The human immunodeficiency virus (HIV) continues to be a public health challenge worldwide. In 2018, the prevalence of HIV was estimated to be approximately 37.9 million [32.7-44.0 million] globally, with sub-Saharan countries accounting for the majority of the population living with HIV (Mahy et al., 2019). In the same year, WHO estimated that there were approximately 1.7 million [1.3–2.2 million] children under the age of 15 years living with HIV (Mahy et al., 2019). This is a significant increase from the 2005 data (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2017). Despite the preventative measures that are put in place to curb the spread, the prevalence of HIV in children seems to increase, with evidence of new infections annually.

Despite the efficacy of the antiretroviral therapy (ART) that has been shown to reduce mortality rates of people living with HIV (Gueler et al., 2017; Samji et al., 2013), improve the immune system of people living with HIV, increase life expectancy and improve quality of life (Achappa et al., 2013; Izugbara & Wekesa, 2011; Oguntibeju, 2012), literature suggests that children living with HIV may be at a greater risk of middle ear pathologies (Chao et al., 2012). Evidence suggests that HIV incapacitates the ability of the immune system to fight pathogens and results in opportunistic infections such as middle ear pathologies (Obasineke et al., 2014). Given that children are known to have weaker immune systems and are more prone to ear infections compared with adults (Ramma & Sebothoma, 2016), HIV may have an additional effect on an already weak immune system.

The existence of middle ear pathologies is concerning given that undetected, late detection and untreated middle ear pathologies may cause hearing impairment and other complications. The WHO has stipulated that approximately 50% of individuals with acute otitis media (AOM) will develop chronic suppurative otitis media (CSOM) (Mahy et al., 2019). Further complications of untreated middle ear pathologies include permanent hearing impairment (Hutz et al., 2018), meningitis (Avnstorp et al., 2016), facial paralysis (Lawler, 2018), and vestibular disturbances (Rehagen et al., 2019). The impacts of these conditions in children can have far-reaching consequences.

The impact of hearing impairments in children are well recorded in the literature. Khoza-Shangase and Michal (2014) reported that children whose hearing loss (HL) is identified late are at a greater risk of developmental milestones. Cole and Flexer (2019) reported that children with HL have limited vocabulary, and often struggle to construct a sentence structure. Furthermore, Maluleke et al. (2019) indicated that children with HL have delayed language and inability to communicate, and they struggle to produce clear speech sounds. Some children may experience listening fatigue (Hornsby et al., 2014), especially in classrooms with poor acoustics such as those in low- and middle-income countries (LMICs) (Ramma, 2007), affecting their learning and overall academic achievement (Abraham et al., 2018).

Based on the evidence presented, it is crucial to conduct a scoping review on middle ear pathologies in children living with HIV. Although studies on HIV and other auditory pathologies exist (Dawood et al., 2019), little is known about this current area of investigation, hence the rationale for conducting this scoping review.

This scoping review followed a six-step framework proposed by Arksey and O’Malley (2005). The framework includes (1) identifying the research question, (2) identifying relevant publications, (3) study selection, (4) charting the data, (5) collating, summarising and reporting the results. There was agreement on the broad research questions between the two co-authors to be addressed by this scoping review and study protocol together with the identification of keywords and search terms, as well as the selection of databases to be searched. The aim of this study was to integrate the evidence that exists regarding middle ear pathologies in children living with HIV so as to map the literature and acquire an opportunity to find gaps in the evidence and types and sources of evidence to guide practice, policymaking, research and training (Daudt et al., 2013).

Figure 1 is a preferred reporting items for systematic reviews and meta-analysis (PRISMA) diagram illustrating the process of the study selection. A total of 350 articles were extracted from different electronic databases. Of these, 127 remained after the removal of the duplicates. The articles were screened based on title and abstract only and 93 were removed at this stage. The 34 remaining articles were included for full-text screening, after which 28 articles were excluded as they did not meet the minimum criteria for this scoping review. The remaining six articles were considered to be relevant to this study and therefore included for further analysis.

The purpose of this review was to determine evidence that exists regarding middle ear pathologies in children living with HIV. According to the researchers’ knowledge, this is the first scoping review study that focuses on this particular area and the findings of this study revealed a clear paucity of evidence in this area. Only six studies were relevant for this review, with one study being a review. This paucity of research in this area is concerning given the high prevalence of HIV in children (UNAIDS, 2020) and the association between HIV and middle ear pathologies that have been established in the literature (Khoza-Shangase & Anastasiou, 2020; Sebothoma & Khoza-Shangase, 2020; Tshifularo et al., 2013). The available research indicated that children living with HIV are at an increased risk of middle ear pathologies (Maro et al., 2016; Taipale et al., 2011; Torre et al., 2016) and the prevalence of middle ear pathologies can be as high as 93.65% (Mwambete & Eulambius, 2018). The difference in these studies with regard to prevalence rates may be because of different sample sizes and the assessment methods used, among other factors. Therefore, there is a need for further studies with large sample sizes to determine the prevalence of middle ear pathologies in children living with HIV.

Furthermore, while the studies reviewed indicated that the prevalence of middle ear pathologies is potentially high, all these studies used tympanometry with single probe tones such as 226 Hz. Literature has shown that tympanometry with a single probe tone has poor sensitivity and specificity in identifying middle ear pathologies (Kaf, 2011; Sebothoma & Khoza-Shangase, 2018). For example, Hunter et al. (2017) found that tympanometry with a single probe tone missed approximately 20% of CHL in children. These findings suggest that further research in children living with HIV must use measures that have high sensitivity and specificity in identifying middle ear pathologies. Wideband acoustic immittance (WAI) has emerged as the potential middle ear measure with higher sensitivity in identifying early signs of middle ear pathologies compared with the conventional tympanometry with single probe tone (Kaf, 2011; Sebothoma & Khoza-Shangase, 2018; Shahnaz et al., 2009; Terzi et al., 2015).

While otomicroscopy is considered gold standard in identifying middle ear pathologies in some countries (Sebothoma & Khoza-Shangase, 2018), the shortages of otolaryngologists in LMICs (Christopher et al., 2013), limit the practicality of this measure. Consequently, video otoscopy used asynchronously has also been shown to be equally sensitive in identifying middle ear pathologies compared with otomicroscopy. Martines et al. (2010) found a substantial agreement (k = 0.7) between the diagnoses made from video otoscopic images and those from onsite otomicroscopy. Sebothoma and Khoza-Shangase (2018) also demonstrated that video otoscopy can produce accurate diagnosis of the middle ear pathology than the conventional tympanometry with single probe tone. It is therefore crucial that future studies include some of these sensitive tests to provide a more accurate picture of the prevalence and nature of middle ear pathologies in children living with HIV.

In this review, HL with a conductive component was found to be the second most reported type of HL in children living with HIV (Christopher et al., 2013). The prevalence of this type of HL was reported to be 36%, with the severity reaching moderate levels (Christopher et al., 2013). Given the fact that CHL was the second most reported type of HL, Dawood et al. (2020) suggest that this type of HL may be associated with otitis media with effusion (OME). In studies reviewed, the prevalence of OME was found to be 6.8% (Martines et al., 2010). These findings are consistent with the study by Christopher et al. (2013), who found that HL with a conductive component in children is likely because of OME, which is one of the common types of middle ear pathologies in children (Vanneste & Page, 2019).

Human immunodeficiency virus-positive children were shown to have more signs and symptoms related to middle ear pathologies compared with children without HIV. These symptoms or signs included otalgia, tympanic membrane perforation, otorrohea and impacted wax (Hrapcak et al., 2016; Maro et al., 2016; Mwambete & Eulambius, 2018; Taipale et al., 2011; Torre et al., 2016). Of all these signs or symptoms, otorrohea, tympanic membrane perforation, history of ear infections, low immune system and WHO stage IV of HIV were associated with middle ear pathologies in children living with (Dawood et al., 2020; Hrapcak et al., 2016; Maro et al., 2016; Mwambete & Eulambius, 2018; Taipale et al., 2011; Torre et al., 2016). Studies on adults living with HIV also reported that middle ear pathologies result from opportunistic infections because of a low immune system resulting from a declined number of CD4 T cells (Obasineke et al., 2014; Van der Westhuizen et al., 2013). However, in one study (Torre et al., 2016), middle ear pathologies were only associated with flat tympanogram and otorrohea. The difference between previous studies and findings in this study by Torre et al. (2016) may be because of different sample sizes. Therefore, these conflicting results warrant further research in order to determine the contributing factors for middle ear pathologies.

Despite the paucity of evidence, this review suggests that middle ear pathologies exist in children living with HIV and may cause HL. Therefore, there is a need for further research to identify the significant relationships or differences that exist between studies. Conducting studies on middle ear pathologies will further enhance our knowledge regarding the middle ear function of children living with HIV and help to provide appropriate services for this population. Early identification of middle ear pathologies is significant for all children, especially those with a compromised immune system. Middle ear pathologies are known to have a negative impact on children’s language and quality of life (Torre et al., 2016). For example, recurrent otitis media (ROM) in children is associated with phonological delay (Torre et al., 2016) and because children with HIV are at a high risk of ROM, it is necessary to identify early signs of their middle ear pathologies so that timeous interventions can be implemented early. Failure to implement early identification and intervention for children living with HIV may contribute to delays in schooling.

For example, about 13% of children with HL and living with HIV never get a chance to attend school (Hrapcak et al., 2016). While some children living with HIV already experience difficulty attending school because of constant sickness (Hrapcak et al., 2016), very few of those who are able to attend school get to perform above average because of HL related to middle ear pathologies. Therefore, it is crucial that children living with HIV receive early identification and intervention for middle ear pathologies. This is even more crucial in LMICs where resources for assessing and managing middle ear pathologies are extremely limited (Fagan & Jacobs, 2009).

The studies reviewed in this scoping review provided evidence that middle ear pathologies in children living with HIV exist and may be severe or chronic, causing HL to various degrees. However, because of the limited number of articles found during this scoping review, the findings must be interpreted with caution. While the studies reviewed provided some important information about middle ear pathologies in children living with HIV, all the studies used measures that have been shown to have poor sensitivity and specificity. Further research using sensitive measures of middle ear pathologies such as WAI and with large sample sizes must be conducted. Furthermore, studies must use longitudinal designs in order to determine the change in middle ear function and pathologies (Sebothoma & Khoza-Shangase, 2020).