HIV in adolescents: what we know and what we need to know

The Associations of Mental Health Disturbances, Self-Esteem, and Partner Violence Victimization with Condom Use in Spanish Adolescents

Risky sexual behaviors, such as not using a condom for preventing sexually transmittable diseases and unwanted pregnancies, are associated with emotional and psychological problems in adolescence, including higher levels of depression, anxiety, stress, and low self-esteem. Adolescents with a history of violence victimization are also at increased risk of engaging in sexual risk behaviors. In this study, we examined the associations between mental health disturbances and partner violence victimization and the non-use of condoms among young people in Spain. We also examined self-esteem as a mediator of mental health problems and unprotected sexual relationships. A cross-sectional study was conducted on a sample of 831 adolescents randomly selected from 25 high schools in Spain. From the initial sample, 285 students (144 men and 141 women) from high schools in Alicante (Spain) who reported having experienced sexual activity with at least one partner were approached. The results showed that one in three adolescents between 14 and 19 years old did not use condoms during sexual intercourse. The factors associated with the non-use of condoms in the estimated models of Poisson robust variance were having a history of physical, psychological, or sexual violence; having been expelled from school because of behavioral problems; and having higher levels of depression, anxiety, and stress and lower levels of self-esteem. Self-esteem was independently associated with the non-use of condoms. Having lower levels of self-esteem increased the risk of not using a condom during participants’ last sexual intercourse. These findings suggest the importance of developing public health strategies for mental health promotion to increase condom use among adolescents.

Psychiatric Disorders in Adolescents Living with HIV and Association with Antiretroviral Therapy Adherence in Sub-Saharan Africa: A Systematic Review and Meta-analysis

In sub-Saharan Africa (SSA), a systematic approach to exploring the prevalence of psychiatric disorders (PDs) and adherence to antiretroviral treatment (ART) in adolescents living with HIV (ALWHIV) is lacking. This study aimed to systematically review the studies conducted in SSA on the prevalence of PDs among ALWHIV and their association with ART adherence. A systematic search of all English studies assessing PDs among ALWHIV using the Web of Science, PubMed, and EBSCO databases was conducted between March 1 and September 30, 2019. Forty-two studies published between 2009 to 2019 met the inclusion criteria, of which 15 were included in the meta-analysis. The most common PDs were depression (0.24, 95% CI 0.14-0.36) and anxiety disorder (0.26, 95% CI 2-0.44). The available evidence could not conclude on the definitive association between PDs and ART adherence; therefore, further research is required. However, the need for mental health integration in the care for ALWHIV is evident.

Unwelcoming: The Church Experiences of HIV-Infected Adolescents and Emerging Adults

Acceptance among family, friends, and within the community is a critical developmental milestone during adolescence. Having a diagnosis of HIV may hinder or impede one's ability to develop socially. The purpose of our original study was to describe the role spirituality may play in HIV-infected adolescents and emerging adults. We interviewed 21 Christian-identified males using constructivist grounded theory methodology. The theory of the church not embracing HIV-infected youth was generated. The theme "unwelcoming" describes young people's attempts to connect with the church. Embracing adolescents and emerging adults in church may offer support and enhance their ability to cope with HIV.

A comparative study of the psychological problems of HIV-infected and HIV-uninfected children in a South African sample

According to research children living with HIV experience elevated levels of depression, anxiety, ADHD and disruptive behavioural disorders. Although South Africa's paediatric population that is infected with the human immunodeficiency virus (HIV) is the largest worldwide, little research has been conducted on their mental health challenges. However, attributing high levels of mental health problems solely to their HIV status can be problematic as there may be other contributory factors. This research explored the mental health problems of HIV-infected children and compared these to the mental health problems of their HIV-unaffected peers from similar backgrounds. Data was gathered from two samples of child and caregiver pairs. HIV-infected children (aged 6-12 years) and their caregivers/mothers (n = 54) were recruited from the Kalafong paediatric clinic where they received medical treatment and routine ART. A comparison group of 113 HIV-uninfected children and their uninfected mothers were recruited from primary care clinics in the same community. Caregivers completed the Child Behaviour Checklist (CBCL) to assess children's mental health. Children completed the Self-Description Questionnaire (SDQ-I) and the Revised Children's Manifest Anxiety Scale (RCMAS). The scores of the psychometric sub-scales of the two groups were compared using parametric and non-parametric statistics. HIV-infected children experienced more somatic and affective problems, physiological anxiety, less ADHD and lower self-esteem than HIV-uninfected children in the comparison group, while controlling for age differences. The high levels of mental health problems of both groups of children may be attributed to similar difficult socio-economic circumstances. The fact that most infected children were not aware of their HIV-status could have influenced the results. Mental health services should not be limited to HIV-infected children but should form part of all health care services.

The relationship between future time perspective, self-efficacy and risky sexual behaviour in the Black youth of central South Africa

BACKGROUND

An interest exists in understanding why adolescents partake in risky sexual behaviours, as well as the risk and protective practices associated with risky sexual behaviour.

AIM

The aim of this study was to investigate the moderator effect of future time perspective in the relationship between self-efficacy and risky sexual behaviour.

METHODS

A random cluster consisting of 467 learners from English medium high schools of central South Africa participated in this study. The participants' risky sexual behaviour, self-efficacy and future time perspective were measured with the Perceptions of HIV/AIDS Risk Survey, Generalised Perceived Self-efficacy Scale and the Zimbardo Time Perspective Inventory, respectively. Product term regression analysis was performed.

RESULTS

It was found that both self-efficacy and future time perspective were negatively related to risky sexual behaviour. No moderating effect was found for future time perspective in the relationship between self-efficacy and risky sexual behaviour.

CONCLUSIONS

Self-efficacy and future time perspective were identified as qualities that protect adolescents from engaging in risky sexual behaviours. This finding can be useful in developing prevention programmes. Intervention programmes aimed at the youth should foster a sense of hope and possibility about the future and the development of goals and aspirations to prevent risky behaviour.

Comparative Effectiveness of Web-Based vs. Educator-Delivered HIV Prevention for Adolescent Substance Users: A Randomized, Controlled Trial

BACKGROUND

Young people who engage in substance use are at risk for becoming infected with HIV and diseases with similar transmission dynamics. Effective disease prevention programs delivered by prevention specialists exist but are rarely provided in systems of care due to staffing/resource constraints and operational barriers-and are thus of limited reach. Web-based prevention interventions could possibly offer an effective alternative to prevention specialist-delivered interventions and may enable widespread, cost-effective access to evidence-based prevention programming. Previous research has shown the HIV/disease prevention program within the Web-based therapeutic education system (TES) to be an effective adjunct to a prevention specialist-delivered intervention. The present study was the first randomized, clinical trial to evaluate the comparative effectiveness of this Web-based intervention as a standalone intervention relative to a traditional, prevention specialist-delivered intervention.

METHODS

Adolescents entering outpatient treatment for substance use participated in this multi-site trial. Participants were randomly assigned to either a traditional intervention delivered by a prevention specialist (n=72) or the Web-delivered TES intervention (n=69). Intervention effectiveness was assessed by evaluating changes in participants' knowledge about HIV, hepatitis, and sexually transmitted infections, intentions to engage in safer sex, sex-related risk behavior, self-efficacy to use condoms, and condom use skills.

FINDINGS

Participants in the TES intervention achieved significant and comparable increases in HIV/disease-related knowledge, condom use self-efficacy, and condom use skills and comparable decreases in HIV risk behavior relative to participants who received the intervention delivered by a prevention specialist. Participants rated TES as easier to understand.

CONCLUSION

This study indicates that TES is as effective as HIV/disease prevention delivered by a prevention specialist. Because technology-based interventions such as TES have high fidelity, are inexpensive and scalable, and can be implemented in a wide variety of settings, they have the potential to greatly increase access to effective prevention programming.

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.

Sexual and reproductive health: progress and outstanding needs

We examine progress towards the 1994 International Conference on Population and Development (ICPD) commitment to provide universal access to sexual and reproductive health (SRH) services by 2014, with an emphasis on changes for those living in poor and emerging economies. Accomplishments include a 45% decline in the maternal mortality ratio (MMR) between 1990 and 2013; 11.5% decline in global unmet need for modern contraception; ~21% increase in skilled birth attendance; and declines in both the case fatality rate and rate of abortion. Yet aggregate gains mask stark inequalities, with low coverage of services for the poorest women. Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 80 developing countries highlight persistent disparities in skilled birth attendance by household wealth: in 70 of 80 countries (88%), ≥80% of women in the highest quintile were attended by a skilled provider at last birth; in only 23 of the same countries (29%) was this the case for women in the lowest wealth quintile. While there have been notable declines in HIV incidence and prevalence, women affected by HIV are too often bereft of other SRH services, including family planning. Achieving universal access to SRH will require substantially greater investment in comprehensive and integrated services that reach the poor.

Immune markers predictive of neuropsychiatric symptoms in HIV-infected youth

The purpose of this study was to evaluate possible associations between systemic immune dysregulation (activated CD8(+) T lymphocytes and natural killer [NK] cell count/function) and symptoms of depression and anxiety in youth with horizontally (behaviorally) acquired HIV infection. This secondary analysis of a previously collected prospective cohort included 323 youth with horizontally acquired HIV infection enrolled in the Reaching for Excellence in Adolescent Care and Health (REACH) cohort of the NICHD/NIH. A multivariable linear regression model with generalized estimating equations for intraindividual repeated measures was used to examine the relationship between flow cytometry measurements of activated T lymphocytes (CD8(+) CD38(+)), NK cells (CD3(-) CD16(+) CD56(+)), and NK cell functional activity (lytic units per NK cell and per peripheral blood mononuclear cell) and their association with subsequent symptoms of depression (Center for Epidemiologic Studies depression scale) and anxiety (Revised Children's Manifest Anxiety Scale). Higher measures of NK cell functional activity were associated with fewer anxiety symptoms measured 12 months later in crude and adjusted analyses. Higher counts of activated T cells were associated with fewer depression symptoms measured 12 months later in adjusted analysis. NK cell function and activated T-lymphocyte count may be related to subsequent symptoms of depression and anxiety.

Behavioral disinhibition and sexual risk behavior among adolescents and young adults in Malawi

BACKGROUND

While behavioral factors such as early age of sexual debut, inconsistent use of condoms and multiple sexual partners have been studied in Africa, less is known about how characteristics such as impulsivity and externalizing behaviors relate to HIV-related sexual risk-taking in that region. The purpose of this study was to develop a culturally adapted behavioral disinhibition index in a sample of adolescents and young adults in Malawi. We then sought to examine the relationship between the index and sexual risk behavior as measured by multiple sexual partners and number of lifetime sexual partners.

METHODS

Cross-sectional data were collected from 2342 participants in rural Malawi aged 15 to 29 years. We constructed a disinhibitory behavior score (DBS) using questions assessing disinhibitory behaviors. Bivariate analyses were conducted to assess the relationships among the individual DBS component behaviors. We utilized multivariable logistic regression to determine the association of the DBS with multiple sexual partners, and negative binomial regression to model the relationship between the DBS and number of lifetime sexual partners.

FINDINGS

Nearly all the DBS component behaviors were significantly associated in the bivariate analyses. The DBS was associated with having multiple sexual partners (OR 1.97; 95% CI 1.57-2.48) in the multivariable logistic regression analysis. Further, negative binomial regression results demonstrated that the DBS was associated with an increased number of lifetime sexual partners (OR 1.11; 95% CI 1.07-1.16).

CONCLUSIONS

HIV preventive programs in Africa should take into consideration disinhibitory behaviors that may be associated with sexual risk-taking. The DBS can be used as a simple tool to identify those who may be more likely to engage in these behaviors and provide useful information regarding which groups of individuals particularly need to be targeted for behavior change interventions.

Family group psychotherapy to support the disclosure of HIV status to children and adolescents

Disclosure of the HIV status to infected children is often delayed due to psychosocial problems in their families. We aimed at improving the quality of life in families of HIV-infected children, thus promoting disclosure of the HIV status to children by parents. Parents of 17 HIV-infected children (4.2-18 years) followed at our Center for pediatric HIV, unaware of their HIV status, were randomly assigned to the intervention group (8 monthly sessions of family group psychotherapy, FGP) or to the control group not receiving psychotherapy. Changes in the Psychological General Well-Being Index (PGWB-I) and in the Short-Form State-Trait Anxiety Inventory (Sf-STAI), as well as the HIV status disclosure to children by parents, were measured. Ten parents were assigned to the FGP group, while 7 parents to the controls. Psychological well-being increased in 70% of the FGP parents and none of the control group (p=0.017), while anxiety decreased in the FGP group but not in controls (60% vs. 0%, p=0.03). HIV disclosure took place for 6/10 children of the intervention group and for 1/7 of controls. Family group psychotherapy had a positive impact on the environment of HIV-infected children, promoting psychological well-being and the disclosure of the HIV status to children.

When HIV-positive children grow up: a critical analysis of the transition literature in developed countries

Young people with perinatally acquired HIV are routinely problematized in the research literature as inadequately equipped to manage transition to adolescent sexuality and adult clinical care without comprehensive interventions, partly because of challenges associated with adolescence itself, and partly because of neurocognitive and psychosocial dysfunctions commonly attributed to these children. However, little is actually known about this population, given their recent emergence in the HIV epidemic. Using critical discourse analysis, we argue that several problematic assumptions operate in this literature, hampering the objective of understanding these young people. Our analysis can contribute to a reframing of future research on HIV-positive adolescents, by encouraging greater attunement to the experiences of the adolescents themselves and to the discursive meanings that underpin research agendas, so that different and more productive questions can be asked and answered.

Computer-assisted HIV prevention for youth with substance use disorders

We developed an interactive, customizable, Web-based program focused on the prevention of HIV, sexually transmitted infections, and hepatitis among youth. Results from a randomized, controlled trial with youth in treatment for substance use demonstrated that this Web-based tool, when provided as an adjunct to an educator-delivered prevention intervention, increased accurate prevention knowledge, increased intentions to carefully choose partners, and was perceived as significantly more useful relative to the educator-delivered intervention when provided alone. Results suggest this Web-based program may be effective and engaging and may increase the adoption of effective HIV and disease prevention science for youth. Limitations are discussed.