Washington D.C., USA, 22-27 July 2012www.aids2012.org
Development challenges in early development
– and HIV
Linda RichterHuman Sciences Research Council, South Africa
Non-Abstract Session Children Growing up with HIV
AIDS 2012, Washington DC25 July 2012
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Outline• Early development• New science of early child development –
longitudinal perspectives• Experience-expectant, experience-dependent
systems – programming• HIV and ART effects on early development• Conclusions
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Early development• Children’s development occurs progressively, in
sequence– One thing follows the other and is dependent on what
goes before – There is no going back
• Incomplete, ill-formed stages can lead to deficits– Especially in the absence of self-righting influences
and experience– Many poor children have few, if any, second chances
• Early development is a period of unique susceptibility to environmental influences
Washington D.C., USA, 22-27 July 2012www.aids2012.org
The first 1000 days270 (pregnancy) + 365 (year 1) + 365 (year 2) = 1000 days
• Period of unique susceptibility to deficits and compensation
• Driven by genetic potential, modified by environment
• Epigenetics – genetic potential modified in utero ad early infancy by prevailing = anticipated environment
• Subsequently less amenable to modification
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Developmental progression
Conception, pregnancy, birth & neonatal period
Infancy (birth-2yrs)
Preschool period
Middle childhood and adolescence
First 1000 days
Maternal health
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Long-term consequencesOf exposures and experiences in early development
on long-term:
• Health• Human capital • Psychosocial adjustment
Data from low and middle income countries
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Long-term studies in LMICsCOHORTS – Consortium of Health-Oriented Research in
Transitioning Societies
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Health• Poor nutrition and growth, during foetal
development and infancy- Constrain adult height, offspring size (inter-generational)- Increase risks for chronic disease – obesity, diabetes, cardiovascular disease- Increase risks for mental illness
• Early exposure to adverse experiences (neglect, domestic violence, parental mental ill-health
or substance use)- Increase risk of chronic disease, mental ill-health and
social maladjustment
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Human capital Stunting before age 3 years (<2SD) is associated with: • Less education
- Lower cognitive test scores- Fewer grades passed- Less learning- average ± minus1 grade of schooling
• Earnings– 8-20% less income– Food supplementation <3yrs, 40 yr follow-up (Guatemala)
• Up to 46% difference in income• Fewer hours worked
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Psychosocial adjustment• Poor in utero growth mental illness (famine
studies)• Adverse childhood experiences (ACE)
- Tobacco, alcohol and drug use, suicide risk, depression
• Toxic stress – stress responsivity - revving engine, hair trigger reaction
- Influences ‘internal working models,expectations of relationships
- Emotional and behavioural control
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HIV (& ARVs) - early development
• Pregnancy and delivery• Birth weight and growth• Feeding• Social and economic security• Psychosocial care• Maternal wellbeing and mental health
Washington D.C., USA, 22-27 July 2012www.aids2012.org
HIV - pregnancy complications• Been aware of possibility since at least1990• Increased spontaneous abortion, perinatal
mortality, prematurity, SGA, low birth weight, neonatal mortality (Brocklehurst & French 1998)
• Earlier studies– ? poor pregnancy weight gain– Seemingly not associated with anti-viral drugs
(Schulte et al, 2007)
– Rather, advanced HIV disease, malaria, intestinal parasites
Washington D.C., USA, 22-27 July 2012www.aids2012.org
HIV, ART and mortalityBrady et al (2011)
- PACTG, USA, multicentre- 3 553 children, 1993-2006- 298 deaths- Deaths decreased from 7.2 to 0.8 per 100 person-
years by 2000, then stable- Co-variates – illness stage, time HAART initiation- Mortality ± 30 times higher than general USA pediatric
population (similar in UK)- Mortality due to infections, multi-organ failure (end stage
AIDS)
Washington D.C., USA, 22-27 July 2012www.aids2012.org
HIV, ART and growthNielsen-Saines et al 2012 – Brazil, India, Thailand, Malawi, SA, Zimbabwe (n=236)- Infants followed up for 18 mo – survival very good- 77% gestation age >37 wks, 86% birth weight ≥2.5 kg - 8% congenital abnormalities; 30% neonatal medical conditions- Growth inversely correlated with maternal viral load – up to 18mo - 38% infants serious adverse events eg anaemia - associated with
less/shorter maternal ARV exposure - ?Finding related to careful surveillance?
Filtreau (2009) – poorer physical growth and development amongst HIV exposed, but uninfected children
Washington D.C., USA, 22-27 July 2012www.aids2012.org
HIV, ART and nutritionInfant and young child feeding
• Low rates of exclusive breastfeeding• Early weaning, partly as a result of confusing policy
(Kuhn & Coovadia, 2012)
• Inadequate weaning diet, feeding frequency low, non-active and non-responsive feeding
• HIV, ART and effects of poor nutrition confounded, including by low levels of active, responsive
feeding due to caregiving stresses
Washington D.C., USA, 22-27 July 2012www.aids2012.org
HIV, ART and developmentAbukaker et al (2008) – HIV: 7 studies in SSA, results comparable to West- Delayed motor development most apparent, detected earliest- Mental development delays by 18mo- Language by 24mo – language, mental harder to measure?- Less secure attachment, less positive affect
Sherr et al (2009) – HIV: systematic review 42 studies- Quality variable- 81% of studies found cognitive deficits
Williams et al (2010) – ART: PACTG, USA, multi-centre- 92% exposed to ART in utero, 8% not- Bayley Developmental Scales at 1 year- No differences in neurodevelopment (environmental effects?)
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Home environment• Biological and environmental factors jointly influence
developmental outcomes• In the USA, behavioural and emotional problems of
CLWH attributed to social risks and not to HIV infection per se (Mellins et al 2004)
• The social context of many families affected by HIV involves poverty, dislocation, isolation, stress,bereavement
• Maternal wellbeing, including depression, and effects on caregiving
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Lancet “Child Development” series 2007 and 2011 review the impacts of poverty and poor home environments on young children’s development
over the long term
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CaregivingInfants and young children - experience-expectant and
experience-dependent caregiving• Emotionally available and responsive• Alert to and delighted by the child’s unfolding
developmental timetable• Attentive to signs of distress, discomfort, illness• Self-efficacy and capacity to respond• Requires:• Good health, lack of stress, emotional wellbeing• Support from partner and intimate others• Security and safety
Washington D.C., USA, 22-27 July 2012www.aids2012.org
HIV and caregivingConditions for optimal caregiving may not be present• Ill-health, preoccupation and anxiety – evidence on parenting
in context of chronic illness• Lack of support and security, isolation
Depression• Life time prevalence among women 10-24%• Higher amongst women of lower SES, during pregnancy and
when children are young• Amongst pregnant WLH as high as 53% (Levine et al, 2008);
Chibanda et al, 2010)
• Associated with poor child outcomes, treatment non-adherence generally (DiMatteo et al, 2000)
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Conclusions• Available evidence suggests that long-term care and
support critical to the survival, growth, health and wellbeing of CLWH and negative children exposed to HIV and ART
• Less evidence than we should have on this important issue – much more research needed- Eg first trimester exposure to ARV during embryogenesis- Critical to follow-up
- HIV+ children in LMICs- HIV- but HIV and ARV–exposed children in LMICs
• Like with breastfeeding, advocate for knowledge and practice to make children’s development
safer, healthier and happier.