Stephen W. Nicholas

Patterns of HIV Status Disclosure to Perinatally HIV-Infected Children and Subsequent Mental Health Outcomes

Increasing numbers of perinatally HIV-infected children are surviving into their teens and beyond. Research and clinical reports suggest that many HIV-infected children, particularly those younger than 13 years, do not know they are HIV infected owing to parental concerns about the impact on their mental health. This study examines patterns of HIV status disclosure to 77 perinatally HIV-infected ethnic minority children (aged 3–13 years), and explores the association between knowledge of HIV status and emotional and behavioral outcomes. The majority of children in this study (70%) did not know their HIV status. On average, children who knew their HIV status were older and tended to have lower CD4%. Child knowledge of HIV status was not associated with gender, ethnicity, caregiver education, parent–child relationship factors, type of placement (biological vs adoptive), or other health status indicators. As hypothesized, HIV status disclosure to infected children did not result in increased mental health problems. There was a statistical trend for children who knew their HIV status to be less depressed than children who did not know. Also, greater social disclosure (e.g. communication of child’s status to family and friends) was found when the child had an AIDS diagnosis or lower CD4%, as well as when the caregiver was HIV negative, African American and not the child’s biological parent. In conclusion, pediatric HIV infection remains a highly stigmatized issue that is difficult to discuss with the infected child and others. Yet, contrary to the beliefs of many caregivers, disclosure did not result in increased mental health problems.

Addressing the Childhood Asthma Crisis in Harlem: The Harlem Children’s Zone Asthma Initiative

OBJECTIVES We determined the prevalence of asthma and estimated baseline asthma symptoms and asthma management strategies among children aged 0-12 years in Central Harlem. METHODS The Harlem Childrens Zone Asthma Initiative is a longitudinal, community-based intervention designed for poor children with asthma. Children aged 0-12 years who live or go to school in the Harlem Childrens Zone Project or who participate in any Harlem Childrens Zone, Inc, program were screened for asthma. Children with asthma or asthma-like symptoms were invited to participate in an intensive intervention. RESULTS Of the 1982 children currently screened, 28.5% have been told by a doctor or nurse that they have asthma, and 30.3% have asthma or asthma-like symptoms. To date, 229 children are enrolled in the Harlem Childrens Zone Asthma Initiative; at baseline, 24.0% had missed school in the last 14 days because of asthma. CONCLUSION The high prevalence of asthma among children in the Harlem Childrens Zone Project is consistent with reports from other poor urban communities. Intensive efforts are under way to reduce childrens asthma symptoms and improve their asthma management strategies.

Advancing population health in the Harlem Children's Zone Project

Dr. Mary E. Northridge is the deputy director o f the Harlem Health Promotion Center at Columbia University in New York City. Dr. Betina Jean-Louis, director o f evaluation, and Ms. Katherine Shoemaker, director o f special projects for the president, are with Harlem Childrens Zone, Inc. Dr. Stephen Nicholas is the director o f Pediatrics at Harlem Hospital Center and the principal investigator o f the asthma initiative

Disclosure of their HIV status to perinatally infected youth using the adapted Blasini disclosure model in Haiti and the Dominican Republic: preliminary results.

Objectives:To assess the safety, acceptability, and preliminary efficacy of a culturally-adapted disclosure intervention for perinatally HIV-infected combined antiretroviral therapy patients in Haiti and the Dominican Republic. Design:A quasi-experimental trial was conducted comparing caregiver–youth pairs who completed the intervention [adapted Blasini disclosure model (aBDM)] to pairs who discontinued aBDM participation before disclosure. aBDM consists of five components: structured healthcare worker training; one-on one pre-disclosure intervention/education sessions for youth (describing pediatric chronic diseases including cancer, diabetes and HIV) and for caregivers (strengthening capacity for disclosure); a scheduled supportive disclosure session; and one-on-one postdisclosure support for caregivers and youth. Methods:Caregivers of nondisclosed combined antiretroviral therapy patients aged 10.0–17.8 years were invited to participate. Data were collected by separate one-on-one face-to-face interviews of caregivers and youth by study staff and medical record review by pediatricians at enrollment and 3 months after disclosure or after intervention discontinuation. Results:To date, 65 Dominican Republic and 27 Haiti caregiver–youth pairs have enrolled. At enrollment, only 46.4% of youth had viral suppression and 43.4% of caregivers had clinically significant depressive symptomatology. To date, two serious study-related adverse events have occurred. Seven of the 92 (7.6%, 6 in the Dominican Republic) enrolled pairs discontinued participation before disclosure and 39 had completed postdisclosure participation. Median plasma HIV-RNA concentration was lower in youth who completed aBDM than in youth who discontinued participation before aBDM disclosure (<40 versus 8673 copies/ml; P = 0.027). Completers expressed considerable satisfaction with aBDM. Conclusion:Preliminary results suggest safety, acceptability, and possible effectiveness of the aBDM.

HIV+ and HIV– youth living in group homes in South Africa need more psychosocial support

Orphans and vulnerable youth who live in group homes are at risk of poor mental health and sexual and drug-using behaviors that increase the risk of HIV transmission. This study explores factors related to this risk among youth living in group homes (“children’s homes”) for orphans and vulnerable children in South Africa, a country afflicted by high levels of parental loss due to HIV. The study explores (1) knowledge and attitudes about HIV, (2) social support, (3) communication with group home caregivers, and (4) the relevance of an existing evidence-based HIV prevention and mental health promotion program to situations where sexual and drug risk behaviors can occur. In-depth qualitative individual interviews were conducted with 20 youth (age 10–16 years) residing in two children’s homes in Durban, South Africa. Content analysis focused on critical themes related to coping and prevention of risk activities. Respondents exhibited inconsistent and incomplete knowledge of HIV transmission and prevention. They displayed positive attitudes toward people living with HIV, but reported experiencing or witnessing HIV-related stigma. Participants witnessed substance use and romantic/sexual relationships among their peers; few admitted to their own involvement. While relationships with childcare workers were central to their lives, youth reported communication barriers related to substance use, sex, HIV, and personal history (including parental loss, abuse, and other trauma). In conclusion, these qualitative data suggest that evidence-based HIV prevention programs that bring caregivers and youth together to improve communication, HIV knowledge, social support, youth self-esteem, and health care, reduce sexual and drug risk behaviors, and strengthen skills related to negotiating situations of sexual and substance use possibility could benefit youth and childcare workers in children’s homes.

HIV infection and prevention of mother-to-child transmission in childbearing women: La Romana, Dominican Republic, 2002-2006

OBJECTIVES To strengthen prevention of mother-to-child HIV transmission (pMTCT) program implementation in La Romana (LR) province, by estimating HIV prevalence and identifying characteristics associated with HIV infection in parturients. METHODS Umbilical cord blood samples were collected at seven obstetrical sites where over 95% of LRs deliveries occur during four phases (pilot, expanded pilot, full study, and pMTCT program monitoring) from 2 August 2002 to 30 September 2006. Results were linked to data abstracted from delivery records. RESULTS HIV seroprevalence was 2.6% (263/10 040 overall; 114/4 452, full-study phase (95% confidence interval = 2.1%-3.1%)). Most HIV-infected parturients were Dominican (68.9%) and urban (64.0%). However, prevalence was higher among Haitians (3.7%) than Dominicans (2.3% (p < 0.001)), especially those aged 21-25 years (5.2% vs. 2.3% (p < 0.001)), and among rural, batey, and peri-urban (vs. urban) parturients (3.4% vs. 2.3%, (p = 0.003)). HIV prevalence was associated with commercial sex work (reported by only 0.4%), and prior pregnancy. In logistic regression analysis, commercial sex work, Haitian nationality, and prior pregnancy were independently associated with HIV infection. Caesarean deliveries were more frequent, and rose in the last years of the study, among HIV seropositives; however, most deliveries among seropositives (57.5%) were vaginal. CONCLUSIONS HIV prevalence among LR parturients was higher than the estimated prevalence in the Dominican Republic (0.8%-1.0%) and, in contrast to past studies, predominantly affected urban Dominicans. HIV prevalence among LR Haitian parturients was higher than among Dominican counterparts and prenatal clinic attendees in Haiti (who had a rate of 3.1%). Consistently implemented, targeted pMTCT interventions are needed.

Costs and benefits of multidrug, multidose antiretroviral therapy for prevention of mother-to-child transmission of HIV in the Dominican Republic

To investigate whether costs of multidose antiretroviral regimens (MD‐ARVs), including highly active antiretroviral therapy (HAART), for prevention of mother‐to‐child transmission (PMTCT) of HIV might be offset by savings gained from treating fewer perinatally acquired infections.

Progress towards Elimination of HIV Mother-to-Child Transmission in the Dominican Republic from 1999 to 2011

In 1999, prevention of mother-to-child transmission (pMTCT) using antiretrovirals was introduced in the Dominican Republic (DR). Highly active antiretroviral therapy (HAART) was introduced for immunosuppressed persons in 2004 and for pMTCT in 2008. To assess progress towards MTCT elimination, data from requisitions for HIV nucleic acid amplification tests for diagnosis of HIV infection in perinatally exposed infants born in the DR from 1999 to 2011 were analyzed. The MTCT rate was 142/1,274 (11.1%) in 1999–2008 and 12/302 (4.0%) in 2009–2011 (P < .001), with a rate of 154/1,576 (9.8%) for both periods combined. This decline was associated with significant increases in the proportions of women who received prenatal HAART (from 12.3% to 67.9%) and infants who received exclusive formula feeding (from 76.3% to 86.1%) and declines in proportions of women who received no prenatal antiretrovirals (from 31.9% to 12.2%) or received only single-dose nevirapine (from 39.5% to 19.5%). In 2007, over 95% of DR pregnant women received prenatal care, HIV testing, and professionally attended delivery. However, only 58% of women in underserved sugarcane plantation communities (2007) and 76% in HIV sentinel surveillance hospitals (2003–2005) received their HIV test results. HIV-MTCT elimination is feasible but persistent lack of access to critical pMTCT measures must be addressed.

Evaluation of patient care cascade for HIV-positive patients diagnosed in La Romana, Dominican Republic in 2011: a retrospective cohort study

The Caribbean has the highest adult HIV prevalence in the world after sub-Saharan Africa (2011). One sub-population in the Dominican Republic is the migratory Batey community primarily comprised of Haitian immigrants with limited access to healthcare and HIV prevalence rates of between 3.0% and 9.0%, compared to 0.7% nationally. This retrospective cohort study describes the cumulative retention from diagnosis to virological suppression for newly-diagnosed HIV-infected adults presenting to the Clínica de Familia and its Batey programme in La Romana, during 2011. Of the patients diagnosed with HIV, 65% entered into care, 59% completed immunologic testing, 53% were eligible for antiretroviral therapy (ART) initiation, 36% initiated ART within three months of eligibility and 27% were retained in care. Seventeen per cent of those retained on ART with a 12-month viral load measure had undetectable viral load. Attrition primarily occurred before ART initiation. The Batey programme had a first step lost-to-follow-up of 88% compared to 20% at the clinic (p < 0.001). This retrospective study details the continuum of care and indicates where structural changes must occur to increase continuity between steps. The manuscript results are important to help implement programmes to enhance engagement and retention in HIV primary care.