Relationships Between Familial HIV/AIDS and Symptoms of Anxiety and Depression: The Mediating Effect of Bullying Victimization in a Prospective Sample of South African Children and Adolescents

South African children and adolescents living in HIV/AIDS-affected families are at elevated risk of both symptoms of anxiety and depressive symptoms. Poverty and HIV/AIDS-related stigma are additional risk factors for these negative mental health outcomes. Community level factors, such as poverty and stigma, are difficult to change in the short term and identifying additional potentially malleable mechanisms linking familial HIV/AIDS with mental health is important from an intervention perspective. HIV/AIDS-affected children are also at increased risk of bullying victimization. This longitudinal study aimed to determine whether prospective relationships between familial HIV/AIDS and both anxiety symptoms and depressive symptoms operate indirectly via bullying victimization. Adolescents (M = 13.45 years, 56.67 % female, n = 3,515) from high HIV-prevalent (>30 %) communities in South Africa were interviewed and followed-up one year later (n = 3,401, 96.70 % retention). Census enumeration areas were randomly selected from urban and rural sites in two provinces, and door-to-door sampling included all households with a resident child/adolescent. Familial HIV/AIDS at baseline assessment was not directly associated with mental health outcomes 1 year later. However, significant indirect effects operating via bullying victimization were obtained for both anxiety and depression scores. Importantly, these effects were independent of poverty, HIV/AIDS-related stigma, and baseline mental health, which highlight bullying victimization as a potential target for future intervention efforts. The implementation and rigorous evaluation of bullying prevention programs in South African communities may improve mental health outcomes for HIV/AIDS-affected children and adolescents and this should be a focus of future research and intervention

Validation of a brief stigma-by-association scale for use with HIV/AIDS-affected youth in South Africa

This study validated a brief stigma-by-association scale for use with South African youth (adapted from the HIV Stigma-by-Association Scale for Adolescents). Participants were 723 youth (364 male, 359 female) from poor urban communities around Cape Town. Youths completed the brief stigma-by-association scale and measures of bullying victimisation and peer-problems, as well as inventories measuring symptoms of depression and anxiety. Exploratory analyses revealed that the scale consists of two subscales: (1) experience of stigma-by-association and (2) consequences of stigma-by-association. This two factor structure was obtained in the full sample and both the HIV/AIDS-affected and unaffected subgroups. The full stigma-by-association scale showed excellent reliability (α = 0.89–0.90) and reliabilities for both subscales were also good (α = 0.78–0.87). As predicted, children living in HIV/AIDS-affected households obtained significantly higher stigma-by-association scores than children in non-affected households [F(1, 693) = 46.53, p<0.001, partial η 2=0.06] and hypothesized correlations between stigma-by-association, bullying, peer problems, depression and anxiety symptoms were observed. It is concluded that the brief stigma-by-association scale is a reliable and valid instrument for use with South African youth; however, further confirmatory research regarding the structure of the scale is required

Psychometric Properties of the Child PTSD Checklist in a Community Sample of South African Children and Adolescents

Objective: The current study assessed the basic psychometric properties of the Child PTSD Checklist and examined the structure of symptoms of posttraumatic stress disorder (PTSD) in a large sample of South African youth. Methodology: The checklist was completed by 1025 (540 male; 485 female) South African youth (aged between 10 and 19 years). The factor structure of the scale was assessed with a combination of confirmatory and exploratory techniques. Internal consistencies for the full scale and all subscales were evaluated with Cronbach’s alpha and McDonald’s omega. Validity was assessed by comparing PTSD scores obtained by children who had and had not experienced a traumatic event, and by examining associations between total PTSD scores and known correlates of PTSD. Results: Scores on the Child PTSD Checklist clearly discriminated between youth who had experienced a traumatic event and those who had not. Internal consistencies for the full scale (and all subscales) were acceptable to good and hypothesized correlations between PTSD, depression, anxiety, somatic symptoms, and age were observed. Two of the reported fit statistics for the tripartite DSM-IV-TR model of PTSD did not meet traditional criteria and further exploratory analyses revealed a four-factor structure (broadly consistent with Simms and colleagues’ Dysphoria Model of PTSD symptoms) which provided a better fit to the observed data. Conclusion: Given the continued use of the Child PTSD Checklist in South Africa, findings offer an important first step in establishing the reliability and validity of the checklist for use with South African youth. However, further evaluation of the checklist in South African samples is clearly required before conclusions regarding its use as diagnostic tool in this context can be made

‘At school I got myself a certificate’: HIV/AIDS Orphanhood and Secondary Education: a Qualitative Study of Risk and Protective Factors

Secondary school is a period during which risk of school dropout is highest. To date, little research has examined reasons for school dropout amongst HIV/AIDS-orphaned children, who are affected economically, psychosocially and educationally. HIV/AIDS orphanhood can perpetuate poverty and increase school dropout in a range of ways, including inability to pay school fees, family disruption and stigma. Related research mostly focuses on school performance and completion and, more recently, on context-specific approaches to measure educational outcomes. The primary aim of this qualitative study was to examine how HIV/AIDS orphanhood influences participation in secondary education in South Africa and to investigate why some HIV/AIDS-orphaned adolescents find it easier to stay in school than others. Specifically, the study aimed to explore, interpret and elicit the perceptions of South African HIV/AIDS-orphaned adolescents (N = 243, aged 13–22, 53 % female, 47 % male) towards potential risk and protective factors influencing their secondary school attendance. Findings suggest complex and interconnecting multiple risk factors such as poverty pre- and post-parental death, crisis-fosterage often accompanied by further traumatic events, changing schools sporadically, recurring household migration and forced employment all of which can create obstacles to secondary education. Protective factors that emerged included extra-curricular activities and teacher/community support. These findings highlight the need for evidence-informed school and community policies, which consider the effects of household poverty, migration and living arrangements, if secondary school participation for HIV/AIDS-orphaned adolescents is to be promoted and sustained

The synthesis and development of novel, easily processable poly (n-isopropylacrylamide)-based hyrdogels.

This work describes the invention of a synthetic method which allows a fully-reacted PNIPAM/clay nanocomposite system to remain a watery liquid until it is cooled to a predetermined temperature. Beyond this temperature, the polymer/clay precursor hydrogel liquid (PCPH) spontaneously forms a cross-linked hydrogel that does not re-liquefy upon re-heating, but instead, possesses all of the highly utilisable stimuli-responsive properties typical of PNIPAM-based nanocomposite hydrogels synthesised in situ. This novel methodology simultaneously addresses issues including cytotoxicity, processability, injectability, cross-linking and mechanical stability. In addition, PCPH synthesis requires no specialist equipment, inexpensive and basic components typical of cross-linked hydrogels (water, monomer, clay and initiator), requires no purification steps and can be maintained as a fully-reacted liquid at evaluated temperatures for up to several weeks with no apparent loss of eventual functionality. The ability to create a fully polymerised hydrogel polymer with a liquid intermediate state has allowed the incorporation of biologically active dopants which can be dispersed and distributed homogeneously throughout the matrix prior to "phase transition triggered nanoparticle anchored gelation" (or PTTNAG) of the hydrogel.Human mesenchymal stem cells (MSCs), have been incorporated into the gel by i) placing them on the assembled gel surface - the cells responded by migrating and proliferating throughout the matrix of the gel, and more interestingly, ii) combining the MSCs with the PCPH in the liquid phase and allowing PTTNAG of the polymer matrix to occur around the cells. In both cases, cell viability was excellent throughout a series of 14-28 day experiments. The work was expanded by the exploration of PTTNAG temperature tailorability. This was achieved with the incorporation of the relatively polar comonomer dimethylacrylamide (DMAc), and non-polar comonomer glycedyl methacrylate (GMAc) which respectively increased and decreased the PTTNAG and lower-critical solution temperature (LCST) of the resulting gels. Crucially, it was found that the PTTNAG temperature can be tailored precisely and incorporation of DMAc did not affect cell viability. The process also opened several novel avenues for gel processing possibilities, including facile casting, extruding and electrospinning. Well defined and uniform electrospun fibres with diameters ~300nm are presented. The production of continuous, uniform flat PNIPAM/ clay sheets of 300pm -1000pm achieved using an industrial film extrusion line is detailed. This work represents an innovation in the way in which such hydrogels can be manufactured and produced safely and cleanly, with no additives, no energy input and no toxic by-products.Interactions between polymer and water are examined by monitoring the dehydration of 3 separate hydrogel formulations using ATR-FTIR. The pseudo diffusion coefficient (in this instance, the diffusion of water out of the polymer matrix) was not affected by dopant composition, but instead, the intercept of the slope was altered markedly. Cross-link type, cross-link density, initiation method and addition of dopants have a strong influence on the swelling/ deswelling behaviour of the hydrogels under study. PNIPAM/ clay gels exhibit much larger volume changes than those prepared with chemical cross-linking agent methylenebisacrylamide (BIS). Deswelling magnitude increases with decreasing cross-linker content for all gel types examined. Thermal deswelling is hindered in dopant-incorporated networks. The aqueous dilution of the nanocomposite in the liquid phase affects gel deswelling behaviour when clay concentration is low. De/reswelling of PNIPAM/ clay, PNIPAM/BIS and gelatine-doped PNIPAM/ clay gels can be induced by adjusting the alcohol volume fraction of the media. BIS cross-linked gels exert restricted swelling/deswelling behaviours compared to those cross-linked with clay. Cross-link density within systems does not have a significant impact on cononsolvency behaviour, although the incorporation of gelatine imposes some restriction on it, directly relative to gelatine concentration.X-ray diffraction (XRD) data proved the exfoliation of clay in the nanocomposite system post-PTTNAG. DMA data revealed that the viscoelasticity of the gels can be tailored with varying the nature and quantity of dopant materials. Gels doped with hyaluronic acid (HA) most closely resemble the mechanical properties of bovine NP tissue

Accommodation needs for carers of and adults with intellectual disability in regional Australia: Their hopes for and perceptions of the future

Introduction: This article provides an in-depth investigation of the accommodation circumstances of a population of aging adults with intellectual disability living at home with parents or in supported accommodation in an Australian regional centre. Given the ageing of both the carer and adult population with intellectual disability our research explored the accommodation needs and perceptions of future lifestyle issues from the perspective of both the carers and the adults with intellectual disability. This study aimed to describe these accommodation circumstances related to a regional/rural location and did not make direct comparisons with urban/metropolitan situations. Methods: A mixed methods approach, specifically an explanatory design, participant selection model was utilised for the overall study. This article reports on the qualitative study consisting of data from both free response open-ended survey questions and semi-structured interviews with selected adults with intellectual disability and their carers. This study explored and described participants’ experiences and perceptions regarding their accommodation needs and future lifestyle issues. A purposive sampling technique was used to identify a representative sample of participants for interviews. The interview questions were guided by the results of the quantitative first study phase. Data were analysed by content analysis for major themes emerging from the interview and free response survey data. Results: A total of 146 carers (mean age 61.5 years; range 40–91 years) and 156 adults with intellectual disability (mean age 37.2 years; range 18–79 years) participated in the study. Data saturation was reached after 10 interviews were undertaken with carers (mean age 60 years) and 10 with adults with intellectual disability (no age criteria applied). Six major themes were identified: ageing, family issues, living at home, living away from home, government support and funding, and future needs. The perceptions and views of both adults with intellectual disability and their carers around these major themes are reported and discussed. Conclusions: This study indicates that there is a lack of suitable, available, supported accommodation for people aged 18 years and older with intellectual disability in this Australian regional centre. Consequently, aging parents caring at home have little choice but to continue in their caring role. For those caring away from home, existing services are decreasingly seen as fitting the ideal life they want for the person with intellectual disability for whom they care. The told experiences, perceptions and views of older carers of and adults with intellectual disability have highlighted their increasing vulnerability to the ‘disability system’. The findings suggest that government and disability services must acknowledge the changing needs of people with intellectual disability in connection with their advancing age and the urgency of increasing care needs due to the advancing age of their carer/s. The overwhelming feeling is that the carer’s voice will only be heard when the situation reaches crisis point. For many carers and their families this has already occurred

Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: A propensity-score-matched case-control study

Background: Effective and scalable HIV prevention for adolescents in sub-Saharan Africa is needed. Cash transfers can reduce HIV incidence through reducing risk behaviours. However, questions remain about their effectiveness within national poverty-alleviation programmes, and their effects on different behaviours in boys and girls.Methods: In this case-control study, we interviewed South African adolescents (aged 10–18 years) between 2009 and 2012. We randomly selected census areas in two urban and two rural districts in two provinces in South Africa, including all homes with a resident adolescent. We assessed household receipt of state-provided child-focused cash transfers, incidence in the past year and prevalence of transactional sex, age-disparate sex, unprotected sex, multiple partners, and sex while drunk or after taking drugs. We used logistic regression after propensity score matching to assess the effect of cash transfers on these risky sexual behaviours.We interviewed 3515 participants (one per household) at baseline, and interviewed 3401 at follow-up. For adolescent girls (n=1926), receipt of a cash transfer was associated with reduced incidence of transactional sex (odds ratio [OR] 0.49, 95% CI 0.26–0.93; p=0•028), and age-disparate sex (OR 0.29, 95% CI 0.13–0.67; p=0.004), with similar associations for prevalence (for transactional sex, OR 0.47, 95% CI 0.26–0.86; p=0.015; for age-disparate sex, OR 0.37, 95% CI 0.18–0.77; p=0.003). No significant effects were shown for other risk behaviours. For boys (n=1475), no consistent effects were shown for any of the behaviours.Interpretation: National, child-focused cash transfers to alleviate poverty for households in sub-Saharan Africa can substantially reduce unsafe partner selection by adolescent girls. Child-focused cash transfers are of potential importance for effective combination strategies for prevention of HIV

The hidden harm of home-based care: Pulmonary tuberculosis symptoms among children providing home medical care to HIV/AIDS-affected adults in South Africa

Millions of children in sub-Saharan Africa undertake personal and medical care for family members who are unwell with AIDS. To date, no research has investigated whether such care provision places children at heightened risk for pulmonary tuberculosis. This study aimed to address this gap by identifying risk factors for paediatric pulmonary tuberculosis symptomatology. In 2009–2011, 6002 children aged 10–17 years were surveyed using door-to-door household sampling of census enumeration areas. These were randomly sampled from six urban and rural sites with over 30% HIV prevalence, within South Africa's three highest tuberculosis-burden provinces. Validated scales and clinical tuberculosis symptom checklists were modelled in multivariate logistic regressions, controlling for socio-demographic co-factors.Findings showed that, among children, severe pulmonary tuberculosis symptomatology was predicted by primary caregiver HIV/AIDS-illness [odds ratio (OR): 1.63, confidence interval (CI): 1.23–2.15, p<0.001], and AIDS-orphanhood (OR: 1.44, CI: 1.04–2.00, p<0.029). Three-fold increases in severe tuberculosis symptoms were predicted by the child's exposure to body fluids through providing personal or medical care to an ill adult (OR: 3.12, CI: 1.96–4.95, p<0.001). Symptoms were also predicted by socio-economic factors of food insecurity (OR: 1.52, CI: 1.15–2.02, p<0.003) and household overcrowding (OR: 1.35, CI: 1.06–1.72, p<0.017). Percentage probability of severe tuberculosis symptoms rose from 1.4% amongst least-exposed children, to 18.1% amongst those exposed to all above-stated risk factors, independent of biological relationship of primary caregiver-child and other socio-demographics. Amongst symptomatic children, 75% had never been tested for tuberculosis. These findings identify the risk of tuberculosis among children providing home medical care to their unwell caregivers, and suggest that there are gaps in the health system to screen and detect these cases of paediatric tuberculosis. There is a need for effective interventions to reduce childhood risk, as well as further support for community-based contact-tracing, tuberculosis screening and anti-tuberculosis treatment for children caring for ill adults in contexts with a high burden of HIV and tuberculosis

School, Supervision and Adolescent-Sensitive Clinic Care: Combination Social Protection and Reduced Unprotected Sex Among HIV-Positive Adolescents in South Africa

Social protection can reduce HIV-risk behavior in general adolescent populations, but evidence among HIV-positive adolescents is limited. This study quantitatively tests whether social protection is associated with reduced unprotected sex among 1060 ART-eligible adolescents from 53 government facilities in South Africa. Potential social protection included nine 'cash/cash-in-kind' and 'care' provisions. Analyses tested interactive/additive effects using logistic regressions and marginal effects models, controlling for covariates. 18 % of all HIV-positive adolescents and 28 % of girls reported unprotected sex. Lower rates of unprotected sex were associated with access to school (OR 0.52 95 % CI 0.33-0.82 p = 0.005), parental supervision (OR 0.54 95 % CI 0.33-0.90 p = 0.019), and adolescent-sensitive clinic care (OR 0.43 95 % CI 0.25-0.73 p = 0.002). Gender moderated the effect of adolescent-sensitive clinic care. Combination social protection had additive effects amongst girls: without any provisions 49 % reported unprotected sex; with 1-2 provisions 13-38 %; and with all provisions 9 %. Combination social protection has the potential to promote safer sex among HIV-positive adolescents, particularly girls

The synthesis and development of novel, easily processable poly (n-isopropylacrylamide)-based hyrdogels.

This work describes the invention of a synthetic method which allows a fully-reacted PNIPAM/clay nanocomposite system to remain a watery liquid until it is cooled to a predetermined temperature. Beyond this temperature, the polymer/clay precursor hydrogel liquid (PCPH) spontaneously forms a cross-linked hydrogel that does not re-liquefy upon re-heating, but instead, possesses all of the highly utilisable stimuli-responsive properties typical of PNIPAM-based nanocomposite hydrogels synthesised in situ. This novel methodology simultaneously addresses issues including cytotoxicity, processability, injectability, cross-linking and mechanical stability. In addition, PCPH synthesis requires no specialist equipment, inexpensive and basic components typical of cross-linked hydrogels (water, monomer, clay and initiator), requires no purification steps and can be maintained as a fully-reacted liquid at evaluated temperatures for up to several weeks with no apparent loss of eventual functionality. The ability to create a fully polymerised hydrogel polymer with a liquid intermediate state has allowed the incorporation of biologically active dopants which can be dispersed and distributed homogeneously throughout the matrix prior to "phase transition triggered nanoparticle anchored gelation" (or PTTNAG) of the hydrogel.Human mesenchymal stem cells (MSCs), have been incorporated into the gel by i) placing them on the assembled gel surface - the cells responded by migrating and proliferating throughout the matrix of the gel, and more interestingly, ii) combining the MSCs with the PCPH in the liquid phase and allowing PTTNAG of the polymer matrix to occur around the cells. In both cases, cell viability was excellent throughout a series of 14-28 day experiments. The work was expanded by the exploration of PTTNAG temperature tailorability. This was achieved with the incorporation of the relatively polar comonomer dimethylacrylamide (DMAc), and non-polar comonomer glycedyl methacrylate (GMAc) which respectively increased and decreased the PTTNAG and lower-critical solution temperature (LCST) of the resulting gels. Crucially, it was found that the PTTNAG temperature can be tailored precisely and incorporation of DMAc did not affect cell viability. The process also opened several novel avenues for gel processing possibilities, including facile casting, extruding and electrospinning. Well defined and uniform electrospun fibres with diameters ~300nm are presented. The production of continuous, uniform flat PNIPAM/ clay sheets of 300pm -1000pm achieved using an industrial film extrusion line is detailed. This work represents an innovation in the way in which such hydrogels can be manufactured and produced safely and cleanly, with no additives, no energy input and no toxic by-products.Interactions between polymer and water are examined by monitoring the dehydration of 3 separate hydrogel formulations using ATR-FTIR. The pseudo diffusion coefficient (in this instance, the diffusion of water out of the polymer matrix) was not affected by dopant composition, but instead, the intercept of the slope was altered markedly. Cross-link type, cross-link density, initiation method and addition of dopants have a strong influence on the swelling/ deswelling behaviour of the hydrogels under study. PNIPAM/ clay gels exhibit much larger volume changes than those prepared with chemical cross-linking agent methylenebisacrylamide (BIS). Deswelling magnitude increases with decreasing cross-linker content for all gel types examined. Thermal deswelling is hindered in dopant-incorporated networks. The aqueous dilution of the nanocomposite in the liquid phase affects gel deswelling behaviour when clay concentration is low. De/reswelling of PNIPAM/ clay, PNIPAM/BIS and gelatine-doped PNIPAM/ clay gels can be induced by adjusting the alcohol volume fraction of the media. BIS cross-linked gels exert restricted swelling/deswelling behaviours compared to those cross-linked with clay. Cross-link density within systems does not have a significant impact on cononsolvency behaviour, although the incorporation of gelatine imposes some restriction on it, directly relative to gelatine concentration.X-ray diffraction (XRD) data proved the exfoliation of clay in the nanocomposite system post-PTTNAG. DMA data revealed that the viscoelasticity of the gels can be tailored with varying the nature and quantity of dopant materials. Gels doped with hyaluronic acid (HA) most closely resemble the mechanical properties of bovine NP tissue