Early childhood learning activities buffer adverse effects of HIV exposure on infant cognitive development: A longitudinal study

Abstract

Food insecurity (FI) and HIV exposure have been hypothesized to deleteriously affect infant cognitive development (ICD). Yet few studies have examined these relationships, and to our knowledge, none have done so longitudinally. Further, strategies to improve ICD in low-resource settings are limited. Therefore, our objectives were to determine if (1) FI and HIV-exposure had independent or joint effects on ICD at 3, 9, or 12 months postpartum; (2) assess longitudinally, whether FI and HIV exposure were predictive of ICD in the first year of life; (3) examine the extent to which early childhood learning activities (ECLA) may serve as a buffer against the deleterious effects of HIV exposure on ICD.

Data for this study were drawn from infants born to mothers enrolled in a longitudinal pregnancy cohort study in western Kenya (n=224). At 3, 9, and 12-month postpartum clinic visits, many covariates were assessed, including ICD, food insecurity (Individual Food Insecurity Access Scale), ECLA, maternal depression (Center for Epidemiological Studies-Depression scale), perceived stress, social support, and socio-demography. ICD was assessed using the Malawi Developmental Assessment Tool (MDAT). ECLA included parental reports of singing, counting, reading and telling stories to their infants.

Following descriptive and bivariate analyses, we built multivariate models by including all covariates significant at p<0.2 in the bivariate model. We then examined whether effects of FI and ECLA varied by HIV status by including interaction terms between these factors. Generalized estimating equations were fit assessing associations over time, adjusting for covariates and including interaction terms between FI and ECLA with HIV.

In bivariate models, maternal FI (β=−2.03; p≤0.05), infant HIV exposure (β=−1.43, p≤0.05), and ECLA (β=1.25; p≤0.001) at 9 months postpartum were associated with ICD at 12 months. In multivariable cross-sectional analyses, FI was not significantly associated with ICD at any time point (Table 1). However, HIV exposure was negatively associated with ICD at 3 and 12 months postpartum (β=−1.17, 95% CI: −2.15, −0.17; β=−1.47, 95%CI: −2.79, −0.13). The interaction of FI and infant HIV exposure was not significantly associated with cognitive development scores at any time point. However, ECLA was positively associated with infant cognitive development at 12 months postpartum (β=0.93; 95% CI: 0.27, 1.59). In longitudinal GEE models, HIV exposure was associated with lower ICD scores (β=−2.78; 95% CI: −4.69, −0.86) while ECLA predicted higher ICD scores (β=0.90; 95% CI: 0.51, 1.29). The interaction term between HIV and ECLA (β=0.69; 95% CI: 0.15, 1.24) suggests that ECLA can buffer the negative effects of HIV exposure on infant cognitive development

These data suggest that ECLA can improve ICD and mitigate some of the adverse effects of HIV exposure. Future research should explore the pathways through which ECLA impacts ICD within the context of HIV

Full text

POSTER'TITLE'
Author'List'
Department'of'Biomedical'Engineering,'Northwestern'University,'Evanston,'IL,'USA'
Results: Figure 5. HIV exposure is significantly associated with
lower cognitive development mean scores at 3 and 12 months (n=220)!
Results: Predictors of Infant Cognitive Development in the first year of life!
H1. Infant HIV exposure will be deleterious to infant cognitive
development in the first year of life.!
!
H2. Maternal food insecurity will be deleterious on infant’s cognitive
development in the first year of life. !
!
H3. Early Childhood Learning Activities will have positive effects on
infant cognitive development.!
!
H4. Early Childhood Learning Activities will buffer the negative
effects of infant HIV exposure. !
!
!
Funding & Acknowledgements!
Biomedical Engineering
Early Childhood Learning Activities Buffer Adverse Effects of HIV Exposure on Infant Cognitive
Development: A Longitudinal Study !
Godfred O. Boateng1, Maricianah Onono2, Shalean Collins1, Eleonore Baughan3, Pauline Wekesa2, Itziar Familiar4, Elizabeth Widen5, Sera L. Young1,6!
!
1Department of Anthropology, Northwestern University, Evanston IL; 2Kenya Medical Research Institute, Nairobi, Kenya; 3Nutritional Sciences, Cornell, Ithaca NY; 4Department of Psychiatry,
Michigan State University, East Lansing MI, 5University of Texas, Austin, Texas; 6Institute for Policy Research, Northwestern University, Evanston IL.!
Hypotheses!
Conclusion!
This study was supported by K01 MH098902 from
the National Institute of Mental Health. We
warmly thank KEMRI for their support and
collaboration, the Pith Moromo participants, and
study nurses: Joy China, Joyce Bonke, and Tobias
Odwar, study trackers: Beneter Ogwana, Teresa
Owade, and Sarah Obaje, and our study
anthropologist: Patrick Mbullo. !
Contact Information!
Godfred O. Boateng, MPhil, Ph.D. !
Department of Anthropology!
Weinberg College of Arts & Sciences!
Northwestern University!
Evanston, IL 60208!
godfred.boateng@northwestern.edu!
² Infant HIV exposure is negatively associated with infant cognitive development in the first year of life and consistent
with existing research.!
!
² Simple Early Childhood Learning Activities, such as reading, telling stories, counting, singing and playing, were
positively associated with infant cognitive development!
² Supporting evidence that a stimulating learning environment is important for infant cognitive
development. 
!
² Among HIV-exposed infants, Early Childhood Learning Activities can buffer the adverse effects of HIV-exposure on
infant cognitive development. 
!
² Future studies should explore how Early Childhood Learning Activities leverage programmatically on infant cognitive
development in the context of HIV.!
Food insecurity (FI) and HIV exposure have been hypothesized to deleteriously affect infant cognitive development (ICD). Yet few studies have
examined these relationships, and to our knowledge, none have done so longitudinally. Further, strategies to improve ICD in low-resource settings
are limited. Therefore, our objectives were to determine if (1) FI and HIV-exposure had independent or joint effects on ICD at 3, 9, or 12 months
postpartum; (2) assess longitudinally, whether FI and HIV exposure were predictive of ICD in the first year of life; (3) examine the extent to which
early childhood learning activities (ECLA) may serve as a buffer against the deleterious effects of HIV exposure on ICD. Data for this study were
drawn from infants born to mothers enrolled in a longitudinal pregnancy cohort study in western Kenya (n=224). At 3, 9, and 12-month postpartum
clinic visits, many covariates were assessed, including ICD, food insecurity (Individual Food Insecurity Access Scale), ECLA, maternal depression
(Center for Epidemiological Studies-Depression scale), perceived stress, social support and socio-demography. ICD was assessed using the Malawi
Developmental Assessment Tool (MDAT). ECLA included parental report of singing, counting, reading and telling stories to their infants. Following
descriptive and bivariate analyses, we built multivariate models by including all covariates significant at p<0.2 in the bivariate model. We then
examined whether effects of FI and ECLA varied by HIV status by including interaction terms between these factors. Generalized estimating
equations were fit assessing associations over time, adjusting for covariates and including interaction terms between FI and ECLA with HIV.!
In bivariate models, maternal FI (β=-2.03; p≤0.05), infant HIV exposure (β=-1.43, p≤0.05), and ECLA (β=1.25; p≤0.001) at 9 months
postpartum were associated with ICD at 12 months. In multivariable cross-sectional analyses, FI was not significantly associated with ICD at any
time point (Table 1). However, HIV exposure was negatively associated with ICD at 3 and 12 months postpartum (β=-1.17, 95% CI: -2.15, -0.17;
β=-1.47, 95%CI: -2.79, -0.13). The interaction of FI and infant HIV exposure was not significantly associated with cognitive development scores at
any time point. However, ECLA was positively associated with infant cognitive development at 12 months postpartum (β=0.93; 95% CI: 0.27,
1.59). In longitudinal GEE models, HIV exposure was associated with lower ICD scores (β=-2.78; 95% CI: -4.69, -0.86) while ECLA predicted
higher ICD scores (β=0.90; 95% CI: 0.51, 1.29). The interaction term between HIV and ECLA (β=0.69; 95% CI: 0.15, 1.24) suggests that ECLA
can buffer the negative effects of HIV exposure on infant cognitive development. These data suggest that ECLA can improve ICD and mitigate some
of the adverse effects of HIV exposure. Future research should explore the pathways through which ECLA impacts ICD within the context of HIV!
Abstract # 3905 !
Background!
² The 1000 days between pregnancy and 24 months of an infant’s
life are critical for the cognitive development of infants.!
!
!
² Developmental delays have consequences for school performance,
earning potential, and gross domestic product.!
!
² Cross-sectional studies have provided evidence of the deleterious
effects of food insecurity and HIV infection/exposure on infant
cognitive development (ICD).!
!
² Few studies have examined the longitudinal effects of food
insecurity and HIV. None have examined the buffering effect of
early childhood learning activities on infant cognitive development.!
H1. Assessed differences in cognitive development mean scores between HIV
unexposed and exposed infants.!
!
H1-3. Examined the longitudinal effect of HIV exposure, food insecurity, and learning
activities on infant cognitive development using generalized estimating equations. !
!
H4. Assessed the interaction between HIV exposure and learning activities on changes
in cognitive development over time.!
Study setting: 7 clinical sites
in Nyanza region, Kenya.!
!
!
Study population: 266
participants enrolled into an
ongoing observational
cohort study at delivery. !
!
Methods!
Time varying variables:!
!
Infant cognitive development measured by
Malawi Developmental Assessment Tool
(MDAT).!
!
MDAT consists of four domains: fine and
gross motor skills, language and social skills.!
!
Infant cognitive development (ICD) scores:
sum of scores on fine and gross motor skills,
language and social skills [1-36].!
!
Food insecurity measured by Individual Food
Insecurity Access Scale (IFIAS) [0-24].!
!
Early Childhood Learning Activities (ECLA)
measured by mother or any member of the
household reading books, telling stories,
singing songs, counting, playing and
spending time with the child [0-6]. !
HIV exposure, birth weight, asset score,
educational status, marital status, place
of residence, maternal age, religion, and
clinical site.!
H1. HIV exposure was associated with lower
infant cognitive development scores in the
first year of life (Fig.5,6).!
!
H2. Maternal food insecurity was not
associated with infant cognitive
development scores in the first year of life
(Fig.6).!
!
H3. The Effect of a 1 unit increase in learning
activities among HIV-unexposed infants
increased infant cognitive development
scores by 0.9 (Fig. 6). !
!
H4. The Effect of a 1 unit increase in learning
activities among HIV-exposed infants
increased infant cognitive development
scores by 0.69 (Fig. 6). !
10!
12!
14!
16!
18!
20!
22!
24!
26!
28!
0!2!4!6!8!
Predicted Cognitive Development Scores!
Early Childhood Learning Activities Scores!
Figure 7. Predicted effect of learning activity
scores on infant cognitive development by HIV-
exposure status!
!
HIV unexposed!HIV exposed!
*p≤0.05!
First'''''''
ANC visit!
8'months'
gestation!
1 wk
postpartum!
6'wks'' 3'
months'''
6
months !
9'
months'''
12
months !
ICD!
IFIAS!
ECLA!
'
ICD!
IFIAS!
ECLA'
ICD!
IFIAS!
ECLA'
Time point!
Food
insecurity,
-0.1!
HIV exposed,
-0.84*!
Learning
activities,
1.12*!
Urban,-0.81*!
-1!
-0.5!
0!
0.5!
1!
1.5!
Adjusted Beta Coefficients for ICDs !
Figure 6.HIV exposure and learning activities
predict infant cognitive development in the first
year of life (n=660 observations)!
*p≤0.05!
Food
insecurity,
-0.03!
HIV exposure,
-2.78*!
Learning
activities #HIV
unexposed,
0.90*!
HIV exposed
# Learning
activities,
0.69*!
-3!
-2.5!
-2!
-1.5!
-1!
-0.5!
0!
0.5!
1!
1.5!
Adjusted Beta Coefficients for ICDs!
Figure 6. Learning activities buffer the effect of
HIV exposure (n=660 observations)!
!
H4. With zero exposure to learning activities,
the predicted infant cognitive development
score was higher for HIV unexposed (16.9)
than HIV exposed (14.2).!
!
At a learning activity score of 4, both HIV
exposed and unexposed infants had an equal
predicted cognitive development score of
20.56 (Fig. 7).!
!
Beyond the inflection score of 4, with every
unit increase in learning activity scores, the
predicted cognitive development score is
higher for HIV exposed than HIV unexposed
infants (Fig.7).!
Data Analysis: !
LAKE VICTORIA!
Figure 2: Geographical location of
study sites in Nyanza region, Kenya.!
Figure 1. A study nurse
collecting data on infant
cognitive development from
a nursing mother at a clinical
site in Kenya.'
Data Collection: !
15.9!
14.3!
24.2!23.9!
20.6!19.2!
0!
5!
10!
15!
20!
25!
30!
HIV
unexposed!
HIV exposed!HIV
unexposed!
HIV exposed!HIV
unexposed!
HIV exposed!
3 Months!9 Months!12 Months!
MEAN ICD SORES!
Months postpartum !
Gross Motor Skills!Fine Motor Skills!Language Skills !Social Skills !Total ICD Scores!
*!*!
Figure 8: Summary of Results!
Figure 4: An example of a learning
activity!
Methods !
*p≤0.05!
Time invariant variables !
Figure 3: MDAT Timeline of Language
milestone !Infant Cognitive
Development!