Psychiatric disorders and young adult milestones in HIV-exposed, uninfected youth

"We did more than survive": lessons learned from studies of risk and resilience of young people growing up with HIV and mental health needs

Despite advances in HIV-treatment, adolescents and young adults (AYA) with HIV (AYAHIV) face myriad challenges. They are less likely than children and older adults to be virally suppressed and are at higher risk for mental health conditions compared to their peers who do not have HIV. AYA are also developing in the context of numerous biomedical, neurocognitive, and psychosocial developmental changes. Normative challenges during this time can be exacerbated by HIV and can result in significant physical and mental health problems. Yet, many AYAHIV have shown resilience with positive assets and resources and few health or mental health problems. Historically research has had a risk-focused approach to understanding AYAHIV needs. This paper discusses the rationale for a shift from a risk-focused only approach to one that examines AYAHIV needs from both a risk and resilience perspective. This paper presents: (1) epidemiological data on AYAHIV; (2) conceptual models for understanding both risk (e.g., poverty, stress, trauma, limited resources) and resilience/protective factors (e.g., family and peer support, future orientation, problem-solving skills); (3) global data examining risk and protective factors for physical and mental health challenges; and (4) promising interventions that incorporate elements of resilience to improve overall outcomes among AYAHIV.

Adults with Perinatally Acquired HIV; Emerging Clinical Outcomes and Data Gaps

In resourced settings, adults living with perinatally acquired HIV are approaching the 5th decade of life. Their clinical and psychological outcomes highlight potential future issues for the much larger number of adolescents growing up with HIV in sub-Saharan Africa, and will inform the development of appropriate healthcare services. Lifelong exposure to HIV, and increasingly to antiretroviral therapy throughout growth and development, contrasts with adults acquiring HIV in later life. This review describes the clinical outcomes for adults living with perinatally acquired HIV including post transition mortality, morbidity and retention in care. Rates of viral suppression, drug resistance and immunological function are explored. Co-morbidities focus on metabolic, cardiovascular, respiratory and bone health with quality-of-life data including neurocognitive functioning and mental health. Sexual and reproductive health including vaccine-preventable disease and the prevention of onward transmission to partners and infants are considered. The data gaps and future research questions to optimise outcomes for this emerging adult cohort are highlighted.

Psychiatric disorders in perinatally HIV-exposed, uninfected children: a systematic review

The population of perinatally HIV-exposed but uninfected (HEU) children is growing rapidly globally. However, perinatal HIV and antiretroviral (ARV) medicine exposure in HIV-uninfected children has raised concerns about HEU children's mental well-being. The objective of this study was to systematically review the literature on psychiatric disorders in HEU children. The PRISMA guideline was used as a methodical frame of reference. A systematic search was conducted in 5 databases. Data from the included studies were extracted, and the results were summarized qualitatively. The search identified 1,976 articles of which 105 were eligible for full-text analysis. 13 studies met the inclusion criteria. Eight studies compared psychiatric disorder prevalence in perinatally HIV-infected children with HEU children, and only one study found a difference between the two groups. Three studies found that HEU children had a higher prevalence of psychiatric disorders compared with HIV-unexposed, uninfected (HUU) children. These findings indicate that factors such as psychosocial stress, socioeconomic status, and stigma contribute to the increased risk of mental disorders in HEU children. More research is needed comparing HEU children with HUU children adjusting for potential confounders that might partially explain the higher rates seen in the HIV-exposed population.Prospero ID: CRD42020212420.

Psychiatric Diagnoses Among HIV-Exposed and HIV-Unexposed Uninfected Children: A Danish Nationwide Cohort Study

This nationwide registry-based cohort study aimed to compare the risk of psychiatric diagnoses among HIV-exposed uninfected (HEU) children with a matched comparison group of HIV-unexposed uninfected (HUU) children, born in Denmark. We hypothesized that HEU children had an increased risk of psychiatric diagnoses and that this increased risk may differ by sex and age. All HEU children born in Denmark between year 2000 and 2020 were included. Each HEU child was matched by year of birth, maternal age at birth, and maternal immigration status to 10 HUU children. The primary outcome was risk of any psychiatric diagnosis (International Classification of Diseases, 10th Revision F00-F99). Incidence rate ratios (IRRs) were estimated using Poisson regression. Analyses stratifying by sex and age were also conducted. In total, 550 HEU children and 5500 HUU children were included. HEU children had an increased risk of any psychiatric disorder [IRR 1.45; 95% confidence interval (CI): 1.04-2.04] in the unadjusted analysis, but in the adjusted analysis, the risk was only significant for children aged 6-11 years [adjusted incidence rate ratio (aIRR) 1.93; 95% CI: 1.14-3.28]. Stratifying by sex, girls aged 6-11 years had an increased risk of any psychiatric disorder (aIRR 3.04; 95% CI: 1.27-7.28), while boys had an increased risk at age 12-20 years (aIRR 2.47; 95% CI: 1.18-5.17). In conclusion, HEU girls aged 6-11 years and HEU boys aged 12-20 years had an increased risk of any psychiatric disorder compared with HUU girls and boys, respectively. These findings highlight the importance of addressing the mental health needs of HEU children/adolescents.

Interventions to address the mental health of adolescents and young adults living with or affected by HIV: state of the evidence

INTRODUCTION

Adolescents and young adults (AYA) remain vulnerable to HIV-infection and significant co-morbid mental health challenges that are barriers to treatment and prevention efforts. Globally millions of AYA are living with HIV (AYALH) and/or have been affected by HIV in their families (AYAAH), with studies highlighting the need for mental health programmes. With no current guidelines for delivering mental health interventions for AYALH or AYAAH, a scoping review was undertaken to explore current evidence-based mental health interventions for AYALH and AYAAH to inform future work.

METHODS

The review, targeting work between 2014 and 2020, initially included studies of evidence-based mental health interventions for AYALH and AYAAH, ages 10 to 24 years, that used traditional mental health treatments. Given the few studies identified, we expanded our search to include psychosocial interventions that had mental health study outcomes.

RESULTS AND DISCUSSION

We identified 13 studies, seven focused on AYALH, five on AYAAH, and one on both. Most studies took place in sub-Saharan Africa. Depression was targeted in eight studies with the remainder focused on a range of emotional and behavioural symptoms. Few studies used evidence-based approaches such as Cognitive Behaviour Therapy; psychosocial approaches included mental health treatments, group-based and family strengthening interventions, economic empowerment combined with family strengthening, group-based mindfulness and community interventions. Eleven studies were randomized control trials with four pilot studies. There was variation in sample size, treatment delivery mode (individual focus, group-based, family focus), and measures of effectiveness across studies. Most used trained lay counsellors as facilitators, with few using trained mental health professionals. Eleven studies reported positive intervention effects on mental health.

CONCLUSIONS

Despite the need for mental health interventions for AYALH and AYAAH, we know surprisingly little about mental health treatment for this vulnerable population. There are some promising approaches, but more work is needed to identify evidence-based approaches and corresponding mechanisms of change. Given limited resources, integrating mental health treatment into healthcare settings and using digital health approaches may support more standardized and scalable treatments. Greater emphasis on implementation science frameworks is needed to create sustainable mental health treatment for AYALH and AYAAH globally.

State of the Mind: Growing up with HIV

Human immunodeficiency virus (HIV) is a neurotropic virus that has a detrimental impact on the developing central nervous system (CNS) of children growing up with perinatal HIV (PHIV) due to a combination of pathophysiological processes related to direct viral cytopathic effects and immune activation. This leads to a spectrum of neurocognitive impairment ranging from severe encephalopathy to subtle domain-specific cognitive impairments, as well as psychological disorders that are compounded by HIV-related stigma and sociodemographic factors that disproportionately affect PHIV children. Early commencement and consistent use of combination antiretroviral therapy (cART) has resulted in a dramatic improvement in neuropsychological outcomes for PHIV children; however, they remain vulnerable to cognitive impairment and psychological disorders, as evidenced by imaging findings, randomised clinical trials and observational studies. An optimal neuroprotective cART regimen remains elusive in children, but systemic viral suppression, regular neurocognitive and psychological screening and ready access to neuropsychological management strategies are key components for optimising neuropsychological outcomes. However, a lack of standardised and validated screening tools, particularly in resource-limited settings, hinders a precise understanding of the nature, prevalence and associations between neuropsychological symptomatology and HIV health. This article reviews the natural history, cellular pathophysiology and structural and functional imaging findings for children growing up with HIV, as well as summarising management strategies related to antiretroviral therapy, screening tools and specific interventions for neurocognitive impairments and psychological disorders.

Psychiatric trajectories across adolescence in perinatally HIV-exposed youth: the role of HIV infection and associations with viral load

OBJECTIVE

Identify factors associated with trajectories of psychiatric disorder among 340 adolescents and young adults (AYA) living with perinatal HIV infection (PHIV) and perinatal HIV-exposure but not infection (PHEU).

DESIGN

Longitudinal cohort study of AYA in New York City, 9-16 years at enrollment.

METHODS

We used multivariate longitudinal latent class analysis to identify trajectories of psychiatric disorder, and logistic regression to examine predictors of trajectories (e.g. PHIV status) and associations between trajectories and viremia in young adulthood (AYA with PHIV only).

RESULTS

Among all AYA, we identified three psychiatric trajectories: relatively 'low disorder' (63%), 'consistent anxiety' (26%), and 'escalating comorbidity' (11%). Compared with AYA with 'low disorder', AYA with 'escalating comorbidity' were significantly older, reported more neighborhood stress, and lived with a caregiver with alcohol use disorder, whereas AYA with 'consistent anxiety' were more likely female individuals. Although we found no statistically significant HIV status differences, among AYA with PHIV, nearly half (48%) were viremic in young adulthood, with higher odds of viremia among AYA with 'escalating comorbidity' (OR: 3.88, 95% CI: 0.93-16.26) and 'consistent anxiety' (OR: 2.41, 95% CI: 1.011-5.75) compared with 'low disorder'.

CONCLUSION

Despite significant adversity, AYA with PHIV and PHEU had relatively low prevalence of psychiatric disorder over time, although one-third had consistent or escalating psychiatric disorders. Among AYA with PHIV, psychiatric trajectories were associated with viremia in young adulthood. Given the growing population of AYA living with PHIV and PHEU worldwide, addressing the substantial and evolving mental health needs of both groups as they reach young adulthood is critical.