Discussion
REGRESSION
This study defined caregiver-child characteristics that predicted caregiver compliance to a disclosure intervention for children living with HIV and their families in western Kenya. We also used instrumental variable methods to explore local average treatment effects of disclosure post-intervention on HIV, mental health, and behavioral health outcomes. In completing this analysis, we aimed to isolate disclosure as a variable separate from intervention participation to independently assess the independent prediction and impact of disclosure.Two caregiver-child characteristics were found to be predictive of compliance to the HIV disclosure intervention: caregiver isolation and the length of time that the child had been taking ARVs.While almost 85% of non-isolated caregivers disclosed their child's HIV status to them after the intervention, less than 40% of caregivers who self-reported feeling isolated complied with HIV disclosure. This finding substantiates qualitative research conducted within this population prior to the intervention when caregivers cited their own isolation and fears of their child's isolation post-HIV status disclosure as reasons for not previously disclosing their child's HIV status (In combination, this research suggests that HIV-related stigma may isolate caregivers and impact their willingness to disclose HIV status, even after specific curriculum within a disclosure intervention to address and attempt to combat HIV stigma. These isolated caregivers may continue to have substantial fear about the potential for a disclosed child to share about HIV status with others and subsequently be subject to further stigma. It also proposes the need for increased focus on caregiver HIV status and stigma within pediatric HIV disclosure interventions, which has already been implemented in various disclosure models (Caregivers of children who were on ARVs for a longer time were also less likely to disclose post-intervention in this study. The average length of time on ARVs for children who were disclosed was more than 1 year less than those who were not disclosed. This result is surprising, since other studies have found that increased length of time on ARV medication was significantly associated with HIV disclosure (Of note, this study did not find that any of the other 78 baseline caregiver-child characteristics were significantly associated with disclosure post-intervention The full list of baseline characteristics included in the regression model can be found in the Our study did not find statistically significant differences in CD4 percentage, PHQ-9 score, or SDQ score between children based on disclosure status across the intervention. Disclosure was shown to not impact mental health or HIV outcomes, which contradicts caregiver fears that disclosing HIV status would worsen children's mental health and control over HIV treatment (These outcomes fit within growing literature that suggests that disclosure of HIV status to children in resource-limited settings may lead to improved HIV, psychological, and quality of life outcomes. One unmatched case control study of 309 children living with HIV in Tanzania found that patients who had their HIV status disclosed to them were more likely to have improved ART adherence as measured by a treatment adherence manual and improved quality of life as measured by World Health Organization Quality of Life standard tool (Although the HADITHI trial found improved outcomes among children living with HIV when comparing children who completed the disclosure intervention to those who did not (Our study contained numerous limitations. First, this analysis was limited by its sample size since the study was not sufficiently powered for effect sizes. Almost 50% of children who participated in the HADITHI intervention were already aware of their HIV status at baseline, significantly limiting the number of caregiver-child pairs in this analysis and thus the study's power. Second, the definition of disclosure used in this quantitative analysis could not capture the nuances of disclosure studied in this and other settings. Some caregiver-child dyads reported divergent answers for disclosure across the study—with the caregiver stating that they disclosed to the child but the child not expressing knowledge of their HIV status or vice-versa. For this analysis, we defined disclosure as both the parent and the child reporting disclosure, but this may underestimate study results. In addition, it is well-studied that disclosure is not a binary variable but a longitudinal process (