Survival is possible for children perinatally exposed to or infected by Human Immunodeficiency Virus (HIV) in the post-combined antiretroviral therapy era, but the long-term effects of HIV exposure on children and their caregivers are still being explored. Identifying factors affecting children’s ability to thrive within an HIV context has great public health significance, particularly within a sub-Saharan context where the burden of HIV is felt disproportionately by women and children. Additionally, caregiver mental health is an important focus given its bidirectional relationship with child behavior. Previous studies on these topics have not included a full complement of HIV exposure or infection groups, considered how caregivers’ mental health may depend on child serostatus, and or are investigated in HIV endemic areas. The three aims presented in this dissertation will explore how perinatal HIV infection and exposure can affect caregivers and school-aged children. In Aim one, we compare depressive symptoms among caregivers of 3 groups of 6-10 year old children in Uganda with known HIV exposure status: children HIV-infected perinatally (CPHIV, n=102), children born to HIV-infected mothers, but HIV negative (CPHEU, n=101), and HIV-unexposed, uninfected community controls (CHUU, n=103). Caregiver depression symptoms were assessed using the Hopkins Symptom Checklist. In Aims two and three, child executive functioning (EF) assessed by caregiver report was compared across the three HIV exposure groups; effect modification of these associations by social support and wealth was also explored. We used random effects general linear models to estimate mean differences among the three HIV exposure groups. Adjusted models included caregiver age, education, social support, lifetime trauma, and wealth as covariates. In aim one, we observed that perinatal HIV exposure status was associated with mean caregiver depression symptoms. Specifically, in unadjusted analyses, depression symptoms were higher among CPHEU compared to CPHIV caregivers (unstandardized beta coefficient [B]=-3.5, 95% confidence interval [CI] -5.3, -1.8). We also observed that caregiver social support modified the findings above (p < 0.10) with CPHEU caregivers with lower social support and lower wealth reporting higher caregiver depressive symptoms compared to CPHIV caregivers. We repeated all analyses within the subsample of biological mothers to examine whether their own diagnostic status drove any findings we observed; our pattern of results remained unchanged. For Aim two, in our unadjusted analyses, perinatal HIV exposure was not associated with the Global Executive Composite (GEC) and Metacognition Index (MCI) scores of EF. However, for the Behavioral Regulation Index (BRI), the CPHIV group had lower levels of problems relative to the CHUU and CPHEU groups (B= -0.40, 95% CI -0.77, -0.03, B=-0.40, 95%CI -0.76, -0.02 respectively). For Aim three, we observed that the child’s sex and caregiver depression symptoms modified the association between HIV status and specific subscales of EF. Future directions for this work should include investigation into what drives the difference in caregiver depression symptoms between exposure groups. Additionally, collecting longitudinal measures of child EF and caregiver depression would help further interrogate time order between caregiver and child functioning among families affected by HIV. Lastly, continued investigation on how our findings relate to outcomes linked to EF such as academic achievement and behavioral problems would help to establish the importance of EF as a potential intervention target to improve school readiness.
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