In the current study, high levels of symptoms of anxiety were observed in this population of youth affected by HIV, with constant fidgeting, headaches/stomachaches, and restlessness being reported by over 80% of youth. A review by Donenberg et al.,22
indicates that youth affected by HIV have internalizing symptoms, including anxiety, depression, and social withdrawal. For youth in central Haiti, their daily functioning as well as their school performance can be negatively affected as a result of these symptoms.23–27,48
The high levels of anxiety experienced by youth were coupled with a significant degree of depressive symptoms among their caregivers, nearly 89% of whom were HIV positive and approximately 73% of whom were women. These symptoms were not only common but severe; over two thirds experienced sadness “quite a bit” or “extremely frequently” and nearly 20% reported this level of distress related to “thoughts of ending your life.” While significant levels of depression or depressive symptoms have also been observed for HIV-positive populations,17–19,49,50
particularly among women,20,51
the significant level of these symptoms has not been described in Haiti and is not being addressed by the majority of HIV programs within Haiti or other resource-poor settings.
This study demonstrates an association between parents' depressive symptoms and their children's symptoms that ranged from 1.6- to 2.4-fold, suggesting that parents' depressive symptoms are associated with approximately a 2-fold increase in risk of children's symptoms of anxiety, depression, anger, and loss of concentration. A U.S.-based study among HIV-affected youth demonstrated that maternal depression was more significantly associated with anxiety in their early adolescent children (ages 10–14; β
0.001) compared with similar maternal symptoms in caregivers of youth not affected by HIV. The association between maternal depression resulting in internalizing symptoms (β
0.001) and externalizing behaviors (β
0.001) among HIV-affected youth has also been reported by Mellins et al.52
Among HIV-affected adolescents in New York, depressive symptoms were significantly associated with parental depression (p
In addition to psychological symptomatology, nearly 30% of youth expressed that these symptoms had affected their daily psychosocial functioning. Although the magnitude of the associations between parents' depressive symptoms and their children's psychosocial functioning (Models 3 and 4, ) was not as strong as the associations with their children's psychological symptoms (Models 1 and 2, ), the relationships were in the same direction and marginally significant. Interestingly, the associations between the parents' depressive symptoms and their children's psychosocial functioning were affected by other factors to a much greater degree compared to the affect on children's symptoms. For example, the impact that the parents' symptoms had on the children's level of psychosocial functioning was affected by the living conditions of the child. When the death of a parent from HIV was controlled for the association between parents' symptoms and children's psychosocial functioning increased. When four family-related factors were simultaneously included in the final model, the overall strength of the association between parents' depressive symptoms and their children's psychosocial functioning increased. The strongest family-related factors associated with children's psychosocial functioning were death of a parent from HIV (OR
1.9) and living with a stepparent (OR
In a qualitative study among youth orphaned by HIV in South Africa, bereavement over the loss of a parent was an important factor linked with emotional or behavioral problems. Youth and caregivers in this study also referred to the quality of caregiving and the home environment as having beneficial or harmful effects on youth's mental health, depending on the conditions at home.54
Although some studies have shown that orphan status does not place youth at greater risk of negative health outcomes compared to other youth in high HIV burden areas,55–59
other studies have observed a negative impact.54,60–64
Despite this varying evidence in the literature, at the service provision level the child's loss of a parent should still be considered by clinicians in terms of addressing any current situation as well as preventing future health problems. It is widely known that a death of a parent can have a significant impact on the child's well-being65–69
this has also been documented among youth who have lost their parents to HIV. In a fairly large study by Cluver et al.54
among adolescents in South Africa, elevated rates of posttraumatic stress disorder (PTSD), depression, conduct problems, and delinquency were observed among youth whose parents died of HIV. This evidence is corroborated by earlier studies that demonstrated higher rates of depression and anxiety among youth who lost a parent to HIV compared to children from the same community who were not orphans.14,61,62
In a study of rural Chinese children living in orphanages, the youth described feelings of depression, fear, confusion, anger as well as engaging in fights with other youth in school.70
In addition, youth's psychological distress may have an effect on risk of HIV infection. In particular, “externalizing” can result in a higher likelihood of engagement in HIV risk behaviors in adolescents.21,71–73
Internalizing symptoms, such as depression, may be related to lower self-esteem and a reduction in self-care—also possibly increasing the risk of acquiring a sexually transmitted infection in youth.74–76
The youth's living situation or family functioning can have a short-term as well as long-term impact on a child.77–83
In addition to the evidence of the association between parents' level of depressive symptoms and youth's psychological distress, the impact on the child's psychosocial functioning appears to be greater when parental support is lost through death or significantly changed through inclusion of a stepparent; although these associations were stronger for the caregiver report of psychosocial functioning versus youth's self-report. Patel et al.84
describe the importance of family functioning in relation to children's mental health. In particular, family indicators that have an impact on the mental health of children include not only parental mental health, but also parent–child attachment, family cohesion, and supervision of children's activities, all of which can be affected by changes in family structure, such as the addition of a stepparent and/or death of a parent. Similar to the results from the present study, Lee et al.85
observed that depressive symptoms among adolescents affected by HIV in New York were positively associated with death of a parent as a result of AIDS. In the same cohort of youth, Lee et al.53
also reported an association between the youth's living situation and depressive symptoms, offering evidence for the important role of the home environment even after they controlled for level of parental depression.
For children's self-report of psychosocial functioning, although the association between this outcome and the parents' depressive symptoms is attenuated compared to adult report, a key factor is social support of the parent/caregiver in terms of instrumental support. For those parents who reported that they did not have someone who could lend them money when they needed it, there was a 1.9-fold increase in risk of poor psychosocial functioning among the youth. In this regard, economic support of the family may have a protective effect on the youth's psychosocial functioning. Other studies have shown a positive association between household's low socioeconomic status and psychological symptoms and/or poor psychosocial functioning in children.74,86–90
These findings suggest that poverty reduction strategies may promote not only positive physical health outcomes, but may improve psychosocial functioning among youth affected by HIV.
Last, poor psychosocial functioning of children can worsen parents' anxiety and depression. This can have an impact on the treatment and prognosis of disease. Among HIV-positive individuals, depression has been shown to be associated with poor antiretroviral regimen adherence,91,92
increased progression of HIV,93,94
Thus, for psychosocial functioning of both parent and child and for potentially improving physical health outcomes, mental health should be considered an important aspect of the treatment of HIV.
There are a number of limitations in the study, including the cross-sectional design since the analysis relied on baseline data. In this regard, one cannot determine the temporal relationship between parents' depressive symptoms and children's psychosocial functioning from this study. In addition, given the high level of depressive symptoms among caregivers at baseline, there may be a possibility that parents had overreported psychological symptoms in their children. However, the positive relationships between parents' depressive symptoms and children's psychosocial outcomes were largely observed in analyses that included children's self-report of their own status. Another limitation relates to the missing data in the multivariate analysis. The greatest degree of missing data was for Model 3 (), where 49 observations were dropped because of missing data. Distribution of most sociodemographic factors was similar for these youth compared to those included in Model 3 (n
443). However, differences were observed comparing youth who were missing versus those who were included for the home environment, whereby youth who were missing were less likely to have lived with their father and more likely to have lived with their grandmother, grandfather, aunt, or uncle.
However, this pattern of missing data would bias the results toward the null. Finally, the instruments used were not validated for use in central Haiti; although the findings from the present study, demonstrating associations in the expected direction, offer a degree of face validity of these measures in this context.
In conclusion, this study demonstrates a high level of psychological vulnerability among children affected by HIV and their caregivers and that depressive symptomatology among parents/caregivers may negatively impact youth symptoms and psychosocial functioning. In addition, the psychosocial functioning of youth can impact the levels of depression in their parents/caregivers. These findings were observed despite all of the participants having access to free and comprehensive HIV treatment including antiretroviral therapy and suggest an important role for interventions specifically designed to address anxiety, depression and parent–child relationships within the context of medical care of HIV.
Evidence for a family-centered approach to services for children in high HIV burden settings has been put forth by the Joint Learning Initiative on Children and HIV/AIDS (JLICA).96
In addition, there is evidence that children/youth orphaned within the context of HIV are not worse off economically compared to other youth in high HIV burden settings.97
However, the potential impact of the death of a parent on a child's psychosocial functioning remains a critical issue at the service delivery level. The current findings demonstrated that a youth's loss of a parent and living with a stepparent significantly increased the risk of poor psychosocial functioning. This suggests that while a family-focused approach may be critical for addressing the needs of youth affected by HIV/AIDS, a deeper understanding of the youth's experience of the death of a parent as well as the family structure and functioning in the new environment is important when offering support for families in high HIV burden areas. This indicates that there is a need for enhanced psychosocial support of families affected by HIV/AIDS, in addition to economic support.
In the present study in central Haiti, the poverty level was extreme and severity of poverty within the family was associated with lower psychosocial functioning by youth self-report. Richter et al.97
indicated that poverty-reduction strategies, such as cash transfers to families in high HIV burden areas, will greatly reduce the impact of HIV in resource-poor communities. In addition, the data also suggest the need to assess the family's circumstances when offering services to ensure that youth are receiving the appropriate care for the situation, since a wide range of family functioning has been observed in high HIV burden settings, including cases of child neglect and abuse.55
Implications for services suggest that there is a greater need for psychosocial support for HIV-affected families within the context of expanding HIV-related services in resource-limited settings. In the United States, psychosocial interventions among HIV-affected families have demonstrated effectiveness in enhancing youth's short- and long-term outcomes.21,98
A holistic approach to HIV prevention and care (i.e., integrated services that are family-focused) that addresses the family's needs (e.g., supporting parents/caregivers, promoting family functioning, addressing physical as well as mental health needs, and offering financial support when needed) as well as the broad range of needs for youth (access to school, physical health needs, promotion of mental health, etc.), may be necessary to reduce the burden of the HIV pandemic and offset the negative consequences of HIV infection for current and future generations.