Effects of improved complementary feeding and improved water, sanitation and hygiene on early child development among HIV-exposed children: substudy of a cluster randomised trial in rural Zimbabwe

Chandna, Jaya; Ntozini, Robert; Evans, Ceri; Kandawasvika, Gwendoline; Chasekwa, Bernard; Majo, Florence D; Mutasa, Kuda; Tavengwa, Naume V.; Mutasa, Batsirai; Mbuya, Mduduzi N N; Moulton, Lawrence H.; Humphrey, Jean H.; Prendergast, Andrew J.; Gladstone, Melissa

doi:10.1136/bmjgh-2019-001718

Cited by 25 publications

(48 citation statements)

References 19 publications

(28 reference statements)

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“…Among 5280 enrolled pregnant women, there were 738 HIV‐exposed and 3989 HIV‐unexposed live births; of these, 323 HIV‐exposed and 1655 CHU were assessed in the ECD sub‐study at two years of age (Figure ). Mothers of children included in the ECD sub‐study were about two years older compared to mothers of those not included; other baseline characteristics were broadly similar (as reported previously and shown in Table ).…”

Section: Resultssupporting

confidence: 60%

“…Overall, 5280 pregnant women were recruited from 211 clusters at a median gestational age of 12.5 weeks and randomized to standard‐of‐care (SOC); IYCF (20 g small‐quantity lipid‐based nutrient supplement (SQ‐LNS) per day from six to eighteen months of age, complementary feeding counselling); WASH (ventilated improved pit latrine and 2 hand‐washing stations, monthly liquid soap and chlorine, a play‐space to separate children from livestock and to reduce geophagia, hygiene counselling); or IYCF plus WASH (all interventions). The primary findings and ECD findings among a subgroup of children at 24 months have been reported previously, stratified by maternal HIV status .…”

Section: Methodsmentioning

confidence: 61%

“…It is critical to evaluate whether interventions can reduce the neurodevelopmental gap between CHEU and CHU. We showed previously in SHINE that CHEU randomized to the combined IYCF plus WASH intervention had significant improvements in ECD scores . This is in contrast to CHU, who had no meaningful improvements in ECD scores in response to the IYCF or WASH interventions, whether delivered alone or in combination.…”

Section: Discussionmentioning

confidence: 76%

“…The purpose of this analysis was to estimate the differences in ECD outcomes at 24 months of age between CHEU and CHU. We have previously reported the effects of the randomized SHINE interventions, which differed between these two groups of children . Among CHU, there was little evidence of effect of either intervention on any measure of child development; by contrast, among CHEU, there were large benefits of the combined IYCF plus WASH intervention on MDAT and MacArthur CDI vocabulary scores, but no evidence of effects from either the IYCF or WASH intervention when implemented alone.…”

Section: Methodsmentioning

confidence: 99%

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Early child development in children who are HIV‐exposed uninfected compared to children who are HIV‐unexposed: observational sub‐study of a cluster‐randomized trial in rural Zimbabwe

et al. 2020

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Introduction Exposure to maternal HIV may affect early child development (ECD), although previous studies have reported heterogeneous findings. We evaluated ECD among children who were HIV‐exposed uninfected (CHEU) and children who were HIV‐unexposed (CHU) recruited to the SHINE trial in rural Zimbabwe. Methods SHINE was a community‐based cluster‐randomized trial of improved infant feeding and/or improved water, sanitation and hygiene. Pregnant women were enrolled between 2012 and 2015. We assessed ECD in a sub‐study at 24 months of age, between 2016 and 2017, using the Malawi Developmental Assessment Tool (MDAT; assessing motor, cognitive, language and social development); MacArthur‐Bates Communicative Development Inventory (CDI) (assessing vocabulary and grammar); A‐not‐B test (assessing object permanence); and a self‐control task. Mothers and infants were tested longitudinally for HIV. We used generalized estimating equations to compare ECD scores between CHEU and CHU, accounting for the cluster‐randomized design. Primary results were adjusted for trial‐related factors that could affect measurement reliability of ECD: study nurse, age of child, calendar month of birth, sex and randomized arm. Results A total of 205 CHEU and 1175 CHU were evaluated. Mean total MDAT score was 90.6 (SD 8.7) in CHEU compared to 92.4 (9.1) in CHU (adjusted mean difference −1.3, 95% CI: −2.3, −0.3), driven mostly by differences in gross motor (−0.5, 95% CI: −0.9, −0.2) and language scores (−0.6, 95% CI: −1.1, −0.1). There was evidence that fine motor scores were lower in CHEU (adjusted mean difference −0.4, 95% CI: −0.8, 0.0) but no evidence of a difference in social scores (0.1, 95% CI: −0.2, 0.4). Mean MacArthur‐Bates CDI vocabulary score was 57.9 (SD 19.2) in CHEU compared to 61.3 (18.8) in CHU (adjusted mean difference −2.9 words, 95% CI: −5.7, −0.1). Object permanence and self‐control scores were similar between groups. Conclusions CHEU in rural Zimbabwe had total child development and vocabulary scores that were approximately 0.15 standard deviations lower than CHU at two years of age. More detailed and specific studies are now needed to unravel the reasons for developmental delay in CHEU and the likelihood that these delays persist in the longer term.

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Section: Resultssupporting

confidence: 60%

Section: Methodsmentioning

confidence: 61%

Section: Discussionmentioning

confidence: 76%

Section: Methodsmentioning

confidence: 99%

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Early child development in children who are HIV‐exposed uninfected compared to children who are HIV‐unexposed: observational sub‐study of a cluster‐randomized trial in rural Zimbabwe

et al. 2020

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“…For the nine studies that included analyses on early life nutrition-related variables and infant neurodevelopment, cohort characteristics and comparison groups based on nutritional intervention (if relevant) are reported in Figure 2. Within these nine studies, two reported data on longitudinal neurodevelopmental assessments (for cognitive (n = 2), motor (n = 2), and language (n = 1) outcomes) [50,51], and seven reported cross-sectional assessment data (for cognitive (n = 7), motor (n = 7), language (n = 7), and behavioural (n = 3) outcomes) [52][53][54][55][56][57][58]. [34] of studies reporting on neurodevelopmental outcomes in infants in relation to HIV-exposure status.…”

Section: Study Location Demographics and Designmentioning

confidence: 99%

In Utero HIV Exposure and the Early Nutritional Environment Influence Infant Neurodevelopment: Findings from an Evidenced Review and Meta-Analysis

White

Connor

2020

Nutrients

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The developing brain is especially vulnerable to infection and suboptimal nutrition during the pre- and early postnatal periods. Exposure to maternal human immunodeficiency virus (HIV) infection and antiretroviral therapies (ART) in utero and during breastfeeding can adversely influence infant (neuro) developmental trajectories. How early life nutrition may be optimised to improve neurodevelopmental outcomes for infants who are HIV-exposed has not been well characterised. We conducted an up-to-date evidence review and meta-analysis on the influence of HIV exposure in utero and during breastfeeding, and early life nutrition, on infant neurodevelopmental outcomes before age three. We report that exposure to maternal HIV infection may adversely influence expressive language development, in particular, and these effects may be detectable within the first three years of life. Further, while male infants may be especially vulnerable to HIV exposure, few studies overall reported sex-comparisons, and whether there are sex-dependent effects of HIV exposure on neurodevelopment remains a critical knowledge gap to fill. Lastly, early life nutrition interventions, including daily maternal multivitamin supplementation during the perinatal period, may improve neurodevelopmental outcomes for infants who are HIV-exposed. Our findings suggest that the early nutritional environment may be leveraged to improve early neurodevelopmental trajectories in infants who have been exposed to HIV in utero. A clear understanding of how this environment should be optimised is key for developing targeted nutrition interventions during critical developmental periods in order to mitigate adverse outcomes later in life and should be a priority of future research.

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Neurodevelopment among children exposed to HIV and uninfected in sub‐Saharan Africa

Bulterys,

Njuguna,

Mahy

et al. 2023

J Int AIDS Soc.

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IntroductionThe population of 16 million children exposed to HIV and uninfected (CHEU) under 15 years of age continues to expand rapidly, and the estimated prevalence of CHEU exceeds 20% in several countries in sub‐Saharan Africa with high HIV prevalence. Some evidence suggests that CHEU experience suboptimal neurodevelopmental outcomes compared to children born to women without HIV. In this commentary, we discuss the latest research on biologic and socio‐behavioural factors associated with neurodevelopmental outcomes among CHEU.DiscussionSome but not all studies have noted that CHEU are at risk of poorer neurodevelopment across multiple cognitive domains, most notably in language and motor skills, in diverse settings, ages and using varied assessment tools. Foetal HIV exposure can adversely influence infant immune function, structural brain integrity and growth trajectories. Foetal exposure to antiretrovirals may also influence outcomes. Moreover, general, non‐CHEU‐specific risk factors for poor neurodevelopment, such as preterm birth, food insecurity, growth faltering and household violence, are amplified among CHEU; addressing these factors will require multi‐factorial solutions. There is a need for rigorous harmonised approaches to identify children at the highest risk of delay. In high‐burden HIV settings, existing maternal child health programmes serving the general population could adopt structured early child development programmes that educate healthcare workers on CHEU‐specific risk factors and train them to conduct rapid neurodevelopmental screening tests. Community‐based interventions targeting parent knowledge of optimal caregiving practices have shown to be successful in improving neurodevelopmental outcomes in children and should be adapted for CHEU.ConclusionsCHEU in sub‐Saharan Africa have biologic and socio‐behavioural factors that may influence their neurodevelopment, brain maturation, immune system and overall health and wellbeing. Multidisciplinary research is needed to disentangle complex interactions between contributing factors. Common environmental and social risk factors for suboptimal neurodevelopment in the general population are disproportionately magnified within the CHEU population, and it is, therefore, important to draw on existing knowledge when considering the socio‐behavioural pathways through which HIV exposure could impact CHEU neurodevelopment. Approaches to identify children at greatest risk for poor outcomes and multisectoral interventions are needed to ensure optimal outcomes for CHEU in sub‐Saharan Africa.

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Effects of improved complementary feeding and improved water, sanitation and hygiene on early child development among HIV-exposed children: substudy of a cluster randomised trial in rural Zimbabwe

Cited by 25 publications

References 19 publications

Early child development in children who are HIV‐exposed uninfected compared to children who are HIV‐unexposed: observational sub‐study of a cluster‐randomized trial in rural Zimbabwe

Early child development in children who are HIV‐exposed uninfected compared to children who are HIV‐unexposed: observational sub‐study of a cluster‐randomized trial in rural Zimbabwe

In Utero HIV Exposure and the Early Nutritional Environment Influence Infant Neurodevelopment: Findings from an Evidenced Review and Meta-Analysis

Neurodevelopment among children exposed to HIV and uninfected in sub‐Saharan Africa

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