HIV-positive children more likely to have developmental disabilities

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HIV-positive children in South Africa are more likely to have developmental disabilities compared to children who are HIV negative, according to researchers at Columbia University’s Mailman School of Public Health. HIV-positive children ages 4 to 6 had nearly four times the odds of delays in sitting, standing, walking, and speaking, and more than twice the odds of a hearing disability and cognitive delay compared to HIV-negative children.

The children were tested through a widely used screening process called the Ten Question (TQ) screen which showed that more than 59% of the HIV-positive children reported delays compared to 43% of HIV-negative children. This is the first report of the use of the TQ screen in the Zulu language, and it was found to have high sensitivity for detecting serious developmental disabilities, especially in HIV-positive children. The TQ Screen measures caregiver perception of how well their child functions compared to his or her peers with regard to neuro-developmental functioning.

“This screening tool was developed to identify moderate and severe cognitive, motor, seizure, speech, vision and hearing disabilities and developmental delays in settings with limited access to professional resources,” said Dr Justin Knox, a postdoctoral research fellow in the department of epidemiology. “We found this test to be a very effective way to screen HIV-positive children for neuro-developmental problems in resource-poor areas.”

The proportion of children who screened positive among those both HIV positive and HIV negative were among the highest reported in population-based studies. Gross motor concerns were especially prominent, including delays in learning to sit and stand, difficulty walking or moving arms, and weakness in the arms or legs.

An initial door-to-door survey identified 14,425 households, including 2,049 children ages 4-6 years old who were residents of KwaZulu-Natal, South Africa for the past six months and 1,231 of their caregivers. A medical doctor conducted a physical examination and noted the children’s medical history. Hearing and vision screenings were conducted as well as a psychological assessment for cognition and language delay, and voluntary HIV testing.

At the conclusion of the study, 62 children were identified as HIV positive (5%) – approximately three times the number known prior to the study.

South Africa has among the highest HIV/Aids prevalence in the world with over 7m people living with HIV in 2016, including 320,000 children below the age of 14. Prior to availability of effective antiretroviral therapies, neurodevelopmental disabilities were among the earliest recognized features of paediatric HIV infection, affecting as many as 50% of children. Although early initiation of treatment appears to prevent many of the most severe neurologic impairments, it remains an important co-morbidity among children living with HIV.

“Many HIV positive children continue to have unrecognised neuro-developmental disabilities,” said Dr Leslie Davidson, professor of epidemiology and paediatrics, and the senior author of the study. “Increased attention to early HIV diagnosis and intervention is critical to prevent these neuro-cognitive issues, as much as possible.”

The study was supported by National Institute on Drug Abuse (DA023697).

Co-authors are Stephen Arpadi, Fatimatou Bah, Claude Mellins and Leslie Davidson, Mailman School of Public Health; Shuaib Kauchali, Nelson Mandela School of Medicine, University of KwaZulu-Natal, South Africa; Murray Craib, Jane Kvalsvig, and Myra Taylor, Public Health Medicine, University of KwaZulu-Natal, South Africa.

Abstract
Background: While neurodevelopmental abnormalities are common in children with HIV infection, their detection can be challenging in settings with limited availability of health professionals. The aim of this study was to assess the ability to identify developmental disability among HIV positive and HIV negative children living in South Africa with an internationally used screen.
Methods and findings: This analysis uses a sample of 1,330 4–6 year old children and 1,231 of their caregivers in KwaZulu-Natal, South Africa, including administration of the Ten Questions (TQ) screen, a standardized medical history and physical examination conducted by a medical doctor, with hearing and vision screening, psychological assessment for cognition and language delay, and voluntary HIV testing. There was a high prevalence of disability among the sample. Compared to HIV negative children, HIV positive children were more likely to screen positive on at least one TQ item (59.3 vs 42.8%, p = 0.01), be delayed in sitting, standing or walking (OR 3.89, 95% CI = 2.1–7.2) and have difficulty walking or weakness in the arms or legs (OR = 2.7, 95%CI = 0.8–9.37). By medical doctor assessment, HIV positive children were more likely to be diagnosed with gross motor disability (OR = 3.5, 95%CI = 1.3–9.2) and hearing disability (OR = 2.5, 95%CI = 1.2–5.3). By independent psychological assessment, HIV positive children were more likely to have cognitive delay (OR = 2.2, 95%CI = 1.2–3.9) and language delay (OR = 4.3, 95%CI = 2.2–8.4). Among HIV positive children, the sensitivity and specificity of the TQ for serious disability (vs. no disability) was 100% and 51.2%, respectively. Among HIV-negative children, the sensitivity and specificity of the TQ for serious disability (vs. no disability) was 90.2% and 63.9%, respectively.
Conclusions: In this first report of the use of the TQ screen in the isiZulu language, it was found to have high sensitivity for detecting serious developmental disabilities in children, especially HIV positive children. The performance of the TQ in this sample indicates utility for making best use of limited neurodevelopmental resources by screening HIV positive children.

Authors
Justin Knox, Stephen M Arpadi, Shuaib Kauchali, Murray Craib, Jane D Kvalsvig, Myra Taylor, Fatimatou Bah, Claude Mellins, Leslie L Davidson

Columbia University’s Mailman School of Public Health material
PLOS One abstract


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