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

Living with HIV, disclosure patterns and partnerships a decade after the introduction of HIV programmes in rural South Africa

Prevention of mother-to-child Transmission and HIV Treatment programmes were scaled-up in resource-constrained settings over a decade ago, but there is still much to be understood about women's experiences of living with HIV and their HIV disclosure patterns. This qualitative study explored women's experiences of living with HIV, 6–10 years after being diagnosed during pregnancy. The area has high HIV prevalence, and an established HIV treatment programme. Participants were enrolled in a larger intervention, “Amagugu”, that supported women (n = 281) to disclose their HIV status to their children. Post-intervention we conducted individual in-depth interviews with 20 randomly selected women, stratified by clinic catchment area, from the total sample. Interviews were entered into ATLAS.ti computer software for coding. Most women were living with their current sexual partner and half were still in a relationship with the child's biological father. Household exposure to HIV was high with the majority of women knowing at least one other HIV-infected adult in their household. Eighteen women had disclosed their HIV status to another person; nine had disclosed to their current partner first. Two main themes were identified in the analyses: living with HIV and the normalisation of HIV treatment at a family level; and the complexity of love relationships, in particular in long-term partnerships. A decade on, most women were living positively with HIV, accessing care, and reported experiencing little stigma. However, as HIV became normalised new challenges arose including concerns about access to quality care, and the need for family-centred care. Women's sexual choices and relationships were intertwined with feelings of love, loyalty and trust and the important supportive role played by partners and families was acknowledged, however, some aspects of living with HIV presented challenges including continuing to practise safe sex several years after HIV diagnosis

Communication about HIV and death: Maternal reports of primary school-aged children's questions after maternal HIV disclosure in rural South Africa

Introduction: Children's understanding of HIV and death in epidemic regions is under-researched. We investigated children's death-related questions post maternal HIV-disclosure. Secondary aims examined characteristics associated with death-related questions and consequences for children's mental health. Methods: HIV-infected mothers (N = 281) were supported to disclose their HIV status to their children (6–10 years) in an uncontrolled pre-post intervention evaluation. Children's questions post-disclosure were collected by maternal report, 1–2 weeks post-disclosure. 61/281 children asked 88 death-related questions, which were analysed qualitatively. Logistic regression analyses examined characteristics associated with death-related questions. Using the parent-report Child Behaviour Checklist (CBCL), linear regression analysis examined differences in total CBCL problems by group, controlling for baseline. Results: Children's questions were grouped into three themes: ‘threats’; ‘implications’ and ‘clarifications’. Children were most concerned about the threat of death, mother's survival, and prior family deaths. In multivariate analysis variables significantly associated with asking death-related questions included an absence of regular remittance to the mother (AOR 0.25 [CI 0.10, 0.59] p = 0.002), mother reporting the child's initial reaction to disclosure being “frightened” (AOR 6.57 [CI 2.75, 15.70] p=<0.001) and level of disclosure (full/partial) to the child (AOR 2.55 [CI 1.28, 5.06] p = 0.008). Controlling for significant variables and baseline, all children showed improvements on the CBCL post-intervention; with no significant differences on total problems scores post-intervention (β -0.096 SE1.366 t = -0.07 p = 0.944). Discussion: The content of questions children asked following disclosure indicate some understanding of HIV and, for almost a third of children, its potential consequence for parental death. Level of maternal disclosure and stability of financial support to the family may facilitate or inhibit discussions about death post-disclosure. Communication about death did not have immediate negative consequences on child behaviour according to maternal report. Conclusion: In sub-Saharan Africa, given exposure to death at young ages, meeting children's informational needs could increase their resilience

Evaluation of a Brief Intervention to Improve the Nursing Care of Young Children in a High HIV and AIDS Setting

The HIV epidemic in South Africa is putting great strain on health services, including the inpatient care of young children. Caregivers and young children (107 pairs) and 17 nurses participated in an intervention to improve the care of young children in hospital in a high HIV and AIDS setting. The intervention addressed caregiver expectations about admission and treatment, responsive feeding, coping with infant pain and distress, assistance with medical procedures, and preparation for discharge and home care. Following a preparatory and piloting phase, measures of nurse burnout, caregiver physical and emotional well-being, and caregiver-child interaction were made before and after intervention. No changes were found between before and after intervention on assessments of caregiver wellbeing. However, mothers in the postintervention phase rated nurses as more supportive; mother-child interaction during feeding was more relaxed and engaged, and babies were less socially withdrawn. While the intervention proved useful in improving certain outcomes for children and their caregivers, it did not address challenging hospital and ward administration or support needed by caregivers at home following discharge. To address the latter need, the intervention has been extended into the community through home-based palliative care and support

Breastfeeding, HIV exposure, childhood obesity, and prehypertension: a South African cohort study

Background: Evidence on the association between breastfeeding and later childhood obesity and blood pressure (BP) is inconsistent, especially in HIV-prevalent areas where, until recently, HIV-infected women were discouraged from breastfeeding, but obesity is increasingly prevalent. Methods and findings: The Siyakhula cohort (2012–2014), a population-based prospective cohort study, collected data over 3 visits on HIV-negative children ages 7 to 11 years in rural South Africa. We used weight (body mass index [BMI]), fat, and BP as outcome variables and incorporated early life (including mother’s age at delivery and HIV status) and current life factors (including maternal education and current BMI). Our primary exposure was breastfeeding duration. We dichotomized 3 outcome measures using pre-established thresholds for clinical interpretability: (1) overfat: ≥85th percentile of body fat; (2) overweight: >1 SD BMI z score; and (3) prehypertension: ≥90th percentile for systolic BP (SBP) or diastolic BP (DBP). We modelled each outcome using multivariable logistic regression, including stopping breastfeeding, then early life, and finally current life factors. Of 1,536 children (mean age = 9.3 years; 872 girls; 664 boys), 7% were overfat, 13.2% overweight, and 9.1% prehypertensive. Over half (60%) of the mothers reported continued breastfeeding for 12+ months. In multivariable analyses, continued breastfeeding between 6 and 11 months was associated with approximately halved odds of both being overfat (adjusted odds ratio [aOR] = 0.43, 95% confidence interval [CI] 0.21–0.91, P = 0.027) and overweight (aOR = 0.46, CI 0.26–0.82, P = 0.0083), but the association with prehypertension did not reach statistical significance (aOR = 0.72, CI 0.38–1.37, P = 0.32). Children with a mother who was currently obese were 5 times more likely (aOR = 5.02, CI 2.47–10.20, P < 0.001) to be overfat and over 4 times more likely to be overweight (aOR = 4.33, CI 2.65–7.09, P < 0.001) than children with normal weight mothers. Differences between HIV-exposed and unexposed children on any of the outcomes were minimal and not significant. The main study limitation was that duration of breastfeeding was based on maternal recall. Conclusions: To our knowledge, this is the first study examining and quantifying the association between breastfeeding and childhood obesity in an African setting with high HIV prevalence. We observed that breastfeeding was independently associated with reduced childhood obesity for both HIV-exposed and unexposed children, suggesting that promoting optimal nutrition throughout the life course, starting with continued breastfeeding, may be critical to tackling the growing obesity epidemic. In the era of widespread effective antiretroviral treatment for HIV-infected women for life, these data further support the recommendation of breastfeeding for all women

Public perceptions, beliefs and experiences of fostering and adoption : a national qualitative study in South Africa

In South Africa, rates of adoption remain low while the number of fostered children continually rises. Little is known about the public perceptions, beliefs and experiences that inform decisions to either foster or adopt in South Africa. This qualitative research explored these issues among a national sample of childless adults, biological parents, kin and non-kin fostering parents and prospective and successful adopters. Fostering is driven predominantly by access to subsidies but is also informed by socio-cultural beliefs. Low adoption rates are influenced by an absence of subsidies, poor access to quality adoptive services and a lack of information about adoption.http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1099-0860hb2016Sociolog

Risk factors for vulnerable youth in urban townships in South Africa: the potential contribution of reactive attachment disorder

Reactive attachment disorder (RAD) is a psychiatric disorder developing in early or middle childhood as a consequence of significant failures in the caregiving environment. RAD results in children failing to relate socially, either by exhibiting markedly inhibited behaviour or by indiscriminate social behaviour and is associated with significant socio-behavioural problems in the longer term. This study examined RAD in South Africa, a setting with high environmental risks. We recruited a sub-sample of 40 10-year-old children from a cohort enrolled during pregnancy for whom early attachment status was known. Children were purposefully selected to represent the four attachment categories using the data available on the strange situation procedure (SSP) at 18 months. The Manchester Child Attachment Story Task (MCAST) assessed current attachment and RAD was diagnosed using a standardised assessment package. A high proportion of the children (5/40% or 12.5%) fulfilled diagnostic criteria for RAD; all were boys and were displaying the disinhibited type. SSP classification at 18 months was not significantly associated with RAD symptoms at age of 10 years, while current MCAST classifications were. This suggests that children in this sample are at much higher risk of RAD than in high-income populations, and despite a fairly typical attachment distribution in this population at 18 months, RAD was evidenced in later childhood and associated with current attachment disorganisation. The strengths of this research include its longitudinal nature and use of diagnostic assessments. Given increasing evidence that RAD is relatively stable over time and introduces longer term socio-behavioural risks; the high rate of RAD in this sample (12.5%) highlights potential developmental threats to children in low- and middle-income countries (LMICs). Our results should be interpreted with caution given sample size and risk of selection bias. Further research is needed to confirm these findings

Prevalence and risk factors for child mental disorders in a population-based cohort of HIV-exposed and unexposed African children aged 7–11 years

Despite being home to a large population of vulnerable children there is a dearth of population-based evidence on childhood mental disorders in sub-Saharan Africa. Parent and child mental health are rarely measured concurrently, despite potential for confounding with other risk factors, including parental HIV. Using the parent-report Child Behaviour Checklist (CBCL) we assessed children's mental health in a population-based cohort of 1536 HIV-negative children (31% HIV-exposed, 18% HIV-affected, 51% HIV-unexposed) aged 7-11 years. CBCL was scored using CBCL Rating-to-Score software. A binary indicator was determined using the clinical threshold ≥ 65. We modelled mental disorders using logistic regression, including covariates associated with the mother, child, household, and parenting. Structural equation modelling techniques also derived continuous latent variables representing the underlying mental health and parent-relationship constructs. Prevalence of conduct disorders (11.8%) was high, regardless of HIV exposure, while HIV-affected children had increased odds of affective disorders. Maternal depression increased odds of externalising disorders; maternal anxiety was associated with affective and anxiety disorders. Mother-child relationship dysfunction increased odds of all disorders, including: affective [aOR = 5.1 (2.6-9.9)]; oppositional [aOR = 7.9 (4.0-15.5)]; conduct [aOR = 4.3 (2.6-7.2)] disorders. Food insecurity and male gender increased odds of somatic disorders; breastfeeding halved odds of conduct disorders. In the latent model, associations were substantially stronger for the mother-child relationship and externalising disorders (Oppositional 0.464 p < 0.001; Conduct 0.474 p = <0.001). Conduct disorders were high for all children regardless of HIV exposure. The mother-child relationship was strongly related to all child disorders, suggesting potential for concurrent interventions targeting child behaviours and the parent-child or mother-child relationship

Cross-sectional associations between mental health indicators and social vulnerability, with physical activity, sedentary behaviour and sleep in urban African young women

Background Relationships between mental health and multiple health behaviours have not been explored in young South African women experiencing social constraints. The aim of this study was to identify associations between mental health indicators and risk factors with physical activity, sedentary behaviour, and sleep, amongst young women living in Soweto, a predominantly low-income, urban South African setting. Methods For this cross-sectional study, baseline measurements for participants (n = 1719, 18.0–25.9 years old) recruited for the Healthy Life Trajectories Initiative were used including: physical activity, sedentary behaviour (sitting, screen and television time), sleep (duration and quality), depression and anxiety indicators, emotional health, adverse childhood experiences, alcohol-use risk; social vulnerability, self-efficacy, and social support. Results Multiple regression analyses showed that depression (β = 0.161, p < 0.001), anxiety (β = 0.126, p = 0.001), adverse childhood experiences (β = 0.076, p = 0.014), and alcohol-use risk (β = 0.089, p = 0.002) were associated with poor quality sleep. Alcohol-use risk was associated with more screen time (β = 0.105, p < 0.001) and television time (β = 0.075, p < 0.016). Social vulnerability was associated with lower sitting time (β = − 0.187, p < 0001) and screen time (β = − 0.014, p < 0.001). Higher self-efficacy was associated with more moderate- to vigorous-intensity physical activity (β = 0.07, p = 0.036), better-quality sleep (β = − 0.069, p = 0.020) and less television time (β = − 0.079, p = 0.012). Having no family support was associated with more sitting time (β = 0.075, p = 0.022). Binomial logistic regression analyses supported these findings regarding sleep quality, with anxiety and depression risk doubling the risk of poor-quality sleep (OR = 2.425, p < 0.001, OR = 2.036, p = 0.003 respectively). Conclusions These findings contribute to our understanding of how mental health indicators and risk factors can be barriers to health behaviours of young women in Soweto, and that self-efficacy and social support can be protective for certain of these behaviours for these women. Our results highlight the uniqueness of this setting regarding associations between mental health and behaviours associated with non-communicable diseases risk

Addressing social issues in a universal HIV test and treat intervention trial (ANRS 12249 TasP) in South Africa: methods for appraisal

Background: The Universal HIV Test and Treat (UTT) strategy represents a challenge for science, but is also a challenge for individuals and societies. Are repeated offers of provider-initiated HIV testing and immediate antiretroviral therapy (ART) socially-acceptable and can these become normalized over time? Can UTT be implemented without potentially adding to individual and community stigma, or threatening individual rights? What are the social, cultural and economic implications of UTT for households and communities? And can UTT be implemented within capacity constraints and other threats to the overall provision of HIV services? The answers to these research questions will be critical for routine implementation of UTT strategies. Methods/design: A social science research programme is nested within the ANRS 12249 Treatment-as-Prevention (TasP) cluster-randomised trial in rural South Africa. The programme aims to inform understanding of the (i) social, economic and environmental factors affecting uptake of services at each step of the continuum of HIV prevention, treatment and care and (ii) the causal impacts of the TasP intervention package on social and economic factors at the individual, household, community and health system level. We describe a multidisciplinary, multi-level, mixed-method research protocol that includes individual, household, community and clinic surveys, and combines quantitative and qualitative methods. Discussion: The UTT strategy is changing the overall approach to HIV prevention, treatment and care, and substantial social consequences may be anticipated, such as changes in social representations of HIV transmission, prevention, HIV testing and ART use, as well as changes in individual perceptions and behaviours in terms of uptake and frequency of HIV testing and ART initiation at high CD4. Triangulation of social science studies within the ANRS 12249 TasP trial will provide comprehensive insights into the acceptability and feasibility of the TasP intervention package at individual, community, patient and health system level, to complement the trial's clinical and epidemiological outcomes. It will also increase understanding of the causal impacts of UTT on social and economic outcomes, which will be critical for the long-term sustainability and routine UTT implementation. Trial registration: Clinicaltrials.gov: NCT01509508; South African Trial Register: DOH-27-0512-3974