Parenting support in the context of HIV
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The document discusses the critical role of parenting in the context of HIV, emphasizing the need for parental support to prevent vertical transmission and enhance child well-being. It highlights the significant mental and physical health challenges faced by parents living with HIV, which in turn affect their children. Furthermore, it stresses the importance of stable family structures and interventions such as cash transfers to improve outcomes for children affected by HIV.
Parenting support in the context of HIV
- 1. Parenting and HIV Lorraine Sherr UCL London
- 2. 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
- 3. 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
- 4. 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
- 5. 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
- 6. Quality of parenting Early child development Child stimulation Parenting in the presence of HIV infection
- 7. 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
- 8. HIV associated with parenting disruptions Parental illness Importance of Families Mental and physical effects of HIV in parents Parental death Child caring for ill parent Child caring for other children Parenting arrangements Alternative care arrangements Fathers Grandparents Kin Parental death (Orphanhood) Institutionalised care
- 9. Parental HIV Depression Stigma Secrets Illness Death
- 10. 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
- 11. Dually-affected (n=56) Mental illness (n=171) HIV/AIDS illness (n=106) Non-affected (n=473) Any difficulty Behaviour Attention Coping with change Playing 80.4 33.9 37.5 37.5 10.7 75.4 21.1 24 22.2 5.3 57.5 14.2 19.8 19.8 2.8 58.8 15.6 15.6 18.4 2.5
- 12. Tasks of parenting Feeding and nurturing Love attention, stimulation, protection and support Deciding an HIV free infant Disclosure Preparation for illness, treatment (and death)
- 13. Fascination with the unusual Parentification Child headed households Grandparent headed households Parenting under adversity Stresses of parenting under adversity have negative mental health impacts
- 14. Child takes on responsibilities as a caregiver
- 15. 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
- 17. Parentification
- 18. 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
- 19. Institutionalised care Good evidence on negative effects Yet number going up rather than down Fuelled by: Poverty; HIV Politics
- 20. Author N Design -ve effect Ahmad 2005 Kurdistan 142 Foster care vs orphanage Yes Beckett et al 2007 Romania 156 Adopted from Institutions vs non 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
- 21. Miller 2005 Guatamala USA 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 vs family reared Yes
- 22. 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
- 23. 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
- 24. Damaging care environments Place –vs-Circumstance Street children Out of school children Abused children Trafficked children Refugee children Hospitalised children
- 25. Dangers Orphan tourism (Richter et al 2010) Cost effective
- 26. Fathers
- 27. 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)
- 28. 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
- 29. Study Father findings Thurman 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 2008 predictor of lower height and schooling Vreeman et al 2008, Kenya Odds of ART non adherence increase with both parents dead Birdthistle et al 2008, Zimb Increased 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 SA Survival status and residency of M and F affected mobility.. Doring et al 2005 Brazil HIV positivity multiplied the child's chances of institution 4.6 fold, losing mother 5.9, losing both 3.7 Watts et al 2005 Zimbabwe Mortality higher in orphans.
- 30. Nyamukapa et al 2005 Zimbabwe lower primary school completion. Sustained high levels of primary school completion amongst paternal and double orphans--particularly for girls. Crampin et al 2003 Malawi Death of HIV-positive mothers, but not of HIV-negative mothers or of fathers, associated with increased child mortality. Lindblade et al 2003 Kenya No 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 ECS Maternal injecting drug use, single parenthood and health status were the major reasons necessitating alternative care Kang et al 2008 Zimbabwe Paternal orphans were more likely to have ever been homeless and to be out of school Parikh et al 2007 South Africa No 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 Ethiopia The 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 Zimb Paternal family caring in only 16% families
- 31. 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?
- 32. 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
- 33. Siblings Good evidence on importance of sibling relationships Separation of siblings is often noted Horizontal care
- 34. HIV affects adult mental health Anxiety Depression PTSD Suicidality Adult mental health affects parenting and child develop-ment Child impact Parental mental health
- 35. Cumulative effects of parental AIDS and parent psychological disorder on children’s mental health (n=2600 children, 2600 parents) 13 21 31 40 45 40 35 30 25 20 15 10 5 0 Carer no disorder, Child not AIDS-affected Carer no disorder, Child AIDS-affected Carer disorder, Child not AIDS-affected Carer disorder, Child AIDS-affected % children with disorder Kuo & Cluver in preparation
- 36. Abuse Abuse predicts Psychological distress Children in AIDS affected family 3 fold abuse No interventions found
- 37. Poverty – only 2 studies in LAMI countries exploring connections Poverty Interventions Child Mental Health Family AIDS Cash transfers Treatment Cluver et al 2013
- 38. Cash transfers reduce girl’s sexual risk behaviours Na: onal,%stateHrun%cash%transfers%reduce%incidence%and% prevalence%of%age4disparate%sex%for%girls% 8 7 6 5 4 3 2 1 0 !%!Incidence!of!ageGdisparate!sex!! (OR!.29!CI!.13G.67**)! 12H14%years% 15H17%years% No%cash%transfer% % Child%cash%transfer% Na: onal,%stateHrun%cash%transfers%reduce%incidence%and% prevalence%of%transac0onal%sex%for%girls% 8% 7% 6% 5% 4% 3% 2% 1% 0% !%!Incidence!of!transac8onal!sex! !(OR!.49!CI!.26G.93*)! 12H14%years% 15H17%years% 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
- 39. Cash + Care goes even further Cluver Boyes Orkin and Sherr in press AIDS no!support! cash! cash!plus!care! no!support! cash! cash!plus!care!