Home stimulation programme shows positive impacts on the neurodevelopmental status of children infected with HIV

Participation in a basic home stimulation programme can lead to improvements in both motor and cognitive development in HIV-positive children under 30 months, according to findings from a study presented at the Fourth South African AIDS Conference in Durban in early April.

The results of this study also support the inclusion of developmental screening and long-term management of all children who are infected with HIV, especially those in developing countries who do not have easy access to antiretroviral therapy.

Dr Joanne Potterton of the University of the Witwatersrand and colleagues conducted a randomised controlled trial to measure the impact of the home stimulation programme on the neurodevelopment status of HIV-positive children.

HIV is neurotropic (i.e. a virus capable of affecting nerve cells) and hence can have a negative effect on the development of the central nervous system. Many questions remain regarding the natural progression and pathogenic mechanisms of HIV-related central nervous system disease in children.

Affected children initially present with developmental delay, failure to achieve development milestones and deterioration of intellectual abilities. Although HIV affects all facets of neural development, children may present with spastic quadriparesis (a spastic rigidity of the limbs often accompanied by difficulty in swallowing and seizures), dystonic posturing (abnormal or `locked in` movements) and regression in motor milestones as the disease progresses.

Understanding the impact of HIV on development is critical given that the rehabilitation needs of HIV-positive children on antiretroviral therapy (ART) will increase as the chronic manifestations of HIV infection become more apparent.

For this study, 122 HIV-positive children were recruited from a paediatric HIV clinic at Chris Hani Baragwanath hospital in Soweto, South Africa.

After randomisation, children in the control group continued to receive all the standard services at the clinic while children in the experimental group received a home stimulation programme in addition to the standard services.

The aim of the home programme was to optimise the child’s functional potential and to encourage age-appropriate activities and normal movement patterns. All children were seen at their routine clinic visits every three months. Baseline demographic information was collected and children’s heights, weights and head circumferences were measured at each visit. The home programme was updated at each visit.

Developmental status of the children was assessed using the Bayley Scales of Infant Development II, by a blinded assessor at baseline, six and twelve months. This included measuring change in cognitive (MDI) and motor (PDI) developmental status over time.

For MDI, the amount of change that occurred over time was significantly greater in the experimental group compared to the control group (p=0.01). Although improvements occurred in both groups over time, the amount of improvement in the experimental group was significantly greater than that in the control group (p=0.02).

Children who were older, in the experimental group and from a household with a higher income were more likely to show an improvement in MDI over a one-year period. Improvements in PDI over one year were more likely in children who were older, in the experimental group and on ART.

The results of the study suggest that ART may have a positive impact on motor development.

The baseline developmental scores were extremely low for both MDI and PDI. Poverty, malnutrition and lack of access to antiretroviral therapy may all contribute to these very low scores. Although the children in the experimental group did improve through the use of the basic home programme, they remained delayed and need further long-term follow-up, according to the study.

While the findings from this study have positive implications for the neurodevelopment of HIV-positive children, the study also illustrates that South African children who are infected with HIV are at risk of severe cognitive and motor delay. While the participation in a basic home stimulation programme led to improvements in both motor and cognitive development, the results of this study also support the inclusion of developmental screening and long-term management of all children who are infected with HIV, especially those in developing countries who do not have easy access to antiretroviral therapy.