Burden of HIV among primary school children and feasibility of primary school-linked HIV testing in Harare, Zimbabwe: A mixed methods study

Figures & data

Table 1. Baseline characteristics of participants.

Characteristic	Total (N=4386)
Age-group
≤10 years	2938 (67.0%)
>10 Years	1448 (33.0%)
Median age	9 years (IQR 8–11 years)
Sex
Male	1999 (45.6%)
Orphan
Paternal	473 (10.8%)
Maternal	150 (3.6%)
Double	153 (3.5%)
≥1 class year behind^Footnotea
Yes	181 (4.1%)
Stunting^Footnoteb
Yes	−0.25 (IQR −0.94 to 0.49)
Median height-for age z-score	49 (1.1%)
Wasting^Footnotec
Yes	218 (5.0%)
Median weight-for age z-score	−0.32 (IQR −0.97 to 0.32)

Notes: ^aDue to illness.

^b Height-for-age z-score<−2.

^c Weight-for-age z-score <−2.

Table 2. Factors associated with being HIV infected among primary school children (N=4386).

		Univariate		Multivariate
Characteristic	HIV prevalence N=117 (2.7%)	Unadjusted OR (95% CI)	p-Value	Adjusted OR (95% CI)	p-Value
Age group
>10 years	3.6%	1.6 (1.2–2.2)	0.009	–	–
Gender
Female	2.8%	1.1 (0.7–1.7)	0.671	–	–
Orphan
Yes	7.0%	4.3 (2.7–6.9)	<0.001	3.9 (2.3–25.7)	0.001
≥1 class year behind^Footnotea
Yes	18.4%	8.8 (2.1–36.9)	0.011	–	–
Stunting^Footnoteb
Yes	19.9%	12.6 (5.7–27.8)	<0.001	11.2 (4.9–25.7)	0.001
Wasting^Footnotec
Yes	14.2%	7.9 (3.7–16.8)	0.001	–	–

Notes: ^aDue to illness.

^b Height-for-age z-score<−2.

^c Weight-for-age z-score<−2.

Table 3. Uptake of school-linked HIV counselling and testing.

	No (N=1886)	Percentage
School children	47	2.5
Siblings^Footnotea	36	1.9
Biological mother	80	4.2
Biological father	22	1.2
Other relatives	1633	86.6
Teachers	68	3.6
Total adults tested (≥15 years)	1827	96.9
Total children tested (<15 years)	59	3.1

Note: ^aTwenty-four siblings were aged 15 years or older.

Table 4. Themes and quotes from qualitative survey.

Theme	Quotes
(1) Community awareness of benefits of HIV testing connected to accessing treatment	1.1 The child might survive and also do all the activities that are done by other children. (FGD, cmty1, parent5) 1.2 A lot of people are now aware because many people are going around [openly] saying, ‘I thought I was dead but I have actually survived.’ (FGD, cmty4, parent2)
(2) Protecting children from distressing news	2.1 I had a funeral in the counselling room. They were about five [of them]. They all started screaming. To them this child is dying … it is a challenge. These people are screaming like this: what are they going to do to the child when they get home? How are they going to help this child? (HCT counsellor 3) 2.2 When they go to play with their friends, mothers would then say, ‘Go away from here because you have AIDS. You will infect our children with AIDS. Move away and play at your house.’ (FGD, cmty4, pupil1) 2.3 Sometimes they are scared; that concern is being driven by fear that this child is going to infect our children. [They ask questions like] ‘how about my cup, how about my plate that he sometimes uses?’ ‘So if she sits on the toilet seat, are we not going to get infected?’ (HCT counsellors 2&3) 2.4 If some of the children find out, [they] could just start avoiding her. Or refuse to play with her and they will be afraid of her. … so she might end up without any friends (FGD, cmty1, parent6) 2.5 For a child to tell another child.he can only laugh saying, ‘so this is what you are like, where did you get it and the like?’ (informal interview, grade2 mother) 2.6 These are young people; … children can mock each other terribly. And it is not good for a child to be mocked. She will be stressed out and might end up thinking about things that are bad. Maybe she might think of committing suicide. Therefore I am saying it is good for the family to know only. (FGD, cmty4, parent10)
(3) Evidence of a positive shift in perceptions	3.1 I think it is good. Isn't it we were talking about that boy [whose] father is late? His mother was ill and he has been ill for 12 years. I realized that when they got tested they supported one another and said, ‘we are in this situation [together]’. I can actually see that it would be good if both the parent and the child are tested. (informal interview, cmty3) 3.2 Yes, as the child's parent I should also get tested. If my child tests positive to HIV, I should agree to get tested so that I will be able to get treatment together with the child. (FGD, cmty2, parent9) 3.3 Sharing helps. Sharing things like food helps because you will find some refusing to eat with her. (FGD, cmty2, teacher9) 3.4 I am not saying that she will not agree, but I want to say that if she has love for her brother's child, she could let her get tested. … Because a person who wants someone to be tested is interested in protecting that person's health. (FGD, cmty1, parent2)
(4) Internalised self isolating behaviour	4.1 During participant observation, pupils who were actively playing together tried unsuccessfully to include another child. When pressed, she acknowledged that she was ‘sick’ and was worried that she might pass on her illness to the other pupils if she played with them. (participant observation, cmty4)
(5) A child's HIV status reflects that of the parents	5.1 There is no way that this child could have been infected except through me as the parent. (FGD, cmty1, parent7) 5.2 When you know [that your child is HIV + ], that will make you die promptly. (informal interview, grade 4 mother) 5.3 I am afraid that when we go for testing as a family I might test positive to HIV while my parents are negative. I am afraid that they might wonder where I contracted it from. (FGD, cmty3, pupil6) 5.4 I would be worried that if my child is tested and is HIV positive, how about my own status? Maybe I am also HIV positive which will stress me out. (FGD, cmty2, parent1)
(6) Test but don't disclose	6.1 I am not able to tell him. So its better that I tell my older sister in case I might travel and my child might need to take his pills. … and if he asks me ‘what are [the pills] for?’ I will tell him ‘they are pills you are supposed to take for you painful stomach or headache.’ Or I could tell him that ‘these are pills for you to be good in school’ so that he does not get frustrated. (informal interview, grade 2 mother)
(7) Health care workers' concerns	7.1 Zimbabwe we have a challenge that people have not yet reached the level of accepting it. They [still] think this disease is for people that are promiscuous and are prostitutes. (FGD, cmty3, parent1) 7.2 Not having a language to talk about HIV to young people, because all of our focus has been on multiple partners, so there is nothing relevant for young people. … It takes time to find the appropriate language that … can be understood by a child. (HCT counsellor1) 7.3 It is also difficult to [explain to] the child that they might have been infected by their mother or father. There is need to include biology which is difficult for a child to comprehend. (HCT counsellor1) 7.4 At times you had to ask a child; ‘before coming here with your parent or guardian, were you told anything about why you are here or do you understand what will be going on?’. You would then hear them saying ‘they told me that we are here for this reason’, which will be a different story altogether. It then becomes a challenge because you wouldn't know how to break the news to the child when she has not been told by the parent or the guardian. (HCT counsellor2)

Figure 1. A conceptual framework for barriers to diagnosis in older children.