Determinants of HIV/AIDS Disclosure in Pediatrics Age from 5-14 Years on ART in South Wollo, North East Ethiopia, 2019: Un-matched Case-Control study

Wolde Melese Ayele^1*, Seid Fentaw Getahun² and Mastewal Arefayne Temesgen^3
*Correspondence: Wolde Melese Ayele, Department of Epidemiology and Biostatistic, School of Public Health, Wollo University, Dessie, Ethiopia, Tel: +251921885231, Email:

Keywords

Paediatric HIV • Disclosure • Caregiver-child pair • Ethiopia

Introduction

Disclosure of paediatrics HIV status to HIV-infected children is telling children their diagnosis of HIV virus and the purpose of medication they take, which requires good preparation, communication techniques, and appropriate counselling [1]. Disclosure of the diagnosis of HIV infection to HIV-infected children has become a more common clinical dilemma. It is one of the most difficult problem that families and their medical providers facing [2,3].

United Nations joint HIV/AIDS program (UNAIDS) 2017 report shows that 1.8 million people became newly infected with HIV, 940,000 people died from AIDS-related illnesses [4].

There is a significant improvement in ART coverage among children; however it is still not satisfactory. At the end of 2016, it was estimated that only 43% of children aged <15 years living with HIV/AIDS were receiving ART. Without treatment, 50 percent of HIV-positive children will die before their second birthday, and 80 percent before turning 5 years of age [5]. More than 180,000 children were infected with HIV in 2017 [6,7]. The number of persons requiring ART stands at 718,498 in 2009 EFY (Ethiopian Financial Year) out of which 426,472 (59%) is currently receiving treatment [8].

Paediatrics HIV status may have affected by pertinent factors like demographic factor of care giver, demographic factor of the child, socio cultural factors, clinical factors and program related factors are most common. The disclosure to children has also shown to be associated with positive familial relationships, better psychosocial adjustment and increased adherence to treatment [9].

Materials and Methods

Study setting and subjects

The study was conducted in five public health facilities which providing children ART care service, Dessie, Ethiopia. These institutions are Dessie referral hospital, Borumeda hospital, Buanbua health center, Segno gebeya health center, and Dessie health center. The children at the clinic either have mothers already known to be HIV seropositive during pregnancy through the program for the Prevention Of Mother-To-Child Transmission (PMTCT), are discovered to be infected with HIV after presenting with an AIDS-defining illness, or are diagnosed after either a symptomatic fraternal or parent was found to be HIV positive.

The care givers were identified through the Paediatric HIV/AIDS Care program. Over the period of the study, January to February, 2019, all the families attending the clinic with children aged 5-14 years were offered to participate.

All participants gave informed consent in order to participate and child participants required both caregiver consent and child assent. There was no stipend given to participants, instead participants were given the opportunity to refuse or withdraw from the study at any point. The study was approved by the Wollo University, College of Medicine and Health Sciences Review Committee.

Study design

Unmatched case-control study was conducted from January to February 2019 to determine factors associated with HIV infected children (5-14 years old) disclosure status.

Definitions

Case: 5-14 years age child who disclosed his/her HIV positive status.

Controls: 5-14 years age child who did not disclosed his/her HIV positive status during study period.

Disclosure: Where the caregiver said that the child knows his/her HIV diagnosis.

Non-disclosure: Where the caregiver said that the child does not know his/her infection.

Caregiver: A person who lives with the child, participates in the child’s daily care and is presented along with child’s health care during data collection. They were either biological parents or guardians acting as surrogate parents to the child.

Sampling procedures

Cases and controls were selected from their follow up chart based on their HIV status disclosure status. Sample size in each facility was allocated based on the numbers of children on ART service. Five ART providing health institutions found in the region were selected in simple random sampling, lottery method.

Data processing and analysis

Data were collected by eight trained data collectors and supervised by two supervisors. Data were collected using an interviewer-administered questionnaire. The data were entered using Epi Data version 4.2.1 statistical package and analyzed with SPSS version 23. In the bi-variable logistic regression analysis variables with p-value less than 0.2 were fitted to the final multivariable logistic regression model. Hosmer and Lemeshow goodness of test was considered for model fitness, p-value >0.05 as cut point. A multi-variable logistic regression analysis was performed to control possible confounders. Factors associated with disclosure were described using Odds Ratio (OR) and Confidence Interval (CI) to test the presence and strength of association.

Results

Socio-demographic characteristics of caregivers & children pairs

A total of 374 children and care givers pair were included in the study, making 96.6% of response rate. One hundred thirty-eight (36.6%) and 236(63.10%) of care givers were cases and controls respectively. Among children 49(35.5%) of cases and 74(31.35%) of controls were females. The mean age of the children was 10.3 (SD ± 2.46) years. Concerning care givers educational status, 24(17%) of cases and 50(21.18%) of controls were unable to write and read (Table 1).

Clinical characteristics of caregivers and children

Among care givers, 116(84%) of cases and 176(74.57%) of controls were HIV sero-positive. Out those whose HIV sero-positive care givers, almost all of cases and controls were started Anti-Retroviral Treatment (ART). Regarding children, 58 (42.03%) of cases and 112(47.45%) of controls were diagnosed with opportunistic infections during the study period. Ninety-six (69.56%) of cases and only 20(8.47%) controls had organizational support (Table 2).

Determinants of HIV disclosure

In bi-variable analysis six variables; care givers educational status, organization support, discussion with health care worker, care giver relation to the child, child age, and distance from home to ART sites were eligible for the multivariable logistic regression analysis. In multivariable logistic regression model, organization support, child age, and care giver discussion with health care worker were remained statistically significantly associated with children HIV disclosure status.

Organizational support of children was found to be associated with HIV disclosure status of children. Children who had organization support were 27.77 times more likely disclosed their HIV status compared to those children had no organization support (AOR=27.77, 95% CI: 12.472, 61.819). Age of the children was also statistically significant associated with HIV status disclosure. Children aged 10 to 14 years had about three times more odds of HIV status disclosure comparing with 5 to 9 years age children (AOR= 3, 95% CI; 1.423, 6.536). Likewise, discussion with health care providers was statistically significant associated predictor with HIV status disclosure of children. The care givers who discussed with health care providers about the benefits of HIV status disclosure were 17.65 times more likely to disclosed the child’s HIV status compared with those care givers who had no discussion (AOR=17.65, 95% CI; 6.611, 47.002) (Table 3).

Discussion

This study was aimed to identify determinants of HIV status disclosure among children on ART in Dessie city. The result revealed that age of the child, organizational support, and discussion with health care providers were statistically significantly associated with paediatrics HIV status disclosure. In this study, the odd of HIV status disclosure was three times higher among children aged 10 to 14 years compared with 5 to 9 years old. This is in line with study done in Ethiopia, and hospital based unmatched case control study done in Tanzania [10-13]. This might be due to the fact that younger children should be informed incrementally to accommodate their cognitive skills and emotional maturity [14,15]. The prominent reasons for disclosure as mentioned by caregivers were “child thought to be matured”. This could be explained by care givers may worry mentally and psychologically harm if children are too young [2,13]. Similarly, caregivers consider younger children as too young both emotionally and cognitively to their illness and the implications thereof [16]. There is also a significant decline in age at disclosure over time according to a study in the PACTG 219C [17].

As the result of this study, children who had organizational support were more odds of HIV status disclosure compared with their counter parts. This is supported by the studies in a multi-centered cross sectional study in Addis Ababa, Addis Ababa, Ethiopia, Kigali university teaching Hospital, and in low and middle income countries [2,18,19].

In the current study, care givers who had discussion with health care provider about the benefits of disclosure were 17.65 times more likely to disclose their HIV status disclosure when compared to those who did not discussed with health care worker. This finding is supported by the WHO and national guidelines of paediatrics HIV disclosure. According to the aforementioned guideline, children’s HIV status disclosure should be done by discussion of care givers and health care providers depending on the child’s developmental and cognitive stage. Disclosure can be seen as a step in the process of adjusting to an illness and the life challenges it poses [13,20,21].

Moreover, the result noted is congruent with a cross sectional study conducted in Addis Ababa university, systematic review in low and middle income countries, systematic study in resource limited area, and study in North Gondar about HIV status disclosure and its factors among children, HIV disclosure among pregnant women in Northern Ethiopia [2,18,22-26].

The limitations of this study are those it employed a quantitative data collection, and the reasons for non-disclosure from the care givers’ perspective did not explored. Furthermore, the study did not explore the benefits of disclosure such as adherence and clinical improvement in HIV disease. In addition, it was conducted at institution level, might not be representative of the general population. Therefore, for effective interventions, qualitative approach study is recommended.

Conclusion

In conclusion age of child, discussion with health care providers, and organizational support were the independent predictors of children’s HIV status disclosure. Therefore, this study noted the need to shift the emphasis from whether or not to disclose to the HIV-infected child to providing psychological support, frequent discussion about its benefits, and age-appropriate information on the HIV status of the child.

Ethical Approval and Consent Participate

Ethical approval was obtained from ethical review committee of Wollo University, College of Medicine and Health Sciences. Verbal consent from care takers and assent from the children was obtained after careful description of the objective of the study. The questionnaire was translated in to the local (Amharic) language to facilitate their understanding. Data collection was taken place on silent place separately from children to avoid an influence on each other. Confidentiality of information collected is kept anonymously.

Acknowledgments

We would like to thank Wollo University, college of medicine and health sciences ethical review committee in assuring the ethical issues. We would like to express our thanks to health institutions found in the region. Finally, we also want to express our deep gratitude for the study participants.

Availability of Data and Materials

Questionnaire used for data collection is available from the corresponding author on reasonable request. All other necessary data are included in the manuscript.

Conflict of Interests

The authors declared that they have no competing interest

Funding

This investigation received no specific grant from funding agency in public commercial, or for profit sectors.

Authors Contributions

WMA, SFG and MAT are authors involved in the design, implementation, data collection, analysis and draft the manuscript. SFG is also involved in the evaluation and was the principal investigator. All authors have read and approved the manuscript.

References

1. Elaine, Abrams, El-Sadr Wafaa and Rabkin Harripersaud. "The Pediatric Clinical Manual." (2004).
2. Negewo R. "Assessment of magnitude and factors that affect care givers’ disclosure of HIV diagnosis to their HIV infected children in Addis Ababa Ethiopia." Addis Abeba Universty (2014).
3. Dachew, Berihun Assefa, Tadis Brhane Tesfahunegn and Anteneh Messele Birhanu. "Adherence to highly active antiretroviral therapy and associated factors among children at the University of Gondar Hospital and Gondar Poly Clinic, Northwest Ethiopia: A cross-sectional institutional based study." 14 (2014): 875.
4. Biambo, Aminu, Aliyu Samaila, Nuruddeen Usman and Hamidu Liman. "Evaluation of CD4 Count Progression in HIV-Infected Patients on Different Classes of Antiretroviral Regimens." Nigerian J Pharmaceutical Res 15 (2019): 19-26.
5. Sessions, Myra. "Overview of the president’s Emergency Plan for AIDS Relief (PEPFAR)." Center for Global Development (2013).
6. Nkosi, Sebenzile, EileeRich, Connie Kekwaletswe and Neo Morojele. "Experiences of alcohol consumption and taking antiretroviral medication among men living with HIV in Tshwane, South Africa." Afr J AIDS Res 15 (2016): 367-376.
7. Wadunde, Ignatius, Doreen Tuhebwe, Michael Ediau and Gildo Okure, et al. "Factors associated with adherence to antiretroviral therapy among HIV infected children in Kabale district, Uganda: A cross sectional study." BMC Res Notes 11 (2018): 466.
8. Assefa, Yibeltal, Degu Jerene, Sileshi Lulseged and Gorik Ooms, et al. "Rapid scale-up of antiretroviral treatment in Ethiopia: successes and system-wide effects." PLoS Med 6 (2009): e1000056.
9. Bhatia, Amiya, Jenny Ruducha, Katherine Semrau and Carlyn Mann, et al. "Disclosure of children’s HIV status in four high prevalence states in india." Boston University OVC-CARE Project (2012).
10. Adekunle, MO, Olutekunbi OA, Animasahun BA and Afadapa MA, et al. "Determinants of HIV serostatus disclosure and assessment of the competence of health care personnel in HIV serostatus disclosure." Ann Heath Res 5 (2019): 268-279.
11. Endalamaw, Aklilu, Nega Tezera, Setegn Eshetie and Sintayehu Ambachew, et al. Adherence to highly active antiretroviral therapy among children in Ethiopia: a systematic review and meta-analysis. 22 (2018): 2513-2523.
12. Tamir, Yezihalem, Mekonen Aychiluhem and Dube Jara. "Disclosure status and associated factors among children living with HIV in east Gojjam, northwest of Ethiopia." Qual Prim Care 23 (2014): 223-230.
13. Bulali, Regina Edward, Stephen Matthew Kibusi and Bonaventura CT Mpondo. "Factors associated with hiv status disclosure and its effect on treatment adherence and quality of life among children 6–17 years on antiretroviral therapy in southern highlands zone, Tanzania: unmatched case control study." Int J Pediat (2018).
14. Lesch, Anthea Marian, Leslie Swartz, Ashraf Kagee, Keymanthri Moodley, et al. "Paediatric HIV/AIDS disclosure: towards a developmental and process-oriented approach." AIDS Care 19 (2007): 811-816.
15. Kouyoumdjian, Fiona, Tammy Meyers and Sylvia Mtshizana. "Barriers to disclosure to children with HIV." J Trop Pediat 51 (2005): 285-287.
16. Lester, Patricia, Margaret Chesney, Molly Cooke and Robert Weiss, et al. "When the time comes to talk about HIV: factors associated with diagnostic disclosure and emotional distress in HIV-infected children." J Acquir Immune Defic Syndr (2002): 309-317.
17. Butler, Anne, Paige Williams, Lois Howland and Deborah Storm, et al. "Impact of disclosure of HIV infection on health-related quality of life among children and adolescents with HIV infection." Pediatrics 123 (2009): 935-943.
18. Biadgilign, Sibhatu, Amare Deribew, Alemayehu Amberbir and Horacio Ruiseñor Escudero, et al. "Factors associated with HIV/AIDS diagnostic disclosure to HIV infected children receiving HAART: a multi-center study in Addis Ababa, Ethiopia." PloS One 6 (2011): e17572.
19. Ingabire, SP and Leon Mutesa. "factors determining disclosure by parents among children living with hiv/aids attending the center of excellence in Kigali University Teaching Hospital." Rwanda Med J 71 (2014): 5-11.
20. World Health Organization. "Guideline on HIV disclosure counseling for children up to 12 years of age." (2011).
21. Federal Ministry of Health. "National guidelines for comprehensive HIV prevention, care and treatment." FMOH Addis Ababa, Ethiopia. (2014).
22. Britto, Carl, Kayur Mehta, Rwituja Thomas and Anita Shet. "Prevalence and correlates of HIV disclosure among children and adolescents in low-and middle-income countries: A systematic review." J Development Behavior Pediat 37 (2016): 496.
23. Ubesie, Agozie, Kene Iloh, Ifeoma Emodi and Ngozi Ibeziako, et al. "HIV status disclosure rate and reasons for non-disclosure among infected children and adolescents in Enugu, southeast Nigeria." J Social Asp HIV/AIDS 13 (2016): 136-141.
24. Negese, Digsu, Kefyalew Addis, Akilew Awoke and Zelalem Birhanu, et al. "HIV-positive status disclosure and associated factors among children in North Gondar, Northwest Ethiopia." Int Scholarly Res Notices 2012 (2012).
25. Muluye, Dagnachew, Desalegn Woldeyohannes, Mucheye Gizachew and Moges Tiruneh. "Infant feeding practice and associated factors of HIV positive mothers attending prevention of mother to child transmission and antiretroviral therapy clinics in Gondar Town health institutions, Northwest Ethiopia." BMC Public Health 12 (2012): 240.
26. Alemayehu, Daniel, Sebsibe Tadesse, Mulat Adefris and Zelalem Birhanu. "HIV serostatus disclosure and associated factors among HIV positive pregnant women attending antenatal care services in northwest Ethiopia." Int J Infect Contr 10 (2014): 10.3396.