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Emotional and behavioral resilience among children with perinatally acquired HIV in Thailand and Cambodia

Malee, Kathleen M.a; Kerr, Stephenb; Paul, Robertc; Puthanakit, Thanyaweeb,d; Thongpibul, Kulvadeee; Kosalaraksa, Popef; Ounchanum, Pradthanag; Kanjanavanit, Suparath; Aurpibul, Lindai; Ngampiyaskul, Chaiwatj; Luesomboon, Wicharnk; Wongsawat, Jurail; Vonthanak, Saphonnm; Ly, Penh S.n; Chettra, Kean; Suwanlerk, Tulathipb,o; Sophonphan, Jiratchayab; Valcour, Victorp; Ananworanich, Jintanatq,r,s,t; Mellins, Claude A.u on behalf of the PREDICT Resilience study

doi: 10.1097/QAD.0000000000002182
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Objectives: Psychosocial challenges associated with perinatally acquired HIV (PHIV) infection are well known, yet many children infected with HIV since birth demonstrate positive outcomes, referred to as resilience. The purpose of this study was to evaluate emotional–behavioral development and identify salient predictors of resilience among long-term survivors of PHIV.

Design: Prospective investigation of children with PHIV compared with demographically similar perinatally HIV-exposed but uninfected (PHEU) and HIV-unexposed, uninfected (HUU) children, all from Thailand and Cambodia.

Methods: The Child Behavior Checklist (CBCL; parent version) was administered at baseline and annual follow-up visits (median follow-up of 3 years) to children age 6–14. Resilience was defined as consistent CBCL scores on the Internalizing, Externalizing or Total Problem T scales within normative ranges (T-scores <60) at every time point. Generalized estimating equations examined CBCL scores over time and logistic models examined demographic, socioeconomic, and cultural predictors of resilience.

Results: Participants included 448 children (236 PHIV, 98 PHEU, 114 HUU), with median (interquartile range) age at first evaluation of 7 (6–9) years. Children with PHIV exhibited similar rates of resilience as PHEU and HUU on the Externalizing and Total Problems scales. Resilience on the Internalizing scale was more likely in PHEU (71%) compared with PHIV (59%) or HUU (56%), P = 0.049. Factors associated with resilience in adjusted models included: HIV-exposed but uninfected status, higher household income, Cambodian nationality, female sex, and caregiver type.

Conclusion: Despite biopsychosocial risks, resilience is observed among PHIV and PHEU children. Further study is needed to understand mechanisms underlying associated factors and intervention priorities.

aDepartment of Psychiatry and Behavioral Science, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

bHIV-NAT, The Thai Red Cross AIDS Research Center, Bangkok, Thailand

cMissouri Institute of Mental Health, University of Missouri-St. Louis, St. Louis, Missouri, USA

dDepartment of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok

eDepartment of Psychology, Faculty of Humanities, Chiang Mai University, Chiang Mai

fDepartment of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen

gDepartment of Pediatrics, Chiangrai Prachanukroh Hospital, Chiang Rai

hNakornping Hospital

iResearch Institute for Health Sciences, Chiang Mai

jPrapokklao Hospital, Chanthaburi

kQueen Savang Vadhana Memorial Hospital, Chonburi

lBamrasnaradura Infectious Diseases Institute, Nonthaburi, Thailand

mUniversity of Health Science

nNational Center for HIV/AIDS Dermatology and STDs, Phnom Penh, Cambodia

oTREAT Asia, amfAR - The Foundation for AIDS Research, Bangkok, Thailand

pDepartment of Neurology, Memory and Aging Center, University of California, San Francisco, San Francisco, California, USA

qSEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand

rThe Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda

sU.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA

tDepartment of Global Health, University of Amsterdam, Amsterdam, The Netherlands

uHIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, New York, USA.

Correspondence to Kathleen M. Malee, PhD, Ann & Robert H. Lurie Children's Hospital, 225 E. Chicago Avenue, Box 155, Chicago, IL 60611, USA. Tel: +1 312 227 8271; e-mail:

Received 23 March, 2018

Revised 6 February, 2019

Accepted 7 February, 2019

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