Reflections on the Use of Audio Diaries to Access Young People's Lived Experiences of HIV in Zimbabwe.

This methodological article reflects on the contribution audio diaries can make to accessing important, and commonly silenced, dimensions of the lived experience of growing up with HIV and their acceptability to children. Audio diaries were used by 12 young people, aged 11 to 13 years, as part of a longitudinal qualitative study embedded within the Anti-Retroviral Research for Watoto (ARROW) clinical trial. The method provided an alternative means for young people to express detailed reflections on their day-to-day encounters, as well as ordinarily silenced topics, including hidden and suppressed emotions regarding the circumstance surrounding their perinatal infection. Although the audio diary has great potential as method, its efficacy rests on young people's understanding of how to use it. There are ethical challenges around maintaining confidentiality while participants are in possession of the diaries and provision of appropriate support. The technology used in the study was in many ways cumbersome compared with opportunities increasingly available.

Evaluating the effectiveness of a multi-component intervention on early childhood development in paediatric HIV care and treatment programmes: a randomised controlled trial.

BACKGROUND: HIV infection in a family may affect optimum child development. Our hypothesis is that child development outcomes among HIV-exposed infants will be improved through a complex early childhood stimulation (ECS) programme, and income and loans saving programme for HIV positive parents. METHODS: The study was a cluster-randomized controlled trial in 30 clinic sites in two districts in Zimbabwe. Clinics were randomised in a 1:1 allocation ratio to the Child Health Intervention for Development Outcomes (CHIDO) intervention or Ministry of Health standard care. The CHIDO intervention comprises three elements: a group ECS parenting programme, an internal savings and lending scheme (ISALS) and case-management home visits by village health workers. The intervention was aimed at caregiver-child dyads (child aged 0-24 months) where the infant was HIV exposed or infected. The primary outcomes were cognitive development (assessed by the Mullen Scales of Early Learning) and retention of the child in HIV care, at 12 months after enrolment. A comprehensive process evaluation was conducted. DISCUSSION: The results of this cluster-randomised trial will provide important information regarding the effects of multi-component interventions in mitigating developmental delays in HIV-exposed infants living in resource-limited environments. TRIAL REGISTRATION: This trial is registered with the Pan African Clinical Trials Registry ( www.pactr.org ), registration number PACTR201701001387209; the trial was registered on 16th January 2017 (retrospectively registered).

Can AIDS stigma be reduced to poverty stigma? Exploring Zimbabwean children's representations of poverty and AIDS.

OBJECTIVE: We use children's drawings to investigate social stigmatization of AIDS-affected and poverty-affected children by their peers, in the light of suggestions that the stigmatization of AIDS-affected children might derive more from the poverty experienced by these children than from their association with AIDS. METHODS: A qualitative study, in rural Zimbabwe, used draw-and-write techniques to elicit children's (10-12 years) representations of AIDS-affected children (n= 30) and poverty-affected children (n= 33) in 2009 and 2010 respectively. RESULTS: Representations of children affected by AIDS and by poverty differed significantly. The main problems facing AIDS-affected children were said to be the psychosocial humiliations of AIDS stigma and children's distress about sick relatives. Contrastingly, poverty-affected children were depicted as suffering from physical and material neglect and deprivation. Children affected by AIDS were described as caregivers of parents whom illness prevented from working. This translated into admiration and respect for children's active contribution to household survival. Poverty-affected children were often portrayed as more passive victims of their guardians' inability or unwillingness to work or to prioritize their children's needs, with these children having fewer opportunities to exercise agency in response to their plight. CONCLUSIONS: The nature of children's stigmatization of their AIDS-affected peers may often be quite distinct from poverty stigma, in relation to the nature of suffering (primarily psychosocial and material respectively), the opportunities for agency offered by each affliction, and the opportunities each condition offers for affected children to earn the respect of their peers and community. We conclude that the particular nature of AIDS stigma offers greater opportunities for stigma reduction than poverty stigma.

Causes and consequences of psychological distress among orphans in eastern Zimbabwe.

Substantial resources are invested in psychological support for children orphaned or otherwise made vulnerable in the context of HIV/AIDS (OVC). However, there is still only limited scientific evidence for greater psychological distress amongst orphans and even less evidence for the effectiveness of current support strategies. Furthermore, programmes that address established mechanisms through which orphanhood can lead to greater psychological distress should be more effective. We use quantitative and qualitative data from Eastern Zimbabwe to measure the effects of orphanhood on psychological distress and to test mechanisms for greater distress amongst orphans suggested in a recently published theoretical framework. Orphans were found to suffer greater psychological distress than non-orphans (sex- and age-adjusted co-efficient: 0.15; 95% CI 0.03-0.26; P=0.013). Effects of orphanhood contributing to their increased levels of distress included trauma, being out-of-school, being cared for by a non-parent, inadequate care, child labour, physical abuse, and stigma and discrimination. Increased mobility and separation from siblings did not contribute to greater psychological distress in this study. Over 40% of orphaned children in the sample lived in households receiving external assistance. However, receipt of assistance was not associated with reduced psychological distress. These findings and the ideas put forward by children and caregivers in the focus group discussions suggest that community-based programmes that aim to improve caregiver selection, increase support for caregivers, and provide training in parenting responsibilities and skills might help to reduce psychological distress. These programmes should be under-pinned by further efforts to reduce poverty, increase school attendance and support out-of-school youth.

Measuring trends in age at first sex and age at marriage in Manicaland, Zimbabwe.

OBJECTIVE: To identify reporting biases and to determine the influence of inconsistent reporting on observed trends in the timing of age at first sex and age at marriage. METHODS: Longitudinal data from three rounds of a population-based cohort in eastern Zimbabwe were analysed. Reports of age at first sex and age at marriage from 6837 individuals attending multiple rounds were classified according to consistency. Survival analysis was used to identify trends in the timing of first sex and marriage. RESULTS: In this population, women initiate sex and enter marriage at younger ages than men but spend much less time between first sex and marriage. Among those surveyed between 1998 and 2005, median ages at first sex and first marriage were 18.5 years and 21.4 years for men and 18.2 years and 18.5 years, respectively, for women aged 15-54 years. High levels of reports of both age at first sex and age at marriage among those attending multiple surveys were found to be unreliable. Excluding reports identified as unreliable from these analyses did not alter the observed trends in either age at first sex or age at marriage. Tracing birth cohorts as they aged revealed reporting biases, particularly among the youngest cohorts. Comparisons by birth cohorts, which span a period of >40 years, indicate that median age at first sex has remained constant over time for women but has declined gradually for men. CONCLUSIONS: Although many reports of age at first sex and age at marriage were found to be unreliable, inclusion of such reports did not result in artificial generation or suppression of trends.

Trends in marriage and time spent single in sub-Saharan Africa: a comparative analysis of six population-based cohort studies and nine Demographic and Health Surveys.

OBJECTIVES: To describe trends in age at first sex (AFS), age at first marriage (AFM) and time spent single between events and to compare age-specific trends in marital status in six cohort studies. METHODS: Cohort data from Uganda, Tanzania, South Africa, Zimbabwe and Malawi and Demographic and Health Survey (DHS) data from Uganda, Tanzania and Zimbabwe were analysed. Life table methods were used to calculate median AFS, AFM and time spent single. In each study, two surveys were chosen to compare marital status by age and identify changes over time. RESULTS: Median AFM was much higher in South Africa than in the other sites. Between the other populations there were considerable differences in median AFS and AFM (AFS 17-19 years for men and 16-19 years for women, AFM 21-24 years and 18-19 years, respectively, for the 1970-9 birth cohort). In all surveys, men reported a longer time spent single than women (median 4-7 years for men and 0-2 years for women). Median years spent single for women has increased, apart from in Manicaland. For men in Rakai it has decreased slightly over time but increased in Kisesa and Masaka. The DHS data showed similar trends to those in the cohort data. The age-specific proportion of married individuals has changed little over time. CONCLUSIONS: Median AFS, AFM and time spent single vary considerably among these populations. These three measures are underlying determinants of sexual risk and HIV infection, and they may partially explain the variation in HIV prevalence levels between these populations.