Potentially traumatic experiences and sexual health among orphaned and separated adolescents in five low- and middle-income countries.

Orphans and separated children (OSC) are a vulnerable population whose numbers are increasing, particularly in sub-Saharan Africa and Asia. Over 153 million children worldwide have lost one or both parents, including 17 million orphaned by AIDS, and millions more have been separated from their parents. As younger orphans enter adolescence, their sexual health and HIV-related risk behaviors become key considerations for their overall health. Importantly, their high prevalence of exposure to potentially traumatic events (PTEs) may put OSC at additional risk for adverse sexual health outcomes. The Positive Outcomes for Orphans study followed OSC randomly sampled from institution-based care and from family-based care, as well as a convenience sample of non-OSC, at six sites in five low-and middle-income countries. This analysis focused on the 90-month follow-up, during which adolescents 16 and older were assessed for sexual health, including age at sexual debut, past-year sex, past-year condom use, and perceptions of condom use. We specifically examined the relationship between PTEs and sexual health outcomes. Of the 1258 OSC and 138 non-OSC assessed, 11% reported ever having sex. Approximately 6% of participants reported recent sex and 5% reported having recent unprotected sex. However, 70% of those who had recent sex reported that they did not use a condom every time, and perceptions of condom use tended to be unfavorable for protection against sexual risk behavior. Nearly all (90%) of participants reported experiencing at least one lifetime PTE. For those who experienced "any" PTE, we found increased prevalence of recent sex (PR = 1.39 [0.47, 4.07]) and of recent unprotected sex (PR = 3.47 [0.60, 19.91]). This study highlights the need for caregivers, program managers, and policymakers to promote condom use for sexually active OSC and identify interventions for trauma support services. Orphans living in family-based care may also be particularly vulnerable to early sexual debut and unprotected sexual activity.

Civic engagement among orphans and non-orphans in five low- and middle-income countries.

BACKGROUND: Communities and nations seeking to foster social responsibility in their youth are interested in understanding factors that predict and promote youth involvement in public activities. Orphans and separated children (OSC) are a vulnerable population whose numbers are increasing, particularly in resource-poor settings. Understanding whether and how OSC are engaged in civic activities is important for community and world leaders who need to provide care for OSC and ensure their involvement in sustainable development. METHODS: The Positive Outcomes for Orphans study (POFO) is a multi-country, longitudinal cohort study of OSC randomly sampled from institution-based care and from family-based care, and of non-OSC sampled from the same study regions. Participants represent six sites in five low-and middle-income countries. We examined civic engagement activities and government trust among subjects > =16 years old at 90-month follow-up (approximately 7.5 years after baseline). We calculated prevalences and estimated the association between key demographic variables and prevalence of regular volunteer work using multivariable Poisson regression, with sampling weights to accounting for the complex sampling design. RESULTS: Among the 1,281 POFO participants > =16 who were assessed at 90-month follow-up, 45 % participated in regular community service or volunteer work; two-thirds of those volunteers did so on a strictly voluntary basis. While government trust was fairly high, at approximately 70 % for each level of government, participation in voting was only 15 % among those who were > =18 years old. We did not observe significant associations between demographic characteristics and regular volunteer work, with the exception of large variation by study site. CONCLUSION: As the world's leaders grapple with the many competing demands of global health, economic security, and governmental stability, the participation of today's youth in community and governance is essential for sustainability. This study provides a first step in understanding the degree to which OSC from different care settings across multiple low- and middle-income countries are engaged in their communities.

Low rates of child testing for HIV persist in a high-risk area of East Africa.

Children in low- and middle-income countries (LMIC) are the least touched by recent successes in the diagnosis and treatment of HIV/AIDS globally. Early treatment is essential for a child's longer and higher quality of life; however, by 2011, only a small proportion of HIV-seropositive children in LMIC countries were receiving treatment, in part because of persisting low rates of diagnosis. This study of the prevalence and characteristics of children tested for HIV was embedded in the Coping with HIV/AIDS in Tanzania (CHAT) study in which HIV-seropositive and HIV-seronegative adults, and adults with unknown HIV status were asked about HIV testing for their children. Data were gathered from November 2009 to August 2010 during the scale-up of Prevention of Mother To Child Transmission and Early Infant Diagnosis programs in the region. Reports on 1776 children indicate that 31.7% of all children were reported to have been tested, including only 42.9% of children with an HIV-seropositive caregiver. In general, children more likely to be HIV tested were biological children of study participants, younger, of widowed adults, living in urban areas, and of HIV-seropositive parents/caregivers. Children belonging to the two indigenous tribes, Chagga and Pare, were more likely to be tested than those from other tribes. Rates of testing among children less than two years old were low, even for the HIV-seropositive caregiver group. The persistence of low testing rates is discussed in terms of the accessibility and acceptability of child testing in resource poor settings.

Treating maladaptive grief and posttraumatic stress symptoms in orphaned children in Tanzania: group-based trauma-focused cognitive-behavioral therapy.

This study was designed to test the feasibility and child clinical outcomes for group-based trauma-focused cognitive behavior therapy (TF-CBT) for orphaned children in Tanzania. There were 64 children with at least mild symptoms of grief and/or traumatic stress and their guardians who participated in this open trial. The TF-CBT for Child Traumatic Grief protocol was adapted for use with a group, resulting in 12 weekly sessions for children and guardians separately with conjoint activities and 3 individual visits with child and guardian. Using a task-sharing approach, the intervention was delivered by lay counselors with no prior mental health experience. Primary child outcomes assessed were symptoms of grief and posttraumatic stress (PTS); secondary outcomes included symptoms of depression and overall behavioral adjustment. All assessments were conducted pretreatment, posttreatment, and 3 and 12 months after the end of treatment. Results showed improved scores on all outcomes posttreatment, sustained at 3 and 12 months. Effect sizes (Cohen's d) for baseline to posttreatment were 1.36 for child reported grief symptoms, 1.87 for child-reported PTS, and 1.15 for guardian report of child PTS.

A brief assessment of learning for orphaned and abandoned children in low and middle income countries.

Assessment of children's learning and performance in low and middle income countries has been critiqued as lacking a gold standard, an appropriate norm reference group, and demonstrated applicability of assessment tasks to the context. This study was designed to examine the performance of three nonverbal and one adapted verbal measure of children's problem solving, memory, motivation, and attention across five culturally diverse sites. The goal was to evaluate the tests as indicators of individual differences affected by life events and care circumstances for vulnerable children. We conclude that the measures can be successfully employed with fidelity in non-standard settings in LMICs, and are associated with child age and educational experience across the settings. The tests can be useful in evaluating variability in vulnerable child outcomes.

More than the loss of a parent: potentially traumatic events among orphaned and abandoned children.

This study examines rates of potentially traumatic events and associated anxiety and emotional/behavioral difficulties among 1,258 orphaned and abandoned children in 5 low- and middle-income countries. The study quantifies the types of events the children experienced and demonstrates that anxiety and emotional/behavioral difficulties increase with additional exposure. As policies for orphaned and abandoned children are being implemented, this study helps policy makers and care providers recognize that (a) children and caregivers are willing to report experiences of potentially traumatic events, (b) those who report such events are at higher risk for experiencing additional events, (c) resulting symptomatology indicates a need for appropriate mental health services, and (d) boys are as vulnerable as girls, indicating an equal need for protection.

Child work and labour among orphaned and abandoned children in five low and middle income countries.

BACKGROUND: The care and protection of the estimated 143,000,000 orphaned and abandoned children (OAC) worldwide is of great importance to global policy makers and child service providers in low and middle income countries (LMICs), yet little is known about rates of child labour among OAC, what child and caregiver characteristics predict child engagement in work and labour, or when such work infers with schooling. This study examines rates and correlates of child labour among OAC and associations of child labour with schooling in a cohort of OAC in 5 LMICs. METHODS: The Positive Outcomes for Orphans (POFO) study employed a two-stage random sampling survey methodology to identify 1480 single and double orphans and children abandoned by both parents ages 6-12 living in family settings in five LMICs: Cambodia, Ethiopia, India, Kenya, and Tanzania. Regression models examined child and caregiver associations with: any work versus no work; and with working <21, 21-27, and 28+ hours during the past week, and child labour (UNICEF definition). RESULTS: The majority of OAC (60.7%) engaged in work during the past week, and of those who worked, 17.8% (10.5% of the total sample) worked 28 or more hours. More than one-fifth (21.9%; 13% of the total sample) met UNICEF's child labour definition. Female OAC and those in good health had increased odds of working. OAC living in rural areas, lower household wealth and caregivers not earning an income were associated with increased child labour. Child labour, but not working fewer than 28 hours per week, was associated with decreased school attendance. CONCLUSIONS: One in seven OAC in this study were reported to be engaged in child labour. Policy makers and social service providers need to pay close attention to the demands being placed on female OAC, particularly in rural areas and poor households with limited income sources. Programs to promote OAC school attendance may need to focus on the needs of families as well as the OAC.

Family Composition and Stability for Orphans: A Longitudinal Study of Well-Being in 5 Low- and Middle-Income Countries.

Objectives: Many orphaned children in low- and middle-income countries live with family. Yet, their household composition and its stability are not well-characterized, nor is impact of stability on longer-term outcomes. Methods: We used the longitudinal, multi-country Positive Outcomes for Orphans cohort to describe adult family living with orphans. Stability was measured by changes in presence of six familial relations over time, and related to three outcomes: 1) incident abuse, 2) cognitive functioning, 3) emotional difficulties. Associations were estimated using generalized linear models fit with generalized estimating equations. For abuse, Poisson regression estimated risk ratios. For continuous scores of cognitive functioning and emotional difficulties, linear models estimated mean differences (MDs) with 95% confidence intervals. Results: Among 1,359 orphans, 53-61% reported living with their mother each year; 7-13% with father; nearly 60% reported ≥1 change in composition over follow-up. Compared to 0 changes, difficulties increased with 1 change [MD: 0.23 (-0.33, 0.79)], 2 changes [MD: 0.57 (0.00, 1.16)] and ≥3 changes [MD: 0.73 (0.18, 1.29)]. No associations were found with abuse or cognitive functioning. Conclusion: Orphan well-being may be improved through supports stabilizing household composition or targeting emotional resilience.

Prevalence and predictors of HIV-related stigma among institutional- and community-based caregivers of orphans and vulnerable children living in five less-wealthy countries.

BACKGROUND: In the face of the HIV/AIDS epidemic that has contributed to the dramatic increase in orphans and abandoned children (OAC) worldwide, caregiver attitudes about HIV, and HIV-related stigma, are two attributes that may affect caregiving. Little research has considered the relationship between caregiver attributes and caregiver-reported HIV-related stigma. In light of the paucity of this literature, this paper will describe HIV-related stigma among caregivers of OAC in five less wealthy nations. METHODS: Baseline data were collected between May 2006 through February 2008. The sample included 1,480 community-based and 192 institution-based caregivers. Characteristics of the community-based and institution-based caregivers are described using means and standard deviations for continuous variables or counts and percentages for categorical variables. We fit logistic regression models, both for the full sample and separately for community-based and institution-based caregivers, to explore predictors of acceptance of HIV. RESULTS: Approximately 80% of both community-based and institution-based caregivers were female; and 84% of institution-based caregivers, compared to 66% of community-based caregivers, said that they would be willing to care for a relative with HIV. Similar proportions were reported when caregivers were asked if they were willing to let their child play with an HIV-infected child. In a multivariable model predicting willingness to care for an HIV-infected relative, adjusted for site fixed effects, being an institution-based caregiver was associated with greater willingness (less stigma) than community-based caregivers. Decreased willingness was reported by older respondents, while willingness increased with greater formal education. In the adjusted models predicting willingness to allow one's child to play with an HIV-infected child, female gender and older age was associated with less willingness. However, willingness was positively associated with years of formal education. CONCLUSIONS: The caregiver-child relationship is central to a child's development. OAC already face stigma as a result of their orphaned or abandoned status; the addition of HIV-related stigma represents a double burden for these children. Further research on the prevalence of HIV-related acceptance and stigma among caregivers and implications of such stigma for child development will be critical as the policy community responds to the global HIV/AIDS orphan crisis.

Trauma, mental health, distrust, and stigma among HIV-positive persons: implications for effective care.

Individuals living with HIV often have complicated histories, including negative experiences such as traumatic events, mental illness, and stigma. As the medical community in the United States adapts to managing HIV as a chronic disease, understanding factors such as these negative experiences that may be associated with poorer adherence to treatment regimens, greater HIV risk behavior, and lower patient quality of life becomes critical to HIV care and prevention. In less wealthy nations, these issues are also critical for addressing quality of life as well as medication adherence in the areas where antiretroviral therapies are being made available. This article presents a review of the literature regarding the following psychosocial factors as they relate to HIV/AIDS in the US and globally: traumatic events; mental illness, including depression, anxiety, and posttraumatic stress disorder; lack of trust in the healthcare system and government; and experiences of stigma among individuals with HIV disease. These factors have been found to be prevalent among individuals with HIV/AIDS, regardless of gender or race/ethnicity. Traumatic events, mental illness, distrust, and stigma have also been linked with poorer adherence to medication regimens and HIV risk behavior.

Exploring Factors Associated with Educational Outcomes for Orphan and Abandoned Children in India.

India has more than 25 million orphan and abandoned children (UNICEF, 2012). The burden of care for these OAC is on caregivers that are often ill equipped to meet their needs due to inadequate assets. Previous studies suggest that in communities with limited resources, OAC residing with non-biological caregivers are more at risk than those fostered by a biological parent. This study explores the association of caregiver and child characteristics with OAC educational outcome in India. The analysis was conducted using hierarchical logistic regression. The findings have implications for practice and policy in the global child welfare field.

Prevalence and Incidence of Traumatic Experiences Among Orphans in Institutional and Family-Based Settings in 5 Low- and Middle-Income Countries: A Longitudinal Study.

BACKGROUND: Policy makers struggling to protect the 153 million orphaned and separated children (OSC) worldwide need evidence-based research on the burden of potentially traumatic events (PTEs) and the relative risk of PTEs across different types of care settings. METHODS: The Positive Outcomes for Orphans study used a 2-stage, cluster-randomized sampling design to identify 1,357 institution-dwelling and 1,480 family-dwelling orphaned and separated children in 5 low- and middle-income countries (LMICs) in sub-Saharan Africa and Asia. We used the Life Events Checklist developed by the National Center for Posttraumatic Stress Disorder to examine self-reported PTEs among 2,235 OSC ages 10-13 at baseline. We estimated prevalence and incidence during 36-months of follow-up and compared the risk of PTEs across care settings. Data collection began between May 2006 and February 2008, depending on the site. RESULTS: Lifetime prevalence by age 13 of any PTE, excluding loss of a parent, was 91.0% (95% confidence interval (CI) = 85.6, 94.5) in institution-dwelling OSC and 92.4% (95% CI = 90.3, 94.0) in family-dwelling OSC; annual incidence of any PTE was lower in institution-dwelling (23.6% [95% CI = 19.4, 28.7]) than family-dwelling OSC (30.0% [95% CI = 28.1, 32.2]). More than half of children in institutions (50.3% [95% CI = 42.5, 58.0]) and in family-based care (54.0% [95% CI = 50.2, 57.7]) had experienced physical or sexual abuse by age 13. Annual incidence of physical or sexual abuse was lower in institution-dwelling (12.9% [95% CI = 9.6, 17.3]) than family-dwelling OSC (19.4% [95% CI = 17.7, 21.3]), indicating statistically lower risk in institution-dwelling OSC (risk difference = 6.5% [95% CI = 1.4, 11.7]). CONCLUSION: Prevalence and incidence of PTEs were high among OSC, but contrary to common assumptions, OSC living in institutions did not report more PTEs or more abuse than OSC living with families. Current efforts to reduce the number of institution-dwelling OSC may not reduce incidence of PTEs in this vulnerable population. Protection of children from PTEs should be a primary consideration, regardless of the care setting.

Changes in HIV Outcomes Following Depression Care in a Resource-Limited Setting: Results from a Pilot Study in Bamenda, Cameroon.

BACKGROUND: Little is known about how improved depression care affects HIV-related outcomes in Africa. In a sample of depressed HIV patients in a low income, sub-Saharan country, we explored how implementing measurement-based antidepressant care (MBC) affected HIV outcomes over 4 months of antidepressant treatment. METHODS: As part of a project adapting MBC for use in Cameroon, we enrolled 41 depressed HIV patients on antiretroviral therapy in a pilot study in which a depression care manager (DCM) provided an outpatient HIV clinician with evidence-based decision support for antidepressant treatment. Acute depression management was provided for the first 12 weeks, with DCM contact every 2 weeks and HIV clinician appointments every 4 weeks. We measured HIV clinical and psychiatric outcomes at 4 months. RESULTS: Participants were moderately depressed at baseline (mean Patient Health Questionnaire [PHQ] score = 14.4, range 13.1, 15.6). All HIV clinical outcomes improved by four month follow-up: mean (range) CD4 count improved from 436 (2, 860) to 452 (132, 876), mean (range) log-viral load decreased from 4.02 (3.86, 4.17) to 3.15 (2.81, 3.49), the proportion with virologic suppression improved from 0% to 18%, mean (range) HIV symptoms decreased from 6.4 (5.5, 7.3) to 3.1 (2.5, 3.7), the proportion reporting good or excellent health improved from 18% to 70%, and the proportion reporting any missed ARV doses in the past month decreased from 73% to 55%. Concurrently, psychiatric measures improved. The mean (range) PHQ score decreased from 14.4 (13.1, 15.6) to 1.6 (0.8, 2.4) and 90% achieved depression remission, while mean maladaptive coping style scores decreased and mean adaptive coping scores and self-efficacy scores improved. CONCLUSION: In this pilot study of an evidence-based depression treatment intervention for HIV-infected patients in Cameroon, a number of HIV behavioral and non-behavioral health outcomes improved over 4 months of effective depression treatment. These data are consistent with the hypothesis that better depression care can lead to improved HIV outcomes.

Child and Caregiver Concordance of Potentially Traumatic Events Experienced by Orphaned and Abandoned Children.

Exposure to trauma is associated with significant emotional and behavioral difficulties among children (Perepletchikova & Kaufman, 2010). Overall, reports of trauma and violence experienced by children are discrepant from those of their caregivers (Lewis et al., 2012). Even less is known about the extent of concordance between orphans and their caregivers. This study examines the correlates of concordance in reported traumatic experiences between 1,269 orphaned and abandoned children (OAC) and their caregivers. The OAC lived in family-settings in 5 low and middle income countries and were part of a longitudinal study, "Positive Outcomes for Orphans" (POFO) that enrolled children aged 6 to 12 at baseline. By examining concordance with respect to specific types of trauma reported, this study expands the understanding of who reports which types of traumas experienced by orphaned and abandoned children, thereby improving the potential to provide targeted interventions for children who have experienced such events. In this study, children and caregivers were asked separately if the child had experienced different types of potentially traumatic events. Children were significantly more likely to report physical abuse, sexual abuse and family violence than were caregivers. Caregivers were significantly more likely than children to report natural disasters and accidents. High levels of concordance were found in the reporting of wars, riots, killings, and deaths in the family. The impacts of trauma on behavior and mental health are profound, and highly effective interventions targeting sequelae of childhood trauma are currently being developed for use in low resource areas. Findings from this study demonstrate that it is feasible to conduct screening for potentially traumatic events utilizing child self-report in resource limited settings and that child self-report is crucial in evaluating trauma, particularly family violence and physical or sexual assault.

Reduced adherence to antiretroviral therapy among HIV-infected Tanzanians seeking cure from the Loliondo healer.

: The predictors for seeking alternative therapies for HIV-infection in sub-Saharan Africa are unknown. Among a prospective cohort of 442 HIV-infected patients in Moshi, Tanzania, 249 (56%) sought cure from a newly popularized religious healer in Loliondo (450 km away), and their adherence to antiretrovirals (ARVs) dropped precipitously (odds ratio = 0.20, 95% confidence interval: 0.09 to 0.44, P < 0.001) after the visit. Compared with those not attending Loliondo, attendees were more likely to have been diagnosed with HIV more remotely (3.8 vs. 3.0 years before, P < 0.001), have taken ARVs longer (3.4 vs. 2.5 years, P < 0.001), have higher median CD4 lymphocyte counts (429 vs. 354 cells/mm, P < 0.001), be wealthier (wealth index: 10.9 vs. 8.8, P = 0.034), and receive care at the private versus the public hospital (P = 0.012). In multivariable logistic regression, only years since the start of ARVs remained significant (odds ratio = 1.49, 95% confidence interval: 1.23 to 1.80). Treatment fatigue may play a role in the lure of alternative healers.

Three-year change in the wellbeing of orphaned and separated children in institutional and family-based care settings in five low- and middle-income countries.

BACKGROUND: With more than 2 million children living in group homes, or "institutions", worldwide, the extent to which institution-based caregiving negatively affects development and wellbeing is a central question for international policymakers. METHODS: A two-stage random sampling methodology identified community representative samples of 1,357 institution-dwelling orphaned and separated children (OSC) and 1,480 family-dwelling OSC aged 6-12 from 5 low and middle income countries. Data were collected from children and their primary caregivers. Survey-analytic techniques and linear mixed effects models describe child wellbeing collected at baseline and at 36 months, including physical and emotional health, growth, cognitive development and memory, and the variation in outcomes between children, care settings, and study sites. FINDINGS: At 36-month follow-up, institution-dwelling OSC had statistically significantly higher height-for-age Z-scores and better caregiver-reported physical health; family-dwelling OSC had fewer caregiver-reported emotional difficulties. There were no statistically significant differences between the two groups on other measures. At both baseline and follow-up, the magnitude of the differences between the institution- and family-dwelling groups was small. Relatively little variation in outcomes was attributable to differences between sites (11-27% of total variation) or care settings within sites (8-14%), with most variation attributable to differences between children within settings (60-75%). The percent of variation in outcomes attributable to the care setting type, institution- versus family-based care, ranged from 0-4% at baseline, 0-3% at 36-month follow-up, and 0-4% for changes between baseline and 36 months. INTERPRETATION: These findings contradict the hypothesis that group home placement universally adversely affects child wellbeing. Without substantial improvements in and support for family settings, the removal of institutions, broadly defined, would not significantly improve child wellbeing and could worsen outcomes of children who are moved from a setting where they are doing relatively well to a more deprived setting.

Factors associated with change in sexual transmission risk behavior over 3 years among HIV-infected patients in Tanzania.

BACKGROUND: The reduction of HIV transmission risk behaviors among those infected with HIV remains a major global health priority. Psychosocial characteristics have proven to be important correlates of sexual transmission risk behaviors in high-income countries, but little attention has focused on the influence of psychosocial and psychological factors on sexual transmission risk behaviors in African cohorts. METHODOLOGY AND PRINCIPAL FINDINGS: The CHAT Study enrolled a representative sample of 499 HIV-infected patients in established HIV care and 267 newly diagnosed HIV-infected individuals from the Kilimanjaro Region of Tanzania. Participants completed in-person interviews every 6 months for 3 years. Using logistic random effects models to account for repeated observations, we assessed sociodemographic, physical health, and psychosocial predictors of self-reported unprotected sexual intercourse. Among established patients, the proportion reporting any recent unprotected sex was stable, ranging between 6-13% over 3 years. Among newly diagnosed patients, the proportion reporting any unprotected sex dropped from 43% at baseline to 11-21% at 6-36 months. In multivariable models, higher odds of reported unprotected sex was associated with female gender, younger age, being married, better physical health, and greater post-traumatic stress symptoms. In addition, within-individual changes in post-traumatic stress over time coincided with increases in unprotected sex. CONCLUSIONS AND SIGNIFICANCE: Changes in post-traumatic stress symptomatology were associated with changes in sexual transmission risk behaviors in this sample of HIV-infected adults in Tanzania, suggesting the importance of investing in appropriate mental health screening and intervention services for HIV-infected patients, both to improve mental health and to support secondary prevention efforts.

Trauma history and depression predict incomplete adherence to antiretroviral therapies in a low income country.

BACKGROUND: As antiretroviral therapy (ART) for HIV becomes increasingly available in low and middle income countries (LMICs), understanding reasons for lack of adherence is critical to stemming the tide of infections and improving health. Understanding the effect of psychosocial experiences and mental health symptomatology on ART adherence can help maximize the benefit of expanded ART programs by indicating types of services, which could be offered in combination with HIV care. METHODOLOGY: The Coping with HIV/AIDS in Tanzania (CHAT) study is a longitudinal cohort study in the Kilimanjaro Region that included randomly selected HIV-infected (HIV+) participants from two local hospital-based HIV clinics and four free-standing voluntary HIV counselling and testing sites. Baseline data were collected in 2008 and 2009; this paper used data from 36 month follow-up interviews (N = 468). Regression analyses were used to predict factors associated with incomplete self-reported adherence to ART. RESULTS: Incomplete art adherence was significantly more likely to be reported amongst participants who experienced a greater number of childhood traumatic events: sexual abuse prior to puberty and the death in childhood of an immediate family member not from suicide or homicide were significantly more likely in the non-adherent group and other negative childhood events trended toward being more likely. Those with incomplete adherence had higher depressive symptom severity and post-traumatic stress disorder (PTSD). In multivariable analyses, childhood trauma, depression, and financial sacrifice remained associated with incomplete adherence. DISCUSSION: This is the first study to examine the effect of childhood trauma, depression and PTSD on HIV medication adherence in a low income country facing a significant burden of HIV. Allocating spending on HIV/AIDS toward integrating mental health services with HIV care is essential to the creation of systems that enhance medication adherence and maximize the potential of expanded antiretroviral access to improve health and reduce new infections.

Correlates of poor health among orphans and abandoned children in less wealthy countries: the importance of caregiver health.

BACKGROUND: More than 153 million children worldwide have been orphaned by the loss of one or both parents, and millions more have been abandoned. We investigated relationships between the health of orphaned and abandoned children (OAC) and child, caregiver, and household characteristics among randomly selected OAC in five countries. METHODOLOGY: Using a two-stage random sampling strategy in 6 study areas in Cambodia, Ethiopia, India, Kenya, and Tanzania, the Positive Outcomes for Orphans (POFO) study identified 1,480 community-living OAC ages 6 to 12. Detailed interviews were conducted with 1,305 primary caregivers at baseline and after 6 and 12 months. Multivariable logistic regression models describe associations between the characteristics of children, caregivers, and households and child health outcomes: fair or poor child health; fever, cough, or diarrhea within the past two weeks; illness in the past 6 months; and fair or poor health on at least two assessments. PRINCIPAL FINDINGS: Across the six study areas, 23% of OAC were reported to be in fair or poor health; 19%, 18%, and 2% had fever, cough, or diarrhea, respectively, within the past two weeks; 55% had illnesses within the past 6 months; and 23% were in fair or poor health on at least two assessments. Female gender, suspected HIV infection, experiences of potentially traumatic events, including the loss of both parents, urban residence, eating fewer than 3 meals per day, and low caregiver involvement were associated with poorer child health outcomes. Particularly strong associations were observed between child health measures and the health of their primary caregivers. CONCLUSIONS: Poor caregiver health is a strong signal for poor health of OAC. Strategies to support OAC should target the caregiver-child dyad. Steps to ensure food security, foster gender equality, and prevent and treat traumatic events are needed.

Prevalence of psychological trauma and association with current health and functioning in a sample of HIV-infected and HIV-uninfected Tanzanian adults.

BACKGROUND: In high income nations, traumatic life experiences such as childhood sexual abuse are much more common in people living with HIV/AIDS (PLWHA) than the general population, and trauma is associated with worse current health and functioning. Virtually no data exist on the prevalence or consequences of trauma for PLWHA in low income nations. METHODOLOGY/PRINCIPAL FINDINGS: We recruited four cohorts of Tanzanian patients in established medical care for HIV infection (n = 228), individuals newly testing positive for HIV (n = 267), individuals testing negative for HIV at the same sites (n = 182), and a random sample of community-dwelling adults (n = 249). We assessed lifetime prevalence of traumatic experiences, recent stressful life events, and current mental health and health-related physical functioning. Those with established HIV infection reported a greater number of childhood and lifetime traumatic experiences (2.1 and 3.0 respectively) than the community cohort (1.8 and 2.3). Those with established HIV infection reported greater post-traumatic stress disorder (PTSD) symptomatology and worse current health-related physical functioning. Each additional lifetime traumatic experience was associated with increased PTSD symptomatology and worse functioning. CONCLUSIONS/SIGNIFICANCE: This study is the first to our knowledge in an HIV population from a low income nation to report the prevalence of a range of potentially traumatic life experiences compared to a matched community sample and to show that trauma history is associated with poorer health-related physical functioning. Our findings underscore the importance of considering psychosocial characteristics when planning to meet the health needs of PLWHA in low income countries.