Megan S. McHenry

A Systematic Review of Nutritional Supplementation in HIV-Infected Children in Resource-Limited Settings

Background: In resource-limited settings, malnutrition is the major cause of death in young children, but the precise benefits of nutritional supplementation for HIV-infected children are not well understood. Methods: Two researchers reviewed studies conducted in low- or middle-income countries that involved macro- and micronutrient supplementation in HIV-infected individuals ≤18 years. Results: Fifteen studies focused on micronutrients, including vitamin A, zinc, multivitamins, and multiple-micronutrient supplementation. The 8 macronutrient studies focused on ready-to-use foods (4 studies), spirulina, whey protein, general food rations, and F75 and F100 starter formulas. Vitamin A was associated with improved mortality rates, ranging from 28% to 63%. Multiple-micronutrient supplementations were not associated with improvement of measured health outcomes. Ready-to-use foods were associated with improvement in certain anthropometrics. Conclusion: Periodic vitamin A supplementation is associated with reduced mortality. Macronutrient supplementation is linked to improved anthropometrics. More research is needed to determine how nutritional supplementation benefits this particularly vulnerable population.

'Why did you not tell me?': perspectives of caregivers and children on the social environment surrounding child HIV disclosure in Kenya.

Objective:We sought to better understand how social factors shape HIV disclosure to children from the perspective of caregivers and HIV-infected children in Kenya. Design:We conducted a qualitative study using focus group discussions (FGDs) to gain perspectives of caregivers and children on the social environment for HIV disclosure to children in western Kenya. FGDs were held with caregivers who had disclosed the HIV status to their child and those who had not, and with HIV-infected children who knew their HIV status. Methods:FGD transcripts were translated into English, transcribed, and analyzed using constant comparison, progressive coding, and triangulation to arrive at a contextualized understanding of social factors influencing HIV disclosure. Results:Sixty-one caregivers of HIV-infected children participated in eight FGDs, and 23 HIV-infected children participated in three FGDs. Decisions around disclosure were shaped by a complex social environment that included the caregiver–child dyad, family members, neighbors, friends, schools, churches, and media. Whether social actors demonstrated support or espoused negative beliefs influenced caregiver decisions to disclose. Caregivers reported that HIV-related stigma was prominent across these domains, including stereotypes associating HIV with sexual promiscuity, immorality, and death, which were tied to caregiver fears about disclosure. Children also recognized stigma as a barrier to disclosure, but were less specific about the social and cultural stereotypes cited by the caregivers. Conclusion:In this setting, caregivers and children described multiple actors who influenced disclosure, mostly due to stigmatizing beliefs about HIV. Better understanding the social factors impacting disclosure may improve the design of support services for children and caregivers.

Adapting health behavior measurement tools for cross-cultural use

Abstract Background: Addressing health disparities in the global community requires awareness of how cultural differences in beliefs, traditions, norms, and values shape health problems and

HIV Stigma Perspectives from Kenyan Child Caregivers and Adolescents Living with HIV

Stigma shapes all aspects of HIV prevention and treatment, yet there are limited data on how HIV-infected youth and their families are affected by stigma in sub-Saharan Africa. The authors conducted a qualitative study using focus group discussions among 39 HIV-infected adolescents receiving care at HIV clinics in western Kenya and 53 caregivers of HIV-infected children. Participants felt that while knowledge and access to treatment were increasing, many community members still held negative and inaccurate views about HIV, including associating it with immorality and believing in transmission by casual interactions. Stigma was closely related to a loss of social and economic support but also included internalized negative feelings about oneself. Participants identified treatment-related impacts of stigma, including nonadherence, nondisclosure of status to child or others, and increased mental health problems. Qualitative inquiry also provided insights into how to measure and reduce stigma among affected individuals and families.

The Prevalence of At-Risk Development in Children 30 to 60 Months Old Presenting With Disruptive Behaviors

Objective. This study assessed the prevalence of failed developmental screens in 30- to 60-month-old children who presented with a behavioral complaint of disruptive behavior to a referral clinic. Methods. A retrospective chart review was performed in a specialty behavioral pediatric clinic. Outcome measures were obtained from children referred to the clinic with parental concern of disruptive behavior. Results. Out of 151 patients, 66% (99/151) had been screened for developmental delays with a formal screening instrument. Of these, 71% (70/99) failed developmental screening in one or more domains. Conclusions. Preschoolers referred to a behavioral clinic for parental concerns of disruptive behaviors were more than 4 times more likely to be at risk for developmental delays than the general population, with a majority of suspected delays in communication and problem-solving domains. This finding suggests that developmental screening should be a part of the initial workup for children with disruptive behaviors.

Vitamin A supplementation for the reduction of the risk of mother-to-child transmission of HIV

Although advances in HIV prevention and treatment suggest the possibility of creating an AIDS-free generation, many areas of the world still suffer from high rates of mother-to-child transmission (MTCT) of HIV. Interventions proven to significantly decrease rates of MTCT of HIV are often unavailable in resource-limited settings due to lack of reliable clean water, low numbers of hospital deliveries and inconsistent availability of antiretroviral medications. Vitamin A, with its multiple roles in epithelial, reproductive and immune function, has been evaluated as a possible intervention for preventing MTCT. Early observational studies suggested an association between vitamin A deficiency and increased rates of MTCT of HIV; however, the controlled studies that followed did not find a benefit for vitamin A in decreasing MTCT rates. Although vitamin A has some benefits for infants postpartum, it is not recommended for the reduction of the risk of MTCT of HIV.

Neurodevelopment in Young Children Born to HIV-Infected Mothers: A Meta-analysis

In this review, we report worse developmental outcomes in both HIV+ and HEU children compared with HUU children. CONTEXT: HIV-infected (HIV+) children have worse neurodevelopmental outcomes compared with HIV-uninfected children. However, little is known regarding the differences in neurodevelopment between young HIV+ children, HIV-exposed but uninfected (HEU) children, and HIV-unexposed and uninfected (HUU) children. OBJECTIVE: To systematically review and meta-analyze data on neurodevelopmental performance between young HIV+, HEU, and HUU children. DATA SOURCES: We systematically searched the following electronic bibliographic databases: Ovid Medline, Embase, PsycINFO, Education Resources Information Center, and the Cochrane Database of Systematic Reviews. STUDY SELECTION: Studies were selected on the basis of defined inclusion criteria. Titles, abstracts, and full texts were assessed by 2 independent reviewers. DATA EXTRACTION: Data were extracted by 2 independent reviewers and cross-checked by 2 additional reviewers. RESULTS: Forty-five studies were identified for inclusion in the systematic review, and of these, 11 were included in the meta-analysis on the basis of availability of Bayley Scales of Infant and Toddler Development scores. Within the meta-analysis, when compared with their HUU peers, HIV+ and HEU children had lower cognitive and motor scores. HIV+ and HEU children with antiretroviral (ARV) exposure had lower cognitive and motor scores compared with those without ARV exposure. LIMITATIONS: We were unable to control adequately for intravenous drug use, geographic location, or quality of the assessment independently. CONCLUSIONS: Both HIV+ and HEU children had worse developmental outcomes compared with HUU children. HIV+ and HEU children with ARV exposure also had worse developmental outcomes compared with those without exposure; however, these results should be interpreted with caution. More research is needed to identify the impact of ARV exposure on young children.

A systematic review of portable electronic technology for health education in resource-limited settings:

Objective: The objective of this study is to conduct a systematic review of the literature of how portable electronic technologies with offline functionality are perceived and used to provide health education in resource-limited settings. Methods: Three reviewers evaluated articles and performed a bibliography search to identify studies describing health education delivered by portable electronic device with offline functionality in low- or middle-income countries. Data extracted included: study population; study design and type of analysis; type of technology used; method of use; setting of technology use; impact on caregivers, patients, or overall health outcomes; and reported limitations. Results: Searches yielded 5514 unique titles. Out of 75 critically reviewed full-text articles, 10 met inclusion criteria. Study locations included Botswana, Peru, Kenya, Thailand, Nigeria, India, Ghana, and Tanzania. Topics addressed included: development of healthcare worker training modules, clinical decision support tools, patient education tools, perceptions and usability of portable electronic technology, and comparisons of technologies and/or mobile applications. Studies primarily looked at the assessment of developed educational modules on trainee health knowledge, perceptions and usability of technology, and comparisons of technologies. Overall, studies reported positive results for portable electronic device-based health education, frequently reporting increased provider/patient knowledge, improved patient outcomes in both quality of care and management, increased provider comfort level with technology, and an environment characterized by increased levels of technology-based, informal learning situations. Negative assessments included high investment costs, lack of technical support, and fear of device theft. Conclusions: While the research is limited, portable electronic educational resources present promising avenues to increase access to effective health education in resource-limited settings, contingent on the development of culturally adapted and functional materials to be used on such devices.

Adolescent Burmese Refugees Perspectives on Determinants of Health

Over 70,000 Burmese refugees have resettled in the United States in the past decade. While Burmese adolescents quickly acculturate into American society, their perspectives on health are not well-known. The purpose of this study was to identify adolescent Burmese refugee perspectives on determinants of health and health-related experiences after resettlement. In this qualitative study, Burmese adolescents took photographs depicting health-related experiences that were used as elicitation tools during focus groups. These discussions were recorded, transcribed, and analyzed for themes. Participants described positive determinants of health, including family and church. Rampant tobacco use was identified by the participants as a determinant of poor health within the Burmese community. Notably, the participants were proud to serve as liaisons within their community, despite the stressful nature of this role. Our results highlight the need to screen this population for anxiety, secondary to serving as a liaison for their community, as well as tobacco use.

Interventions for developmental delays in children born to HIV-infected mothers: a systematic review

ABSTRACT Children born to HIV-infected mothers have worse developmental outcomes compared to HIV-unexposed children. However, little is known about interventions to improve developmental outcomes in this population. This study systematically reviews the literature on interventions to improve development in children born to HIV-infected mothers. We systematically searched the following electronic bibliographic databases: Ovid MEDLINE, Embase, PsycINFO, Education Resources Information Center, and the Cochrane Database of Systematic Reviews. Studies were selected on the basis of defined inclusion criteria and excluded if antiretroviral medication was the only intervention. Titles, abstracts, and full texts were assessed by 2 independent reviewers. Data were collected on characteristics of the study design, intervention, and developmental outcomes measured. Risk of bias and strength of evidence were assessed on all included articles. Our search resulted in 11,218 records. After our initial review, 43 records were appraised in their entirety and 9 studies met all inclusion criteria. Six were performed in sub-Saharan Africa, while the remaining 3 were performed in the United States. Eight were randomized-controlled trials and one was a retrospective chart review. Four studies focused on caregiver-training, 2 studied massage therapy, and the remaining studies focused on maternal vitamin supplementation, video-based cognitive therapy, or center-based interventions. Massage therapy had the most consistent improvements in the domains measured, while caregiver training and cognitive therapy interventions had limited benefits. The center-based intervention showed no benefit. Only 3 studies had a low risk of bias, and 4 studies had good strength of evidence. Most studies found some benefit. However, these findings are limited by the quality of the study designs, small sample size, and heterogeneity of the interventions and assessments used to measure outcomes. There is a critical need for the creation of evidence-based interventions to promote development in this vulnerable population.