We have previously shown that adherence to HAART is inversely associated with the number of children living in the household.18
The strengths of this analysis compared to our previous findings are that we now adjusted for and examined different stressors that may affect a women's adherence. Specifically, we have now adjusted for the household composition, child care burden, health care utilization, and social services. It appears that women with HIV and children under 18 years old living in their household experience increased burdens compared to HIV-infected women without children, which subsequently results in poorer adherence to HAART.
Previous studies have shown life stressors impact HIV compliance.26,27
This has resulted in attempts to implement stress management interventions to improve HIV adherence.28,29
We believed that stress was likely the reason we have previously found mothers have lower adherence. However, other authors have suggested that not stress but a women's predilection to place their child's needs above their own results in lower adherence.19,30
Our findings are consistent with this latter theory, as previously explained the best indicator for adherence was the presence of children not other stressors or household members. There appears to be something about caring for children beyond the specific stress that results in lower adherence rates. Based on our previous research we hypothesized that a mothers' psychosocial well-being, having a significant other, additional housemates, receiving social services, and access to community based resources would result in higher adherence rates. However, these a priori
hypotheses were not supported by our analyses. There is therefore something specifically about children that seems to be related to adherence, not simply the number of household members since neither the number nor type of adult living in the household was associated with adherence.
Our study has several important limitations. WIHS primarily collects data on the women themselves and information about the children they report living with them is limited as is more robust information about the specific details of the social services women receive. Thus, data on the age, HIV, and general health status of the children, if the participants have disclosed their HIV status to household members and the specific reasons women were receiving social services are lacking. This is all potentially important information, as for example, mothers have been reported to approach their HIV status differently according to the age of their children.31
Also, since adherence was self-reported, there is a possibility of misclassification whereby HIV-infected participants may tend to over-report adherence. There is no reason to believe that the rate of misclassification would be any higher among women without children than among women with children (i.e., differential misclassification) and any nondifferential misclassification would bias our estimates of association towards the null.32
Additionally, previous WIHS research has shown self-reported adherence to be consistent with objective measures, such as CD4 count, HIV viral load and self report of physical functioning.33
It is also possible that participants with less stress participate more in study visits, however our overall rates of retention are greater than 90%.
In two different analyses, this one being more robust, we have shown that the more children a women lives with, the worse her adherence to HAART is likely to be. The importance of family-centered care on children's health has long been recognized and examined on multiple levels.34
Conversely, the role the child plays in the health of parents has not been as readily explored and we have shown that this role may potentially be very important. Further research into this relationship should help elucidate this issue, alert patients and health care providers to potential problems and result in approaches to address decreased adherence due to child care burden.