing their lifelong treatment or disclosing to their children exposed to their daily treatment practices. However, limited data are available regarding parental HIV disclosure to children in Burkina Faso. Do parents on antiretroviral therapy disclose their HIV status to their children? What drives them? How do they proceed and how do children respond? We conducted in-depth interviews with 63 parents of children aged seven and above where the parents had been in treatment for more than 3 years in two major cities of Burkina Faso. Interviews addressed parental disclosure and the children's role in their parents' treatment. The rate of parental HIV status disclosure is as high as that of non-disclosure. Factors associated with parental disclosure include female sex, parent's older age, parent's marital history and number of children. After adjustment, it appears that the only factor remaining associated with parental disclosure was the female gender of the parent. In most of the cases, children suspected, and among non-disclosers many believed their children already knew without formal disclosure. Age of the children and history of divorce or widowhood were associated with parental disclosure. Most parents believed children do not have the necessary emotional skills to understand or that they cannot keep a secret. However, parents who disclosed to their children did not experience blame nor was their secret revealed. Rather, children became treatment supporters. Challenges to parental HIV disclosure to children are neither essential nor specific since disclosure to adults is already difficult because of perceived risk of public disclosure and subsequent stigma. However, whether aware or not of their parents' HIV-positive status, children contribute positively to the care of parents living with HIV. Perceptions about children's vulnerability and will to protect them against stigma lead parents to delay disclosure and not to overwhelm them with their experience of living with HIV. Finally, without institutional counselling support, disclosure to children remains a challenge for both parents and children, which suggests a need for rethinking of current counselling practices.

Communicating in complex situations: a normative approach to HIV-related talk among parents who are HIV+

Parents with HIV/AIDS are confronted with unique challenges when discussing HIV-related information with their children. Strategies for navigating these challenges effectively have not been systematically examined. In this study, we conducted in-depth interviews with 76 parents with HIV/AIDS who had children ages 10-18 years. Guided by O'Keefe and Delia's definition of a complex communication situation and Goldsmith's normative approach to interpersonal communication, we examined parents' goals for discussing HIV-related information, factors that made conversations challenging, and instances where these conversational purposes conflicted with one another. Our data reveal the following parent-adolescent communication predicaments: relaying safety information about HIV while minimizing child anxiety, modeling open family communication without damaging one's parental identity, and balancing parent-child relational needs amid living with an unpredictable health condition. Parents also described a variety of strategies for mitigating challenges when discussing HIV-related topics. Strategies parents perceived as effective included reframing HIV as a chronic, manageable illness; keeping talk educational; and embedding HIV-related topics within more general conversations. The theoretical and practical applications of these findings are discussed with regard to their relevance to health communication scholars and HIV care professionals.

Facilitators and barriers to discussing HIV prevention with adolescents: perspectives of HIV-infected parents

OBJECTIVES

We examined HIV-infected parents' conversations about HIV prevention with their uninfected children, including what facilitated or hindered communication.

METHODS

Parents with HIV/AIDS (n = 90) who had children aged 10 to 18 years were recruited for a mixed method study from 2009 to 2010. Interviews assessed facilitators and barriers to discussing HIV prevention. A questionnaire identified the frequency and content of conversations, parental confidence level, and perceived importance of discussing preventive topics.

RESULTS

Eighty-one percent of parents reported "sometimes" or "often" communicating about HIV prevention. A subset of parents found these conversations difficult; 44% indicated their desire for support. Facilitators to communication included utilizing support, focusing on the benefits of talking, and having a previous relationship with one's child. Barriers to discussions included fear of negative consequences, living in denial, and lacking a parental role model who discussed safer sex. Parents varied as to how they believed their HIV status affected communication. Those who did not disclose their HIV status to their children reported less frequent communication; self-efficacy partially mediated this relationship.

CONCLUSIONS

Findings highlighted the need for communication skills training that support HIV-infected parents in their efforts to discuss HIV-related information with adolescents.

HIV+ children and their families in the UK: results from a family-clinic based 'look-back' exercise in London

Advances in antiretroviral treatment have resulted in a growing number of HIV+ children surviving into adolescence and adulthood. However, HIV remains a chronic condition compounded by additional psychosocial stressors associated with living with HIV. The gold standard for treatment of HIV+ children and young people is within a family context. This 'look-back' exercise was conducted within an HIV family clinic context in London. HIV+ children's clinical notes were examined with the aim of describing the medical and social context of the families attending the clinic. Results showed that families are living with many psychosocial challenges that may have an impact on their ability to respond effectively to the challenge of living with HIV disease.

Maternal HIV disclosure to HIV-uninfected children in rural South Africa: a pilot study of a family-based intervention

Background

As access to treatment increases, large numbers of HIV-positive parents are raising HIV-negative children. Maternal HIV disclosure has been shown to have benefits for mothers and children, however, disclosure rates remain low with between 30-45% of mothers reporting HIV disclosure to their children in both observational and intervention studies. Disclosure of HIV status by parent to an HIV-uninfected child is a complex and challenging psychological and social process. No intervention studies have been designed and tested in Southern Africa to support HIV-positive parents to disclose their status, despite this region being one of the most heavily affected by the HIV epidemic.

Method

This paper describes the development of a family-centred, structured intervention to support mothers to disclose their HIV status to their HIV-negative school-aged children in rural South Africa, an area with high HIV prevalence. The intervention package includes printed materials, therapeutic tools and child-friendly activities and games to support age-appropriate maternal HIV disclosure, and has three main aims: (1) to benefit family relationships by increasing maternal HIV disclosure; (2) to increase children’s knowledge about HIV and health; (3) to improve the quality of custody planning for children with HIV-positive mothers. We provide the theoretical framework for the intervention design and report the results of a small pilot study undertaken to test its acceptability in the local context.

Results

The intervention was piloted with 24 Zulu families, all mothers were HIV-positive and had an HIV-negative child aged 6–9 years. Lay counsellors delivered the six session intervention over a six to eight week period. Qualitative data were collected on the acceptability, feasibility and the effectiveness of the intervention in increasing disclosure, health promotion and custody planning. All mothers disclosed something to their children: 11/24 disclosed fully using the words "HIV" while 13/24 disclosed partially using the word "virus".

Conclusion

The pilot study found the intervention was feasible and acceptable to mothers and counsellors, and provides preliminary evidence that participation in the intervention encouraged disclosure and health promotion. The pilot methodology and small sample size has limitations and further research is required to test the potential of this intervention. A larger demonstration project with 300 families is currently underway.

I wish I could tell you but I can't: adolescents with perinatally acquired HIV and their dilemmas around self-disclosure

Many young people growing up with HIV are choosing not to disclose their status to others, yet are likely to face difficult decisions and conversations such as explaining school absence, taking medication, coping with physical changes and for many, parental bereavement. This study aims to describe and explore the attitudes and opinions of adolescents with perinatally acquired HIV towards disclosure. Semi-structured interviews were conducted with nine young people aged 13-19 and analysed using Interpretative Phenomenological Analysis. Four themes emerged to illuminate the young people's attitudes towards disclosure. These were 1) myths and assumptions, 2) the disclosure dilemma, 3) fear and 4) keeping HIV in its place. This study confirms that many young people with HIV are choosing not to disclose. However, it appears that it is a complex decision-making process that changes over time and is influenced by developmental factors and societal attitudes towards HIV. Recommendations are suggested for services to better support adolescents growing up with HIV.

Disclosure of parental HIV infection to children: a systematic review of global literature

This review examines the global empirical literature regarding disclosure of parental HIV infection to children. Thirty-eight articles published in English-language journals prior to 2011 were retrieved and reviewed regarding disclosure process, reasons for disclosure/non-disclosure and impacts of disclosure/non-disclosure. Disclosure rate was relatively low worldwide. The decision making of disclosure or non-disclosure was mainly affected by children's development level, stigma, consideration of children's benefits, and parenting practices. Unintentional and forced disclosures were common. Findings regarding the impacts of disclosure/non-disclosure were mixed but disclosure tended to have long-term positive impacts on the well-being of children, parents and family in general. This review underscores the importance of developing evidence-informed developmentally and culturally appropriate interventions to assist HIV-positive parents to disclose their HIV status to children, particularly in low-resource settings.

Disclosure of maternal HIV status to children: considerations for research and practice in sub-Saharan Africa

An estimated 2.8 million children are born to HIV-infected mothers each year, 2.5 million of whom are likely to be HIV-exposed but uninfected. In sub-Saharan Africa up to 40% of pregnant women are HIV-infected, resulting in large numbers of HIV-uninfected children living with at least one HIV-infected parent. These parents face many challenges, including the dilemma of when and how to disclose their HIV status to their children, particularly those who are pre-adolescent. This article summarizes the current evidence on maternal HIV disclosure to their HIV-uninfected children, explores the reported benefits of disclosure to children and mothers, highlights the gaps in knowledge and areas for future research, and discusses possible future intervention models focusing on primary school-aged children in sub-Saharan Africa.

The impact of fear, secrecy, and stigma on parental disclosure of HIV status to children: a qualitative exploration with HIV positive parents attending an ART clinic in South Africa

South Africa is one of the sub Saharan countries where considerable progress in providing antiretroviral treatment (ART) has been made. The increased access to ART contributes to improvements in the prognosis of HIV and parents are more likely to raise their children than ever before. The study examined the social context influencing disclosure of parental HIV status to children from the perspectives of fathers and mothers accessing ART from an academic hospital in South Africa. Three focus group interviews were conducted with 26 non-disclosed biological parents of children aged between 7 and 18 years. Their ages ranged between 20-60 years and they cared for a total of 60 children. Parental decision not to disclose their HIV status to children was influenced by the fear of death and dying, the influence of television and media, stigma and discrimination. Parents delayed disclosure of their HIV status to children because children believed that AIDS kills. Parents also feared that the child may not be able to keep the parent's HIV status secret and might result in the family being subjected to stigma, discrimination, and isolation. Fear of stigma and discrimination were also responsible for the continuous efforts by parents to protect their HIV status from their children, family and neighbour's. Parents also delayed disclosure to children because they lacked disclosure skills and needed support for disclosure from health care providers. Healthcare providers are in a unique position to provide such support and guidance and assist parents to disclose and children to cope with parental HIV infection.

A discussion of HIV/AIDS family interventions: implications for family-focused nursing practice

AIM

This article presents a discussion on the role of family interventions in HIV/AIDS disease prevention and care.

BACKGROUND

Although HIV/AIDS epidemic and its impact on the society traditionally has been measured in terms of individual risk behaviours and individual-level HIV prevention, HIV/AIDS family-focused prevention and management strategies are increasingly becoming a priority. However, little is known as to what constitutes a HIV/AIDS family intervention.

DATA SOURCES

The search was limited to English and published literature starting in the year 1983 to date. CINAHL and PubMed were emphasized using a combination of text words and subject headings. Cochrane Library, PsycInfo, Scopus, and the ISI Web of Science databases were also searched using keywords and in the case of PsycInfo, subject headings were used. The main keywords were 'nurse', or 'nursing', 'HIV/AIDS', 'family interventions', 'family support' and 'family education', and/or 'family subsystems'.

DISCUSSION

The process of theorizing about 'family interventions' and 'HIV/AIDS-family interventions' is critical for putting forth essential components unique for designing culturally specific HIV/AIDS family interventions. In addition, any proposed design of HIV/AIDS family intervention should consider the impact of HIV/AIDS on the family across the family life span, disease trajectory, and from an interdisciplinary perspective.

CONCLUSION

Training needs of family nurses should be met when designing multidisciplinary HIV/AIDS-FIs. Furthermore, nurses should be proactive in advocating for HIV/AIDS family intervention and HIV/AIDS family policies to improve outcomes in family functioning, processes, and relationships. More needs to be done in regard to research on families, family interventions, effectiveness, and cost of family-focused approaches.