In the past decade increasing numbers of controlled studies and systematic reviews have identified negative psychological impacts on children of parental HIV/AIDS [10, 11]. Most of this research has focused on children orphaned by parental HIV, finding heightened rates of depression and post-traumatic stress compared to children who are not orphaned, and also compared to children whose parents had died of other causes such as non-AIDS illnesses or violent deaths [12]. These findings seem similar across broad settings – Sub-Saharan Africa, the United States and China [13141516]. Perhaps, most worryingly, new findings show that the negative psychological impacts are long-lasting, with worsening mental health status for AIDS-orphaned children over a 4-year period [17]. Not surprisingly the broader early childhood developmental literature would point to the fact that chronic stress, toxic trauma and scant ameliorating input may contribute to a continuum of burden, which may manifest itself in later life with reduced chances of children meeting their potential [18].

More recently, studies have found heightened rates of depression, post-traumatic stress disorder (PTSD) and in particular anxiety amongst children whose parents or primary caregivers were alive but unwell with symptomatic AIDS [19, 5]. Qualitative data suggests that this anxiety is linked to fears for the health and survival of their parents [20]. Therefore, the impacts of parental AIDS illness seem to be at least as severe, if not more so, than those of AIDS-orphanhood. However, very little is known about the impacts of parental asymptomatic HIV-positive status on children, and this requires further investigation.

Studies of HIV-positive children and adolescents have found increased depression and internalizing mental health problems in multiple countries [21, 22], as well as neurocognitive impacts for HIV-positive children that may have implications for emotional and behavioural difficulties [23]. It is unclear whether the cognitive and developmental challenges are caused by exposure to the virus, exposure to treatment, exposure to HIV-positive parents or a complex combination of all [24]. For perinatally infected children, parental HIV and often orphanhood are integral to their experiences of growing up with the virus [25]. Those infected sexually, in later childhood or adolescence, are likely to share many of the difficulties described in Cournos’ and colleagues’ chapter above, as well as those particular to children. Little is known about the psychological impacts of HIV acquired through sexual abuse on children, although it is likely that these are particularly severe [26].

Understanding how parental HIV/AIDS leads to negative child outcomes or to resilient outcomes is essential for informing effective interventions for AIDS-affected children. It is also important to identify modifiable factors in pathways of risk and resilience [27]. Whilst AIDS-orphanhood and parental and child HIV-positive status are currently irreversible, the linkages between these and child psychological distress are not direct, but rather indirect pathways via social and economic sequelae of HIV/AIDS. Elements that are reversible may need to be high intervention priorities. The biggest predictor of double orphanhood (death of both parents) is the HIV rate in a country 9 years previously. A policy that would ensure combination antiretroviral treatment for parents could mitigate parental illness and death, which in turn could enhance parenting environment through increased employment and healthy functioning. Similarly, early identification and treatment of child HIV may mitigate negative outcomes.

Perhaps the strongest pathway from family AIDS to psychological distress is stigma. Quantitative and qualitative evidence demonstrates the severe effects of both internalized and enacted stigma [28] on people living with HIV/AIDS, their families and their children [29303132333435]. For both HIV-positive and AIDS-affected children, stigma can take forms such as peer exclusion, bullying and discrimination related to misunderstandings regarding routes of infection, for example, people being afraid to touch them, to share eating utensils or toilet seats. Given that childhood and adolescence are essential developmental stages in establishing social identity, the impacts of stigma may be especially harmful. Stigma may also cause chain effects such as lowered social support [36, 37], loss of income, family conflict, intimate partner violence and – in extreme cases – community violence, which themselves lead to psychological distress.

In addition, the household-level economic shock of HIV/AIDS is an important mediator between parental AIDS illness and death, and child mental health [38]. Medical and funeral expenses, combined with the loss of income-earning adults, have particularly severe impacts on AIDS-affected families in contexts where social security provision is limited or lacking [39, 40].

The combined impacts of stigma and poverty seem to have an especially serious link to increased levels of child abuse – possibly related to the challenges of parenting and supervision in highly stressful contexts (Cluver et al., 2012). Studies in South Africa of children who are orphaned by AIDS or have AIDS-ill parents are more likely (by a factor of two to three) to experience physical, emotional and sexual abuse [41]. The extreme negative psychological impacts of child abuse have been extensively demonstrated – with long-term implications for suicidality, depression and risk of HIV infection [42–45].

Psychological distress amongst children and adolescents is also directly related to the mental and physical health of their parents or caregivers [46–49]. The extensive psychological impacts of adult HIV infection that are described in Cournos et al.’s [50, 51] chapter are linked to the psychological impacts of HIV on the parent-child relationship. Children report psychological distress that fluctuates with the extent of illness and disability that their parents are experiencing – understandably, the more unwell their parents, the more worried the children [52]. These linkages demonstrate that antiretroviral medication and effective psychological support for adults is likely to have positive effects on their children’s mental health. Interventions for post-natal depression in HIV-positive women, for example, have shown specific child development gains [53]. For HIV-positive children and adolescents, their own poor physical health (as well as those of their parents) is linked to depression and anxiety [54, 55]. Studies suggest that disclosure to perinatally infected children of their own HIV status, and to all children of their parents’ HIV status, has long-term positive impacts, but must be done with care and sensitivity to minimize potentially negative effects in the short term [56].

In their chapter, Francine Cournos et al