Building Opportunities for Nurturing care to enhance Development in Eastern and Southern Africa (BONDS)

Two-thirds of all children in Eastern and Southern Africa fail to reach their full developmental potential, and the risk for suboptimal development is particularly high among children who are HIV-exposed but uninfected (CHEU), a population that accounts for a large proportion of children under-5 in these regions. We propose to adapt and test a package of effective evidence-based interventions developed and tested in Eastern and Southern Africa to provide nurturing care for CHEU in 3 countries (Botswana, Kenya, Zimbabwe). The intervention package (BONDS) will include problem-solving therapy [friendship bench], a curriculum based infant and young child feeding program, and a play-based learning curriculum, administered from pregnancy to 2-years of age, designed to be delivered by community health workers and to address the five components of the WHO nurturing care framework (NCF) (good health nutrition, safety/security, early learning, responsive caregiving). In aim 1, we will adapt and refine protocols for the friendship bench for pregnancy and postpartum, infant and young child feeding modules, and a play-based learning curriculum for Botswana, Kenya, Zimbabwe to create a intervention package (BONDS). We will partner with local country stakeholders in a user-centered co-design approach to select appropriate adaptations for each country while maintaining core intervention components. In aim 2, we will test the efficacy of BONDS to improve neurodevelopment in CHEU and children who are HIV- unexposed (CHU) in an individual randomized controlled trial of mother-child pairs in Botswana, Kenya, and Zimbabwe. A total of 606 women living with HIV and 606 women without HIV will be enrolled in pregnancy, randomized to BONDS vs. standard of care, and mother-infant pairs followed for 2 years. The primary outcome is a total neurodevelopment score assessed using the Malawi Developmental Assessment Tool (MDAT) at age 2 years. Secondary outcomes include domain specific MDAT scores (gross and fine motor, social, language), MacArthur Bates Communicative Development Inventory language scores, Global Scales of Early Development scores and growth z-scores. We hypothesize that children whose mothers are randomized to BONDS vs. standard of care will have better global neurodevelopment at 2 years of age, and that CHEU will have greater benefit from the BONDS intervention than CHU, given their higher levels of adversity and vulnerability in infancy. In aim 3, we will evaluate the mechanism of action through which the BONDS intervention works or does not work using structural equations modelling methods to evaluate hypothesized pathways aligned to the NCF. This project will determine whether a community health worker-delivered nurturing care intervention that incorporates all five components of the WHO NCF will improve neurodevelopment for all children and closes the developmental gap between CHEU and CHU. The project will also provide important data on implementation across diverse settings in Eastern and Southern Africa and model large-scale impact of interventions in CHEU. Project Number: 1U19HD118601-01 | Fiscal Year: 2025 | NIH Institute/Center: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) | Principal Investigator: Christine McGrath | Institution: UNIVERSITY OF WASHINGTON, SEATTLE, WA | Award Amount: $1,178,860 | Activity Code: U19 | Study Section: Special Emphasis Panel[ZHD1 DSR-B (50)] View on NIH RePORTER: https://reporter.nih.gov/project-details/1U19HD11860101