Understanding the mental health of youth living with perinatal HIV infection: lessons learned and current challenges

Stimulant Medications and Cognition, Behavior and Quality of Life in Children and Youth with HIV

BACKGROUND

Limited empirical investigation exists into longitudinal changes in cognition, behavior or quality of life (QOL) in children with perinatal HIV who are prescribed stimulants.

METHODS

This study was an analysis of longitudinal data from children age 3-19 years, with perinatal HIV infection, with and without prescriptions for stimulant medications [prescription (PG) and comparison (CG) groups, respectively], matched on age, availability of CD4% and outcome measures of cognition, behavior and QOL. Generalized estimating equation models were used to evaluate effects of stimulant exposure on change in measured outcomes over 3 years of follow-up, adjusting for baseline levels of outcomes and relevant covariates.

RESULTS

Children in both the PG (n = 132) and the CG (n = 392) obtained mean verbal and performance (nonverbal) intelligence quotients (VIQ and PIQ, respectively) in the low-average range for age. At baseline, those in PG demonstrated more frequent signs of hyperactivity, impulsivity and conduct and learning problems than those in CG (P ≤ 0.003 in unadjusted analyses). At follow-up, after adjustment for baseline functioning and other relevant covariates, there were no significant changes from baseline in VIQ or PIQ. Stimulant prescription use, however, was associated with worsening symptoms of hyperactivity (P = 0.01), impulsivity (P = 0.04), learning problems (P < 0.001) and worsening of perceived health status (P < 0.001).

CONCLUSIONS

The results suggest expectations for behavioral improvement may not align well with long-term effects of stimulant prescription use on behavior and QOL in children with HIV. Further research is necessary to determine if there are subsets of children who may benefit from stimulant therapy.

Marijuana Use and Psychiatric Disorders in Perinatally HIV-Exposed Youth: Does HIV Matter?

OBJECTIVE

 To examine longitudinal reciprocal relationships between marijuana use and psychiatric disorders, and identify the role of HIV in a sample (N = 340) of youth perinatally infected with HIV (PHIV+) and youth perinatally exposed but uninfected with HIV (PHIV-) (60.6% PHIV+; 9-16 years at baseline; 51% female). 

METHODS

 Cross-lagged structural equation modeling was used to examine longitudinal associations between changes in marijuana use and changes in any behavioral, mood, and anxiety disorders at three time points across adolescence. 

RESULTS

 Marijuana use predicted behavioral and mood disorders in youth, regardless of HIV status. Behavioral and mood disorders predicted marijuana use for PHIV- youth; behavioral disorders predicted marijuana use for PHIV+ youth. Anxiety disorders and marijuana use were not associated for either group. 

CONCLUSIONS

 For PHIV+ and PHIV- youth, interventions that target early marijuana use may reduce later psychiatric disorders. Similarly, treatment for early behavioral disorders may prevent subsequent marijuana use.

90-90-90--Charting a steady course to end the paediatric HIV epidemic

INTRODUCTION

The new "90-90-90" UNAIDS agenda proposes that 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression by 2020. By focusing on children, the global community is in the unique position of realizing an end to the paediatric HIV epidemic.

DISCUSSION

Despite vast scientific advances in the prevention and treatment of paediatric HIV infection over the last two decades, in 2014 there were an estimated 220,000 new paediatric infections attributed to mother-to-child HIV transmission (MTCT) and 150,000 HIV-related paediatric deaths. Furthermore, adolescents remain at particularly high risk for acquisition of new HIV infections, and HIV/AIDS remains the second leading cause of death in this age group. Among the estimated 2.6 million children less than 15 years of age living with HIV infection, only 32% were receiving life-saving antiretroviral treatment. After decades of languishing, good progress is now being made to prevent MTCT. Unfortunately, efforts to scale up HIV treatment services have been less robust for children and adolescents compared with adult populations. These discrepancies reflect substantial gaps in essential services and numerous missed opportunities to prevent HIV transmission and provide effective life-saving antiretroviral treatment to children, adolescents and families. The road to an AIDS-free generation will require bridging the gaps in HIV services and addressing the particular needs of children across the developmental spectrum from infancy through adolescence. To reach the ambitious new targets, innovations and service improvements will need to be rapidly escalated at each step along the prevention-treatment cascade.

CONCLUSIONS

Charting a successful course to reach the 90-90-90 targets will require sustained political and financial commitment as well as the rapid implementation of a broad set of systematic improvements in service delivery. The prospect of a world where HIV no longer threatens the lives of infants, children and adolescents may finally be within reach.

The physical and psychological effects of HIV infection and its treatment on perinatally HIV-infected children

INTRODUCTION

As highly active antiretroviral therapy (HAART) transforms human immunodeficiency virus (HIV) into a manageable chronic disease, new challenges are emerging in treating children born with HIV, including a number of risks to their physical and psychological health due to HIV infection and its lifelong treatment.

METHODS

We conducted a literature review to evaluate the evidence on the physical and psychological effects of perinatal HIV (PHIV+) infection and its treatment in the era of HAART, including major chronic comorbidities.

RESULTS AND DISCUSSION

Perinatally infected children face concerning levels of treatment failure and drug resistance, which may hamper their long-term treatment and result in more significant comorbidities. Physical complications from PHIV+ infection and treatment potentially affect all major organ systems. Although treatment with antiretroviral (ARV) therapy has reduced incidence of severe neurocognitive diseases like HIV encephalopathy, perinatally infected children may experience less severe neurocognitive complications related to HIV disease and ARV neurotoxicity. Major metabolic complications include dyslipidaemia and insulin resistance, complications that are associated with both HIV infection and several ARV agents and may significantly affect cardiovascular disease risk with age. Bone abnormalities, particularly amongst children treated with tenofovir, are a concern for perinatally infected children who may be at higher risk for bone fractures and osteoporosis. In many studies, rates of anaemia are significantly higher for HIV-infected children. Renal failure is a significant complication and cause of death amongst perinatally infected children, while new data on sexual and reproductive health suggest that sexually transmitted infections and birth complications may be additional concerns for perinatally infected children in adolescence. Finally, perinatally infected children may face psychological challenges, including higher rates of mental health and behavioural disorders. Existing studies have significant methodological limitations, including small sample sizes, inappropriate control groups and heterogeneous definitions, to name a few.

CONCLUSIONS

Success in treating perinatally HIV-infected children and better understanding of the physical and psychological implications of lifelong HIV infection require that we address a new set of challenges for children. A better understanding of these challenges will guide care providers, researchers and policymakers towards more effective HIV care management for perinatally infected children and their transition to adulthood.

Factors associated with depression among adolescents living with HIV in Malawi

BACKGROUND

Prior research suggests that a high prevalence of depression, with a detrimental impact on treatment outcomes exists among HIV-infected youth. Data on potential risk factors of depression among HIV-infected youth in sub-Saharan Africa are scarce. This cross-sectional study aimed to identify contributory/protective factors associated with depression in Malawian adolescents 12-18 years old living with HIV.

METHODS

Depression was measured by a validated Chichewa version of the Beck Depression Inventory version-II (BDI-II) and the Children's Depression Rating Scale-Revised (CDRS-R). Data on variables thought to potentially be contributory/protective were collected and included: socio-demographics, past traumatic events/stressors, behavioural factors/social support, and bio-clinical parameters. Chi-square test or two-sample t-test was used to explore associations between factors and depression. Additional testing via linear/logistic regression, adjusting for age and sex, identified candidate variables (p < 0.1). Final regression models included variables with significant main effects and interactions.

RESULTS

Of the 562 participants enrolled (mean age, 14.5 years [SD 2.0]; 56.1% female), the prevalence of depression was 18.9%. In multivariate linear regression, the variables significantly associated with higher BDI-II score were female gender, fewer years of schooling, death in the family/household, failing a school term/class, having a boyfriend/girlfriend, not disclosed or not having shared one's HIV status with someone else, more severe immunosuppression, and bullied for taking medications. Bullying victimization was reported by 11.6% of respondents. We found significant interactions: older participants with lower height-for-age z-scores and dissatisfied with their physical appearance had higher BDI-II scores. In multivariate logistic regression, factors significantly associated with depression were: older age, OR 1.23 (95% CI 1.07-1.42); fewer years of schooling, OR 3.30 (95% CI 1.54-7.05); and bullied for taking medications, (OR 4.20 (95% CI 2.29-7.69).

CONCLUSION

Having fewer years of schooling and being bullied for taking medications were most clearly associated with depression. Programmes to support the mental health needs of HIV-infected adolescents that address issues such as disclosure, educational support, and, most notably, bullying may improve treatment outcomes and are recommended.

Intimate relationships in young adults with perinatally acquired HIV: a qualitative study of strategies used to manage HIV disclosure

An increasing number of children born with perinatally acquired HIV (PAH) are surviving into late adolescence and early adulthood. At this developmental stage, forming and sustaining intimate relationships is important. Young adults with PAH face both normative challenges and additional, HIV-related, relationship stressors. One key issue is the decision about whether and how to share their HIV status with others. Being able to disclose one's HIV status to sexual partners may reduce the risk of onward HIV transmission but is associated with the fear of rejection. There has been little research on how young people with PAH manage such disclosure-related stressors in intimate relationships. This study examined how disclosure challenges are managed by young adults with PAH in the UK within their intimate relationships. Seven participants (five females and two males) currently or previously in an intimate relationship, aged 18-23 years, were recruited from a UK hospital clinic. The majority of participants were of sub-Saharan African origins. They took part in in-depth interviews, with data analysed according to the principles of interpretative phenomenological analysis. Four themes were elicited: (1) decisions about starting, continuing or resuming relationships shaped by disclosure, (2) disclosing early to avoid the pain of future rejection, (3) using condoms to avoid disclosure and (4) testing likely partner reactions to disclosure. The study revealed the significant extent to which HIV disclosure affected the experience of relationships in this population. Interventions to support adolescents and young adults with PAH to disclose to their partners should be developed alongside guidance for professionals. Future research should include older samples of adults with PAH and studies in sub-Saharan African settings.

[Consensus document on psychiatric and psychological aspect in adults and children with HIV infection]

OBJECTIVE

This consensus document is an update of psychiatric and psychological disorders guidelines in HIV-patientes, from the standpoint of care.

METHODS

This document has been approved by expert panel of SPNS, SEP, GESIDA and SEIP, after reviewing the results of efficacy and safety of clinical trials, cohort and pharmacokinetic studies published in biomedical journals (PubMed and Embase) or presented at conferences. The strength of recommendation and gradation of their evidence are based onthe GRADE system.

RESULTS

HIV Patient care should include psychological and psychiatric care which is necessary for early detection thereof. Should suicidal ideation, refer the patient to a psychiatric unit. Pharmacological treatment is recommended when there is comorbidity with moderate or severe depression. You should look for the etiology of neuropsychiatric disorder before using psychoactive drugs in HIV patients. The overall management of the health of HIV adolescents should include an assessment of mental health, environmental stressors and support systems. Training in the management of the patient both own emotions is critical to getting provide optimal care.

CONCLUSIONS

These new guidelines updated previous recommendations regarding psychiatric and psychological disorders, including the most common pathologies in adults and children.

Contemporary issues on the epidemiology and antiretroviral adherence of HIV-infected adolescents in sub-Saharan Africa: a narrative review

Introduction

Adolescents are a unique and sometimes neglected group in the planning of healthcare services. This is the case in many parts of sub-Saharan Africa, where more than eight out of ten of the world's HIV-infected adolescents live. Although the last decade has seen a reduction in AIDS-related mortality worldwide, largely due to improved access to effective antiretroviral therapy (ART), AIDS remains a significant contributor to adolescent mortality in sub-Saharan Africa. Although inadequate access to ART in parts of the subcontinent may be implicated, research among youth with HIV elsewhere in the world suggests that suboptimal adherence to ART may play a significant role. In this article, we summarize the epidemiology of HIV among sub-Saharan African adolescents and review their adherence to ART, emphasizing the unique challenges and factors associated with adherence behaviour.

Methods

We conducted a comprehensive search of online databases for articles, relevant abstracts, and conference reports from meetings held between 2010 and 2014. Our search terms included “adherence,” “compliance,” “antiretroviral use” and “antiretroviral adherence,” in combination with “adolescents,” “youth,” “HIV,” “Africa,” “interventions” and the MeSH term “Africa South of the Sahara.” Of 19,537 articles and abstracts identified, 215 met inclusion criteria, and 148 were reviewed.

Discussion

Adolescents comprise a substantial portion of the population in many sub-Saharan African countries. They are at particular risk of HIV and may experience worse outcomes. Although demonstrated to have unique challenges, there is a dearth of comprehensive health services for adolescents, especially for those with HIV in sub-Saharan Africa. ART adherence is poorer among older adolescents than other age groups, and psychosocial, socio-economic, individual, and treatment-related factors influence adherence behaviour among adolescents in this region. With the exception of a few examples based on affective, cognitive, and behavioural strategies, most adherence interventions have been targeted at adults with HIV.

Conclusions

Although higher levels of ART adherence have been reported in sub-Saharan Africa than in other well-resourced settings, adolescents in the region may have poorer adherence patterns. There is substantial need for interventions to improve adherence in this unique population.

Health-related quality of life in perinatally HIV-infected children in the Netherlands

Combination antiretroviral therapy (cART) can alter HIV infection in children into a chronic condition. Studies investigating health-related quality of life (HRQoL) in HIV-infected children are scarce, and lacking from Western Europe. This study aimed to compare the HRQoL of clinically stable perinatally HIV-infected children to healthy, socioeconomically (SES)-matched controls as well as the Dutch norm population, and to explore associations between HIV and cART-related factors with HRQoL. HIV-infected and healthy children aged 8-18 years completed the Pediatric Quality of Life Inventory™ 4.0 (PedsQL™). We determined differences between groups on PedsQL™ mean scores, and the proportion of children with an impaired HRQoL per group (≥1 SD lower than the Dutch norm population). Logistic regression models were used to explore associations between disease-related factors and HRQoL impairment. In total, 33 HIV-infected and 37 healthy children were included. There were no differences in the mean PedsQL™ subscales between HIV-infected children and both control groups. The proportion of children with an impaired HRQoL was higher in the HIV-infected group (27%) as compared to the healthy control group (22%) and the Dutch norm (14%) on the school functioning subscale (HIV vs. Dutch norm: P = .045). Mean scores of HRQoL of perinatally HIV-infected children in the Netherlands were not different from a SES-matched control group, or from the Dutch norm population. However, the HIV-infected group did contain more children with HRQoL impairment, suggesting that HIV-infected children in the Netherlands are still more vulnerable to a compromised HRQoL.

Immunological correlates of behavioral problems in school-aged children living with HIV in Kayunga, Uganda

BACKGROUND

HIV can affect the neuropsychological function of children, including their behavior. We aim to identify immunological correlates of behavioral problems among children living with HIV in Uganda.

METHODS

Children participating in a parent randomized control trial in Kayunga, Uganda were assessed with the Behavior Rating Inventory of Executive Function (BRIEF) and the Child Behavior Checklist (CBCL). We constructed simple and multiple linear regression models to identify immunological correlates of behavioral problems.

RESULTS

A total of 144 children living with HIV (50% male) with a mean age of 8.9 years [Standard Deviation (s.d.) = 1.9] were included in the analysis. Eighty-two children were on antiretroviral therapy. Mean CD4 cell count % was 35.1 cells/μl (s.d. = 15.0), mean CD4 cell activation 5.7% (s.d. = 5.1), mean CD8 cell activation was 17.5% (s.d. = 11.2) and 60 children (41.7%) had a viral load of <4000 copies/ml. In the adjusted models for the BRIEF, higher scores were associated with higher viral loads (aβ = 16.7 × 10-6, 95% CI -5.00 × 10-6 to 28.4 × 10-6), specifically on the behavioral regulation index. Higher mean CD8 activation % was associated with higher scores on the Externalizing Problems  and Total Problems  scales of the CBCL (aβ = 0.17, 95% CI 0.04-0.31 and aβ = 0.15, 95% CI 0.00-0.28, respectively).

CONCLUSIONS

Poorer behavioral outcomes were associated with higher viral loads while higher CD8 activation was associated with poorer emotional and behavioral outcomes. Complete immunological assessments for children living with HIV could include commonly used viral and immunological parameters to identify those at higher risk of having negative behavior outcomes and who would benefit the most from behavioral interventions.

Psychiatric symptoms and antiretroviral nonadherence in US youth with perinatal HIV: a longitudinal study

OBJECTIVES

The relationship of specific psychiatric conditions to adherence has not been examined in longitudinal studies of youth with perinatal HIV infection (PHIV). We examined associations between psychiatric conditions and antiretroviral nonadherence over 2 years.

DESIGN

Longitudinal study in 294 PHIV youth, 6-17 years old, in the United States and Puerto Rico.

METHODS

We annually assessed three nonadherence outcomes: missed above 5% of doses in the past 3 days, missed a dose within the past month, and unsuppressed viral load (>400 copies/ml). We fit multivariable logistic models for nonadherence using Generalized Estimating Equations, and evaluated associations of psychiatric conditions (attention deficit hyperactivity disorder, disruptive behavior, depression, anxiety) at entry with incident nonadherence using multivariable logistic regression.

RESULTS

Nonadherence prevalence at study entry was 14% (3-day recall), 32% (past month nonadherence), and 38% (unsuppressed viral load), remaining similar over time. At entry, 38% met symptom cut-off criteria for at least one psychiatric condition. Greater odds of 3-day recall nonadherence were observed at week 96 for those with depression [adjusted odds ratio (aOR) 4.14, 95% confidence interval (CI) 1.11-15.42] or disruptive behavior (aOR 3.36, 95% CI 1.02-11.10], but not at entry. Those with vs. without attention deficit hyperactivity disorder had elevated odds of unsuppressed viral load at weeks 48 (aOR 2.46, 95% CI 1.27-4.78) and 96 (aOR 2.35, 95% CI 1.01-5.45), but not at entry. Among 232 youth adherent at entry, 16% reported incident 3-day recall nonadherence. Disruptive behavior conditions at entry were associated with incident 3-day recall nonadherence (aOR 3.01, 95% CI 1.24-7.31).

CONCLUSION

In PHIV youth, comprehensive adherence interventions that address psychiatric conditions throughout the transition to adult care are needed.

Executive function and attention-deficit/hyperactivity disorder in Ugandan children with perinatal HIV exposure

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is among the most commonly diagnosed mental disorders in childhood and is associated with substantial deficits in executive functioning and lost academic and occupational attainment. This study evaluates symptoms of ADHD and their association with neurocognitive deficits in a cohort of rural Ugandan children who were born to HIV-infected mothers.

METHODS

We assessed ADHD symptoms and executive function (including memory and attention) in a non-clinical sample of children born to HIV-infected mothers in rural eastern Uganda. Analyses included assessments of the psychometric properties, factor structure, and convergent and discriminant validity of the ADHD measure (ADHD-Rating Scale-IV); and executive function deficits in children meeting symptom criteria for ADHD.

RESULTS

232 children [54% female; mean age 7.8 years (s.d. 2.0)] were assessed for ADHD and executive function deficits. The ADHD measure showed good internal consistency (α = 0.85.) Confirmatory factor analysis showed an acceptable fit for the diagnostic and statistical manual of mental disorders (DSM-5) two-factor model. Subjects meeting DSM-5 symptom criteria for ADHD had worse parent-rated executive function on six out of seven subscales.

CONCLUSIONS

Our results demonstrate structural validity of the ADHD measure with this population, strong associations between ADHD symptom severity and poorer executive function, and higher levels of executive function problems in perinatally HIV-exposed Ugandan children with ADHD. These findings suggest that ADHD may be an important neurocognitive disorder associated with executive function problems among children in sub-Saharan African settings where perinatal HIV exposure is common.

Rates and correlates of antiretroviral therapy use and virologic suppression among perinatally and behaviorally HIV-infected youth linked to care in the United States

OBJECTIVE

To measure rates of antiretroviral therapy (ART) use and virologic suppression among perinatally HIV-infected youth (PIY) and behaviorally HIV-infected youth (BIY) linked to care in the United States and examine the effects of demographic, biomedical, and psychosocial factors on those rates.

METHODS

Between 2009 and 2012, 649 PIY and 1547 BIY in 20 Adolescent Medicine Trials Network for HIV/AIDS Interventions sites completed cross-sectional surveys through audio computer-assisted self-interviews. Viral load data were collected from chart abstraction or blood draw.

RESULTS

Overall 82.4% of PIY and 49.1% of BIY reported current ART use. Only 37.0% of PIY and 27.1% of BIY were virologically suppressed. Virologic suppression rates did not vary as a function of time since HIV diagnosis in either group. Consistent HIV care and no current substance abuse were significant correlates of ART use among PIY. These variables and non-African American race were some factors associated with virologic suppression for PIY [odds ratios (ORs) P < 0.05]. Among BIY, older age, heterosexuals, employment, and education were significantly related to ART use (ORs: P < 0.05); suppression was related to ART use ≥6 months, ≥90% ART adherence, and consistent HIV care (ORs: P < 0.05). Nearly 75% (n = 498) of nonsuppressed youth reported unprotected sex in the past 3 months.

CONCLUSIONS

There are continued challenges with successfully treating youth even once diagnosed and linked to HIV care. Strategies targeting barriers to ART access, use, and virologic suppression are needed to optimize the impact of the "Treatment as Prevention" paradigm among PIY and BIY.

Mental health and support among young key populations: an ecological approach to understanding and intervention

INTRODUCTION

The patterning of the HIV epidemic within young key populations (YKPs) highlights disproportionate burden by mental disorders in these populations. The mental wellbeing of YKPs is closely associated with biological predispositions and psychosocial factors related to YKPs' sexual and gender identities and socio-economic status. The purpose of this paper is to highlight sources of risk and resilience, as well as identify treatment and supports for mental health disorders (MHDs) among YKPs.

DISCUSSION

This paper utilizes Bronfenbrenner's Bioecological Systems Theory and the Social Stress Model to explore the risk and protective factors for MHDs across YKPs' ecological systems, and identify current gaps in treatment and support for MHDs among these youth. We emphasize the fluidity and intersections across these categorizations which reinforce the vulnerability of these populations, the lack of concrete data to inform mental health interventions among YKPs, and the need to ground YKP interventions and programmes with human rights principles stipulated in the convention on the rights of a child.

CONCLUSIONS

We put forth recommendations for future research and strategies to address the mental wellbeing of YKPs, including the need for integrated interventions that address the multiplicity of risk factors inherent in the multiple group membership, rather than single-focus interventions whilst addressing the unique needs or challenges of YKPs.

What am I 'living' with? Growing up with HIV in Uganda and Zimbabwe

As paediatric HIV treatment has become increasingly available across the world, the global perinatally infected cohort is ageing. However, we know surprisingly little about what it is like to grow up with HIV in resource-stretched settings. We draw on findings from a prospective, qualitative study with HIV-positive children, their carers and healthcare workers from four clinics in Uganda and Zimbabwe to examine children's experiences of living with HIV on treatment. We consider how the HIV experience is made in a symbiotic relationship between children, carers and healthcare workers and shaped by broader discourses. Despite the radical development in prognosis for children, their experience of HIV is largely constructed in relation to a language of 'sickness' through the promotion of medicalised talk and the recounting of past illness stories. This narrow narrative framework both reflects and reproduces core dimensions of the lived experience of growing up with HIV, which emphasises an absence of resilient healthiness in the face of ongoing vulnerability and risk. The challenges that children encounter in articulating alternative narratives that prioritise the relative buoyancy of their health is indicative of the broader uncertainty that exists around the future for these children at this point in the epidemic.

Paediatric HIV grows up: recent advances in perinatally acquired HIV

This review is an update focusing on the current status of paediatric HIV in the UK and Ireland. Successes in prevention of mother to child transmission are highlighted. The changing epidemiology of the UK cohort is summarised and the shift in emphasis of treatment guidelines beyond limiting short-term morbidity and mortality to ensuring optimal health status in adult life is discussed. Current and future challenges relating to an aging cohort, successful transition to adult services and the prospect of a lifetime on antiretroviral therapy (ART), as well as the possibility of ART-free survival are also considered. While numbers of HIV-infected children in the UK are now decreasing, lessons we have learned in the last 30 years from this relatively small cohort are increasingly applicable to the global paediatric HIV population.

Development of a psychosocial distress measure for Ugandan adolescents living with HIV

Psychological distress among adolescents living with HIV (ALH) has been associated with risky behaviors including non-adherence to anti-retroviral therapy, leading to increased risk for AIDS morbidity and mortality. Efforts to establish the nature, prevalence, and impact of psychological distress among ALH in Uganda are hindered by the lack of culturally relevant assessment tools. The purpose of this study was to develop and test a measure for psychological distress for Ugandan ALH aged 12-19 years (N = 508; 53.1 % female). Using a mixed method approach, we developed and tested a 25-item checklist with six subscales-anhedonia, depressive-anxiety, isolation, suicidal ideation, sleep problems, and somatization. We found adequate reliability for the scale (α = 0.89), and a satisfactory measurement structure in our confirmatory factor analyses (RMSEA <1.0, and CFI and TLI >0.90). We discuss the potential use of this culturally sensitive scale to examine psychological distress among ALH in Uganda.

"The sky is the limit": adhering to antiretroviral therapy and HIV self-management from the perspectives of adolescents living with HIV and their adult caregivers

Introduction

Worldwide, HIV-related mortality among adolescents living with HIV (ALHIV) increased by 50% from 2005 to 2012 and is attributed in part to a lack of support for adolescent retention to care and adherence to antiretroviral therapy (ART). This vulnerability reinforces the need to better understand incomplete ART adherence among ALHIV, particularly in sub-Saharan Africa, where the majority of the world's 2.1 million ALHIV reside.

Methods

From December 2011 to February 2012, we conducted in-depth interviews with 32 ALHIV (aged 15 to 18) and 23 of their adult caregivers in the Copperbelt Province of Zambia. Interviews were transcribed and translated. An iterative qualitative process was used to code and analyze the data and main themes were summarized regarding the barriers to and facilitators of ART adherence.

Results

More than a quarter of ALHIV reported missing a day or more of ART (ranging from one day to six months). Barriers to ART adherence included fear of disclosure and anticipated stigma. Few youth were willing to take their drugs outside of the home, which led to missed doses of ART. Similarly, families tended to manage HIV within the home only. As a result, although caregivers and families were often the greatest source of emotional and instrumental support, they coped with HIV in isolation of other potential support from their communities, schools or churches. Factors that supported ART adherence included attending clinic-sponsored youth groups, wanting to maintain one's health and using phone and clock alarms. Involvement of adult caregivers in HIV management varied greatly and was often based on the age and health status of the youth. Some caregivers struggled with letting the adolescents assume responsibility for their medication, and ALHIV had few self-management skills and tools to help them regularly take ART.

Conclusions

These data highlight the importance of families and home environments in supporting adherence to ART among ALHIV. Skill-building and family-based interventions to prepare ALHIV and their adult caregivers for HIV self-management and HIV status disclosure by youth are of paramount importance. Future research and programmes also need to address the fears adolescents and families have regarding HIV-related stigma that shape young peoples’ adherence behaviours.

Growth patterns in the first year of life differ in infants born to perinatally vs. nonperinatally HIV-infected women

OBJECTIVE

To compare the growth patterns in the first year of life between children born to perinatally HIV-infected (PHIV) vs. nonperinatally HIV-infected (NPHIV) women in the United States.

DESIGN

Retrospective cohort study of HIV-infected pregnant women who received care and delivered a live-born at two urban tertiary centers from January 2004 to March 2012.

METHODS

We collected data via chart review on demographics, behavioral risk factors, HIV clinical markers, combination antiretroviral therapy (cART), mode of HIV acquisition, pregnancy outcomes, and infant anthropometrics on study participants. Mixed-effects models were used to assess the association between maternal mode of HIV acquisition and weight-for-age z-score (WAZ), length-for-age z-score (LAZ), and weight-for-length z-score (WLZ).

RESULTS

Of the 152 pregnancies evaluated, 32 and 120 infants were born to 25 PHIV and 99 NPHIV women, respectively. Infants of PHIV women exhibited lower mean WAZ and LAZ throughout the first year of life in unadjusted analyses. After adjusting for potential confounders, the relationship between PHIV women and LAZ persisted (β = -0.54, P = 0.026). Small-for-gestational age for each birth anthropometric parameter (birth length, birth weight, and both birth length and weight) was associated with decreased LAZ (β = -0.48, P = 0.007), WAZ (β = -0.99, P < 0.001), and WLZ (β = -0.36, P = 0.027), respectively. A delivery HIV RNA level below 400 copies/ml was associated with increased WAZ and WLZ (β = 0.43, P = 0.015 and β = 0.38, P = 0.021, respectively).

CONCLUSIONS

Infants of PHIV women may remain at persistently decreased lengths throughout the first year of life. Further studies aimed at understanding intrauterine and environmental factors in PHIV women are warranted.

Substance use and the development of sexual risk behaviors in youth perinatally exposed to HIV

OBJECTIVE

To examine the longitudinal association between sexual behavior and substance use in perinatally HIV-infected (PHIV+) and perinatally HIV-exposed-but-uninfected (PHIV-) youth.

METHODS

Growth curve modeling was used with data from N = 340 PHIV-exposed youth (60.6% PHIV+; 9-22 years) to estimate the onset of penetrative and unprotected sex across time, adding alcohol and marijuana use trajectories as time-varying covariates and examining HIV-status differences.

RESULTS

The odds of penetrative or unprotected sex more than doubled across time. Alcohol and marijuana use significantly increased the odds of engaging in sex and unprotected sex, with no HIV-status differences. The association between unprotected sex and alcohol use was less salient for PHIV+ than PHIV- youth.

CONCLUSIONS

Similar to youth from other populations, PHIV+ and PHIV- youth are increasingly engaging in sex and substance use as they age. Targeted interventions to prevent sexual risk behavior and further HIV transmission should address the influence of substance use.

A systematic review of psychological functioning of children exposed to HIV: using evidence to plan for tomorrow's HIV needs

Prevention of mother to child transmission of HIV can virtually eliminate paediatric HIV infection. Studies are needed to understand child development outcomes for children exposed to HIV in utero but born HIV negative (HIV affected children). This systematic review examined cognitive, developmental and behavioural outcomes for HIV affected children compared to control unexposed and uninfected children. Key word searches of electronic databases generated 1,739 hits and 11 studies with adequate quality design and measures of standardised cognitive, behavioural and developmental indices. Cognitive performance, behaviour and developmental delay were measured with 15 different standardised scales from 650 HIV affected children, 736 control children and 205 HIV positive children. Performance scores for HIV affected children were significantly lower than controls in at least one measure in 7/11 studies. An emerging pattern of delay seems apparent. HIV affected children will grow in number and their development needs to be monitored and provided for.

Adapting Evidence-Based Interventions to Meet the Needs of Adolescents Growing Up with HIV in South Africa: The VUKA Case Example

The VUKA family program is one of the only evidence-based interventions to promote positive psychosocial outcomes in South African HIV-infected pre- and early adolescents and their families. In this paper, we discuss the collaborative process by which a multidisciplinary team of clinicians, researchers, counselors, and artists/educators and families adapted and developed VUKA for this population using community-based participatory research methods. We describe the intervention and explore lessons learned that may be applicable across contexts related to international collaboration and adapting evidence-based interventions so that they are likely to be acceptable, feasible, and effective in a given setting and country context.

HIV and child mental health: a case-control study in Rwanda

BACKGROUND

The global HIV/AIDS response has advanced in addressing the health and well-being of HIV-positive children. Although attention has been paid to children orphaned by parental AIDS, children who live with HIV-positive caregivers have received less attention. This study compares mental health problems and risk and protective factors in HIV-positive, HIV-affected (due to caregiver HIV), and HIV-unaffected children in Rwanda.

METHODS

A case-control design assessed mental health, risk, and protective factors among 683 children aged 10 to 17 years at different levels of HIV exposure. A stratified random sampling strategy based on electronic medical records identified all known HIV-positive children in this age range in 2 districts in Rwanda. Lists of all same-age children in villages with an HIV-positive child were then collected and split by HIV status (HIV-positive, HIV-affected, and HIV-unaffected). One child was randomly sampled from the latter 2 groups to compare with each HIV-positive child per village.

RESULTS

HIV-affected and HIV-positive children demonstrated higher levels of depression, anxiety, conduct problems, and functional impairment compared with HIV-unaffected children. HIV-affected children had significantly higher odds of depression (1.68: 95% confidence interval [CI] 1.15-2.44), anxiety (1.77: 95% CI 1.14-2.75), and conduct problems (1.59: 95% CI 1.04-2.45) compared with HIV-unaffected children, and rates of these mental health conditions were similar to HIV-positive children. These results remained significant after controlling for contextual variables, there were no significant differences on mental health outcomes groups, reflecting a potential explanatory role of factors such as daily hardships, caregiver depression, and HIV-related stigma [corrected].

CONCLUSIONS

The mental health of HIV-affected children requires policy and programmatic responses comparable to HIV-positive children.

Evidence of impact: health, psychological and social effects of adult HIV on children

There is a growing evidence base on the immediate and short-term effects of adult HIV on children. We provide an overview of this literature, highlighting the multiple risks and resultant negative consequences stemming from adult HIV infection on the children they care for on an individual and family basis. We trace these consequences from their origin in the health and wellbeing of adults on whom children depend, through multiple pathways to negative impacts for children. As effective treatment reduces vertical transmission, the needs of affected children will predominate. Pathways include exposure to HIV in utero, poor caregiver mental or physical health, the impact of illness, stigma and increased poverty. We summarize the evidence of negative consequences, including those affecting health, cognitive development, education, child mental health, exposure to abuse and adolescent risk behaviour, including sexual risk behaviour, which has obvious implications for HIV-prevention efforts. We also highlight the evidence of positive outcomes, despite adversity, considering the importance of recognizing and supporting the development of resilience. This study is the first in a series of three commissioned by President's Emergency Plan for AIDS Relief (PEPFAR)/United States Agency for International Development (USAID), the summary provided here was used to inform a second study which seeks to identify insights from the broader child development field which will help us predict what long-term negative consequences children affected by HIV and AIDS are likely to experience. The third study discusses the design of a model to estimate these consequences. Although comprehensive, the review is often hampered by poor-quality research, inadequate design, small sample sizes and single studies in some areas.

Perinatally acquired HIV infection: long-term neuropsychological consequences and challenges ahead

Over the past three decades, perinatal HIV infection in the United States has evolved from a fatal disease to a manageable chronic illness. As the majority of youth with perinatal HIV infection age into adolescence and adulthood, management of this stigmatizing, transmittable disease in the backdrop of a cadre of environmental stressors presents challenges beyond those of other chronic illnesses. The neurologic and neuropsychological consequences of this neurotropic virus have important implications for the successful navigation of responsibilities related to increasingly independent living of this aging population. This article will review the neurologic and neuropsychological consequences of perinatal HIV infection and concomitant factors in the era of highly active antiretroviral therapy and will provide an overview of the neuropathology, pathogenesis, neuroimaging findings, and treatment of perinatal HIV infection, as well as recommendations for service provision and future research.

Enhancing the Emotional Wellbeing of Perinatally HIV Infected Youth across Global Contexts

Increased access to antiretroviral treatment worldwide makes it more possible for children diagnosed with HIV before their 15^th birthday to age into adolescence and beyond. Many HIV+ youth navigate stressors including poverty and resource scarcity, which may converge to produce emotional distress. For over a decade, CHAMP (Collaborative HIV Prevention and Adolescent Mental Health Project) investigators partnered with youth, caregivers, providers and community stakeholders to address the health, mental health and risk taking behaviors of perinatally HIV-infected youth. This paper explores the mental health needs of aging cohorts of HIV+ youth, across three global contexts, New York (U.S.), Buenos Aires (Argentina), and KwaZulu-Natal (South Africa), to inform the development and implementation of combination HIV care and prevention supports for HIV+ youth.

METHODS

Analysis of data pooled across three countries involving HIV+ early adolescents and their caregivers over time (baseline and three month follow-up) was conducted. Univariate and multivariate analyses were applied to data from standardized measures used across sites to identify mental health needs of youth participants. The impact of the site specific versions of a family-strengthening intervention, CHAMP+U.S., CHAMP+Argentina, CHAMP+SA, was also examined relative to a randomized standard of care (SOC) comparison condition.

RESULTS

Analyses revealed mental health resilience in a large proportion of HIV+ youth, particularly behavioral functioning and overall mental health. Yet, significant numbers of caregivers across country contexts reported impaired child emotional and prosocial wellbeing. Significant site differences emerged at baseline. Involvement in the CHAMP+ Family Program was related to significant improvement in emotional wellbeing and a trend towards enhanced prosocial behavior relative to SOC across global sites.

CONCLUSIONS

Ongoing partnerships with youth, family and provider stakeholders across global sites helped to tailor programs like CHAMP+ to specific contextual needs. This has global intervention research and care implications as cohorts of HIV+ children age into adolescence.

Perinatally acquired HIV infection in adolescents from sub-Saharan Africa: a review of emerging challenges

Worldwide, more than three million children are infected with HIV, 90% of whom live in sub-Saharan Africa. As the HIV epidemic matures and antiretroviral treatment is scaled up, children with HIV are reaching adolescence in large numbers. The growing population of adolescents with perinatally acquired HIV infection living within this region presents not only unprecedented challenges but also opportunities to learn about the pathogenesis of HIV infection. In this Review, we discuss the changing epidemiology of paediatric HIV and the particular features of HIV infection in adolescents in sub-Saharan Africa. Longstanding HIV infection acquired when the immune system is not developed results in distinctive chronic clinical complications that cause severe morbidity. As well as dealing with chronic illness, HIV-infected adolescents have to confront psychosocial issues, maintain adherence to drugs, and learn to negotiate sexual relationships, while undergoing rapid physical and psychological development. Context-specific strategies for early identification of HIV infection in children and prompt linkage to care need to be developed. Clinical HIV care should integrate age-appropriate sexual and reproductive health and psychological, educational, and social services. Health-care workers will need to be trained to recognise and manage the needs of these young people so that the increasing numbers of children surviving to adolescence can access quality care beyond specialist services at low-level health-care facilities.

Quality of life and psychosocial well-being among children living with HIV at a care home in Southern India

This study was designed to evaluate the quality of life (QOL) of children living with HIV at an institutional care home in Bangalore, India. The Sneha Care Home is a unique residence that provides educational and community support with a focus on physical, nutritional, medical, and psychological care for orphans and vulnerable children. Cross-sectional health measures and interview data were collected from 97 residents including 52 boys and 45 girls between 5 and 12 years of age (mean age = 9). QOL was measured with the Pediatric Quality of Life 4.0 (PedsQL) Inventory. Caregivers perceived children to have an overall higher QOL than was self-reported by children (total score 83 vs. 78). Our findings indicated self-reported QOL decreased with age of the child, while caregiver-reported QOL increased with age, suggesting a need to ensure greater psychological support for older children. Physical measures showed the children's clinical severity of disease remained well controlled living in this residential, values-based care home.

Youth in transition: life skills among perinatally HIV-infected and HIV-exposed adolescents

OBJECTIVE

To examine mastery of life skills necessary for independent adulthood among perinatally HIV-infected (PHIV+) and perinatally HIV-exposed but uninfected (PHIV-) youth.

METHODS

Participants were recruited from four medical centers in New York City as part of a longitudinal study. Data for this article came from interviews of 150 PHIV+ and 95 PHIV- youth (age 13-24 years) and their caregivers. Life skills mastery was assessed using the Ansell-Casey Life Skills Assessment (ACLSA).

RESULTS

PHIV+ youth had lower daily living skill mastery than PHIV- youth according to both youth and caregivers, and lower self-care mastery according to caregiver report. No HIV-status group differences were found in social relationships scores, but PHIV- youth had higher scores than an ACLSA benchmark sample.

CONCLUSIONS

PHIV+ youth may need supportive services in daily living and self-care needs to transition into adulthood. Normal-to-high functioning in social relationships may be important for learning to live independently.

The challenges of success: adolescents with perinatal HIV infection

The great success in the prevention and treatment of pediatric HIV in high resource countries, and now in low resource countries, has changed the face of the HIV epidemic in children from one of near certain mortality to that of a chronic disease. However, these successes pose new challenges as perinatally HIV-infected youth survive into adulthood. Increased survival of HIV-infected children is associated with challenges in maintaining adherence to what is likely life-long therapy, and in selecting successive antiretroviral drug regimens, given the limited availability of pediatric formulations, limitations in pharmacokinetic and safety data of drugs in children, and the development of extensive drug resistance in multi-drug-experienced children. Pediatric HIV care must now focus on morbidity related to long-term HIV infection and its treatment. Survival into adulthood of perinatally HIV-infected youth in high resource countries provides important lessons about how the epidemic will change with increasing access to antiretroviral therapy for children in low resource countries. This series of papers will focus on issues related to management of perinatally infected youth and young adults.