Page 360 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 9 of 10 Original Research

formulations, the association remained when corrected for included all children aged 5 years or older when addressing
age. Possibly an easier routine with syrups does not require their HRQoL. Although we suggest doing similar research in
the need to disclose. Children on PI-based regimens with other settings to ensure generalisability of the data, another
stavudine and didanosine had less likely received disclosure. strength of this study was the reasonable sample size.
Current guidelines recommend replacing stavudine and
didanosine with abacavir and will therefore not be part of Conclusion
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future regimens. Multiple clinical characteristics associated
with disclosure in univariate analyses attenuated in This cross-sectional study shows a low proportion of children
multivariate analyses, explained by the child’s age (lopinavir/ knowing about their HIV status. Older age of the child was
ritonavir syrup, NNRTI-based regimens, efavirenz regimens, strongly associated with disclosure. We found a less stringent
duration on treatment and starting treatment in the first year need for caregivers to disclose the child’s HIV status to the
of life). Children on lopinavir/ritonavir syrup were less likely child when ART was tolerated well and no condition-related
disclosed. This could be explained by the regimen generally difficulties were experienced (e.g. high HRQoL for both the
being given to young children and being changed to tablet child and the caregiver and family activities not affected by
form for older children. Although the general experience of chronic disease). Well-functioning families, with caregivers
side effects did not affect disclosure, side effects affecting the who received higher level of education and children from
central nervous system, unusual dreams and trouble sleeping households with better SES, provided an environment
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(efavirenz) and severe rash (nevirapine) likely contributed enabling and promoting disclosure of the HIV status to the
to the decision of caretakers to disclose the HIV status to child. Disclosure can only be beneficial when there is a
children on regimens including NNRTIs. Children who were supportive social structure. Non-disclosure can indicate a
on treatment for longer duration had more likely received sub-optimal social structure, which could negatively affect
disclosure. Guidelines in South Africa regard all HIV-positive adherence and viral suppression. In order to successfully
children eligible to initiate ART irrespective of CD4 count or address disclosure, the complex social context needs to be
clinical staging. Older children, who are more likely on taken into account. When families are in a good space, there
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treatment for longer duration, more often receive disclosure, is no pressing need to start the disclosure process. However,
10
potentially explaining why the association attenuated in these circumstances positively enable the disclosure process.
multivariate analysis. Other studies have confirmed the Targeting these families for disclosure interventions and the
association we find between longer time on ART and support of families to reach such an enabling environment
disclosure. Children who started treatment in the first year can therefore be especially successful.
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of life, however, less likely received disclosure. Disclosure did
not seem as urgent for caregivers when the same routine with Acknowledgements
their child could be maintained from birth and no failure of
treatment occurred. The authors thank the study participants, the staff at the
clinical site, TC Newman Hospital and Anova Health
Socio-economic characteristics associated with disclosure Institute and also Mrs H. Lesch for her assistance with the
included family functioning, affected daily activities and data collection.
waterborne sanitation. Although some studies have
described an association with disclosure and the child’s Competing interests
family situation, 10,14 no specific measures for family
functioning or activities were reported in the literature. The authors have no conflict of interests.
24
Indicators of SES including financial problems and the
14
child being hungry are reported in the literature as a Authors’ contributions
predictor of disclosure. Although we did not find an S.L.v.E. and A.M.v.F. conceived this cohort study. S.L.v.E.,
association between SES index and disclosure, despite a A.M.v.F., M.F.C. and R.P.H.P. contributed to the conception of
large number of people living in informal settlements, we design and methodology of the study and prepared the
found that children from households with access to protocol. S.L.v.E. and P.K. contributed to acquisition of data,
waterborne sanitation had more likely received disclosure. facilitated by C.G. S.L.v.E. prepared the data sets and
Informal living conditions more often lack waterborne conducted the statistical analyses, which were checked by
sanitation, are more densely populated and lack privacy A.M.v.F., R.P.H.P. and M.O.K. All authors contributed
required to support the disclosure process.
substantially to the interpretation of the data. S.L.v.E. drafted
the manuscript and all authors revised the manuscript
A limitation of our study was the reliance on medical records critically for important intellectual content. All authors
for viral load and CD4 count results. In addition, the reviewed and approved the final manuscript.
questionnaire did not include topics like experience with or
perspectives on disclosure. Literature focuses on healthcare
providers’ perspective 30,31,32 or caregivers’ perspective. 12,14,22,33 Funding Information
The child’s perspective on disclosure is rarely or not studied This research received no specific grant from any funding
at all. A strength of our study was that our interviews agency in the public, commercial or not-for-profit sectors.

http://www.sajhivmed.org.za 353 Open Access