Abubakar;Pwani;Adolescent Executive Functioning Association with Scholastic Outcomes, Risk Taking Behavior and Medical Adherence in the Context of HIV

Children born HIV positive are living longer due to the availability of Antiretroviral (ARVs). However, to realize their full potential these children need to receive interventions that reduce the negative impact of HIV. In Africa, there is limited research evidence to guide the development of these much needed intervention programmes. I propose to study the impact of HIV exposure on the functioning of adolescents aged 10-14 years at the Kenyan Coast. A total of 552 (184 HIV infected, 184 HIV exposed uninfected and 184 unexposed randomly selected from the community) adolescents aged 10-14 years shall be recruited. A longitudinal study design will be used. Each subject will be assessed thrice, within a 24 months period with 12 months between each assessment. We will use direct psychological assessment complemented by parental report and will statistically analyse the data to identify the nature and antecedents of HIV-related impairments. Identifying sources of poor neuropsychological outcomes will provide information on useful points of intervention.

At least 2.3 million children in Africa are infected by HIV most of whom were vertically infected. A further 60 million are exposed to HIV, mainly by exposure to HIV in utero. With the increased availability of anti-retrovirals in Africa, a significant number of children vertically infected with HIV are surviving to adolescence and may increase their exposure through risky behaviour. There is a growing concern about the outcomes of HIV positive adolescents, particularly in the following key areas: poor educational outcomes, lack adherence to prescribed medication and involvement in risky sexual and drug-related behavior. Little is known of the impact of HIV on neuropsychological function of infected and exposed but uninfected adolescents in Africa. I am specifically interested in executive functioning (EF) since this function influences social, emotional and behavioral outcomes. The objective of this study is to investigate the impact of HIV exposure (both infection and exposed uninfected) in children who have survived to early adolescence on their EF and its association to scholastic outcomes, medical adherence and risk taking behaviour. A total of 552 (184 HIV infected, 184 HIV exposed uninfected and 184 unexposed randomly selected from an established database) adolescents aged 10-14 years shall be recruited. A longitudinal study design will be used. Each adolescent will be assessed thrice, within a 24 months period with 12 months between each assessment. Measures of EF (working memory, cognitive flexibility and inhibitory control) and functional abilities will be administered. Additionally scholastic abilities, adaptive behavior, risk taking behavior and adherence to medication will be assessed. Biomedical and psychosocial data (home environment, parent-adolescent relationship and socio-economic status) will be collected. Data will be analysed with multivariate analysis of covariance and other advanced statistical approaches using structural equation modelling.

Who is likely to benefit from this study?
1. Adolescents affected by HIV.
2. Policy makers
3. Practitioners in the educational and health systems
4. Scientific community
5. The African research partner
How they benefit and how we intend to ensure this happens
1. The study findings can be helpful in designing preventive programmes for families of adolescents who are affected by HIV. Information on harmful consequences of HIV and understanding of mechanisms of effect will help to define the benefits of current health care management practices and suggest treatment options to enhance long-term outcomes by suggesting target areas of cognitive intervention; for example, should our remediation efforts be more focused on executive functioning? This information is vital in resource-constrained settings where identification of the specific needs of high-risk groups can help in the allocation and prioritization of limited resources. Specifically, results may suggest a more comprehensive HIV treatment regime for adolescents, and suggest which psychosocial support for adolescents will enhance their neuropsychological functioning, which in turn will improve their scholastic outcomes and quality of life.
2.Policy makers are likely to benefit from getting evidence based information on harmful consequences of HIV and understanding of causal mechanisms that induce the effect. Policies on health care management practices and options to enhance long-term outcomes can be informed by the outcomes of this study. To facilitate these process two workshops will be held to disseminate the findings and discuss potential approaches to implementation.
3.The lack of adequate standardized measures and inadequate opportunity for staff development and training at the Kenya Assessment Centres (government sections for identifying and diagnosing children with different disabling conditions) have often been cited as factors hindering the optimal use of these centres at the regional level. This study will adapt and evaluate measures of adolescent cognitive function. Moreover, the data from the community controls is large enough to provide normative data. We shall run 2 workshops during the second and third year of the study to train members of the Assessment centres on the use and application of our measures.
4.We shall disseminate insights from our study at the grassroots level through preparation of posters (largely pictorial) educating mothers and caregivers. These posters will be placed in health centres and other community meeting places for the members of publics. Women's self-help groups will form an important component in disseminating the information. Additionally, more innovative approaches (e.g., the use of multimedia DVDs, theatre and music groups) will be used to disseminate the information to the general public.
5.Lastly, the African research partner i.e. Pwani University will benefit from the capacity building activities that are going to take place. Especially the establishment of a neurocognitive assessment lab which will be used by their graduate and undergraduate students for training and for collecting data.