HIV-infected parents and their children in the United States

A cluster randomized controlled trial to evaluate a resilience-based intervention for caregivers of HIV-affected children in China

OBJECTIVES

The Child-Caregiver-Advocacy Resilience (ChildCARE) intervention aims to enhance the psychosocial wellbeing of children affected by parental HIV by providing programing at three levels: child, caregiver, and community. The objective of the current study was to evaluate the intervention's efficacy in improving mental health and parenting outcomes for participating caregivers.

DESIGN

A cluster randomized controlled trial was used to evaluate initial efficacy of the intervention.

METHODS

A total of 790 caregivers of children affected by parental HIV were recruited from Henan, China. Caregivers and their children were randomly assigned to one-of-four intervention arms (control, child-only, child + caregiver, child + caregiver + community) to evaluate the multiple components of ChildCARE. Those assigned to receive the caregiver intervention participated in five 2-h intervention sessions designed to improve their parenting skills and enhance their ability to cope with daily stressors. Caregivers reported on their mental health and parenting behaviors at baseline, 12, 24, and 36 months, with mixed effect modeling used to examine intervention effects.

RESULTS

Caregivers who participated in the intervention reported decreased anxiety and parental stress at 12 months (P < 0.05). Participants also reported increased use of structured parenting skills (i.e., parental demandingness) at 12 and 24 months (P < 0.05). However, by 36 months, they reported significantly lower levels of parental competence (P < 0.01) than those assigned to the control condition.

CONCLUSION

Preliminary findings suggest that the caregiving component of ChildCARE yields initial improvements in some key parenting and mental health outcomes. However, the challenges of caring for children affected by HIV are complex and may require more intensive intervention to yield marked, positive changes across key caregiver outcomes.

Alcohol use, mental health, and parenting practices among HIV-positive mothers

Mothers living with HIV (MLH) must balance childcare, their illness, and oftentimes other mental health problems/stressors. It is important to understand how a maladaptive coping strategy, (alcohol use) is linked to poorer parenting practices. We assessed the relationship between mental health/coping (anxiety, depression, alcohol use, social support) and parenting/family dimensions (communication, parenting style/stress, family routines/cohesion) among 152 MLH. Mothers reporting more psychiatric symptoms and less social support also reported poorer parenting practices and interactions. Further, MLH who used more alcohol reported less parenting involvement and fewer family interactions. Alcohol use, even at subclinical levels, can negatively impact the parent-child relationship.

The Impact of AIDS on Parents and Families in Thailand

Local key informants provided data on individual adult cases of AIDS for assessing the impact of the epidemic in Thailand on aged parents and other family members. In most cases, parents provided care for their infected adult children, often assisted with expenses, and frequently played a main role in paying for treatment. For one third of the cases, a family member reduced or stopped working to provide care. For approximately one fifth of parents, the infected adult child was their main income earner. Nevertheless, in most cases, the child’s death was not judged to have a devastating economic impact for the parents, although poorer families were far more likely to be adversely affected than others. Wide availability of basic government health insurance moderated the economic impact. Results are interpreted in terms of patterns of intergenerational exchanges of support and services.

Child-mother attachments in the face of grandparent HIV

Child-mother attachment, as observed in the Strange Situation (SSP), was assessed in 61 families affected by HIV and 18 neighborhood comparison families not affected by HIV, but of similar ethnicity and socioeconomic status. Children were aged one to three years at the assessment. Secure attachment was significantly less likely among children in the HIV-affected group than among comparison group children (36% versus 67%). The most common pattern of attachment in the HIV-affected group was disorganized/disoriented, observed in 41% of children (versus 22% of comparison children). Children from families that included a surviving grandparent with HIV showed disorganized attachments more often than children whose grandparents died (53% versus 36%). Child attachment classifications were not associated with families' participation in a family-based, cognitive-behavioral HIV intervention. These results document the inter-generational impact of young mothers' who were growing up with an HIV-infected parent. These findings suggest that families affected by HIV may benefit from interventions that address attachment issues.

"That's True Love:" Lived Experiences of Puerto Rican Perinatally HIV-Infected Youth within Their Families' Context

The burden of HIV affects not only HIV-infected patients but also their families and caregivers. It is also known that family support is crucial for people living with HIV. A qualitative study was conducted to explore the life experiences, within the family context, of perinatally HIV-infected (pHIV-I) youth in Puerto Rico. Twenty in-depth interviews were performed and audio-recorded. Within the family context, study participants experienced acceptance, love and support but also stigma and discrimination. They reported that family is an essential component in their lives and treatment. Losing one or both parents at a young age was considered more difficult than having HIV. Most participants who lost their parents lived with other family members. This was a challenging situation for both pHIV-I youth and their caregivers. Participants described their healthcare providers as part of their families and would like to keep in touch as they transition to adult care. Despite the challenges, participants expressed a desire to have children. Services targeted to this population should stress social support, incorporate family members into the medical process, provide special guidance and support while transitioning to adult care, and provide them with the latest information regarding HIV and reproductive options.

Differences in housing, health, and well-being among HIV-positive women living in poverty

The social context of living in poverty has a direct and indirect impact on a woman's health and well-being. This cross-sectional study investigates the relationship between housing and adherence to treatment, emotional wellness, environmental safety, physical health status, and risk behaviors among HIV-positive women receiving services from an AIDS service organization in the mid-South. Significant differences were found between stably housed and unstably housed women on the dependent outcome variables. Results suggest that housing services for HIV-positive women may be an effective way to increase their health and well-being as well as prevent transmission to others.

Health-related quality of life dynamics of HIV-positive South African women up to ART initiation: evidence from the CAPRISA 002 acute infection cohort study

Few studies have investigated the long-term dynamics in health-related quality of life (HRQoL) among HIV-positive persons from acute infection. From 2004, 160 women were enrolled into the CAPRISA 002 Acute Infection study at two sites in the province of KwaZulu-Natal and underwent 3-6 monthly HRQoL assessments using the functional assessment of HIV infection (FAHI) instrument. Overall and 5 sub-scale FAHI scores [physical well-being (PWB), emotional well-being (EWB), functional and global well-being (FGWB), social well-being (SWB) and cognitive functioning (CF)] were calculated up to antiretroviral therapy (ART) initiation and scores at enrollment were compared to the acute, early and established infection phases. Mixed-effects regression models adjusting for behavioral and clinical factors were applied to assess HRQoL trends and the proportion of women meeting minimally important differences was calculated. Our analyses revealed that overall/sub-scale scores improved over time, except from PWB and CF. A higher educational status, contraceptive use and a higher BMI were the strongest predictors of higher overall/sub-scale FAHI scores. CD4 count and HIV viral load were strongly associated with PWB and CF, but not overall FAHI and other sub-scales. Women newly diagnosed with acute HIV infection face profound HRQoL challenges. While early ART delivery may be important for PWB and CF, factors such as education, contraception provision and good nutritional status should be promoted to maximize HRQoL in HIV positive individuals.

Gender inequities in quality of care among HIV-positive individuals initiating antiretroviral treatment in British Columbia, Canada (2000-2010)

Objectives

We measured gender differences in “Quality of Care” (QOC) during the first year after initiation of antiretroviral therapy and investigated factors associated with poorer QOC among women.

Design

QOC was estimated using the Programmatic Compliance Score (PCS), a validated metric associated with all-cause mortality, among all patients (≥19 years) who initiated ART in British Columbia, Canada (2000–2010).

Methods

PCS includes six indicators of non-compliance with treatment initiation guidelines at baseline (not having drug resistance testing before treatment; starting on a non-recommended regimen; starting therapy at CD4<200 cells/mm³) and during first-year follow-up (receiving <3 CD4 tests; receiving <3 viral load tests; not achieving viral suppression within six months). Summary scores range from 0–6; higher scores indicate poorer QOC. Multivariable ordinal logistic regression was used to measure if female gender was an independent predictor of poorer QOC and factors associated with poorer QOC among women.

Results

QOC was determined for 3,642 patients (20% women). At baseline: 42% of women (34% men) did not have resistance testing before treatment; 17% of women (9% men) started on a non-recommended regimen (all p<0.001). At follow-up: 17% of women (11% men) received <3 CD4; 17% of women (11% men) received <3 VL; 50% of women (41% men) did not achieve viral suppression (all p<0.001). Overall, QOC was better among men (mean PSC = 1.54 (SD = 1.30)) compared with women (mean = 1.89 (SD = 1.37); p<0.001). In the multivariable model, female gender (AOR = 1.16 [95% CI: 0.99–1.35]; p = 0.062) remained associated with poorer QOC after covariate adjustment. Among women, those with injection drug use history, of Aboriginal ancestry, from Vancouver Island, and who initiated ART in earlier years were more likely to have poorer QOC.

Conclusions

Poorer QOC among women, especially from marginalized communities, demands that barriers undermining women's access to high-quality care be addressed to improve treatment and health for women with HIV.

The impact of social context on self-management in women living with HIV

HIV self-management is central to the health of people living with HIV and is comprised of the daily tasks individuals employ to manage their illness. Women living with HIV are confronted with social context vulnerabilities that impede their ability to conduct HIV self-management behaviors, including demanding social roles, poverty, homelessness, decreased social capital, and limited access to health care. We examined the relationship between these vulnerabilities and HIV self-management in a cross-sectional secondary analysis of 260 women living with HIV from two U.S. sites. All social context variables were assessed using validated self-report scales. HIV Self-Management was assessed using the HIV Self-Management Scale that measures daily health practices, HIV social support, and the chronic nature of HIV. Data were analyzed using appropriate descriptive statistics and multivariable regression. Mean age was 46 years and 65% of participants were African-American. Results indicated that social context variables, particularly social capital, significantly predicted all domains of HIV self-management including daily health practices (F = 5.40, adjusted R(2) = 0.27, p < 0.01), HIV social support (F = 4.50, adjusted R(2) = 0.22, p < 0.01), and accepting the chronic nature of HIV (F = 5.57, adjusted R(2) = 0.27, p < 0.01). We found evidence to support the influence of the traditional social roles of mother and employee on the daily health practices and the chronic nature of HIV domains of HIV self-management. Our data support the idea that women's social context influences their HIV self-management behavior. While social context has been previously identified as important, our data provide new evidence on which aspects of social context might be important targets of self-management interventions for women living with HIV. Working to improve social capital and to incorporate social roles into the daily health practices of women living with HIV may improve the health of this population.

Follow-up care among HIV-infected pregnant women in Mississippi

BACKGROUND

Data from the Centers for Disease Control and Prevention (CDC) indicate that reproductive-age black women in the Southeast are disproportionately affected by the HIV epidemic. There are few data describing HIV infection, pregnancies, and follow-up care in this population.

METHODS

A retrospective chart review was performed at the Perinatal HIV Service at the University of Mississippi Medical Center in Jackson, Mississippi, to identify HIV-infected women ≥ 18 years of age with deliveries from 1999 to 2006. Optimal follow-up was defined as at least two follow-up visits with an HIV provider within 1 year of delivery. Univariate and multivariate logistic regression analyses were used to identify factors associated with optimal adherence.

RESULTS

We identified 274 women with 297 total deliveries. Median age was 25, and 89% were black. Only 37% of women had two or more visits with an HIV provider in the postpartum year. On univariate analysis, presentation before the third trimester was associated with optimal follow-up (p = 0.04). On multivariate analyses, presentation before the third trimester was the only variable associated with optimal follow-up (odds ratio [OR] 2.1, p = 0.02).

CONCLUSIONS

The poor follow-up rates in this growing population highlight the critical need for research and development of targeted interventions to improve rates of retention in care, particularly in women with late trimester presentation.

Women-specific HIV/AIDS services: identifying and defining the components of holistic service delivery for women living with HIV/AIDS

Introduction

The increasing proportion of women living with HIV has evoked calls for tailored services that respond to women's specific needs. The objective of this investigation was to explore the concept of women-specific HIV/AIDS services to identify and define what key elements underlie this approach to care.

Methods

A comprehensive review was conducted using online databases (CSA Social Service Abstracts, OvidSP, Proquest, Psycinfo, PubMed, CINAHL), augmented with a search for grey literature. In total, 84 articles were retrieved and 30 were included for a full review. Of these 30, 15 were specific to HIV/AIDS, 11 for mental health and addictions and four stemmed from other disciplines.

Results and discussion

The review demonstrated the absence of a consensual definition of women-specific HIV/AIDS services in the literature. We distilled this concept into its defining features and 12 additional dimensions (1) creating an atmosphere of safety, respect and acceptance; (2) facilitating communication and interaction among peers; (3) involving women in the planning, delivery and evaluation of services; (4) providing self-determination opportunities; (5) providing tailored programming for women; (6) facilitating meaningful access to care through the provision of social and supportive services; (7) facilitating access to women-specific and culturally sensitive information; (8) considering family as the unit of intervention; (9) providing multidisciplinary integration and coordination of a comprehensive array of services; (10) meeting women “where they are”; (11) providing gender-, culture- and HIV-sensitive training to health and social care providers; and (12) conducting gendered HIV/AIDS research.

Conclusions

This review highlights that the concept of women-specific HIV/AIDS services is a complex and multidimensional one that has been shaped by diverse theoretical perspectives. Further research is needed to better understand this emerging concept and ultimately assess the effectiveness of women-specific services on HIV-positive women's health outcomes.

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.

Sociodemographic factors and health in a population of children living in families infected with HIV in Fortaleza and Salvador, Brazil

This study explores the relationships between demographic, socioeconomic and health statuses of children whose parents were HIV positive in two cities in Northeast Brazil. We conducted a multisite exploratory study in HIV/AIDS referral services for HIV/AIDS in Fortaleza, the capital of Ceará State, and Salvador, the capital of Bahia State, between June 2008 and March 2009. The study population consisted of 562 HIV+ adults - or caretakers of children of HIV+ adults - who provided information about a single index child under 13 years of age of either sex in their household. A structured questionnaire was used for to the adult parent or caretaker. We used multiple correspondence analysis (MCA), as implemented in the software SPAD (Portable Système pour l'Analyse des données). This analysis enabled us to identify the relationships between a large number of variables simultaneously. Of the 562 children, 311 (55.3%) lived in Fortaleza and 251 (44.7%) lived in Salvador. The proportion of HIV-infected children in Fortaleza was 14.2%, and 61.4% (27/44) of these had progressed to AIDS. In Salvador 34.7% of children were seropositive and 95% (83/87) were diagnosed with AIDS. The most important factors that emerged from the study were city and serostatus of the children. These two active variables accounted for 75.3% of the variance. Results are grouped into four profiles that describe the complex of socioeconomic variables closely associated with these families, and the complex and multiple epidemics of HIV, discrimination and poverty associated with these AIDS-affected families.

Efficacy of an intervention for families living with HIV in Thailand: a randomized controlled trial

This study evaluates the efficacy of an intervention for persons living with HIV (PLH) and their family members in Thailand. A randomized controlled trial of 813 PLH and family members was carried out at four district hospitals in Thailand. Participants completed Computer Assisted Personal Interview assessments at baseline, 6, 12, 18, and 24 months. The primary outcome was quality of life (QoL); other measures included depressive symptoms and family functioning. Relative to the standard care condition, the intervention group reported significantly improved QoL at 6 months (P = 0.0014). When the intervention efficacy was stratified by baseline depressive symptoms (low vs. high), intervention efficacy was observed only among those with low depressive symptoms. Study findings suggest that the intervention was more efficacious for participants with less depressive symptoms and better family functioning. Extensive interventions may be optimal for those who have the capacity to learn the tools and skills.

Reducing Sexual Risk Behaviors for HIV/STDs in Women with Alcohol Use Disorders

Objective: A pilot randomized clinical trial (RCT) examined effectiveness of HIV/STD Safer Sex Skills Building + Alcohol (SSB+A) intervention for women with Alcohol Use Disorders (AUDs) in a residential treatment setting. Method: After randomizing thirty-six women with AUDs and reporting having intercourse with a male partner in the past 180 days to SSB+A or HE (standard HIV/STD education) groups, rates of penetrative intercourse with and without condoms at 60 day and 180 day follow-up were compared between SSB+A or HE groups. Results: There was a significant difference in mean number of sex acts with condoms between SSB+A and HE groups over time. Specifically, SSB+A and HE groups did not differ at 60 day follow-up, but at 180 day follow-up, mean sex acts with condoms among SSB+A group was significantly higher than HE. Conclusion: Pilot study findings affirm the effectiveness of the SSB+A in reducing sexual risk behaviors of AUD women and support the need for further research, testing the SSB+A intervention in a larger sample of women and across different treatment modalities. The present study also illustrates the critical link between practice and use of a step by step model of intervention research.

Characteristics of HIV-infected mothers associated with increased risk of poor mother-infant interactions and infant outcomes

INTRODUCTION

The current study aimed to investigate the relationship between individual and familial characteristics of HIV-infected mothers and their psychological health as it relates to parenting as well as their parenting beliefs/abilities.

METHOD

A descriptive correlational design was used. Seventeen HIV-infected mothers and their infants were recruited from a university clinic in Alabama. Assessments were gathered at the infant's pediatric clinic appointments (approximately 6 weeks after delivery) and included a demographic questionnaire, the Beck Depression Inventory-II, the Maternal Confidence Questionnaire, the Parenting Stress Index-Short Form, and the Questionnaire About Physical Contact.

RESULTS

Dysfunctional parent-child interactions significantly correlated with maternal confidence, parent stress, and overall feeling about physical contact. Difficult child temperament correlated with overall and current feelings of physical contact and parent stress. Significant correlations were found between parent distress, parent stress, and maternal depression.

DISCUSSION

Beyond the need to assist HIV-infected mothers with stress and depression, an intervention is needed to facilitate optimal parent-child interactions and improve both child psychosocial and cognitive outcomes.

Examining HIV-positive parents' disclosure to their children: a biopsychosocial approach

In the post HAART era, the biopsychosocial issues now facing HIV-positive parents concerning disclosure of their status to their children need to be understood in the context of chronic disease. This article describes the experiences of 101 adult HIV-positive urban in-treatment mothers and fathers of school-age children on disclosure, psychological distress, social support, and symptom severity. Key variables associated with parents' HIV disclosure were the age of parent and of children in the household, parents' HIV-related symptoms, and parent ethnicity. Cultural and maturational, rather than psychological or social factors were significantly related to parents' HIV disclosure.

Parents living with HIV and children's stress and delinquent behaviors in China

OBJECTIVE: The current study aims to explore the association of parents living with HIV (PLHs) and their children's self-esteem, everyday stress, and delinquent behaviors. DESIGN: The study samples included 79 families with 79 PLHs and 79 children. METHODS: Multiple regression analysis was used on baseline data collected in 2009 from a pilot study in Anhui Province, China. RESULTS: The results indicated that children from a family with both parents infected with HIV or children from families having multiple children were more likely to report a higher level of everyday stress. Male PLHs have significant influence on their children's everyday stress compared with female PLHs. Children reporting a lower level of parental care and lower self-esteem were significantly more likely to report a higher level of delinquent behaviors. In addition, we have found a strong positive correlation between families with multiple children and their children's delinquent behaviors. CONCLUSIONS: The findings indicate that the severity of psychological and behavioral problems of children living in different HIV-affected families may be dependent not only on factors related to the children but also on factors related to their parents and families. Therefore, parental and family level factors should be considered when providing care and support to children living in HIV-affected families.

A multilevel intervention for HIV-affected families in China: Together for Empowerment Activities (TEA)

This article analyzes the efficacy of the Together for Empowerment Activities (TEA) intervention in decreasing depressive symptoms and improving social support for persons living with HIV (PLH) and their family members. A total of 79 families, consisting of 88 PLH and 79 family members, were recruited from Anhui province, China, and randomized to the TEA intervention (n = 38) or a control condition (n = 41). The intervention was delivered at three levels: 1) TEA Gathering (small group for PLH and family members); 2) TEA Time (home-based family activities with children that accompany each TEA Gathering); and 3) TEA Garden (community events that build social integration). Face-to-face interviews were administered at baseline, 3, and 6 months. Mixed-effects regression models and kernel density estimation were used for data analysis. PLH and their family members in the intervention reported significant improvements in depressive symptoms, social support, and family functioning at the 3-month and 6-month follow-up assessments compared to those in the control condition. Heterogeneous intervention effects on social support and family functioning were indicated at the 6-month follow-up. The intervention could have various effect patterns for different subgroups within the intervention condition. This study provides preliminary data to support the feasibility and efficacy of a multilevel intervention.

Religion, relationships and reproduction: correlates of desire for a child among mothers living with HIV

Despite challenges facing HIV-positive women in the U.S., some maintain strong desires and intentions for motherhood. We explore correlates of desire for another child-particularly current parenting experiences (number of children, parenting efficacy, parenting satisfaction, parenting practices, parental distress, and child-related quality of life), age, spirituality/religiosity, stress, coping, hopelessness, partner's desire for a child, social support, and stigma-among a sample of HIV-positive mothers (n = 96) in Alabama. Partner's desire for a child, participation in private religious practices, avoidant coping, and parity were significantly associated with desire for a child in multivariate models. Such findings indicate a need for reproductive counseling and education that is sensitive to the role of religious norms and values in fertility decision-making and suggest opportunities for partnership with faith-based organizations. Further studies examining the impact of relationship dynamics on childbearing desires among U.S. women living with HIV/AIDS are also needed.

Effects of infant massage on HIV-infected mothers and their infants

PURPOSE. To determine the feasibility of implementing an infant massage intervention and to evaluate the preliminary effects of infant massage on HIV-infected mothers and their infants. DESIGN AND METHODS. In this two-group, randomized controlled pilot study, intervention group mothers were taught to perform infant massage daily for 10 weeks. RESULTS. Infant massage training had a positive impact on maternal depression, parental distress, and infant growth along with facilitating more optimal parent-child interactions. PRACTICE IMPLICATIONS. Infant massage, a quick, easy, and inexpensive intervention, is feasible in a clinic setting and may benefit human immunodeficiency virus-infected mothers and their infants.

Main partner factors associated with worse adherence to HAART among women in Baltimore, Maryland: a preliminary study

Compared to US men, US women have worse HAART and HIV health outcomes. The study examined main partner factors associated with women's HAART adherence. The community sample comprised 85% African-Americans; 63% had a main partner and 32% relied on their partner for emotional support. Adherence was highest (92%) among those without a main partner and lowest (57%) among those with an HIV seropositive main partner. In adjusted analysis, adherence was 75% less likely among women with an HIV seropositive main partner and 78% less likely among those relying on their partner for emotional support. Furthermore, HIV seropositive versus other serostatus main partners were most likely to provide medication taking assistance and to be preferred in helping participants deal with HIV, yet were no more likely to be nominated as the most helpful to them. Findings reveal women's perceived unmet support needs from HIV seropositive main partners in this population and the need for interventions to promote their HAART adherence. Seroconcordant couples-focused intervention that enhances mutual support of HAART adherence may be an effective approach to improving women's HAART adherence and reducing US gender disparities in HIV health outcomes.

The effect of peer-driven intervention on rates of screening for AIDS clinical trials among African Americans and Hispanics

OBJECTIVES

We examined the efficacy of a peer-driven intervention to increase rates of screening for AIDS clinical trials among African Americans and Hispanics living with HIV/AIDS.

METHODS

We used a randomized controlled trial design to examine the efficacy of peer-driven intervention (6 hours of structured sessions and the opportunity to educate 3 peers) compared with a time-matched control intervention. Participants were recruited using respondent-driven sampling (n = 342; 43.9% female; 64.9% African American, 26.6% Hispanic). Most participants (93.3%) completed intervention sessions and 64.9% recruited or educated peers. Baseline and post-baseline interviews (94.4% completed) were computer-assisted. A mixed model was used to examine intervention effects on screening.

RESULTS

Screening was much more likely in the peer-driven intervention than in the control arm (adjusted odds ratio [AOR] = 55.0; z = 5.49, P < .001); about half of the participants in the intervention arm (46.0%) were screened compared with 1.6% of controls. The experience of recruiting and educating each peer also increased screening odds among those who were themselves recruited and educated by peers (AOR = 1.4; z = 2.06, P < .05).

CONCLUSIONS

Peer-driven intervention was highly efficacious in increasing AIDS clinical trial screening rates among African Americans and Hispanics living with HIV/AIDS.

Substance use among adolescents of parents living with HIV in New York City

We examined the relationship of community, interpersonal, and personal risk and protective factors to substance use among adolescents of parents with HIV (PWH). Families with HIV (n = 269 PWH and 409 adolescents) from New York City were recruited, and multivariate models were used to examine the associations. Adjusting for age, gender, and ethnicity, substance use was positively associated in univariate analyses with parental substance use, family conflict, adolescent emotional distress, and adverse life events; having academically oriented friends and religiosity were protective. In the multivariate model, multiple problem behaviors (e.g., delinquency) and substance-using peers were significantly associated with substance use. The patterns of associations between the risk factors and substance use are similar to those of adolescents in families not impacted by HIV. Interventions aimed at improving parental care, reducing maladaptive peer networks, and decreasing problem behaviors are important strategies to explore in future prevention studies.

Structural Ecosystems Therapy for recovering HIV-positive women: child, mother, and parenting outcomes

This study presents results of a subgroup analysis from a randomized trial to examine whether Structural Ecosystems Therapy (SET), a family intervention intended to improve medication adherence and reduce drug relapse of HIV-seropositive (HIV+) women recovering from drug abuse, provided benefits for families with children. Data from 42 children and 25 mothers were analyzed at baseline, and 4, 8, and 12 months post-baseline. Results of longitudinal Generalized Estimating Equations analyses suggested that SET was more efficacious than the Health Group (HG) control condition in decreasing children's internalizing and externalizing problems and reducing mothers' psychological distress and drug relapse. Children in SET reported improvements in positive parenting as compared to the children in HG, but there were no differences in mother-reported positive parenting, or parental involvement as reported by either the children or mothers. These findings suggest that family interventions such as SET may be beneficial for mothers and children. An adaptation of SET specifically for families with children could further enhance benefits and improve acceptability and cost-effectiveness.

Parents' disclosure of their HIV infection to their children in the context of the family

We interviewed 33 HIV-infected parents from the HIV Cost and Services Utilization Study (HCSUS), 27 of their minor children, 19 adult children, and 15 caregivers about the process of children learning that their parents were HIV positive. We summarize the retrospective descriptions of parents' disclosure of their HIV status to their children, from the perspective of multiple family members. We analyzed transcripts of these interviews with systematic qualitative methods. Both parents and children reported unplanned disclosure experiences with positive and negative outcomes. Parents sometimes reported that disclosure was not as negative as they feared. However, within-household analysis showed disagreement between parents and children from the same household regarding disclosure outcomes. These findings suggest that disclosure should be addressed within a family context to facilitate communication and children's coping. Parents should consider negative and positive outcomes, unplanned disclosure and children's capacity to adapt after disclosure when deciding whether to disclose.

An introduction to family-centred services for children affected by HIV and AIDS

Family-centred services in the context of HIV/AIDS acknowledge a broad view of a "family system" and ideally include comprehensive treatment and care, community agencies and coordinated case management. The importance of family-centred care for children affected by HIV/AIDS has been recognized for some time. There is a clear confluence of changing social realities and the needs of children in families affected by HIV and AIDS, but a change of paradigm in rendering services to children through families, in both high-prevalence and concentrated epidemic settings, has been slow to emerge.Despite a wide variety of model approaches, interventions, whether medical or psychosocial, still tend to target individuals rather than families. It has become clear that an individualistic approach to children affected by HIV and AIDS leads to confusion and misdirection of the global, national and local response. The almost exclusive focus on orphans, defined initially as a child who had lost one or both parents to AIDS, has occluded appreciation of the broader impact on children exposed to risk in other ways and the impact of the epidemic on families, communities and services for children. In addition, it led to narrowly focused, small-scale social welfare and case management approaches with little impact on government action, global and national policy, integration with health and education interventions, and increased funding.National social protection programmes that strengthen families are now established in several countries hard hit by AIDS, and large-scale pilots are underway in others. These efforts are supported by international and national development agencies, increasingly by governments and, more recently, by UNAIDS and the global AIDS community.There is no doubt that this is the beginning of a road and that there is still a long way to go, including basic research on families, family interventions, and effectiveness and costs of family-centred approaches. It is also clear that many of the institutions that are intended to serve families sometimes fail and frequently even combat non-traditional families.

"My children and my home": the most recent and challenging stressors of HIV-positive women

Because of negative health consequences and differences in exposure and vulnerability to stressful encounters, it is important to examine and understand the stressful experiences faced by women living with HIV. The goal of this study was to examine the most recent and challenging stressors faced and coping strategies adopted by a sample of women living with HIV. Using mixed methodology, narratives of six women's most recent and stressful experience and answers to the Ways of Coping questionnaire were collected and analysed. Two main themes arose from the stressor narratives: child-related concerns and housing issues. To address these stressors, each woman used a variety of coping strategies, the most common being seeking social support even when stressors were analysed separately according to their main themes. Implications of these findings within service provision are discussed.

Family-based processes associated with adolescent distress, substance use and risky sexual behavior in families affected by maternal HIV

The present study investigated how maternal HIV and mediating family processes are associated with adolescent distress, substance use, and risky sexual behavior. Mother-adolescent (ages 12-21) dyads (N = 264) were recruited from neighborhoods where the HIV-affected families resided (161 had mothers with HIV). Mediating family processes were youth aggressive conflict style, maternal bonding, maternal role reversal expectations, and overall family functioning. Results of structural equation modeling indicated that youth aggressive conflict resolution style was strongly associated with adolescent distress, substance use, and risky sexual behavior. In HIV-affected families, youth less frequently reported using an aggressive conflict resolution style and more frequently reported positive maternal bonds; their mothers reported less positive family functioning than control families. Finally, maternal distress indirectly affected adolescent distress and risk behavior via youth aggressive conflict resolution style.

Disrupted caregiving and maternal HIV disease: a proposed model for evaluating HIV-affected children's psychosocial adjustment

A current concern among social science researchers is the impact of human immunodeficiency virus (HIV) disease on the family, especially on the parenting abilities of mothers with HIV. Beginning research suggests that the children of HIV-positive parents are vulnerable, pointing to the impact of HIV disease on children's social and emotional adjustment. The objective of this article is to propose a model of the HIV disease-related disruption of care on children's psychosocial adjustment. The schematic model can be used to evaluate the mechanisms by which maternal HIV disease may influence the psychosocial adjustment of elementary school-age children.

Mothers of adolescent girls: comparing HIV positive and HIV negative women

BACKGROUND

HIV+ mothers of adolescent girls can serve as agents of change, particularly when it comes to preventing patterns of behaviors that are inherently dangerous. In order to do so these women need to be able to communicate with their daughters and educate them about risk behaviors, especially those associated with HIV acquisition. The objective is to describe the sociodemographic and risk profile in a sample of mothers of adolescent girls who are HIV+ or HIV negative and analyze differences between them.

METHODS

A convenience sample was recruited from three sites, the Universidad Central del Caribe School of Medicine, the UPR School of Medicine, and the Ponce School of Medicine. Six focus groups, two in each institution, were conducted following Krueger's methodology with the objective of developing an educational intervention for mothers of adolescent girls. All participants completed two self-administered questionnaires prior to the focus group. A data analysis was performed--descriptive statistics for the sociodemographic measures included frequencies, percents, mean and SD. We used t test and the Fisher's exact test to analyze differences between groups.

RESULTS

A total of 44 participants were enrolled, with 50% being HIV positive mothers and 50% being HIV negative mothers. The mean age for both groups was similar (41 years). Statistically significant differences (P < .05) were observed among HIV diagnosis and for the following variables: education, working status, income, marital status, age at first intercourse, and illicit drug use.

CONCLUSIONS

It is possible that the sociodemographic characteristics of HIV+ women affect their parenting and communication skills. The same factors that may have led to these women being infected by HIV in the first place might in addition be compromising their roles as effective parents.

MOMS: formative evaluation and subsequent intervention for mothers living with HIV

The Making Our Mothers Stronger (MOMS) Project is a randomized controlled behavioral trial, comparing a stress-reduction and social support intervention (Healthy MOMS) to a parenting skills intervention (Parenting Skills for MOMS) for mothers living with HIV. Outcomes include maternal mental and physical health, parenting behaviors, and children's behavior. To ensure that these interventions were tailored to the needs of HIV+ mothers, extensive formative work was conducted with members of the intended audience and relevant service providers. Findings from focus groups and semi-structured interviews highlighted the need for Healthy MOMS to: (1) include appropriate approaches to group discussion and problem solving; (2) address the stressors of being both a parent and a woman living with HIV; and (3) enhance social support. Six weekly group sessions focused on topics including coping with stress and anxiety; enhancing nutrition, exercise, and sexual health; improving medical adherence; improving communication with health care providers; and communicating health needs to family, friends, and co-workers. Initial anecdotal responses from participants suggest that the Healthy MOMS intervention addresses several salient issues for the growing population of HIV+ mothers who can benefit from long-term support in adapting to this chronic disease.

Gender disparities in HIV health care utilization among the severely disadvantaged: can we determine the reasons?

Data repeatedly demonstrate that HIV-infected people who regularly utilize primary health care services are more likely to have access to lifesaving treatments (including antiretroviral medications); have better indicators of health status; survive longer; and use acute care services far less. Women tend to have poorer HIV outcomes than men, which is likely due to gender disparities in optimal utilization of HIV primary care services. To understand the relationship between gender and the HIV health care system, we collected interview and medical record data between August 12, 2004 and June 7, 2005 from 414 severely marginalized, HIV-infected people in New York City and examined whether gender-related disparities in HIV health care utilization existed, and, if so, whether these patterns were explained by patient sociodemographic/behavioral characteristics and/or attitudes toward the health care system and providers. Women were significantly less likely to have optimal HIV health care services utilization, including lower use of HIV primary care services (odds ratio [OR] = 0.56, 95% confidence interval [CI] = 0.35, 0.90) and greater use of the emergency department (OR = 2.13, 95% CI = 1.31, 3.46). Although we identified several factors associated with suboptimal HIV health care services utilization patterns in addition to female gender (low education, insurance status, mistrust of the health care system, and poor trust in health care providers), we were unable to identify factors that explained the observed gender disparities. We conclude that gender disparities in HIV health care utilization are due to a complex array of factors, which require more qualitative and quantitative research attention. Development of intervention strategies that specifically target severely disadvantaged women's HIV health care utilization is in great need.

Parents Living with HIV in China: Family Functioning and Quality of Life

In China, HIV shifts the lifestyle of not only parents living with HIV/AIDS, but also their children, partners, and extended families. We examined factors related to the quality of life of parents living with HIV and the relation between family functioning and individual quality of life. Interviews were conducted with a total of 116 parents living with HIV/AIDS. Analyses of variance, Pearson correlations, and multiple regression analyses were performed to examine the relation between family functioning and quality of life. We found a significant association between family functioning and individual quality of life for parents living with HIV. In particular, family sociability had a strong relationship with the quality of life of parents living with HIV. Parents living with HIV from families where both parents are HIV-positive reported a lower level of family sociability than those from families with only one HIV-positive parent. HIV disclosure, family sociability, and number of children per family were found to be significant predictors of overall quality of life for the population. Study findings underscore the importance of developing interventions that improve family functioning for people living with HIV/AIDS in China.

The longitudinal impact of HIV+ parents' drug use on their adolescent children

The impact of parental substance use on the emotional and behavioral adjustment of their adolescent children was examined over 5 years. A representative sample of 220 parents with HIV (PWH) and 330 adolescent children in New York City were repeatedly assessed. Some parents never used marijuana or hard drugs over the 5 years (nonusers). Among those who were users, substance use varied over time. PWH who used substances during a specific 3-month period were classified as active users and those who abstained from substance use were classified as inactive users. Longitudinal regression analyses were used to analyze the impact of variations in patterns of substance use over time on their adolescent children's emotional adjustment and behavioral problems. PWH relapse exacerbated adolescent substance use, trouble with peers, and adolescent emotional distress. Even time-limited reductions in parents' substance abuse can have a significant positive impact on their adolescent children's emotional and behavioral adjustment. Interventions that address parental substance use among PWH should be developed to ameliorate the impact of substance use relapse on their adolescents.

Impacts of HIV/AIDS Stigma on Family Identity and Interactions in China

This study examines the impact of HIV-related stigma on families living with HIV/AIDS in China. In-depth, semistructured interviews were conducted with 30 people living with HIV/AIDS and with 15 of their family members, including spouses, parents, and siblings. Findings show that HIV-related stigma is associated with bringing shame to the family, losing family "face," and damaging within-family relations and broader family social networks. HIV/AIDS stigma was reported to have major impacts on family identity and interactions. In order to cope with these pressures, families reported joining self-support programs, educating family members, and helping other families. This study illustrates that HIV-related stigma is an issue faced by entire families in China, points to specific aspects of family life in which these impacts take place, and suggests the importance of including families in HIV/AIDS and stigma reduction interventions.

Fears about HIV transmission in families with an HIV-infected parent: a qualitative analysis

OBJECTIVE

Children of HIV-infected parents may be affected by their parents' disease even if not infected themselves. Because of advances in HIV treatment that have reduced the risk for vertical HIV transmission from mother to child, more HIV-infected adults are having children. Few studies have examined whether families with an HIV-infected parent experience fears about transmission to children and how they address such fears. In this article, we describe transmission-related fears in families with an HIV-infected parent.

METHODS

We used semistructured qualitative interviews, conducted in person from March 2004 to March 2005, with 33 HIV-infected parents, 27 minor children who were 9 to 17 years of age, 19 adult children, and 15 caregivers (adult family members or friends who helped care for the children and/or parents) to investigate their fears about HIV transmission. The parents are a subset from the HIV Cost and Services Utilization Study, a study of people in care for HIV throughout the United States. We analyzed the interview transcripts for themes related to transmission fears.

RESULTS

In many of the families, participants identified >or=1 HIV transmission-related fear. Themes included specific fears related to blood contact, bathroom items, kissing/hugging, and food. Families addressed their fears by educating children about modes of HIV transmission and establishing rules or taking precautions to reduce the risk for HIV transmission in the household. HIV-infected parents were also concerned about catching opportunistic infections from a sick child.

CONCLUSIONS

Many of the fears experienced by HIV-infected parents and their children were based on misconceptions about modes of HIV transmission. Pediatricians and others who treat these children may be able to offer counseling to allay fears that family members have about household transmission of HIV.

Children's body mass index and nutrition intake in HIV/AIDS

HIV/AIDS in China poses many challenges for caregivers and their children. A total of 154 caregivers of HIV/AIDS-affected families were interviewed to examine the children's nutrition intake and body mass index (BMI) in the context of HIV/AIDS in the family. The results showed that 25% of children in HIV/AIDS-affected families were underweight or at risk of being underweight according to US criteria. More than half the children reported that their consumption of protein such as meat, eggs or milk ranged from not at all to two times during the past month. About 40% of the children sometimes or often went hungry due to insufficient food. The study findings underscore the need to improve the nutrition and general health of children of people living with HIV/AIDS.

HIV-related stigma among people with HIV and their families: a qualitative analysis

We examined the interconnectedness of stigma experiences in families living with HIV, from the perspective of multiple family members. Semi-structured interviews were conducted with 33 families (33 parents with HIV, 27 children under age 18, 19 adult children, and 15 caregivers). Parents were drawn from the HIV Cost and Services Utilization Study, a representative sample of people in care for HIV in US. All of the families recounted experiences with stigma, including 100% of mothers, 88% of fathers, 52% of children, 79% of adult children, and 60% of caregivers. About 97% of families described discrimination fears, 79% of families experienced actual discrimination, and 10% of uninfected family members experienced stigma from association with the parent with HIV. Interpersonal discrimination seemed to stem from fears of contagion. Findings indicate a need for interventions to reduce HIV stigma in the general public and to help families cope with stigma.

Adjustment of Adolescents of Parents Living with HIV

Family environment and rates of mental health and behavioral problems in HIV-negative adolescents and their parents living with HIV (PWH) were compared to adolescents and parents from non HIV-affected families living in similar inner-city neighborhoods. Adolescents and their parents were interviewed and a case-control sample was constructed. Data on sixty-two matched pairs of adolescents of PWH and those of neighborhood parents and forty-six matched pairs of PWH and HIV-negative parents were examined. Compared to neighborhood controls, adolescents of PWH experienced greater life stressors and family conflict and reported lower self-esteem. PWH reported greater emotional distress and substance use. However, there were no significant differences in emotional distress or externalized problem behaviors between the two adolescent groups. Clinical implications are discussed.

Children of mothers with HIV/AIDS: unmet needs for mental health services

OBJECTIVE

The objective of this study was to use multiple measures and sources to assess mental health over time in uninfected 8- to 12-year-old children of HIV-positive mothers.

METHODS

We recruited from the New York City Division of AIDS Services and Income Support a consecutive sample of 157 single mothers who were living with an HIV-negative child aged 8 to 12. Families were randomly assigned to receive a custody planning intervention, Project Care, or standard care. Data were collected at baseline and 4 subsequent times 6 months apart. Children completed the Children's Depression Inventory; 8- to 10-year-olds completed the Terry, and 11- to 12-year-olds completed the Youth Self-Report. Mothers completed the Child Behavior Checklist. Each measure has a validated cutoff score to signify clinically significant symptoms.

RESULTS

All 5 data points were available on 129 (82%) children. During 2 years, every child had a score in the clinical range (12% once, 25% twice, 26% 3 times, 27% 4 times, and 9% all 5 times). Clinically significant symptoms were most likely at baseline when mothers were sickest. Few had clinically significant symptoms based on maternal report only (5%) or child report only (8%). Chronicity of clinically significant symptoms was not related to child age or gender, maternal health or depression, parent-child relationship, or being assigned to Project Care. Although two thirds of the children received mental health services during the study, <25% did at any 1 time, and 28% of children with chronic clinically significant symptoms never received care.

CONCLUSIONS

Children who are affected by AIDS should be routinely screened for psychiatric problems by using multiple measures and sources to avoid underidentification and be carefully monitored long-term.

Differences in HIV disclosure by modes of transmission in Taiwanese families

HIV serostatus disclosure is a crucial decision, and often perceived as a double-edged sword for people living with HIV. This study was intended to determine the extent of disclosure according to interpersonal relationships, compare the characteristics of disclosure by modes of HIV transmission, and to describe perceived consequences after disclosure to Taiwanese families. Data were collected by in-depth interviews and chart reviews at HIV primary care clinics in a university hospital in southern Taiwan from 2004 to 2005. Of 105 male participants interviewed, 76 (72.4%) had disclosed their HIV status to at least one person, including 62% to an immediate family member and 21% to friends. The HIV disclosure rates were different in three groups divided by modes of transmission, 36% in men having sex with men (MSM), 34% in heterosexuals, and 21% in injection drug users (IDUs). MSM were more likely than heterosexual men or male IDUs to disclose their HIV status directly to friends immediately after leaning of their HIV diagnosis. Heterosexual men and male injection drug users often disclosed to their immediate families a few days after obtaining an HIV diagnosis. Perceived consequences after disclosure included: increased substantial support from family, assistance with medical and healthcare, encouragement of living positively with HIV, being rejected, treated as contagion, and condemnation. Disclosure of HIV-positive status in a family-oriented Taiwanese society is a complex process and different by the modes of transmission.

Children of HIV-infected parents: custody status in a nationally representative sample

OBJECTIVE

The purpose of this work was to determine the rates and predictors of custody status for children of HIV-infected parents.

PARTICIPANTS AND METHODS

Data came from interviews of 538 parents with 1017 children (0-17 years old) from a nationally representative sample of HIV-infected adults receiving health care in the United States. Outcomes were collected at 2 survey waves and included child custody status and who, other than the HIV-infected parent, had custody of the child. Child custody status was categorized as (1) in custody of HIV-infected parent at both survey waves, (2) infected parent had custody at first survey wave but not second survey wave, (3) not in custody of infected parent at either survey wave, and (4) infected parent gained custody between survey waves. Potential custodians included (1) other biological parent, (2) state, foster, or adoptive parent, (3) grandparent, and (4) relative, friend, nonbiological parent, or other. Multinomial logistic regression modeled both outcomes.

RESULTS

Forty-seven percent of the children were in the custody of their HIV-infected parent at both survey waves, 4% were in the parent's custody at the first but not second survey wave, 42% were not in custody at either survey wave, and the parent of 7% gained custody between survey waves. Parents cited drug use (62%) and financial hardship (27%) as reasons for losing custody. Children of HIV-infected fathers, older parents, parents living without other adults, parents with low CD4 counts, drug-using parents, and parents with > or = 1 hospital stay were less likely to be in their parent's custody at either survey wave.

CONCLUSIONS

More than half of the children were not in custody of their HIV-infected parent at some time during the study period. Pediatricians and others taking care of children with HIV-infected parents may be able to offer counseling or referrals to assist parents with child custody issues.

Maternal substance use and HIV status: adolescent risk and resilience

We examined the risk and protective factors and mental health problems of 105 low SES, urban adolescents whose mothers were coping with alcohol abuse and other drug problems. Approximately half of the mothers were also HIV-infected. As hypothesized, there were few differences between adolescents of HIV-infected and HIV-uninfected mothers in background characteristics, mental health issues and current substance use risk behaviors. In addition to maternal substance abuse, youth in both groups experienced similar risk factors including early foster care placement and high levels of maltreatment. Current patterns of emerging risk behaviors were evident among youth in both groups as well as signs of resiliency including high levels of school attendance. These results underscore the importance of interventions for youth of substance abusing mothers, particularly those living in urban poverty.

Gender differences in attitudes toward AIDS clinical trials among urban HIV-infected individuals from racial and ethnic minority backgrounds

Racial/ethnic minorities and women are under-represented in AIDS clinical trials (ACTs). We examined gender differences in willingness to participate in ACTs among urban HIV-infected individuals (N = 286). Sixty percent of participants were male, and most were from racial/ethnic minority backgrounds (55% African-American, 34% Latino/Hispanic, 11% White/other). Knowledge of ACTs was poor. Males and females did not differ substantially in their distrust of AIDS scientists, or in barriers to ACTs. Almost all (87%) were somewhat or very willing to join ACTs. Females were less willing than males to join, including trials testing new medications or new medication combinations. Males and females differed in correlates of willingness to participate in ACTs. Despite long-standing barriers to medical research among minorities and women, willingness to participate was substantial, particularly for men, although the factors that might motivate them to join differed by gender. Women appeared more averse to trials involving new anti-retroviral regimens than men. Gender-specific outreach, behavioural intervention, and social marketing efforts are needed.

Guardianship planning among HIV-infected parents in the United States: results from a nationally representative sample

OBJECTIVE

The purpose of this work was to determine the rates and predictors of guardianship planning and preferred guardians among HIV-infected parents.

PARTICIPANTS AND METHODS

Data were analyzed from interviews with 222 unmarried parents (who had 391 children) from a nationally representative sample of HIV-infected adults receiving health care. Outcome measures included parental report on the level of guardianship planning and on who their preferred guardian for each child was. Level of guardianship planning was categorized as follows: (1) parent had not identified a guardian; (2) parent had identified a guardian, but the guardian had not agreed; (3) identified guardian had agreed; and (4) legal documentation of guardianship plan was complete. We conducted bivariate and ordered logistic regression analyses on the level of guardianship planning and multinomial logistic regression on identification of preferred guardians.

RESULTS

Twelve percent of unmarried HIV-infected parents had not identified a guardian; 6% had identified a guardian but gone no further; 53% said the identified guardian had agreed; and 28% had prepared legal documentation. The preferred guardians included other biological parents (17%), spouse/partners who were not biological parents (2%), grandparents (36%), other relatives (34%), friends (7%), unrelated adoptions (1%), and others (3%). Parents with the lowest CD4 counts and parents living without other adults were more likely to have completed the guardianship planning process. Nonrelatives were most often preferred by mothers and parents with higher CD4 counts; grandparents were most often preferred by younger parents and parents who prefer speaking Spanish.

CONCLUSIONS

Pediatricians and others who take care of children with HIV-infected parents may be able to provide counseling and referrals for guardianship planning.