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 DC
25 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
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Developmental progression
Conception, pregnancy, birth & neonatal period
Infancy (birth-2yrs)
Preschool period
Middle childhood and adolescence
First 1000 days
Maternal health
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Long-term consequences
Of exposures and experiences in early development on long-term:
• Health• Human capital • Psychosocial adjustment
Data from low and middle income countries
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Long-term studies in LMICsCOHORTS – Consortium of Health-Oriented Research in
Transitioning Societies
Washington D.C., USA, 22-27 July 2012www.aids2012.org
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
Washington D.C., USA, 22-27 July 2012www.aids2012.org
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 mortality
Brady 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 growth
Nielsen-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 nutrition
Infant 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
Washington D.C., USA, 22-27 July 2012www.aids2012.org
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
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Caregiving
Infants 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.