The Prevalence and Patterns of Menopausal Symptoms in Women Living with HIV.

Increasing numbers of women with HIV are experiencing menopause. We use data from a large, representative sample of women with HIV to describe the prevalence and clustering of menopausal symptoms amongst pre-, peri- and post-menopausal women using hierarchical agglomerative cluster analysis. Of the 709 women included, 21.6%, 44.9% and 33.6% were pre-, peri- and post-menopausal, respectively. Joint pain (66.4%) was the most commonly reported symptom, followed by hot flashes (63.0%), exhaustion (61.6%) and sleep problems (61.4%). All symptoms were reported more commonly by peri- and post-menopausal women compared to pre-menopausal women. Psychological symptoms and sleep problems clustered together at all menopausal stages. Somatic and urogenital symptom clusters emerged more distinctly at peri- and post-menopause. We recommend regular and proactive assessment of menopausal symptoms in midlife women with HIV, with an awareness of how particular patterns of symptoms may evolve over the menopausal transition.

Effects of Maternal Suicidal Ideation on Child Cognitive Development: A Longitudinal Analysis.

This study aimed to assess the association between suicidal ideation among mothers living with HIV in Zimbabwe and the cognitive development of their children. Participants were mother-child dyads recruited from two rural districts in Zimbabwe. Data were collected at baseline and 12 months follow-up. Suicidal ideation was assessed using item-10 from the Edinburgh postnatal depression scale. Mixed-effects linear regression was used to assess the association of child cognitive outcomes at follow-up (using the Mullen scales of early learning) with maternal suicidal ideation. Mothers with suicidal ideation at baseline (n = 171) tended to be younger, unmarried, experienced moderate to severe hunger, had elevated parental stress and depression symptoms compared with non-suicidal mothers (n = 391). At follow-up, emerging maternal suicidal ideation was associated with poorer child cognitive outcomes (adjusted mean difference - 6.1; 95% CI - 10.3 to - 1.8; p = 0.03). Suicidal ideation affects child cognitive development and should be addressed, particularly in HIV positive mothers.

Investigating Conceptual Models for the Relationship Between Depression and Condomless Sex Among Gay, Bisexual, and Other Men Who have Sex with Men: Using Structural Equation Modelling to Assess Mediation.

The aim of this study is to investigate five hypothesized mechanisms of causation between depression and condomless sex with ≥ 2 partners (CLS2+) among gay, bisexual, and other men who have sex with men (GBMSM), involving alternative roles of self-efficacy for sexual safety and recreational drug use. Data were from the AURAH cross-sectional study of 1340 GBMSM attending genitourinary medicine clinics in England (2013-2014). Structural equation modelling (SEM) was used to investigate which conceptual model was more consistent with the data. Twelve percent of men reported depression (PHQ-9 ≥ 10) and 32% reported CLS2+ in the past 3 months. AURAH data were more consistent with the model in which depression was considered to lead to CLS2+ indirectly via low self-efficacy for sexual safety (indirect Beta = 0.158; p < 0.001) as well as indirectly via higher levels of recreational drug use (indirect Beta = 0.158; p < 0.001). SEM assists in understanding the relationship between depression and CLS among GBMSM.

Evaluating the effectiveness of a multi-component intervention on early childhood development in paediatric HIV care and treatment programmes: a randomised controlled trial.

BACKGROUND: HIV infection in a family may affect optimum child development. Our hypothesis is that child development outcomes among HIV-exposed infants will be improved through a complex early childhood stimulation (ECS) programme, and income and loans saving programme for HIV positive parents. METHODS: The study was a cluster-randomized controlled trial in 30 clinic sites in two districts in Zimbabwe. Clinics were randomised in a 1:1 allocation ratio to the Child Health Intervention for Development Outcomes (CHIDO) intervention or Ministry of Health standard care. The CHIDO intervention comprises three elements: a group ECS parenting programme, an internal savings and lending scheme (ISALS) and case-management home visits by village health workers. The intervention was aimed at caregiver-child dyads (child aged 0-24 months) where the infant was HIV exposed or infected. The primary outcomes were cognitive development (assessed by the Mullen Scales of Early Learning) and retention of the child in HIV care, at 12 months after enrolment. A comprehensive process evaluation was conducted. DISCUSSION: The results of this cluster-randomised trial will provide important information regarding the effects of multi-component interventions in mitigating developmental delays in HIV-exposed infants living in resource-limited environments. TRIAL REGISTRATION: This trial is registered with the Pan African Clinical Trials Registry ( www.pactr.org ), registration number PACTR201701001387209; the trial was registered on 16th January 2017 (retrospectively registered).

Differing psychological vulnerabilities among behaviourally and perinatally HIV infected adolescents in South Africa - implications for targeted health service provision.

HIV infections are growing the fastest amongst adolescents, especially in sub Saharan Africa. On reaching adolescence, perinatally-infected youth may have different needs to those who acquired infection behaviourally. Yet both have sub-optimal adherence with implications for their own health as well as onward transmission. This study uses the world's largest community-based study of HIV-positive adolescents from the Eastern Cape, South Africa. Clinic records at N = 53 district health facilities generated a log of all ART-initiated adolescents who were then interviewed in the community: N = 1058 (90%) were tracked and participated. Ethical approval, informed consent and data collector training preceded data gathering. Inventories comprised validated measures of mental health (depression, anxiety, suicidality and internalised stigma), substance use, ART adherence, and clinic attendance. Analyses were conducted using SPSS25 and STATA15. Perinatally-infected adolescents (n = 792, 77.3%) were significantly more likely to be ART adherent (OR = 1.54 95%CI: 1.14-2.07 p = 0.005), retained in healthcare (OR = 1.59 95%CI1.18-2.14 p = 0.002), and treated well by clinic staff (OR = 2.12 95%CI1.59-3.07 p ≤ 0.001). Behaviourally-infected adolescents were more likely to be depressed (B = 0.81 p ≤ 0.001), anxious (B = 1.36 p ≤ 0.001), report internalised stigma (B = 0.91 p ≤ 0.001), express suicidal ideation (OR = 3.65 95%CI: 1.96-6.82 p ≤ 0.001) and report excessive substance use in the past year (OR = 9.37 95%CI5.73-15.35 p ≤ 0.001). Being older explained most of these differences, with female adolescents living with HIV more likely to report suicidal ideation. However, behaviourally-infected adolescents were more likely to report substance use (OR = 2.69 95%CI: 1.48-4.91 p = 0.001), depression (B = 0.406, p = 0.022), anxiety (B = 1.359, p ≤ 0.001), and internalised stigma (B = 0.403, p = 0.007) in multivariate regression analyses, controlling for covariates. Moderation analyses (adjusting for multiple testing) suggest that behaviourally-infected HIV-positive adolescents who are also maternal orphans are more likely to report higher rates of depression (B = 1.075, p < 0.001). These notable differences by mode of infection suggest that studies which conflate HIV-positive adolescents may blur the clinical and psychological experiences of these two different sub-populations. Drivers of non-adherence, poor retention in care, and mental health problems may differ by mode of infection, requiring tailored interventions. Health and social service provision, if it is to be effective, needs to address these different youth profiles to ensure optimal adherence, development and wellbeing throughout the life course.

Cognitive and physical development in HIV-positive children in South Africa and Malawi: A community-based follow-up comparison study.

BACKGROUND: Child development is negatively impacted by HIV with children that are infected and affected by HIV performing worse than their peers in cognitive assessments. METHODS: We conducted a descriptive follow-up comparison study (n=989) in South Africa and Malawi. We tracked child development in 135 HIV-positive children compared to 854 uninfected children aged 4-13 years attending community-based organizations at baseline and again 12-15 months later. RESULTS: Children with HIV were more often stunted (58.8% vs. 27.4%) and underweight (18.7% vs. 7.1%). They also had significantly poorer general physical functioning (M=93.37 vs. M=97.00). HIV-positive children scored significantly lower on digit span and the draw-a-person task. CONCLUSIONS: These data clearly show that HIV infection poses a serious risk for child development and that there is a need for scaled up interventions. Community-based services may be ideally placed to accommodate such provision and deliver urgently needed support to these children.

Interventions to improve psychosocial well-being for children affected by HIV and AIDS: a systematic review.

In addition to its contribution to child mortality, HIV/AIDS has a substantial impact on the psychosocial well-being of children across the globe and particularly in sub-Saharan Africa. We conducted a systematic review of the literature in order to identify studies that assess the effectiveness of interventions developed to improve the psychosocial well-being of children affected by HIV/AIDS, published between January 2008 and February 2016. Studies that were eligible for the review included male and/or female children under the age of 18 years of age, who had lost a parent to HIV/AIDS, were living with a parent with HIV/AIDS, or were vulnerable because of other social and economic factors and living in communities of high HIV and AIDS prevalence, including child and caregiver reports. Studies were included if they documented any intervention to improve the psychosocial well-being of children including psychological therapy, psychosocial support and/or care, medical interventions and social interventions, with psychological and/or social factors as outcomes. We identified 17 interventions to improve the psychosocial well-being of children affected by HIV/AIDS. Of these, 16 studies took place in eight different low and middle-income countries (LMIC), of which 6 were in southern and eastern Africa. One study took place in a high-income setting. Of the total, fifteen showed some significant benefits of the intervention, while two showed no difference to psychosocial outcomes as a result of the intervention. The content of interventions, dosage and length of follow up varied substantially between studies. There were few studies on children under seven years and several focused mostly on girls. Efforts to improve evaluation of interventions to improve the psychosocial well-being of children affected by HIV/AIDS have resulted in a number of new studies which met the inclusion criteria for the review. Most studies are specially designed research projects and not evaluations of existing services. We call for increased partnerships between policy-makers, practitioners and researchers in order to design evaluation studies and can feed into the growing evidence base.

Age, time living with diagnosed HIV infection, and self-rated health.

OBJECTIVES: An increasing proportion of people living with HIV are older adults, who may require specialized care. Adverse physical and psychological effects of HIV infection may be greatest among older people or those who have lived longer with HIV. METHODS: The ASTRA study is a cross-sectional questionnaire study of 3258 HIV-diagnosed adults (2248 men who have sex with men, 373 heterosexual men and 637 women) recruited from UK clinics in 2011-2012. Associations of age group with physical symptom distress (significant distress for at least one of 26 symptoms), depression and anxiety symptoms (scores ≥ 10 on PHQ-9 and GAD-7, respectively), and health-related functional problems (problems on at least one of three domains of the Euroqol 5D-3L)) were assessed, adjusting for time with diagnosed HIV infection, gender/sexual orientation and ethnicity. RESULTS: The age distribution of participants was: < 30 years, 5%; 30-39 years, 23%; 40-49 years, 43%; 50-59 years, 22%; and ≥ 60 years, 7%. Overall prevalences were: physical symptom distress, 56%; depression symptoms, 27%; anxiety symptoms, 22%; functional problems, 38%. No trend was found in the prevalence of physical symptom distress with age [adjusted odds ratio (OR) for trend across age groups, 0.96; 95% confidence interval (CI) 0.89, 1.04; P = 0.36]. The prevalence of depression and anxiety symptoms decreased with age [adjusted OR 0.86 (95% CI 0.79, 0.94; P = 0.001) and adjusted OR 0.85 (95% CI 0.77, 0.94; P = 0.001), respectively], while that of functional problems increased (adjusted OR 1.28; 95% CI 1.17, 1.39; P < 0.001). In contrast, a longer time with diagnosed HIV infection was strongly and independently associated with a higher prevalence of symptom distress, depression symptoms, anxiety symptoms, and functional problems (P < 0.001 for trends, adjusted analysis). CONCLUSIONS: Among people living with HIV, although health-related functional problems were more common with older age, physical symptom distress was not, and mental health was more favourable. These results suggest that a longer time with diagnosed HIV infection, rather than age, is the dominating factor contributing to psychological morbidity and lower quality of life.

Parenting, the other oldest profession in the world - a cross-sectional study of parenting and child outcomes in South Africa and Malawi.

BACKGROUND: Parenting quality is important in child development. In the presence of HIV poverty and life stress, parenting may be challenged and child development affected. METHODS: This study examines cross-sectional associations of situational factors such as poverty, mental health, HIV status, living with a biological parent, and stigma with good parenting and child outcomes (n=989; age=4-13 years) within the Child Community Care study (South Africa and Malawi). A parenting measure was created from 10 variables comprising 6 child and 4 parent ratings. These were highly correlated. Total parenting score was generated on a 10 point continuous scale, with a good parenting cut off then defined as >=8 out of a possible 10. RESULTS: Five factors were associated with good parenting. Positively associated with good parenting were being the biological parent of the child, parental mental health and dwelling in households with multiple adults. Poverty and stigma were negatively associated with good parenting. Using multiple mediation analysis, a positive direct effect of good parenting was found on child self-esteem, child behaviour and educational risks with a partial mediation via child depression and trauma. CONCLUSIONS: These data highlight possible intervention points. Influences on parenting could be seen through being the biological parent, parental mental health, poverty and stigma. In these challenging environments, health, nutrition, mental health, education, and treatment to keep parents alive are all clearly identified as potential pathways to ensure child well-being.

Community-based organisations for vulnerable children in South Africa: Reach, psychosocial correlates, and potential mechanisms.

Community-based organisations (CBOs) have the potential to provide high quality services for orphaned and vulnerable children in resource-limited settings. However, evidence is lacking as to whether CBOs are reaching those who are most vulnerable, whether attending these organisations is associated with greater psychosocial wellbeing, and how they might work. This study addressed these three questions using cross-sectional data from 1848 South African children aged 9-13. Data were obtained from the Young Carers and Child Community Care studies, which both investigated child wellbeing in South Africa using standardised self-report measures. Children from the Child Community Care study were all CBO attenders, whereas children from Young Carers were not receiving any CBO services, thereby serving as a comparison group. Multivariable regression analyses were used to test whether children attending CBOs were more deprived on socio-demographic variables (e.g., housing), and whether CBO attendance was in turn associated with better psychosocial outcomes (e.g., child depression). Mediation analysis was conducted to test whether more positive home environments mediated the association between CBO attendance and significantly higher psychological wellbeing. Overall, children attending CBOs did show greater vulnerability on most socio-demographic variables. For example, compared to children not attending any CBO, CBO-attending children tended to live in more crowded households (OR 1.22) and have been exposed to more community violence (OR 2.06). Despite their heightened vulnerability, however, children attending CBOs tended to perform better on psychosocial measures: for instance, showing fewer depressive symptoms (B=-0.33) and lower odds of experiencing physical (OR 0.07) or emotional abuse (OR 0.22). Indirect effects of CBO attendance on significantly higher child psychological wellbeing (lower depressive symptoms) was observed via lower rates of child abuse (B=-0.07) and domestic conflict/violence (B=-0.03) and higher rates of parental praise (B=-0.03). Null associations were observed between CBO attendance and severe psychopathology (e.g., suicidality). These cross-sectional results provide promising evidence regarding the potential success of CBO reach and impact but also highlight areas for improvement.

Ageing and menopause considerations for women with HIV in the UK.

OBJECTIVES: Treatment rollout has dramatically improved life expectancy for people with HIV and AIDS. Women represent a substantial proportion of patients in the UK (approximately one-third of patients in care are female according to the HIV Annual Report 2014). This study examines psychosocial and biomedical issues for women diagnosed with HIV in the UK, comparing those above and below 45 years of age to examine menopause and ageing issues. METHODS: Consecutive clinic attenders in a large outpatient London HIV clinic were invited to participate in the study. Data were available for 170 (68%) women. In 57 women above the age of 45 data were available regarding menopause detailed insights. RESULTS: Compared with women aged under 45, women >45 years old were significantly less likely to be in a relationship (P=0.01), had higher anxiety scores (P=0.002), more likely to be classified as moderate to severe (25.9% vs 9.1%; χ2=6.1, P=0.01). There were no differences in terms of suicidal ideation, which was high for both groups of women (56.6%). Older women had higher psychological symptoms on the MSAS scale form and significantly higher PHQ-9 depression levels. A higher proportion of older women scored above the cut-off point for moderate to severe depression (9.2% vs 21.8%; χ2=3.7, P=0.048). Fewer older women had no mental health challenges (26.1% vs 42.4%) and more had multiple comorbidities (P=0.07). CONCLUSIONS: The vast majority of women reported experiencing a variety of physical and psychological menopause-related symptoms and there was a high suicide ideation rate in both groups of women. Over half of the group of menopausal women recorded distressing symptoms such as hot flushes, sweating, decreased sexual desire, back pain, night sweats, avoiding intimacy, involuntary urination and skin changes, yet few sought help. Age-specific, psychosexual and menopause services should be routinely available for women with HIV.

The effects of caregiver and household HIV on child development: a community-based longitudinal study of young children.

OBJECTIVE: Many studies that document child outcomes in the context of parental HIV - which has been established as a risk factor for child development - focus on older children/adolescents. Studies also concentrate on the status of the primary caregiver, not other household members who might be infected. DESIGN: This study examined the effects of caregiver and household HIV on child development (4-13 years) in South Africa and Malawi (2011-2014). METHODS: Data were gathered from 989 children and their primary caregivers at baseline and repeated at 12-15 months follow-up (86.5% follow-up rate). Only caregivers of a single child and caregiver/child dyads without missing data were included, providing a sample of 808 dyads for analysis. Children were divided into three groups according to caregiver-reported HIV burden: having an HIV-positive primary caregiver (19.8%), having HIV in the household (14.2%) or no HIV (66%). RESULTS: The HIV burden was positively associated with an array of negative child outcomes, often mediated by caregiver depression levels. Family HIV burden at baseline affected child behavioural problems at follow-up indirectly through carer depression (B = 0.02; CI = 0.003, 0.06). Internalizing (B = 0.02; CI = 0.002, 0.05) and externalizing problems at follow-up (B = 0.01; CI = 0.0002, 0.03) were also indirectly affected by family HIV burden through caregiver depression. CONCLUSIONS: The data suggest that family HIV can affect child development, emphasizing the important role of depression in the pathway to such an effect. Community-based interventions directed at alleviating parental depression in the presence of HIV may help to interrupt the cycle of family HIV and adverse child outcomes.

Achieving equity in HIV-treatment outcomes: can social protection improve adolescent ART-adherence in South Africa?

Low ART-adherence amongst adolescents is associated with morbidity, mortality and onward HIV transmission. Reviews find no effective adolescent adherence-promoting interventions. Social protection has demonstrated benefits for adolescents, and could potentially improve ART-adherence. This study examines associations of 10 social protection provisions with adherence in a large community-based sample of HIV-positive adolescents. All 10-19-year-olds ever ART-initiated in 53 government healthcare facilities in a health district of South Africa's Eastern Cape were traced and interviewed in 2014-2015 (n = 1175 eligible). About 90% of the eligible sample was included (n = 1059). Social protection provisions were "cash/cash in kind": government cash transfers, food security, school fees/materials, school feeding, clothing; and "care": HIV support group, sports groups, choir/art groups, positive parenting and parental supervision/monitoring. Analyses used multivariate regression, interaction and marginal effects models in SPSS and STATA, controlling for socio-demographic, HIV and healthcare-related covariates. Findings showed 36% self-reported past-week ART non-adherence (<95%). Non-adherence was associated with increased opportunistic infections (p = .005, B .269, SD .09), and increased likelihood of detectable viral load at last test (>75 copies/ml) (aOR 1.98, CI 1.1-3.45). Independent of covariates, three social protection provisions were associated with reduced non-adherence: food provision (aOR .57, CI .42-.76, p < .001); HIV support group attendance (aOR .60, CI .40-.91, p < .02), and high parental/caregiver supervision (aOR .56, CI .43-.73, p < .001). Combination social protection showed additive benefits. With no social protection, non-adherence was 54%, with any one protection 39-41%, with any two social protections, 27-28% and with all three social protections, 18%. These results demonstrate that social protection provisions, particularly combinations of "cash plus care", may improve adolescent adherence. Through this they have potential to improve survival and wellbeing, to prevent HIV transmission, and to advance treatment equity for HIV-positive adolescents.

Do not forget the boys - gender differences in children living in high HIV-affected communities in South Africa and Malawi in a longitudinal, community-based study.

Gender is an important factor in child development. Especially in sub-Saharan Africa, girls have often been shown to be less likely to access education compared to boys. The consequence of this has been that that programmes addressing child development are often aimed at girls in order to redress gender imbalances. This study examines the effect of gender on the development of children attending community-based organisations in high HIV-affected areas, and explores whether community-based organisation attendance was associated with any changes in gender differences over time. Baseline data from 989 children and 12-15 month follow from 854 (86% response rate) were used to examine gender differences in children from Malawi and South Africa. At baseline, where there were differences by gender, these tended to disadvantage boys. It was found that boys were significantly more often found to be subjected to violence. Boys showed worse performance at school and more behavioural problems than girls. These gender differences persisted from baseline to follow-up. At follow-up, boys self-reported significantly worse average quality of life than girls. Only harsh discipline differed by gender in progression over time: boys experienced a stronger reduction in harsh physical discipline than girls from baseline to follow-up. Since harsh discipline was associated with boys' worse educational outcomes and behavioural problems, our data cautiously suggests that gender differences could be reduced over time. In conclusion, our data suggests that, perhaps due to the narrow equity approach focusing on provision for girls, boys may be overlooked. As a result, there are some specific experiences where boys are generally worse off. These differences have distinct ramifications for the educational and emotional development of boys. A broader equity approach to child development might be warranted to ensure that the needs of both girls and boys are considered, and that boys are not overlooked.

Exposure to violence and psychological well-being over time in children affected by HIV/AIDS in South Africa and Malawi.

Many of the risk factors for violence against children are particularly prevalent in families and communities affected by HIV/AIDS. Yet, in sub-Saharan Africa, where HIV rates are high, efforts to prevent or address violence against children and its long-lasting effects are hampered by a lack of evidence. We assessed the relationship between violence exposure and mental health among HIV-affected children attending community-based organisations in South Africa (n = 834) and Malawi (n = 155, total sample n = 989) at baseline and 12-15-month follow-up. Exposure to violence in the home and in the community was high. HIV-negative children who lived with an HIV-positive person experienced most violence overall, followed by HIV-positive children. Children unaffected by HIV experienced least violence (all p < .05). Interpersonal violence in the home predicted child depression (ß = 0.17, p < .001), trauma symptoms (ß = 0.17, p < .001), lower self-esteem (ß = -0.17, p < .001), and internalising and externalising behavioural problems (ß = 0.07, p < .05), while exposure to community violence predicted trauma symptoms (ß = 0.16, p < .001) and behavioural problems (ß = 0.07, p < .05). Harsh physical discipline predicted lower self-esteem (ß = -0.18, p < .001) and behavioural problems for children (ß = 0.24, p < .001). Exposure to home (OR: 1.89, 95% CI: 1.23-2.85) and community violence predicted risk behaviour (OR: 2.39, 95% CI: 1.57-3.62). Over time, there was a decrease in depressed mood and problem behaviours, and an increase in self-esteem for children experiencing different types of violence at baseline. This may have been due to ongoing participation in the community-based programme. These data highlight the burden of violence in these communities and possibilities for programmes to include violence prevention to improve psychosocial well-being in HIV-affected children.

Exposure to violence predicts poor educational outcomes in young children in South Africa and Malawi.

BACKGROUND: Violence during childhood may affect short and long-term educational factors. There is scant literature on younger children from resource poor settings. METHODS: This study assessed child violence experiences (harsh punishment and exposure to domestic or community violence) and school enrolment, progress and attendance in children attending community-based organisations in South Africa and Malawi (n=989) at baseline and at 15 months' follow-up, examining differential experience of HIV positive, HIV affected and HIV unaffected children. RESULTS: Violence exposure was high: 45.4% experienced some form of psychological violence, 47.8% physical violence, 46.7% domestic violence and 41.8% community violence. Primary school enrolment was 96%. Violence was not associated with school enrolment at baseline but, controlling for baseline, children exposed to psychological violence for discipline were more than ten times less likely to be enrolled at follow-up (OR 0.09; 95% CI 0.01 to 0.57). Harsh discipline was associated with poor school progress. For children HIV positive a detrimental effect of harsh physical discipline was found on school performance (OR 0.10; 95% CI 0.02 to 0.61). CONCLUSION: Violence experiences were associated with a number of educational outcomes, which may have long-term consequences. Community-based organisations may be well placed to address such violence, with a particular emphasis on the challenges faced by children who are HIV positive.

Evidence of impact: health, psychological and social effects of adult HIV on children.

There is a growing evidence base on the immediate and short-term effects of adult HIV on children. We provide an overview of this literature, highlighting the multiple risks and resultant negative consequences stemming from adult HIV infection on the children they care for on an individual and family basis. We trace these consequences from their origin in the health and wellbeing of adults on whom children depend, through multiple pathways to negative impacts for children. As effective treatment reduces vertical transmission, the needs of affected children will predominate. Pathways include exposure to HIV in utero, poor caregiver mental or physical health, the impact of illness, stigma and increased poverty. We summarize the evidence of negative consequences, including those affecting health, cognitive development, education, child mental health, exposure to abuse and adolescent risk behaviour, including sexual risk behaviour, which has obvious implications for HIV-prevention efforts. We also highlight the evidence of positive outcomes, despite adversity, considering the importance of recognizing and supporting the development of resilience. This study is the first in a series of three commissioned by President's Emergency Plan for AIDS Relief (PEPFAR)/United States Agency for International Development (USAID), the summary provided here was used to inform a second study which seeks to identify insights from the broader child development field which will help us predict what long-term negative consequences children affected by HIV and AIDS are likely to experience. The third study discusses the design of a model to estimate these consequences. Although comprehensive, the review is often hampered by poor-quality research, inadequate design, small sample sizes and single studies in some areas.

Evidence for a contribution of the community response to HIV decline in eastern Zimbabwe?

Membership of indigenous local community groups was protective against HIV for women, but not for men, in eastern Zimbabwe during the period of greatest risk reduction (1999-2004). We use four rounds of data from a population cohort to investigate: (1) the effects of membership of multiple community groups during this period; (2) the effects of group membership in the following five years; and (3) the effects of characteristics of groups hypothesised to determine their effect on HIV risk. HIV incidence from 1998 to 2003 was 1.18% (95% CI: 0.78-1.79%), 0.48% (0.20-1.16%) and 1.13% (0.57-2.27%), in women participating in one, two and three or more community groups at baseline versus 2.19% (1.75-2.75%) in other women. In 2003-2005, 36.5% (versus 43% in 1998-2000) of women were members of community groups, 50% and 56% of which discussed HIV prevention and met with other groups, respectively; the corresponding figures for men were 24% (versus 28% in 1998-2000), 51% and 58%. From 2003 to 2008, prior membership of community groups was no longer protective against HIV for women (1.13% versus 1.29%, aIRR = 1.25; p = 0.23). However, membership of groups that provided social spaces for dialogue about HIV prevention (0.62% versus 1.01%, aIRR = 0.54; p = 0.28) and groups that interacted with other groups (0.65% versus 1.01%, aIRR = 0.51; p = 0.19) showed non-significant protective effects. For women, membership of a group with external sponsorship showed a non-significant increase in HIV risk compared to membership of unsponsored groups (adjusted odds ratio = 1.63, p = 0.48). Between 2003 and 2008, membership of community groups showed a non-significant tendency towards higher HIV risk for men (1.47% versus 0.94%, p = 0.23). Community responses contributed to HIV decline in eastern Zimbabwe. Sensitive engagement and support for local groups (including non-AIDS groups) to encourage dialogue on positive local responses to HIV and to challenge harmful social norms and incorrect information could enhance HIV prevention.

Doctor-patient concordance during HIV treatment switching decision-making.

OBJECTIVES: The aim of the study was to explore levels of doctor-patient concordance during the making of decisions regarding HIV treatment switching and stopping in relation to patient health-related outcomes. METHODS: Adult patients attending five HIV clinics in the United Kingdom were requested to complete the study questionnaire, which included a Concordance Scale, and measures of symptoms [Memorial Symptom Assessment Short Form (MSAS) index], quality of life (EuroQol), satisfaction, adherence and sexual risk behaviour. Clinical health measures (HIV viral load and CD4 cell count) were also obtained. A total of 779 patients completed the questionnaire, giving a response rate of 86%; of these 779 patients, 430 had switched or stopped their HIV treatment and were thus eligible for inclusion. Of these patients, 217 (50.5%) fully completed the Concordance Scale. RESULTS: Concordance levels were high (88% scored between 30 and 40 on the scale; score range 10-40). Higher concordance was related to several patient outcomes, including: better quality of life (P=0.003), less severe and burdensome symptom experience (lower MSAS-physical score, P=0.001; lower MSAS-psychological score, P=0.008; lower MSAS-global distress index score, P=0.011; fewer symptoms reported, P=0.007), higher CD4 cell count (at baseline, P=0.019, and 6-12 months later, P=0.043) and greater adherence (P=0.029). CONCLUSIONS: High levels of doctor-patient concordance in HIV treatment decision-making are associated with greater adherence and better physical and psychological functioning. More research is needed to establish a causal relationship between concordance and these outcomes.