Parenting and HIV

Lorraine Sherr

UCL London

The Global AIDS Response phases

“APE”

Almost entirely

overlooked/ ignored parenting

Pitted children

against parents

Emerging

importance of parenting• To prevent vertical transmission

• To care for children

• To enhance treatment

• For its own sake

HIV Clusters in families

Diagnosis during pregnancy

Keep children HIV free – keep their parents alive

Fundamental importance of parenting

• Importance of first 1000 days

•Parenting and ECD

Especially true for young children

Family care JLICA endorsed family approach

Core importance of parenting

Good evidence base

Families carry the major burden

Families are good for children

Family interventions (such as cash transfer) benefit child outcomes

Holistic care (a bridge too far?)

http://www.ccaba.org/wp-content/uploads/Final-JLICA-Report.pdf

Non HIV Parenting environment

linked to child development

Parenting style linked to child behaviour

Parents Mental Health state affects child development (Downey et al)

Child illness affects parental state

Post traumatic stress disorder (22% parents of chronically ill children, 4 fold elevation).

Parenting interventions affect child outcome

Quality of parenting Early child development

Child stimulation

Parenting in the presence of HIV infection

Parenting Interventions can

improve child outcomes Systematic review (Gunlicks 2008)

Interventions to ameliorate parental mood can benefit child outcomes

Parenting (Kuo et al)

Mentoring

Physical and mental health benefits

Support groups

USAID Initiative

Parenting and HIV

Parenting

Modelling

HIV associated with parenting

disruptions Parental illness Importance of FamiliesMental and physical effects of HIV in

parentsParental deathChild caring for ill parentChild caring for other children Parenting arrangementsAlternative care arrangements Fathers Grandparents Kin Parental death (Orphanhood) Institutionalised care

Parental HIV

Depression

Stigma

Secrets

Illness

Death

Infected parent

Effects on child development, child care and child outcome (positive and negative)

Well documented physical effects of HIV

Well documented mental health effects of HIV Depression 46%

Anxiety 16%,

Post traumatic stress disorder

Suicidality (31% Sherr et al 2009)

Effects of these on parenting??

HIV field Understudied

HIV positive enhances paediatric adherence

0

10

20

30

40

50

60

70

80

90

100

Any difficulty Behaviour Attention Coping with

change

Playing

80.4

33.937.5 37.5

10.7

75.4

21.124

22.2

5.3

57.5

14.2

19.8 19.8

2.8

58.8

15.6 15.618.4

2.5

Dually-affected (n=56)

Mental illness (n=171)

HIV/AIDS illness (n=106)

Non-affected (n=473)

Tasks of parenting

Feeding and nurturing

Love attention, stimulation,

protection and support

Deciding an HIV free infant

Disclosure

Preparation for illness, treatment

(and death)

Fascination with the unusual

Parentification

Child headed households

Grandparent headed households

Parenting under adversity

Stresses of parenting under adversity have

negative mental health impacts

Child takes on responsibilities

as a caregiver

Inverted parenting

Direct duties

Caring for the sick adult

Administering

medicines

Feeding/bathing

Emotional support

Indirect duties

Taking over adult duties

Household chores

Sibling care

Income generation

Livelihood burden

Substitute parenting

Parentification

Alternative parenting arrangements

Doring et al (Brazil) 2005 care arrangements for children of deceased HIV positive adults (n=1131). 41% resided with their mother,

25% with grandparents and only

5% in institutions.

Families are providing the mainstay of support for OVC children.

HIV positivity was associated with a 4.6 fold chance of institutionalised care

Institutionalised care Good evidence on negative effects

Yet number going up rather than down

Fuelled by:

Poverty;

HIV

Politics

Author N Design -veeffect

Ahmad 2005 Kurdistan

142 Foster care vs orphanage Yes

Beckett et al 2007 Romania

156 Adopted from Institutions vsnon institutions

Yes

Berrick et al 1995

USA

52,

613

Foster care vs institution / group home (+6 beds)

Yes

Bos 2010 Romania 141 Ever institutionalised vs never. Random to community vs no change

Yes

Dobrova Krol 2010 Romania

64 HIV+ve/HIV-ve Inst vs family reared

Yes

Ghera 2009 Romania 208 Randomised stay institution, move foster, vs never institutionalised

Yes

Miller 2005 GuatamalaUSA

103 Foster vs Inst (prior to USA) Yes

Nelson 2007 Bucharest

RCT inst remain or foster care

Yes

Pollack 2010 USA

132 Inst prolonged, brief vs family

Yes

Roy 2006 UK 38 Inst vs control Yes

Smyke 2010 169 Inst random remain, foster vs family control

Yes

Van der Dries 2010 China

92 Foster care vs inst care Yes

Vorria et al 2006 Greece

100 Adopted after 2 year inst vsfamily reared

Yes

Whetten et al 2009 (5 countries)

2,837 Inst living vs community living

No

Wolf 1995 Eritrea

74 Refugee in families vs orphans in institutions

No

Zeanah et al 2009 Romania

170 Remained inst vs foster care vs control

Yes

Zhao 2010 China

176 Care before orphanage (parent, grandparent, relative, non relative)

Grandparent best

Findings

15/17 note negative effects of institutions, 2 do not

Only 4/17 benefited from some randomisation (all showed negative effects)

HIV status of the child may affect cognitive outcomes

Damaging care environments

Place –vs-Circumstance

Street children

Out of school children

Abused children

Trafficked children

Refugee children

Hospitalised children

Dangers Orphan tourism (Richter et al 2010)

Cost effective

Fathers

Parenting Seen

as “woman’s

business”

Systematic review (Nattabi 2009) identified 29 studies – 20 women, 7 couples (only 2 on men reported)

Systematic review (Sherr 2010)

– Pregnancy Intention = 1122

– + HIV = 66

– + Father (Male) = 28

– 13 relevant (9 quantitative, 4 qualitative)

Fathers excluded and understudied Low involvement in HIV testing

(good RCT evidence of benefits

Molala et al, Aloisa et al, Sherr et

al)

Death of a father has negative

effects on child outcome

Obverse – alive fathers? Positive

effects on child outcomes

Cherish fathers – treat their HIV,

keep them alive, keep them in

the family

Study Father findingsThurman et al

2006 South

Africa

Significantly more engaged in sex (49% vs. 39%). 1.5x more likely to have had

sex, younger age of sexual intercourse

Beegle et al

2008predictor of lower height and schooling

Vreeman et al

2008, KenyaOdds of ART non adherence increase with both parents dead

Birdthistle et al

2008, ZimbIncreased HSV2-+ve HIV-+ or ever pregnant maternal orphans, double orphans

and girls who lost their father before age 12

Hosegood et al

2007, Malawi,

SA, Tanzania

Inc orphan prevalence in 3 pops. Paternal death substantially higher than

maternal. 77% paternal orphans live with mother and 68% maternal orphans

with father.

Ford et al 2005

SASurvival status and residency of M and F affected mobility..

Doring et al

2005 BrazilHIV positivity multiplied the child's chances of institution 4.6 fold, losing

mother 5.9, losing both 3.7

Watts et al 2005

ZimbabweMortality higher in orphans.

Nyamukapa et al

2005 Zimbabwelower primary school completion. Sustained high levels of primary school

completion amongst paternal and double orphans--particularly for girls.

Crampin et al

2003 MalawiDeath of HIV-positive mothers, but not of HIV-negative mothers or of

fathers, associated with increased child mortality.

Lindblade et al

2003 KenyaNo diffs on most key health indicators W/H Z-scores in orphans were

almost 0.3 standard deviations lower - more pronounced among paternal

orphans .

Thorne et al 1998

ECSMaternal injecting drug use, single parenthood and health status were the

major reasons necessitating alternative care

Kang et al 2008

ZimbabwePaternal orphans were more likely to have ever been homeless and to be

out of school

Parikh et al 2007

South AfricaNo significant differences in most education, health and labour outcomes.

Paternal orphans more likely to be behind in school.

Timaeus and

BOler 2007

South Africa

Paternal orphanhood and belonging to a different household from ones

father resulted in slower school progress. Absence of father associated with

poverty

Bhargava 2005

EthiopiaThe presence of the father in the hh did not significantly affect chances of

school participation after maternal death. Presence of father in hh positive

and sig effects on scores on emotional adjustment. If father prepared meals

positive association with 60 items of MMPI

Foster et al 1995

ZimbPaternal family caring in only 16% families

Parenting by Grandparents

Increased role of grandparents in care

Traditionally involved

Grandparent care is often grandmother

care

Bereaved grandparents (own child has

died)

Multiple children

Who cares for grandparents?

Variable Under 55 years Over 55

years

Sig

Mental health (B) 28.3% 26.8% Ns

Mental health(Fup) 19.2% 21.7% Ns

Child depression fup .81 .77 Ns

Child trauma .81 .77 Ns

Child stunting 50.6% 51.5% Ns

Child wasted 22.5% 18.5% Ns

Child Underweight 31.1% 23.0% Ns

School attendance 98.3% 97.8% Ns

Digit span child fup 9.00 8.97 Ns

Child self esteem 22.2 22.3 Ns

Suicidal ideation 8.7% 8.8% Ns

Child Behaviour Problems (SDQ) 6.9 5.9 .01

Any Dev Difficulty 63.9% 59.4% .08

Siblings Good evidence on

importance of sibling

relationships

Separation of siblings is

often noted

Horizontal care

HIV affects adult

mental health

Anxiety

Depression

PTSD

Suicidality

Adult mental health affects parenting and child develop-ment

Child impact

Parental mental

health

Cumulative effects of parental AIDS and parent

psychological disorder on children’s mental health (n=2600 children, 2600 parents)

13

21

31

40

0

5

10

15

20

25

30

35

40

45

Carer no disorder,Child not AIDS-

affected

Carer no disorder,Child AIDS-affected

Carer disorder, Childnot AIDS-affected

Carer disorder, ChildAIDS-affected

% c

hild

ren

wit

h d

iso

rde

r

Kuo & Cluver in preparation

Abuse

Abuse predicts Psychological

distress

Children in AIDS affected family

3 fold abuse

No interventions found

Poverty – only 2 studies in

LAMI countries exploring

connections

Child Mental Health

Family AIDS

Poverty Interventions

Cash transfers

Treatment

Cluver et al 2013

0

1

2

3

4

5

6

7

8

12H14%years% 15H17%years%

!%!Incidence!of!ageGdisparate!sex!!(OR!.29!CI!.13G.67**)!

Na: onal,%stateHrun%cash%transfers%reduce%incidence%and%prevalence%of%age4disparate%sex%for%girls%

No%cash%transfer%%Child%cash%transfer%

0%

1%

2%

3%

4%

5%

6%

7%

8%

12H14%years% 15H17%years%

!%!Incidence!of!transac8onal!sex!!(OR!.49!CI!.26G.93*)!

Na: onal,%stateHrun%cash%transfers%reduce%incidence%and%prevalence%of%transac0onal%sex%for%girls%

No%cash%transfer%%Child%cash%transfer%

Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a

propensity-score-matched case-control study case-control study Lucie Cluver, Mark Boyes, Mark Orkin, Marija Pantelic, Thembela Molwena, Lorraine Sherr

Cash transfers reduce girl’s sexual

risk behaviours

no!support! cash! cash!plus!care!no!support! cash! cash!plus!care!

Cash + Care goes even furtherCluver Boyes Orkin and Sherr in press AIDS