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

Prevalence and Correlates of Substance Use Among Youth Living with HIV in Fishing Communities in Uganda

Alcohol and drug use (ADU) poses a significant barrier to optimal HIV treatment outcomes for adolescents and youths living with HIV (AYLHIV). We aimed to investigate the prevalence and correlates of ADU among ALHIV in Ugandan fishing communities, areas characterized by high HIV and poverty rates. AYLHIV aged 18-24, who knew they were HIV-positive, were selected from six HIV clinics. Substance use was determined through self-report in the last 12 months and urine tests for illicit substances. Utilizing a socioecological framework, the study structured variables into a hierarchical logistic regression analysis to understand the multi-layered factors influencing ADU. Self-reported past 12 months substance use was 42%, and 18.5% of participants had a positive urine test for one or more substances, with alcohol, benzodiazepines, and marijuana being the most commonly used. With the addition of individual-level socio-demographics, indicators of mental health functioning, interpersonal relationships, and community factors, the logistic regression analysis revealed greater exposure to adverse childhood experiences increased the odds of substance use (Odds Ratio [OR] = 1.24; 95% Confidence Interval [CI]: 1.03-1.55). Additionally, exposure to alcohol advertisements at community events significantly raised the odds of substance use (OR = 3.55; 95% CI: 1.43-8.83). The results underscore the high prevalence among AYLHIV and emphasize the need for comprehensive interventions targeting individual (e.g., life skills education and mental health supports), interpersonal (e.g., peer support and family-based interventions), community (e.g., community engagement programs, restricted alcohol advertisements and illicit drug access), and policies (e.g., integrated care models and a national drug use strategy), to address ADU.

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.

A qualitative analysis of self-management needs of adolescents and young adults living with perinatally acquired HIV in rural, southwestern Uganda

The number of adolescents living with HIV remains high in sub-Saharan Africa with poorer HIV treatment outcomes among adolescents and young adults compared to individuals in other age groups. For adolescents and young adults living with perinatally acquired HIV (AYLPHIV), the transition from pediatric to adult HIV care is a particularly high-risk period. We conducted a qualitative study to understand self-management needs of AYLPHIV in rural, southwestern Uganda as they prepare to transition to adult HIV care in order to inform relevant interventions that can enable AYLPHIV acquire the necessary skills to manage their illness as they age into adulthood. We conducted 60 in-depth interviews with AYLPHIV (n = 30), caregivers (n = 20) and health care providers (n = 10) from the HIV clinic at Mbarara Regional Referral Hospital. We used an interview guide that focused on perceptions about transition to adult HIV care, challenges with transitioning, navigating HIV care, and self-management needs for AYLPHIV (from the perspectives of AYLPHIV, their caregivers, and health care providers). We used thematic analysis to identify themes related to AYLPHIV's self-management skills. We identified several self-management needs that we grouped under two major themes; social support and empowerment for AYLPHIV to assume responsibility for their own health and to navigate adult HIV care independently. The sub-themes under social support were information support, instrumental support, and emotional support as the sub themes while sub-themes under empowerment included self-advocacy skills, interpersonal skills, self-care skills, and disclosure skills. Taken together, these findings indicate that AYLPHIV need to be supported and empowered to maximize their chances of successfully transitioning to adult HIV care. Support comes from peers and caregivers. AYLPHIV require knowledge about their HIV status and empowerment with different skills including: self-advocacy skills, interpersonal skills, self-care skills, and HIV status disclosure skills, in order to assume responsibilities related to independent HIV care.

Mobile Phone Technology for Preventing HIV and Related Youth Health Problems, Sexual Health, Mental Health, and Substance Use Problems in Southwest Uganda (Youth Health SMS): Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

East and Southern Africa have the highest HIV incidence and prevalence in the world, with adolescents and young adults being at the greatest risk. Despite effective combination prevention tools, including the recently available pre-exposure prophylaxis (PrEP), HIV incidence among adolescents and young adults in Uganda remains high, and PrEP use remains low. Mental health and substance use (behavioral health) play a role in sexual behavior and decision-making, contributing to an increase in the risk for acquiring HIV. Interventions that target multiple HIV risk factors, including sexual and mental health and problematic substance use, are crucial to ending the HIV epidemic. Yet few interventions addressing HIV related health disparities and comorbidities among adolescents and young adults in East and Southern Africa currently exist.

OBJECTIVE

This study aims to evaluate the acceptability and feasibility of Kirabo, an SMS text message intervention informed by the information, motivation, and behavior model and to be disseminated through secondary schools. The study will gather preliminary estimates of Kirabo's effectiveness in increasing HIV testing and linking users to mental health counselors.

METHODS

We identified Mobile 4 Reproductive Health for adaptation using the assessment, decision, administration, production, topical experts, integration, training, testing (ADAPT-ITT) framework. Mobile 4 Reproductive Health is an evidence-based automated 2-way SMS text messaging and interactive voice response platform that offers sexual and reproductive health information and links users to HIV clinics in East Africa. Through ADAPT-ITT we refined our approach and created Kirabo, an SMS text message-based intervention for linking adolescents and young adults to health services, including HIV testing and mental health counseling. We will conduct a 2-arm randomized controlled trial in Masaka, Uganda. Adolescents (N=200) will be recruited from local schools. Baseline sociodemographic characteristics, HIV test history, and behavioral health symptoms will be assessed. We will evaluate acceptability and feasibility using surveys, interviews, and mobile phone data. The preliminary efficacy of Kirabo in increasing HIV testing and linking users to mental health counselors will be evaluated immediately after the intervention and at the 3-month follow-up. We will also assess the intervention's impact on self-efficacy in testing for HIV, adopting PrEP, and contacting a mental health counselor.

RESULTS

Intervention adaptation began in 2019. A pretest was conducted in 2021. The randomized controlled trial, including usability and feasibility assessments and effectiveness measurements, commenced in August 2023.

CONCLUSIONS

Kirabo is a tool that assists in the efforts to end the HIV epidemic by targeting the health disparities and comorbidities among adolescents in Uganda. The intervention includes local HIV clinic information, PrEP information, and behavioral health screening, with referrals as needed. Increasing access to prevention strategies and mitigating factors that make adolescents and young adults susceptible to HIV acquisition can contribute to global efforts to end the HIV epidemic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05130151; https://clinicaltrials.gov/study/NCT05130151.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49352.

Condomless Sex Among HIV-affected AYA in an Era of Undetectable = Untransmittable and Pre-exposure Prophylaxis

Given poor adherence to treatment and prevention techniques, condomless sex jeopardizes adolescents and young adults (AYA) with perinatally-acquired HIV-infection (PHIV) or perinatal HIV-exposure who are uninfected (PHEU). We examined condomless sex and its association with PHIV-status, psychiatric disorder, and sociodemographics. Data come from a US-based study of primarily Black and Latinx AYAPHIV and AYAPHEU (N = 340). Linear regression models examined condomless sex longitudinally by PHIV-status, psychiatric trajectories, and sociodemographics. Rates of viremia (AYAPHIV) and PrEP use (AYAPHEU) were assessed. 56% of participants reported recent condomless sex, with higher prevalence among: AYAPHEU vs. AYAPHIV (24% vs. 19%, p = 0.017); Latinx vs. non-Latinx AYA (25% vs. 17%, p = 0.014); and AYA with increasing psychiatric comorbidity (44%) and consistent anxiety (23%) vs. low-level disorder (17%; p < 0.05). AYAPHIV had high rates of unsuppressed viral load and AYAPHEU limited PrEP use. Preventing condomless sex is challenging within AYAPHIV and AYAPHEU. Developing accessible combination HIV/mental health interventions is much-needed.

Assessing the Feasibility of Economic Approaches to Prevent Substance Abuse Among Adolescents: Protocol for a Mixed Methods Study

BACKGROUND

Adolescent alcohol and drug use (ADU) is a significant public health challenge. Uganda, one of the poorest countries in Sub-Saharan Africa (SSA), has the second-highest rate of per capita alcohol consumption in SSA, and over one-third of Ugandan adolescents have used alcohol in their lifetime (over 50% of them engage in heavy episodic drinking). These estimates further increase in fishing villages, a key HIV-vulnerable population, where ADU is normative. However, few studies have assessed ADU among adolescents and youths living with HIV despite their increased risk for ADU and its impact on engagement in HIV care. Moreover, data on risk and resilience factors for ADU are scarce as only few studies evaluating ADU interventions in SSA have reported positive outcomes. The majority have been implemented in school settings, potentially excluding adolescents in fishing communities with high school dropout rates, and none have targeted risk factors including poverty and mental health, which are rampant among adolescents and youths living with HIV and their families, undermine their coping skills and resources, and have been associated with increased risk for ADU among them.

OBJECTIVE

We propose a mixed methods study with a sample of 200 adolescents and youths living with HIV (aged 18-24 years) seen at 6 HIV clinics in southwestern Uganda's fishing communities to (1) examine the prevalence and consequences of ADU and identify the multilevel risk and resilience factors associated with ADU among them and (2) explore the feasibility and short-term effects of an economic empowerment intervention on ADU among them.

METHODS

This study comprises four components: (1) focus group discussions (FGDs) with adolescents and youths living with HIV (n=20) and in-depth qualitative interviews with health providers (n=10) from 2 randomly selected clinics; (2) a cross-sectional survey with 200 adolescents and youths living with HIV; (3) a randomized controlled trial with a subgroup of adolescents and youths living with HIV (n=100); and (4) 2 postintervention FGD with adolescents and youths living with HIV (n=10 per group).

RESULTS

Participant recruitment for the first qualitative phase has completed. As of May 4, 2023, ten health providers from 6 clinics have been recruited, provided written consent to participate, and participated in in-depth qualitative interviews. Two FGDs was conducted with 20 adolescents and youths living with HIV from 2 clinics. Data transcription, translation, and analysis of qualitative data has commenced. The cross-sectional survey will commence shortly after and dissemination of the main study findings is targeted for 2024.

CONCLUSIONS

Our findings will advance our understanding of ADU among adolescents and youths living with HIV and inform the design of future interventions to address ADU among them.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05597865; https://clinicaltrials.gov/ct2/show/NCT05597865.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46486.

Prevalence and factors associated with substance use among HIV positive youth attending HIV care and treatment centers in Dodoma, Tanzania

BACKGROUND

Substance use among people living with HIV is associated with poor health, social, and psychological outcomes. This study assessed the prevalence of substance use and associated factors among youth attending HIV care and treatment centers (CTCs) in Dodoma, Tanzania.

METHODS

This cross-sectional study was carried out in Dodoma, Tanzania, from February to April 2020 among youth aged 15-24 attending HIV CTCs. Data was collected using sociodemographic, WHO ASSIST Version 3.0, BDI II, and SERAD questionnaires. Data analysis was done using Stata 17. Descriptive statistics were used to summarize continuous and categorical variables. Univariable and multivariable logistic regression analyses were conducted to determine factors independently associated with substance use.

RESULTS

The prevalence of substance use was relatively low (6.6%). Older youth (20 to 24 years) were 2% less likely to use substances compared to the younger ones (15 to 19 years) (AOR: 0.07; 95% CI 0.01, 0.83). There were statistically significant decreasing odds of substance use with every year increase in age at HIV diagnosis (OR: 1.66; 95% CI 1.14, 2.41). Being unemployed was statistically significantly associated with decreased odds of substance use among this population (OR: 0.03; 95% CI 0.02, 0.33). Youth who had detectable viral loads were significantly more likely to use substances compared to those with undetectable viral loads (AOR: 12.9; 95% CI 1.07, 156.05).

CONCLUSIONS

Despite the low prevalence of substance use found in this study, it is important to note that late age of HIV diagnosis, employment, and detectable viral load negatively impacted HIV positive youth with regards to substance use. It is recommended that CTCs emphasize routine screening for substance use among youth who have detectable viral loads.

Sexual Development in Perinatally HIV-Infected Young People: A Systematic Review and Explorative Study

BACKGROUND

Similar to other young people with a chronic health condition, perinatally HIV-infected (PHIV) adolescents may have an impacted sexual development.

OBJECTIVES

This paper aims to compare sexual milestones of PHIV to HIV uninfected peers, through a systematic review (SR) and explorative study.

METHODS

We performed a systematic search in 4 electronic databases (Medline, Embase, Web of Science, and Scopus), according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Last search in all databases was performed in May 2021. We included studies that reported on quantitative data of any of the main outcomes and compared PHIV to HIV uninfected control groups. Main outcomes were defined as the occurrence and/or debut age of sexual milestones (falling in love, having been in a romantic relationship, masturbation, kissing, non-genital caressing (feeling or petting, touching), genital caressing (fingering, handjob), giving or receiving oral sex, and penetrative sex (vaginal or anal). We excluded case reports, audits, guidelines, editorials, abstracts, studies that reported on behaviorally infected HIV patients, studies that did not include an HIV uninfected control group and studies that could not be translated to English or Dutch. We used the Agency for Health Care Research and Quality (AHRQ) Checklist for quality assessment. We performed qualitative synthesis of the data. In the explorative study, we compared sexual milestones of PHIV and HIV uninfected controls matched for age, sex, ethnicity and educational level, using a subset of questions of a validated questionnaire.

RESULTS

We included eighteen studies in the SR, describing outcomes of an estimated 1,963 participants. Seventeen studies compared the occurrence and/or debut age of intercourse in PHIV and HIV uninfected controls and 4 studies reported on any of the other sexual milestones. The majority of studies found no difference in occurrence (12 of 16 studies) or debut age (6 of 8 studies) of intercourse in PHIV compared to controls. Two of 4 studies reporting on any of the other milestones found no significant differences between PHIV and HIV uninfected controls. In the explorative study, we included ten PHIV participants and 16 HIV uninfected, matched controls. PHIV tended to report a later debut age of sexual milestones than controls (not significant).

STRENGTHS AND LIMITATIONS

The SR includes only a small number of studies and few studies report on non-penetrative milestones. The explorative study adds to this review by including non-penetrative milestones and comparing PHIV to HIV-uninfected, well-matched controls. However, the sample size was small.

CONCLUSION

PHIV seem to engage in sexual activities and achieve sexual milestones at a similar rate as their HIV uninfected peers, with a tendency of a later start in well treated PHIV. The review was registered in the PROSPERO database (CRD42021252103) and funded by AIDSfonds. AIDSfonds had no role in the study design or interpretations of this study. ter Haar AM, Fieten A, Van den Hof M, et al. Sexual Development in Perinatally HIV-Infected Young People: A Systematic Review and Explorative Study. Sex Med 2022;10:100578.

Self-Management Frameworks for Youth Living with Human Immunodeficiency Virus

HIV is now a chronic condition that can be managed. Adolescents and emerging adults represent a large proportion of new diagnoses, but struggle with many aspects of HIV-related self-management. Self-management of HIV is critical to maintaining health and involves retention in HIV care, medication adherence to achieve viral suppression, managing substance use, and sexual and general health-related behaviors. This article describes theoretic frameworks for HIV self-management as adapted for youth and reviews self-management interventions developed to improve health outcomes in youth living with HIV identified from a recent systematic review.

Alcohol and illicit drug use among young people living with HIV compared to their uninfected peers from the Kenyan coast: prevalence and risk indicators

BACKGROUND

In sub-Saharan Africa, there is paucity of research on substance use patterns among young people living with HIV (YLWH). To address the gap, we sought to: i) determine the prevalence of substance use, specifically alcohol and illicit drug use, among YLWH compared to their HIV-uninfected peers; ii) investigate the independent association between young people's HIV infection status and substance use; iii) investigate the risk indicators for substance use among these young people.

METHODS

Between November 2018 and September 2019, a cross-sectional study was conducted at the Kenyan coast recruiting 819 young people aged 18-24 years (407 HIV-positive). Alcohol and drug use disorders identification tests (AUDIT and DUDIT) were administered via audio computer-assisted self-interview alongside other measures. Logistic regression was used to determine substance use risk indicators.

RESULTS

The point prevalence of current substance use was significantly lower among YLWH than HIV-uninfected youths: current alcohol use, 13% vs. 24%, p <  0.01; current illicit drug use, 7% vs. 15%, p <  0.01; current alcohol and illicit drug use comorbidity, 4 vs. 11%, p <  0.01. Past-year prevalence estimates for hazardous substance use were generally low among young people in this setting (< 10%) with no significant group differences observed. Being HIV-positive independently predicted lower odds of current substance use, but not hazardous substance use. There was overlap of some risk indicators for current substance use between young people with and without HIV including male sex, khat use and an experience of multiple negative life events, but risk indicators unique to either group were also identified. Among YLWH, none of the HIV-related factors was significantly associated with current substance use.

CONCLUSIONS

At the Kenyan coast, substance use is a reality among young people. The frequency of use generally appears to be low among YLWH compared to the HIV-uninfected peers. Substance use prevention initiatives targeting young people, regardless of HIV infection status, are warranted in this setting to avert their potential risk for developing substance use disorders, including dependence. The multifaceted intrapersonal and interpersonal factors that place young people at risk of substance use need to be addressed as part of the substance use awareness and prevention initiatives.

It Cannot Happen, Never: A Qualitative Study Exploring Youth Views on Disclosure of HIV Diagnosis to Their Sexual Partners in Southern Malawi

ABSTRACT

With the availability of antiretroviral therapy, more children living with HIV live longer than before and grow into young adulthood. This study examined the concerns of youth about disclosure of an HIV diagnosis to their sexual partners and attempted to gain an understanding of their HIV status disclosure experiences, views, and plans. A focused ethnography was undertaken. Using semi-structured interviews, data were collected from 20 youth between the ages of 15 and 24 years who were attending an HIV clinic. The findings highlight that youth generally struggled to disclose their HIV status to their sexual partners. The most frequent reasons for concealing their HIV status was fear of relationship termination, being unmarried, and fear that their sexual partners may reveal their HIV diagnosis to the community, thereby predisposing them to stigmatization, discrimination, and prejudice. There is a need to develop and strengthen HIV disclosure support groups for youth to help them develop life skills for overcoming HIV-related stigma.

The Role of Behavioral and Neurocognitive Functioning in Substance Use Among Youth with Perinatally Acquired HIV Infection and Perinatal HIV Exposure Without Infection

This study examined associations of self-regulatory behavior and cognitive functioning with substance use (SU) to inform interventions for youth with perinatal HIV infection (YPHIV) or exposure but uninfected (YPHEU). Youth aged 7-15 years (YPHIV, n = 390; YPHEU, n = 211) were followed longitudinally with cognitive testing and behavioral questionnaires including self-report of alcohol, marijuana, tobacco, and other SU. Cox proportional hazards analyses were used to examine correlates of initiating each substance for those without prior use at baseline and generalized estimating equation analyses were used to address associations of cognitive/behavioral measurements with SU prevalence for the entire sample. Lower self-reported self-regulation skills, but higher cognitive functioning abilities, were associated with initiation and prevalent use of alcohol and marijuana regardless of HIV status. Our findings suggest SU screening tools and self-regulation interventions developed for general adolescent populations should be implemented for those with PHIV, who may be at heightened risk for SU-related health consequences.

Disclosure of HIV status to sexual partners among perinatally HIV-infected youth in Thailand

Data regarding disclosure of HIV status to sexual partners among perinatally acquired HIV-infected (PHIV) youth are limited, particularly from Asian countries. This cross-sectional study assessed the patterns of, attitudes about, and factors associated with HIV disclosure to sexual partners among PHIV youth aged 15-24 years who attended a pediatric HIV clinic in Thailand. Participants were interviewed using a semi-structured questionnaire designed to elicit demographic and sexual behavior information. Those who had sexual partners were queried about their relationship and HIV status disclosure. Reasons to disclose or not to disclose were assessed accordingly. Among the 51 (44.4%) youth who had sexual partners, 55.8% had steady partners, 45.1% did not always use condoms, and 41.2% disclosed their HIV status. Reasons to disclose included trust and concern about the risk of infection to their partners. Reasons not to disclose included fear of rejection and stigmatization, and not knowing how to disclose. Most youth reported a need for disclosure-related guidance. Knowing their sexual partner's HIV status was the only independent factor associated with disclosure (aOR 14.6; 95% CI 2.8-75.4). This study demonstrates a high rate of unsafe sex and a low rate of partner disclosure in PHIV youth, and highlights the need for a comprehensive guideline for HIV disclosure to sexual partners.

Drug Use Among Adolescents and Young Adults with Unsuppressed HIV Who Use Alcohol: Identifying Patterns of Comorbid Drug Use and Associations with Mental Health

Youth living with HIV (YLWH; aged 16-24) are at elevated risk of alcohol and drug use. Studies in older populations have identified patterns or profiles of multiple substance use differentially associated with mental health and anti-retroviral therapy (ART) adherence. No studies of YLWH have yet examined such patterns. A sample of 179 YLWH, reporting ART non-adherence and alcohol use, were recruited at five Adolescent Trials Network clinics in urban areas of the US between November 2014 and August 2017. Participants completed the Alcohol Smoking and Substance Involvement Screening Test (ASSIST) to assess substance use involvement scores, and the Brief Symptom Inventory. Latent Profile Analysis identified three substance use patterns: minimal illicit drug use (15.1%), cannabis only (56.4%), and global polysubstance use (28.5%). Global polysubstance users experienced more mental health problems compared to the minimal illicit drug use group. The co-occurrence of drug use with alcohol was common among these YLWH-all of whom reported ART adherence problems-indicating the importance of interventions capable of addressing multiple substance use rather than alcohol alone.

Substance use among HIV-infected adolescents in Uganda: rates and association with potential risks and outcome factors

This article sets out to investigate alcohol and substance use (ASU) among adolescents living with HIV (ALWH) in the sub-Saharan African setting of Uganda. A cross-sectional analysis of the records of 479 adolescents (aged between 12and 17 years) attending the study, "Mental health among HIV infected CHildren and Adolescents in KAmpala and Masaka, Uganda (the CHAKA study)" was undertaken. ASU was assessed through both youth self-report and caregiver report using the Diagnostic and Statistical Manual of Mental Disorders-5 referenced instruments, the Youth Inventory-4R and the Child and Adolescent Symptom Inventory-5 (CASI-5). Rates and association with potential risk and outcome factors were investigated using logistic regression models. The rate of ASU was 29/484 (5.9%) with the most frequently reported ASU being alcohol 22/484 (4.3%) and marijuana 10/484 (2.1%). Functional impairment secondary to ASU was reported by 10/484 (2.1%) of the youth. ASU was significantly associated with urban residence, caregiver psychological distress and the psychiatric diagnosis of post-traumatic stress disorder. On associations with negative outcomes, ASU was significantly associated with only "ever had sex". Health care for ALWH in sub-Saharan Africa should include ASU prevention and management strategies.

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

The global population of perinatally HIV-exposed but uninfected (HEU) children is growing, with relatively little known about their psychosocial outcomes, particularly across adolescence and young adulthood. Using data from a longitudinal cohort study of HEU youth in New York City (N = 134), we examine rates of substance use disorders (SUD) and non-SUD psychiatric disorders (mood, anxiety, and behavioral) at five time-points during adolescence and young adulthood, as well as associated demographic and environmental factors and the association of ever having a disorder with young adult developmental milestones. HEU participants in this study experienced high rates of psychiatric disorders, particularly SUD in young adulthood. During the entire study period (2003-2018), over one third were diagnosed at least once with a SUD, and 69% were diagnosed with a non-SUD psychiatric disorder. Older age and female gender were associated with higher rates of non-SUD diagnoses. A history of meeting criteria for any disorder at any time point was associated with reduced odds in young adulthood of working or being in school and increased odds of reporting incarceration, homelessness, and recent condomless sex. There is an urgent need to develop systems to follow HEU youth and provide services to intervene and treat psychiatric disorders, including substance use.

Examining determinants of sexual behavior among indigenous adolescents in Taiwan

A recent Taiwanese government report indicated that there were an increased number of sexual encounters among 15- to 17-year-old adolescents. Among them, indigenous Taiwanese had a higher rate of sexual encounters than did the rest of the population. However, no prior study has surveyed indigenous Taiwanese adolescents' sexual behavior. Therefore, we examined the determinants of sexual behavior among indigenous adolescents in Taiwan.In this cross-sectional study, the researchers chose 16 high schools as the target research population; after 2-stage random sampling, 4 of the 16 high schools were recruited to participate in the research. Data were collected through a self-report questionnaire from the participants, with a total of 521 valid responses.Of the indigenous adolescents surveyed, 53% (N = 275) said they had touching, hugging, or kissing experiences, while 15.7% (N = 82) reported sexual behavior. The higher rate of sexual encounters among indigenous Taiwanese adolescents is associated with the gender, number of current or past romantic partners, drinking, and drug use before sexual intercourse. After adjustment for confounding factors, gender (male vs female, adjusted OR = 3.33, 95% CI: 1.83-6.07), number of heterosexual (≧1 vs no, OR = 1.67, 95% CI: 1.36-2.06), and heterosexual relationship (yes vs no, OR = 3.81, 95% CI: 1.94-7.48) appeared to be statistically significantly related sexual behaviors.This study found that the occurrence rate of sexual behavior for indigenous adolescents was higher than the past research results, and having initiated sexual intercourse in earlier age. The results also showed the indigenous adolescents whose drinking alcohol and drug use are more experiences on sexual behaviors. The results could be applied on sexual education program in campus.

Health risk behavior among perinatally HIV exposed uninfected adolescents: A systematic review

Background: Perinatally HIV exposed uninfected (PHEU) adolescents are an increasing sub-population, especially in high HIV epidemic settings. HIV exposure may have some lasting implications for adolescents’ development, however, longer term health outcomes such as health risk behavior (HRB) are so far not well understood in this adolescent sub-population. Methods: In this systematic review, we identify the prevalent forms, burden, and underlying risk factors for HRB of PHEU adolescents. We searched in PubMed, PsycINFO and Applied Social Sciences Index & Abstracts for peer reviewed empirical studies published between 1980 and August 2018 on HRB among PHEU adolescents aged 10 – 19 years. Results: Eleven eligible studies, all conducted in North America were identified and they showed that sexual risk behavior such as lifetime unprotected sex increased drastically especially in mid-adolescence. PHEU adolescents’ substance use (especially alcohol and marijuana) was high and increased over time. In a significant minority (10-18%) substance use disorder was screened. Some intra and interpersonal risk factors such as caregiver and PHEU adolescents’ mental health problems, age and HIV status were shared across the two forms of HRB. However, other risk factors like race, gender and experience of traumatic life events were behavior specific. Conclusion: Overall, there is need to conduct similar research in other settings especially those with high HIV burden where the PHEU adolescent sub-population is rising. Future research in this area could benefit from examining more forms of HRB and exploring the clustering of HRB among PHEU adolescents.

Behavioural health risks during early adolescence among perinatally HIV-infected South African adolescents and same-age, HIV-uninfected peers

Behavioural health risks, including substance use, early sexual debut, bullying and suicidality, are common during adolescence, but may be complicated among perinatally HIV-infected adolescents. However, there are few data exploring these behaviours in sub-Saharan Africa. We compared behavioural health risks (any self-report of substance use, sexual activity, bullying others or suicidality, or a positive urine toxicology screen) among perinatally-infected adolescents ages 9-14 years to that of an HIV-uninfected comparator group; and explored the effect of behavioural health risks on adolescent and caregiver report of adolescent suboptimal adherence (missed antiretroviral therapy dose(s) on ≥1 day during the preceding 30 days) and elevated HIV viral load (≥50 and ≥1000 copies/mL in sensitivity analyses) in multivariable logistic regression models. Among 506 HIV-infected and 110 HIV-uninfected adolescents (median age overall: 12 years), 15% and 25% reported any behavioural health risk (p = 0.018), respectively. Tobacco and other drug use was uncommon, while alcohol use was reported by 8% of HIV-infected versus 12% of HIV-uninfected adolescents (p = 0.185). One HIV-infected (0.2%) and 3 HIV-uninfected adolescents (3%) reported any sexual activity (p = 0.019). Among HIV-infected adolescents, report of any behavioural health risk was more common among male adolescents [adjusted odds ratio (aOR): 1.78; 95% confidence interval (CI): 1.08-2.95] and was associated with adolescent report of suboptimal adherence (aOR: 1.66; 95% CI: 0.99-2.78) but not with caregiver report of suboptimal adherence or with elevated viral load. In this group of perinatally-infected youth entering early adolescence, the prevalence of behavioural health risks was lower than that among same-age, HIV-uninfected peers. Longitudinal data are needed to explore the reasons underlying these differences, for example the possibility of more protective caregiving and supportive family environments, or of emotional and physical immaturity, as well as the emergence of risk behaviours over time in this population.

Sexual health of young people with perinatal HIV and HIV negative young people in England

As adolescents with perinatal HIV (PHIV) survive into adulthood, gaining insight into sexual behaviour and risk-taking is important. Between 2013–2015, 296 PHIV aged 13–21 years and 96 HIV negative affected adolescents (13–23 years) were recruited to the Adolescents and Adults Living with Perinatal HIV (AALPHI) cohort in England. Sexual health data were collected through computer-assisted self-interview questionnaires. Quality of life and household deprivation were also measured. T-tests compared means, and χ² proportions; logistic regression examined predictors of ever having sex. 120(41%) PHIV and 31(32%) HIV- young people were male, 254(86%) and 70(73%) were black, median age 16 [IQR 15,18] and 16 [14,18] years respectively. 77(26%) PHIV had a previous AIDS diagnosis. 93(32%) PHIV and 38(40%) HIV- had ever had sex; median number of partners was 3 [1,6] and 4 [1,6] respectively. 54 (41%) of 131 young people who were sexually active reported not always using condoms, including 32% (30/93) of PHIV. In multivariable analysis, older age, male sex, worse deprivation score, worse quality of life, and alcohol and/or drugs were associated with ever having sex, but not HIV status. 12/30 PHIV reporting unprotected sex had at least one HIV viral load ≥200c/ml in the previous 12 months. Age at first sex and number of sexual partners were similar among PHIV and HIV-, and comparable to normative data. In conclusion, small numbers of PHIV reported condomless sex with a detectable viral load, which could result in HIV transmission, indicating the need for targeted sexual health and ART adherence interventions for young people with perinatal HIV.

Predicting Arrest in a Sample of Youth Perinatally Exposed to HIV: The Intersection of HIV and Key Contextual Factors

We examined the role of youth HIV status and other key factors on past-year arrest in perinatally HIV-exposed but uninfected (PHIV-) and perinatally HIV-infected (PHIV+) youth using data from a multi-site study of psychosocial behaviors in PHIV-exposed urban youth (N = 340; 61% PHIV+; 51% female; ages 9-16 at baseline). Youth and caregivers were administered 5 interviews, spanning approximately 7.5 years. Using longitudinal logistic mixed-effect models, we explored the association between past year arrest, internal [e.g., substance use disorder (SUD)] and external (e.g., neighborhood arrest rates) contextual factors, and social-regulation processes (e.g., in-school/work). Arrest rates increased from 2.6 to 19.7% across follow-ups; there were no differences in arrest over time by HIV status. In the final model, odds of arrest were greater for youth who were male, with SUD, ≥ 18 years old, with high levels of city stress, and neither in school nor employed. PHIV-exposed, urban youth have much higher rates of arrest than national samples. Lack of differences in arrest by HIV status suggests key contextual factors are more important in promoting arrest.

Psychiatric Disorders, Antiretroviral Medication Adherence and Viremia in a Cohort of Perinatally HIV-Infected Adolescents and Young Adults

BACKGROUND

Perinatally HIV-infected (PHIV+) adolescents and young adults (AYA) are at risk for suboptimal antiretroviral therapy (ART) adherence and mental health and substance use problems that, in HIV-infected adults, predict nonadherence. Studies on the relationship between psychiatric and substance use disorders (SUD) and adherence among PHIV+ AYA are limited, but may be important for informing evidence-based interventions to promote adherence.

METHODS

Data were analyzed from 3 annual follow-up interviews (FU2-FU4, N = 179) in a longitudinal study of PHIV+ AYA. Psychiatric disorders (anxiety, disruptive behavior, mood and SUD) were assessed with the Diagnostic Interview Schedule for Children. Adherence was self-reported missed ART doses within the past week. Viral load (VL) results were abstracted from medical charts. Multiple logistic regression analyzed cross-sectional associations between psychiatric disorders and (1) missed ART dose and (2) VL > 1000 copies/mL. Multiple linear regression assessed associations between psychiatric disorders and proportion of VL values >1000 copies/mL over time.

RESULTS

At FU2, 53% of PHIV+ AYA had any psychiatric disorder, 35% missed an ART dose in the past week and 47% had a VL > 1000 copies/mL. At FU2, behavioral disorders were associated with missed dose (P = 0.009) and VL > 1000 (P = 0.019), and mood disorders were associated with missed dose (P = 0.041). At FU4, behavioral disorders were associated with missed dose (P = 0.009). Behavioral disorders (P = 0.041), SUD (P = 0.016) and any disorder (P = 0.008) at FU2 were associated with higher proportion of VLs >1000 across FU2-FU4.

CONCLUSIONS

Addressing psychiatric disorder and SUD among PHIV+ AYA may improve ART adherence outcomes in this population. Targeted interventions should be developed and tested.

Association Between Psychiatric Disorders, Substance Use, and Sexual Risk Behaviors in Perinatally HIV-Exposed Youth

As youth with perinatally acquired HIV infection age, there is a need for studies that identify predictors and correlates of sexual risk behaviors. We examined the association between psychiatric disorders and substance use disorders (SUD) with sexual risk behaviors in youth with perinatally acquired HIV infection and perinatally HIV-exposed but uninfected youth. Participants were recruited from four medical centers in New York City. The Diagnostic Interview Schedule for Children and the Adolescent Sexual Behavior Assessment were administered to assess psychiatric disorders and sexual behaviors, respectively. SUD and behavior disorders were correlated with either ever having had penetrative sex or recent condomless sex for participants with perinatally acquired HIV infection only. Results suggest that clinicians should screen and treat patients for SUD and behavioral disorders to reduce sexual risk behaviors in youth with perinatally acquired HIV infection.

Interaction Effects of Neighborhood Disadvantage and Individual Social Support on Frequency of Alcohol Use in Youth Living with HIV

Youth living with HIV (YLH) experience multiple disease-related stresses along with the same structural and developmental challenges faced by their uninfected peers; alcohol use among YLH represents a risk behavior by virtue of potential effects on youth health and increased likelihood of engaging in unprotected sex while drinking alcohol. Research aimed at better understanding the interplay of individual- and neighborhood-level influences on alcohol use for YLH is needed to inform interventions. This study examined whether socioeconomic disadvantage (SED) and social support influence, independently and through interaction, alcohol use in YLH. Data from the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) consisted of YLH across 538 neighborhoods in the United States who acquired HIV behaviorally. Neighborhood-specific data were compiled from the 2010 U.S. Census Bureau and matched with individual-level data from the ATN (N = 1,357) to examine effects that contribute to variation in frequency of alcohol use. Other drug use, being male, being non-Black, and older age were associated with greater alcohol use. Higher social support was negatively associated with alcohol use frequency. A cross-level interaction indicated that the association found between decreasing social support and increasing alcohol use frequency was weakened in areas with lower SED. Implications are discussed.

S100A10 identified in a genome-wide gene × cannabis dependence interaction analysis of risky sexual behaviours

BACKGROUND

We conducted a genome-wide gene × environment interaction analysis to identify genetic variants that interact with cannabis dependence (CaD) in influencing risky sexual behaviours (RSB).

METHODS

Our sample included cannabis-exposed and sexually experienced African-American and European-American participants. A DSM-IV CaD diagnosis and RSB were evaluated using the Semi-Structured Assessment for Drug Dependence and Alcoholism. We analyzed RSBs as a score that takes into account experiences of unprotected sex and multiple sexual partners.

RESULTS

A total of 3350 people participated in our study; 43% had a CaD diagnosis, 56% were African-American and 33% were women. We identified a genome-wide significant locus in African-American participants (S100A10 rs72993629, p = 2.73 × 10^-8) and a potential transpopulation signal in women (CLTC rs12944716, p = 5.27 × 10^-8). A resting-state fMRI follow-up analysis of S100A10 rs72993629 conducted in an independent cohort showed 2 significant associations: reduced power of the left paracentral lobule in amplitude of low frequency fluctuations (ALFF) analysis (p = 7.8 × 10^-3) and reduced power of the right pallidum in fractional ALFF analysis (p = 4.6 × 10^-3). The activity of these brain regions is known to be involved in sexual functions and behaviours. The S100A10 result functionally recapitulated our S100B finding observed in our previous genome-wide association study of CaD. The probability of identifying 2 S100 genes in 2 independent genome-wide investigations by chance is approximately 1 in 1.1 million.

LIMITATIONS

We were not able to identify any African-American cohort with appropriate sample size, and phenotypic assessment is available to replicate our findings.

CONCLUSION

The S100A10 and S100B genes, which are located on different chromosomes, encode specialized calcium-binding proteins. These data support a role for calcium homeostasis in individuals with CaD and its induced behaviours.

Changes in Substance Use Symptoms Across Adolescence in Youth Perinatally Infected with HIV

The paper utilizes data collected at three time points in a longitudinal study of perinatally HIV-infected (PHIV+) and a comparison group of perinatally exposed but HIV-uninfected (PHEU) youths in the United States (N = 325). Using growth curve modeling, the paper examines changes in substance use symptoms among PHIV+ and PHEU youths as they transition through adolescence, and assesses the individual and contextual factors associated with the rate of change in substance use symptoms. Findings indicate that substance use symptoms increased over time among PHIV+ youths, but not among PHEU youths. The rate of change in these symptoms was positively associated with an increasing number of negative life events. Study findings underscore the need for early, targeted interventions for PHIV+ youths, and interventions to reduce adversities and their deleterious effects in vulnerable populations.

Using Syndemics Theory to Investigate Risk and Protective Factors Associated with Condomless Sex Among Youth Living with HIV in 17 U.S. Cities

Identifying risk and protective factors associated with condomless sex among youth living with HIV is imperative for developing effective HIV prevention strategies. A cross-sectional sample of 1728 participants, 12-26 years of age, recruited from adolescent medicine clinics in 17 U.S. cities completed an audio-computer assisted self-interview with questions about their substance use, psychosocial factors, and attitudinal and behavioral factors. Guided by syndemics theory, a path analysis was used to assess the interrelations of these factors. Analyses of model fit statistics indicated statistically significant direct pathways between substance use, psychosocial factors, self-efficacy for risk-reduction, alternative risk-reduction attitudes and behaviors and condomless sex. The total indirect effect of self-efficacy for risk-reduction on condomless sex through alternative risk-reduction attitudes and behaviors was also significant. Multi-faceted, tailored interventions that address individual risk and protective factors and their combined synergistic effects are urgently needed to prevent condomless sex among this population.

Patterns and Correlates of Serostatus Disclosure to Sexual Partners by Perinatally-Infected Adolescents and Young Adults

Similar to same-age peers, perinatally HIV-infected (PHIV+) youth in the US are engaging in sex, including condomless sex. Understanding decisions about serostatus disclosure to sexual partners is important to domestic and global HIV prevention efforts, since large numbers of PHIV+ children are entering adolescence and becoming sexually active. Using Social Action Theory (SAT) to inform variable selection, we examined correlates of disclosure among 98 PHIV+ adolescents/young adults in New York City. Over half of these youth reported not disclosing to any casual partners (59 %) or to any partners when using condoms (55 %). In bivariate analyses, increased disclosure was associated with older age; being female; earlier age of learning one's serostatus; and increased STD knowledge, disclosure intentions, and parent-child communication. Multiple regression analyses revealed a strong fit with the SAT model. As with adults, disclosure to sexual partners is difficult for PHIV+ youth and challenges prevention efforts. Effective interventions that help youth with disclosure decisions are needed to curb the epidemic.

Prevalence and correlates of substance use among youth living with HIV in clinical settings

OBJECTIVES

The purpose of this study was to better understand the prevalence and correlates of substance use behaviors among HIV-infected adolescents in HIV care settings.

METHODS

A cross-sectional sample of 2216 youth living with HIV (YLWH; ages 12-26) were recruited through the Adolescent Trials Network for HIV Interventions. Participants completed a one-time survey on sociodemographic factors, substance use and health behaviors. We used logistic regression models to understand the correlates of substance use outcomes.

RESULTS

Overall, weekly or more frequent tobacco use was reported by 32.9% of participants, 27.5% marijuana use, and 21.3% alcohol use; and 22.5% reported any other illicit drug use. In multivariable models, young MSM had higher odds of reporting each substance use behavior, and transgender women had increased odds of marijuana and other illicit drug use. Criminal justice involvement, unstable housing, condomless sex, and suboptimal antiretroviral therapy was associated with increased risk of substance use behaviors.

CONCLUSIONS

Study findings highlight the need for regular screening for substance use in HIV care settings in order to improve access to and delivery of culturally competent substance use prevention and treatment services.

Contraception for HIV-Infected Adolescents

Access to high-quality reproductive health care is important for adolescents and young adults with HIV infection to prevent unintended pregnancies, sexually transmitted infections, and secondary transmission of HIV to partners and children. As perinatally HIV-infected children mature into adolescence and adulthood and new HIV infections among adolescents and young adults continue to occur in the United States, medical providers taking care of such individuals often face issues related to sexual and reproductive health. Challenges including drug interactions between several hormonal methods and antiretroviral agents make decisions regarding contraceptive options more complex for these adolescents. Dual protection, defined as the use of an effective contraceptive along with condoms, should be central to ongoing discussions with HIV-infected young women and couples wishing to avoid pregnancy. Last, reproductive health discussions need to be integrated with discussions on HIV care, because a reduction in plasma HIV viral load below the level of detection (an "undetectable viral load") is essential for the individual's health as well as for a reduction in HIV transmission to partners and children.

Sexual Behavior and Knowledge among Adolescents with Perinatally Acquired Human Immunodeficiency Virus Infection Compared to HIV-Uninfected Adolescents at an Urban Tertiary Center in New Jersey

Background. Sexual behaviors and knowledge among PHIV-infected (PHIV(+)) adolescents in comparison with HIV-uninfected youths are not well understood and continue to be studied actively. Objective. To compare sexual behavior and sexual knowledge of PHIV(+) and HIV-uninfected adolescents at an urban, tertiary-care center in New Jersey. Study Design. Modified Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Surveillance questionnaire was administered to PHIV(+) and HIV-uninfected adolescents to assess and compare sexual behavior and knowledge over a 1-year-period. Results. Twenty-seven PHIV(+) and 100 HIV-uninfected adolescents were studied; 59% PHIV(+) and 52% HIV-uninfected adolescents were sexually active. A significantly higher proportion of PHIV(+) adolescents compared to HIV-uninfected adolescents reported ≥1 occasion of unprotected penetrative sex (p < 0.0001) and reported multiple (>4) sexual partners (p = 0.037). Significantly more PHIV(+) males reported receptive anal intercourse (p < 0.001). About 1/3 of adolescents in both groups were unaware that sexual abstinence can prevent HIV transmission and >80% adolescents in both groups did not consider multiple sexual partners a risk factor for HIV transmission. Only 25% PHIV(+) adolescents reported disclosing their seropositive status to their first sexual partners. Conclusions. High risk sexual behaviors were significantly more prevalent among PHIV(+) youths; however both groups demonstrated considerable gaps in sexual knowledge. There is an urgent need for heightening awareness about risky behaviors, interventions for prevention, and reproductive health promotion among adolescents.

Psychological distress among Ugandan adolescents living with HIV: Examining stressors and the buffering role of general and religious coping strategies

HIV infection increases the risk of psychological distress among adolescents living with HIV (ALHIV), which, in turn, increases risky behaviours such as medication non-adherence, substance use, and sexual risk-taking. The majority of studies on psychological distress among ALHIV have been conducted in high-income countries; data on the prevalence and correlates of psychological distress among ALHIV in sub-Saharan Africa (SSA) are scarce, yet over two-thirds of the global population of ALHIV resides in SSA. The purpose of this study was to identify the contextually relevant correlates of psychological distress among Ugandan ALHIV. Utilizing the stress and coping framework, we explored the risk and protective factors for psychological distress in cross-sectional sample of 464 ALHIV (aged 12-19; 53% female) at a large HIV treatment centre in Kampala, Uganda. The stressors associated with psychological distress included daily hassles, major negative life events, HIV-related quality of life, and stigma. Protective factors included psychosocial resources such as religious coping, satisfaction with social support, and general coping style and behaviours. Social support and optimism were significantly associated with psychological distress. Findings underscore the need for mental health services for ALHIV in Uganda and other resource-limited settings.

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.