Prevention of Mother-to-Child HIV Transmission programmes in sub-Saharan Africa have been extremely successful in reducing the numbers of children infected with HIV. However, in high HIV prevalence areas, up to 40% of pregnant women are HIV-infected, resulting in a large proportion of HIV-uninfected children having at least one HIV-infected parent. HIV-infected mothers face the dilemma of when, and how, to disclose their own HIV status to their children. There is limited research relating to parental HIV disclosure in the African context, and few studies have targeted mothers with primary school-aged children. The proposed research will take place at the Africa Centre for Health and Population Studies (www.africacentre.com), in rural KwaZulu-Natal, South Africa, an area with one of the highest burdens of HIV globally. Extensive pilot work has been conducted at the proposed study site, and a large-scale feasibility and acceptability field test is currently underway. A 6-session home- based intervention to assist mothers to disclosure their HIV status to their HIV-uninfected children, aged 6-9 years, has been developed, and designed to be delivered by lay counselors. Over 200 families have enrolled to date. Preliminary results show that the intervention is highly acceptable, with more than 90% of mothers agreeing to participate, and effective with more than 90% having disclosed to their child. The key issue now is to test this intervention formally in a randomized controlled trial (RCT). We hypothesize that, compared to the clinic-based standard of care; the intervention will significantly increase rates o maternal HIV disclosure and result in improvements in child behavior and emotional well-being. 300 HIV-infected women with HIV-uninfected children aged 6-9 years will be recruited from a large HIV Treatment and Care Programme, a partnership between the local Department of Health and the Africa Centre; 150 will receive the home-based intervention and 150 standard of care. If successful in terms of rates of disclosure, and hypothesized improvements in child outcome and family functioning, the intervention will have enormous benefits with potential applicability across many areas of sub-Saharan Africa. Large numbers of HIV-uninfected children will continue to be born to HIV-infected women in sub-Saharan Africa. HIV-infected mothers are faced with the difficult decision of when and how to disclose their own HIV-positive status to their children. This project will compare, in a randomized control trial, a home-based intervention to assist mothers to disclose their status and plan for their child's future, against standard of care in a primary health care setting in rural South Africa. PUBLIC HEALTH RELEVANCE: The key issue now is to test this intervention formally in a randomized controlled trial (RCT). We hypothesize that, compared to the clinic-based standard of care; the intervention will significantly increase rates of maternal HIV disclosure and result i improvements in child behavior and emotional well-being. 300 HIV-infected women with HIV-uninfected children aged 6-9 years will be recruited from a large HIV Treatment and Care Programme, a partnership between the local Department of Health and the Africa Centre; 150 will receive the home-based intervention and 150 standard of care. If successful in terms of rates of disclosure, and hypothesized improvements in child outcome and family functioning, the intervention will have enormous benefits with potential applicability across many areas of sub-Saharan Africa.