Modeling the long-term impacts of adult HIV and AIDS on affected children Chris Desmond Human Sciences Research Council, South Africa PEPFAR, USAID, CDC, LMG and HSRC Washington, DC: 2 October 2014 Social science that makes a difference
What and why? Predicting the future or understanding the present? Question the data: Concentrating, clustering and compounding Level and frequency of risk Characteristic and context interaction Alternative metrics Model of the impacts of maternal HIV on children The impact of maternal state, socio-economic status, and child age and gender on: School enrolment Mental health Physical and emotional abuse Sexual risk behaviour: debut and condom use
Model structure RISK ENVIRONMENT Incidence, progression, diagnosis, treatment, adherence & mortality rates MALE AGE Prior abuse Child outcome models HIGH INCOME LOW INCOME HIV HIV+ Symptomatic HIV HIV+ Symptomatic Dea d Dea d HIV+ Asymptomatic HIV+ on treatment HIV+ Asymptomatic HIV+ on treatment Maternal health & economic status Age & state specific fertility Maternal health & economic status Age & state specific fertility FEMALE MALE FEMALE AGE AGE AGE No prior abuse Prior abuse No prior abuse Prior abuse No prior abuse Prior abuse Child outcome models Child outcome models Child outcome models Child outcome models Child outcome models Child outcome models Incidence, progression, diagnosis, treatment, adherence & mortality rates No prior abuse Child outcome models
Risks without HIV
120000 100000 80000 60000 40000 20000 0 Women s state, no HIV 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100 Alive Deceased
Age Specific Fertility Rate
Mother state, by child s age
Risks with HIV
With HIV The results presented here are based on South African data. Best to use as much data as possible from a single context. Cohort of 100,000 women Fertility and Mortality rates: state specific Incidence, diagnosis, treatment and adherence rates 50% poverty Risks based primarily on the young carers study: www.youngcarers.org.za
Women s State, by age 120000 100000 80000 60000 40000 20000 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100 HIV Asymptomatic and undiagnosed Symptomatic and undiagnosed Asymptomatic and diagnosed Symptomatic and diagnosed On treatment Stopped treatment Deceased
Age and State Specific Fertility Rate
Base scenario
Model structure RISK ENVIRONMENT Incidence, progression, diagnosis, treatment, adherence & mortality rates MALE AGE Prior abuse Child outcome models HIGH INCOME LOW INCOME HIV HIV+ Symptomatic HIV HIV+ Symptomatic Dea d Dea d HIV+ Asymptomatic HIV+ on treatment HIV+ Asymptomatic HIV+ on treatment Maternal health & economic status Age & state specific fertility Maternal health & economic status Age & state specific fertility FEMALE MALE FEMALE AGE AGE AGE No prior abuse Prior abuse No prior abuse Prior abuse No prior abuse Prior abuse Child outcome models Child outcome models Child outcome models Child outcome models Child outcome models Child outcome models Incidence, progression, diagnosis, treatment, adherence & mortality rates No prior abuse Child outcome models
School model
School enrolment 6 7 8 9 10 11 12 13 14 15 16 17 Population outcomes without HIV Population outcomes with HIV Children affected by maternal HIV
School completion Children affected by maternal HIV Population outcomes with HIV Population outcomes without HIV
Percentage of children suffering at least one episode of depression or anxiety by age 18 Population outcomes: without HIV Population outcomes: with HIV Children affected by maternal HIV
Cumulative percentage of children suffering at least one episode of depression or anxiety, by age and clustering of risk factors Population outcomes with HIV Girls/high income/no abuse/mother alive and HIV- Girls/low income/prior abuse/mother deceased
Percentage of children suffering at least one incident of emotional or physical abuse by age 18 Population outcomes without HIV Population outcomes with HIV Children affected by maternal HIV
Intervention
Base scenario
Prevention
Base scenario
Treatment
Mother deceased, by child age
Mother deceased, by child age
Mother deceased, by child age
Mother deceased, by child age
Reducing the population level impact on schooling 80% HIV no treatment Baseline High treatment and adherence Prevention Poverty reduction 60% 40% 20% 0% -20% -40% -60% -80% -100% -120%
Reducing the population level impact on schooling 80% HIV no treatment Baseline High treatment and adherence Prevention Poverty reduction 60% 40% 20% 0% -20% -40% -60% -80% -100% -120%
Limitations Adult caregivers other than the mother are not included. Data limitations: Consequences of HIV exposure during pregnancy, poor nutrition, child labour and reduced access to health care not included. Risks of abuse, depression and anxiety, prior to 12 years of age, are not included. Impact of PMTCT interventions on diagnoses and timely uptake of treatment were not modelled More pathways modelled, more impact accounted for: Consider poverty interaction Vs poverty increase
Implications 1. Widespread risk large scale prevention of harm, removing risk factors. 2. Concentrated and clustered consequences intensive targeted mitigation interventions. 3. Maternal infection, illness and transition to treatment or death occur most often in the first decade of a child s life focus on affected families with young children. 4. Opportunity for combined adherence / family support: double benefit for children 5. Longitudinal data is needed, beginning with children born into affected families, and children of all ages living with adults on treatment.
Thank you