Women are more at risk of acquiring HIV infection than men in sub-Saharan Africa mainly due to Gender inequality, this relatively increases the risk of children acquiring HIV through mother-to-child-transmission . According to available statistics about 30% of babies born in sub-Saharan Africa to HIV positive mothers will themselves be infected with the virus either through childbirth or through breast-feeding .
From recent data there are about 3.2 million children living with HIV, 91% of these children living with HIV are found in sub-Saharan Africa . The WHO recommendations stipulates that children below the age of 5 diagnosed with HIV should be placed on ART regardless of what their CD4 count is, 28% of these children living with HIV worldwide, requiring antiretroviral treatment (ART) currently have access to these drugs .
Since the onset of the epidemic, most of the children with perinatally acquired HIV in low and middle income countries do not live past infancy [3, 4]. However, results from recent research shows that life expectancy has improved and 36% of these infants live up to 16 years of age . Likewise, strategies employed to screen pregnant mothers and test infants and children at risk for HIV infection, as well as the advances in ART, has improved the quality of life and ensure HIV positive children live longer [6, 7].
However, these children will have to face the challenges of living with a chronic illness, requiring tremendous social support for long, to enable proper development both mentally and physically. For example, recent studies indicate that living with a life-threatening and stigmatizing illness is also difficult and creates great psychological distress for children with HIV . Children living with HIV are often confronted with fears/thoughts about their own death, most of them are stigmatized and discriminated against . Consistent evidence also shows cognitive difficulties for HIV positive children .
1.2. Background and Context
Mental disorder is progressively becoming an important global health concern and the leading cause of disability globally. Depression an ordinary mental disorder, currently afflicts about 350 million people, both adults and children worldwide . An increasing number of mental disorders are ranked among the leading causes of disability in the World Health Organization (WHO) Global Burden of Disease 2004 .
War, poverty, deprivation, marginalization and deracination are among the key social determinants of mental health identified as prevalent in sub-Saharan Africa (SSA) [12-15]. This in turn increases the prevalence of depression in this region, though the number are under-reported. Despite the clear indication that mental health is a huge public health concern in SSA, it has consistently been neglected, due to the preponderance of communicable diseases, malnutrition and other perinatal disorders.
Adults living with a chronic illness like HIV, are prone to psychosocial and psychological stressors so are children living with HIV. They are faced with anxiety associated with living with a chronic illness and the possibilities of death from the infection. High on the list for psychosocial stressor, is the issue of discrimination and stigmatization, as well as struggles with other challenges like malnutrition, poverty and diminished social support . Evidence from studies have shown that children suffering from chronic diseases are more prone to developing mental disorders than their peers that are healthy. In one study  involving children with epilepsy, it was suggested that healthy children were less likely to suffer from mental disorder than those with epileptic conditions that had increased risks. Another study  showed minders of children with sickle cell disease reported more emotional and behavioural abnormalities among these set of children.
Studies from other region of the world have shown that there is a relationship between HIV and mental illness. It has been shown  that early abnormalities in children’s neurological development is attributable to HIV infection and no other factors like environmental and biological risks. The association between HIV and neurological impairment is well researched in children. Learning difficulties, attention deficit disorder [19, 20], behavioural abnormalities [21-23] and cognitive discrepancies [24, 25] are all associated with HIV infection in children. The Pediatric Acquired Immunodeficiency Syndrome Clinical Trials Group (PACTG) in their study reported increased risks for psychiatric hospitalization for children living with HIV compared to other children without the infection . It was also suggested that children with perinatally acquired HIV infection may be susceptible to certain mental disorder due to the effects of HIV infection on neurological development. They also stated that there is a likelihood of increased mental illness among these children as they progress in life.
Result from a study conducted by Mellins et al. that examined psychiatric indicators in children between the ages of 9-16 years with perinatal HIV infection, showed that 11% of the children had oppositional defiant disorder and 13% diagnosed with conduct disorder.
Moreover, other studies have shown that perinatal HIV infected children are at greater risk of experiencing abnormalities in brain development , these abnormalities include delayed motor and cognitive development  and in some cases short-term amnesia and mental retardation as a result of the infection [30, 31]. A study  of Ugandan HIV positive babies followed over a period of one year, showed that 30% of the babies on ART exhibited impaired motor functions while about 26% of the babies displayed impaired cognitive functions, this is in contrast with 5-6% of HIV negative babies that exhibited the same conditions.
Papola et al.  in their study, collected retrospective data on 90 school children living with HIV, in order to examine their developmental and needs. From their findings 44% of the children’s range of intelligence were below average or average, while 56% had language impairment. A similar finding were replicated by Bachanas et al. , result from the study showed that HIV-infected children had lower WISC-III scores and abysmal academic performance. They also exhibited significant psychological functioning deficiency.
1.3. Research Project and significance
With increasing access to ART, the number of children born with perinatal HIV infection getting to adolescence and adulthood has increased tremendously. These children in most cases share stressors experienced by other children living with other chronic illness, like long term medical hospitalization and treatment, and agonizing life experiences. Notwithstanding the burgeoning evidence and psychosocial consequences of living with a chronic disease, there are still dearth of studies that have investigated the mental health concerns of children living with HIV in SSA.
Most research elsewhere focuses on the effect of ART treatment and prevention of HIV. Though, there is an increasing cognizance of the likelihood of increased risk of mental health disorders for people living with HIV in the long run, owing to biomedical changes occasioned by ART and environmental risks.
Based on the glowing evidence from research on correlation between substance abuse, risky sexual behaviours and mental health disorders, it is then pertinent to understand the association between mental health and children living with prenatally acquired HIV infection in sub-Saharan Africa, especially because of its unique environment and the high prevalence of the social determinants of mental illness in the region. This is necessary to inform mental health treatment and prevention programmes.
1.4. Study aim
To review and provide a synthesis of research on the mental health and psychological functioning/outcomes of children who are perinatally-infected with HIV, corresponding risk and protective elements, treatment modes and areas of vital need for future research and interventions.
1.5. Organization of the Thesis
This thesis is organized as follows.
Chapter 1 deals with the scope and objectives of the thesis, it gives a brief background of children living with perinatal HIV infection and the current trend, the mental health issues associated with living with HIV/AIDS.
Chapter 2 deals with the methodology, the literature search and identification of studies, inclusion and exclusion criteria, data extraction, quality assessment and procedures used in the analysis.
Chapter 3 presents the study findings.
Chapter 4 presents the general discussions of the study findings, including limitations of studies included. And also the limitations of a systematic review study, strength and weakness.
Chapter 5 gives the concludes and summarizes the study, giving possible intervention to address the emerging mental health concerns for children living with HIV/AIDS, as well as recommendations and identified areas of future research.
A systematic literature review was conducted using the theme “children living with HIV/AIDS in sub-Saharan Africa and mental health”. The study included studies up until July 2014. The research focuses on papers dealing with children living with HIV/AIDS and the effects on their mental health. The aim is to harness these research papers on the above-mentioned theme, and discuss the subject, present a summary, and highlight areas of future research needs. This informed by the body of evidence suggesting that in the long run, perinatal infected HIV children are liable to mental health issues, arising from factors such as environment, genetics, biomedical and familial [30-33].
Nonetheless, in the course of these research there are dearth of studies using the mental health as outcome and perinatal HIV infection as exposure in SSA. Hence, terms relevant to the review theme were discovered and used in finding the required papers. Studies on children living with HIV and mental health outside sub-Saharan Africa were not included in this review. It is not clear as explained in some studies, whether the mental health condition experienced by HIV positive children is neurologically or psychological. This might be a limitation of this review.
A comprehensive search of online database for published articles on mental health and psychological functioning of children who are perinatally-infected with HIV was conducted. The electronic databases includes: PubMed, EBSCOhost and Science Direct, MEDLINE, Psychinfo, PubMed, JSTOR and Google Scholar. In addition to the online databases, unpublished articles, theses and internal reports will also identified by citation snowballing from the initial journal articles. Data was collected between January 2014 and July 2014 from the databases. The search terms used, identified through MeSH include: mental health, psychiatric/psychological, emotional and behavioural problems, perinatal HIV infection, paediatric HIV and adolescence.
Inclusion and Exclusion criteria
The initial search returned one hundred and eleven studies relevant to children in sub-Saharan African living with HIV and mental health concerns, restrictions were applied in terms of age, geography and study methodology. Only studies that included children between the ages of 1- 15 years were included. Studies conducted outside sub-Saharan African countries were not included. Both quantitative and qualitative studies were included if the primary research was on HIV infection as exposure studied, the researchers had a control group or standardized psychological instrument, mental health disorder/symptoms was the key outcome studied. Only English language articles were included. Out of the 111 studies selected only 10 that were relevant to the review was selected.
As the main aim of this review was to focus on well-grounded findings the mental health and psychological functioning/outcomes of children who are perinatally-infected with HIV, only papers that included both subject were selected. Exclusion of studies outside the geographical area of interest were only performed at a later stage, to ensure that relevant studies that did not stipulate their geographical emphasis in their keywords were not excluded.
Figure 1. Inclusion and exclusion used in systematic review.
Children were classified as infected or uninfected based on their seropositive or negative status. The final synthesized materials were evaluated based on the research methodology employed, age range, and the outcomes from the study. To assist in the analysis Microsoft Excel was used. A content analysis was performed. As the studies used in the systematic review is small, a meta-analysis could not performed.