Development challenges in early development – and HIV Linda Richter

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


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


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


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


Developmental progression

Conception, pregnancy, birth & neonatal period

Infancy (birth-2yrs)

Preschool period

Middle childhood and adolescence

First 1000 days

Maternal health


Long-term consequencesOf exposures and experiences in early development

on long-term:

• Health• Human capital • Psychosocial adjustment

Data from low and middle income countries


Long-term studies in LMICsCOHORTS – Consortium of Health-Oriented Research in

Transitioning Societies


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


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


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


HIV (& ARVs) - early development

• Pregnancy and delivery• Birth weight and growth• Feeding• Social and economic security• Psychosocial care• Maternal wellbeing and mental health


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


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)


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


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


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?)


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


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


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


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)


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.

Development challenges in early development – and HIV Linda Richter

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