DSM psychiatric disorders in the context of pediatric HIV/AIDS

In HIV-infected adults, psychiatric disorders result in poor quality of life, HIV disease progression, poor compliance and increased mortality. The same may be true for children and adolescents challenged with HIV/AIDS. The literature regarding the prevalence of Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) psychiatric disorders in pediatric patients with HIV/AIDS was reviewed. Of over 500 papers reviewed only eight attempted to quantify prevalence in some way. Average prevalences of 28.6% for attention deficit hyperactivity disorder, 24.3% for anxiety disorders and 25% for depression were found with respective risk ratios of 6.0, 3.8 and 7.1. However, sample sizes were small and only two of the eight studies were controlled. Surprisingly little has been done to describe and quantify what mental-health problems these HIV-positive children and adolescents face.     

Psychiatric Symptomatology and Psychological Functioning in HIV-Infected Mothers

The present study examines psychiatric and psychological functioning in HIV-infected mothers with young children. Reflecting the epidemiology of HIV disease in women, the majority were African American and Latina, socioeconomically disadvantaged single parents with histories of substance use. Women were recruited from primary care HIV clinics. They were administered a structured psychiatric interview (SCID-R-Nonpatient form), as well as a psychological symptom questionnaire (Demoralization Scale). Prevalence rates of lifetime psychiatric diagnoses (88%), particularly lifetime histories of Major Depression (58%) and Post-Traumatic Stress Disorder (38%), were considerably higher than in other comparable samples in the literature. History of substance use was associated with history of Post-Traumatic Stress Disorder and the number of traumas experienced was associated with psychiatric and psychological functioning.     

Psychiatric morbidity in HIV-infected children

After the introduction of antiretroviral therapy, HIV infection in children has been transformed from an acute to a chronic illness. The number of HIV-infected children has also increased in recent years. The routes of transmission and clinical manifestation of HIV infection in children are unique and different from those of adults. There are a number of biological, psychological and social factors associated with HIV-infected child that may predispose him/her to develop psychiatric illness. However, there are very few studies on psychiatric morbidity in HIV-infected children. In the existing studies, a number of psychiatric illnesses including: depression, anxiety, disruptive disorders and hyperactive disorders have been observed in HIV-infected children. A number of variables have a bearing on psychiatric morbidity, including experience and expression of physical illness as well as adherence to medications. The physician dealing with HIV-infected children should be aware of the psychological manifestations so that appropriate interventions and referral may be made as needed.     

Adherence to antiretroviral therapy,stigma and behavioral risk factors in HIV-infected adolescents in Asia

We studied behavioral risks among HIV-infected and uninfected adolescents using an audio computer-assisted self-interview. A prospective cohort study was initiated between 2013 and 2014 in Malaysia, Thailand, and Vietnam. HIV-infected adolescents were matched to uninfected adolescents (4:1) by sex and age group (12–14 and 15–18 years). We enrolled 250 HIV-infected (48% male; median age 14.5 years; 93% perinatally infected) and 59 uninfected (51% male; median age 14.1 years) adolescents. At enrollment, HIV-infected adolescents were on antiretroviral therapy (ART) for a median (IQR) of 7.5 (4.7–10.2) years, and 14% had HIV-RNA >1000?copies/mL; 19% reported adherence <80%. Eighty-four (34%) HIV-infected and 26 (44%) uninfected adolescents reported having ever smoked cigarettes or drunk alcohol (p?=?0.13); 10% of HIV-infected and 17% of uninfected adolescents reported having initiated sexual activity; 6 of the HIV-infected adolescents had HIV-RNA >1000?copies/mL. Risk behaviors were common among adolescents, with few differences between those with and without HIV.     

Associations of medically documented psychiatric diagnoses and risky health behaviors in highly active antiretroviral therapy-experienced perinatally HIV-infected youth

The Longitudinal Epidemiologic Study to Gain Insight into HIV/AIDS in Children and Youth (LEGACY) study is a prospective, multisite, longitudinal cohort of U.S. HIV-infected youth. This analysis was limited to perinatally HIV-infected youth (n=197), 13 years and older, with selected variables completely abstracted from HIV diagnosis through 2006. We evaluated relationships between ever having one or more nonsubstance related medically documented psychiatric diagnoses and three risky health behaviors (substance abuse, preadult sexual activity, and treatment adherence problems) recorded between 2001 and 2006. Logistic regression was used for all binary outcomes and participant age was included as a covariate when possible. All 197 participants included in the analysis were prescribed antiretroviral therapy during the study period; 110 (56%) were female, 100 (51%) were black non-Hispanic, and 86 (44%) were Hispanic; mean age at the last visit was 16.8 years, ranging from 13 to 24 years. One hundred forty-six (74%) participants had a history of at least one risky health behavior. There were 108 (55%) participants with at least one medically documented psychiatric diagnosis, 17 (9%) with at least one record of substance abuse, 12 (6%) with documented preadult sexual activity, and 142 (72%) participants with reported adherence problems. In the final model, a history of at least one psychiatric diagnosis was associated with having at least one of the three risky behaviors (odds ratio [OR]=2.33, p=0.015). There is a need for a continued close partnership between HIV specialty care providers and mental health services treating perinatally HIV-infected youth with an added focus on improving treatment adherence.     

High prevalence of non-adherence to antiretroviral therapy among undisclosed HIV-infected children in Ghana

Adherence to antiretroviral therapy (ART) remains one of the greatest obstacles in pediatric HIV care. We sought to determine the prevalence of adherence to ART among undisclosed HIV-infected children and adolescents in Ghana. We analyzed baseline data from HIV-infected children and adolescents aged 7–18 years old enrolled in the SANKOFA Pediatric HIV disclosure intervention study in Ghana. Antiretroviral medication adherence was measured using caregiver 3-day recall; child 3-day recall; and pharmacy records for antiretroviral time-to-refill. Four hundred and twenty child-caregiver dyads were enrolled from January 2013 to June 2016. The median adherence (interquartile range), as measured by time-to-refill, was 93.2% (68.0%–100.0%). However, only 47.5% of children had ≥95% adherence (“good adherence”) using time-to-refill data. Children of caregivers who had received secondary or higher level of education versus no school (aOR, 2.90, 95% Confidence Interval, CI 1.29–6.56), p?=?0.010) or elementary education only (aOR, 2.20, CI, 1.24–3.88, p?=?0.007) were more likely to have “good adherence” (≥95%). In this cohort of children unaware of their HIV positive status, median ART adherence rate was sub-optimal (by World Health Organization definition) while 38% had poor adherence (<85%).     

To tell or not to tell: Dimensions of disclosure to children with HIV in the Zambezi region of Northern Namibia

ABSTRACT

The survival rates of prenatally HIV-infected children in Africa have significantly improved with the advent of antiretroviral therapy (ART). Few studies examined the HIV status disclosure of children and the sociodemographics of their caregivers in Northern Namibia. This was a cross-sectional exploratory study with a sample of 83 caregiver-child dyads of HIV-affected children ages 6–18 in Namibia. The mean age of caregivers was 37.1 [range 15–93, SD?=?11.9], and the majority were female (87.5%). More than half of the HIV-infected children (55.7%) were between 6–10 years of age at the time of the study. More than two thirds of children (67.1%) had their HIV diagnosis disclosed to them. Some caregivers believed it was very important (42.2%) or good (39.8%) to disclose the HIV status to children, and just a few (3.6%) mentioned it was not important at all. More research is warranted to describe HIV-infected children accessing ART and their caregivers to better inform HIV/AIDS interventions and policies.     

Response to measles, mumps, and rubella revaccination in HIV-infected children with immune recovery after highly active antiretroviral therapy.

BACKGROUND: The low prevalence of measles antibody in human immunodeficiency virus (HIV)-infected children after immune recovery as a result of highly active antiretroviral therapy increases the risk of morbidity and mortality from disease. The objective of our study was to evaluate the efficacy and safety of revaccination with measles, mumps, and rubella (MMR) vaccine in HIV-infected children with immune recovery. METHODS: Inclusion criteria were (1) HIV-infected children aged >5 years, (2) a nadir CD4 lymphocyte percentage 15% for >or=3 months after highly active antiretroviral therapy), and (4) no protective antibody against measles. Each child received 1 dose of MMR vaccine, and antibodies were measured at 4 and 24 weeks after vaccination. Protective antibodies were defined as an antimeasles immunoglobulin G (IgG) level >or=320 mIU/mL, an antimumps IgG titer >1:500, and an antirubella IgG level >10 IU/mL. RESULTS: There were 51 participants. The mean age (+/- standard deviation) was 10.2 +/- 2.5 years. Prior to revaccination, 28 participants (55%) had baseline protective antibody to mumps, and 11 (20%) had baseline protective antibody to rubella. The prevalence of protective antibody at 4 weeks was 90%, 100%, and 78% for measles, rubella, and mumps, respectively, and then slightly decreased to 80%, 94%, and 61%, respectively, at 24 weeks after revaccination. No serious adverse reactions were attributed to revaccination. CONCLUSIONS: The majority of HIV-infected children with immune recovery can develop protective antibodies after MMR revaccination. Revaccination with MMR vaccine in HIV-infected children with immune recovery should be considered to ensure individual immunity and limit the spread of disease.     

HIV disclosure and its effect on treatment outcomes in perinatal HIV-infected Thai children

The World Health Organization guideline recommends informing children of their HIV status between the ages of 6–12 years. Primary caregivers of perinatal HIV-infected Thai children ≥6 years were interviewed in order to assess the HIV status disclosure rate. In addition, pill counts of antiretroviral therapy (ART) were performed every three months. CD4 and HIV-RNA were performed every six months. Of the 260 children/adolescents included, the median age of disclosure was 14.8 years. The disclosure rate among those from 6 to 12 years was 21% and for those greater than 12 years of age was 84%. When comparing children aged 6–12 years whose HIV status had been disclosed to them, to children whose HIV had yet to be disclosed, no difference was noted in median ART adherence by pill count, CD4 count, or proportion of HIV-RNA <50 copies/ml (p > 0.05). Factors associated with HIV disclosure were an age of ≥12 years (OR 17.8, 95% CI 8.86–35.79) and a current CD4 ≤ 30% (OR 2.09, 95% CI 1.20–3.62). In conclusion, although the majority of adolescents ≥12 years were aware of their HIV status only one-fifth of children aged 6–12 years were aware. Moreover, the child's/adolescent's disclosure status had no bearing on ART adherence by pill count or immunological and virological outcomes.     

Substance Use and its Association with Psychiatric Symptoms in Perinatally HIV-infected and HIV-Affected Adolescents

Drug use in combination with psychiatric illness may lead to unsafe sexual risk behavior and increased risk for secondary HIV transmission among adolescents with HIV infection. We compared the prevalence of substance use for perinatally HIV-infected youth to uninfected adolescents living in families affected by HIV infection, and evaluated the association of psychiatric symptoms with risk of substance use. Among 299 adolescents (196 HIV+, 103 HIV−) aged 12–18 years enrolled in IMPAACT P1055, a multisite US cohort study, 14% reported substance use at enrollment (HIV+: 13%, HIV−: 16%). In adjusted logistic regression models, adolescents had significantly higher odds of substance use if they met symptom criteria for ADHD [adjusted odds ratio (aOR) = 2.7, Wald χ² = 5.18, P = 0.02], major depression or dysthymia (aOR = 4.0, Wald χ² = 7.36, P = 0.01), oppositional defiant disorder (aOR = 4.8, Wald χ² = 12.7, P = 0.001), or conduct disorder (aOR = 15.4, Wald χ² = 28.12, P = 0.001). Among HIV-infected youth, those with lower CD4 lymphocyte percentage (CD4% < 25%) had significantly increased risk of substance use (aOR = 2.7, Wald χ² = 4.79, P = 0.03). However, there was no overall association of substance use with HIV infection status, and the association between psychiatric symptoms and substance use did not differ by HIV status. Programs to prevent substance use should target both HIV-infected and uninfected adolescents living in families affected by HIV infection, particularly those with psychiatric symptoms.     

Desire for Children and Pregnancy Risk Behavior among HIV-Infected Men and Women in Uganda

To identify ways to improve prevention of mother-to-child transmission (PMTCT) of HIV, we conducted a cross-sectional study of 1,092 HIV-infected men and women attending an AIDS support organization in Jinja, Uganda, between October 2003 and June 2004. Pregnancy risk behavior was defined as having sex without contraceptive or condom. Overall, 42% of participants were sexually active, 33% practiced pregnancy risk behavior, and 18% desired more children. Men were almost four times to want more children than the women (27% vs. 7%). Among those practicing pregnancy risk behavior, 73% did not want more children and were at high risk for unwanted pregnancies. Although 81% knew that mother-to-child transmission of HIV could be prevented, only 22% believed that an HIV-infected woman who received PMTCT therapy could still deliver an HIV-infected child. Lack of MTCT information, having attended the program for ≤2 years and desire for children were independently associated with pregnancy risk behavior. PMTCT and other HIV prevention and care programs should ensure provision of family planning for HIV-infected populations who do not want to become pregnant.     

Poor outcome is associated with delayed tuberculosis diagnosis in HIV-infected children in Baja California, Mexico.

OBJECTIVE: To describe the morbidity and mortality associated with tuberculosis (TB) in human immunodeficiency virus (HIV) infected children in Baja California, Mexico. METHODS: Retrospective review of the medical records of all children with perinatally acquired HIV infection evaluated at Tijuana General Hospital with a diagnosis of TB between 1998 and 2007. The Stegen-Toledo (ST) clinical criteria for the diagnosis of TB were used. RESULTS: A total of 73 HIV-infected children were followed during the study period. Thirteen (18%) children were diagnosed with TB; one was confirmed by culture to be positive. Among these children, the mean ages at HIV and TB diagnosis were respectively 3.6 and 5.3 years. The mean ST score was 8.1; 10/13 had a score of >or=7, or highly probable TB. There were a cumulative 29 hospital admissions prior to TB diagnosis; 24 of these were due to pneumonia. The mean duration of symptoms at TB diagnosis was 73 days. The most common symptoms were cough (92%) and anorexia (85%). Seven patients (54%) had disseminated TB and five (39%) died as a consequence of TB. CONCLUSIONS: We observed high morbidity, hospital utilization and high mortality associated with TB among HIV-infected children in Baja California.     

Failure to test children of HIV-infected mothers in South Africa: implications for HIV testing strategies for preschool children

Objectives To assess the uptake of HIV testing among preschool children with HIV‐positive mothers in a peri‐urban population‐based study in KwaZulu‐Natal, South Africa, an area of high HIV prevalence. Methods All children 4–6 years old and their primary caregivers from the area were invited to participate. All participants were asked about prior HIV testing and were offered counselling and voluntary HIV testing irrespective of previous testing. Twenty‐seven HIV‐infected mothers were interviewed to identify barriers to testing their children. Results One thousand five hundred and eighty‐three children (88% of eligible children) and their caregivers participated. Of the biological mothers, 86% were previously tested for HIV (27% tested positive). Among the surviving 244 children born to an infected mother, only 41% had been tested for HIV (23% tested positive). Subsequently, 90% of previously untested children of infected mothers underwent HIV testing (9.3% were positive). Overall seroprevalence among study children was 4.9%. All infected mothers interviewed endorsed the belief that children of HIV‐infected women should be tested for HIV. Women who missed opportunities for antenatal HIV testing reported no systematic testing of their children at later ages. Conclusions In this community with high HIV prevalence, HIV testing of children is infrequent despite high testing coverage among caregivers. The low proportion of children tested for HIV, particularly those of infected mothers, is of great concern as they are at high risk for morbidity and mortality associated with untreated childhood HIV infection. HIV testing programs should strengthen protocols to include children, especially for those who missed PMTCT opportunities in infancy.     

Prevalence and Pattern of Disclosure of HIV Status in HIV-Infected Children in Ghana

With the advent of highly active antiretroviral therapy (HAART) HIV-infected children are surviving into adulthood. Despite emerging evidence of the benefits of disclosure, when and how to disclose the diagnosis of HIV to children remain a clinical dilemma. We investigated the prevalence and determinants of HIV disclosure in a cross-sectional study of 71 caregiver-child dyads from the Pediatric HIV/AIDS Care Program at Korle-Bu Teaching Hospital (Accra, Ghana). The children were between 8 and 14 years of age (median age, 10.39 years). The prevalence of disclosure was 21%. In the unadjusted analyses, the age of child, the level of education of child, deceased biologic father, administration of own HIV medications, and longer duration on HIV medication were significantly associated with disclosure. The low prevalence of disclosure underscores the need for a systematic and a staged approach in disclosing HIV status to infected children in resource limited countries.     

Adolescents’ and caregivers’ perceptions of caregiver-provided testing and HIV self-testing using oral mucosal transudate tests in Zimbabwe: a short report

ABSTRACT

Uptake of HIV testing remains lower among children and adolescents compared to adults. This study explored adolescents’ perceptions of HIV self-testing (HIVST) and caregivers’ perceptions of testing their children using an oral mucosal transudate (OMT) rapid HIV test (caregiver-provided testing). We conducted 31 interviews with adolescents aged 16–18 years and caregivers of children aged 2–15 years who received an OMT test. Participants described barriers to HIV testing including lack of privacy and the potential for discrimination by community members towards children and adolescents who received an HIV test. Most participants felt caregiver-provided testing and HIVST could address these barriers through increased privacy. Some participants expressed worry about their ability to correctly perform the OMT and their anxious reactions to a positive result. Counseling and assistance from health care workers were viewed as ways to alleviate concerns. Concerns shaped participants’ preferences for facility-based HIVST and caregiver-provided testing. Findings demonstrate HIVST performed by adolescents and caregiver-provided testing could increase the uptake of HIV testing. Concerns related to being able to test correctly and the availability of post-test counseling must be addressed in any future delivery mechanisms.     

HIV-1 co-infection in children hospitalised with tuberculosis in South Africa.

SETTING: Hospitals associated with the Department of Paediatrics at the University of the Witwatersrand, Johannesburg, South Africa. OBJECTIVES: To define the prevalence of human immunodeficiency virus (HIV) co-infection and differences in clinical presentation between HIV-infected and non-infected hospitalised children with tuberculosis. DESIGN: Children were prospectively enrolled between August 1996 and January 1997. RESULTS: Of 161 children enrolled, 42% were HIV-infected, including 67/137 with pulmonary tuberculosis (PTB) and 1/24 with extra-pulmonary disease (EPTB). Positive microscopy or bacteriology did not differ by HIV status for children with either PTB or EPTB. Although age did not differ between HIV-infected and non-infected children with PTB, non-HIV-infected children with EPTB were significantly older than those with PTB only (median age 32 months vs 14.5 months, P = 0.004). Chronic weight loss, malnutrition and the absence of BCG scarring were more common in HIV-infected children with PTB. HIV-infected children were also more likely to show cavitation (P = 0.001) and miliary TB (P = 0.01) on chest X-ray. Reactivity to tuberculin (> or = 5 mm and > or = 10 mm in HIV-infected and non-infected children, respectively) was significantly lower in HIV-infected children, as were CD4+ lymphocyte levels. The mortality rate during the study was 13.4% in HIV-infected children compared with 1.5% in non-HIV-infected children (P = 0.03). CONCLUSIONS: There is a high prevalence of HIV co-infection in children with TB. Progressive PTB and death are more common in HIV-infected children. Tuberculin skin testing is of limited use in screening for TB in HIV-infected children even when using a cut-point of > or = 5 mm.     

Prevalence of protective antibody against measles in HIV-infected children with immune recovery after highly active antiretroviral therapy

OBJECTIVES: This study was conducted to determine the prevalence of measles-protective antibody in HIV-infected children with immune recovery after highly active antiretroviral therapy (HAART). METHODS: Ninety-six HIV-infected children were enrolled in the study. Their mean age was 9.7+/-2.6 years, 47% were boys, and 47% were in Centers for Disease Control and Prevention (CDC) clinical category C. All participants had been treated with HAART until they achieved a CD4 cell percentage > or =15%. Three children with a history of clinical measles infection were not included in the data analysis. RESULTS: Only 39 out of 93 children (42%) had a measles-protective antibody level, defined as an anti-measles immunoglobulin G (IgG) level > or =320 mIU/mL. There was no significant difference between the groups with and without protective levels of measles antibody in gender, clinical category, age at which HAART was started, duration of severe immune suppression, CD4 cell count and percentage, or plasma HIV RNA level before and after HAART. CONCLUSIONS: We conclude that, despite a history of measles immunization and evidence of immune reconstitution after HAART, many healthy HIV-infected children are still susceptible to measles.     

Risk of high-grade squamous intraepithelial lesion in HIV-infected adolescents

BACKGROUND: The risk of developing the human papillomavirus (HPV)-associated precancer high-grade squamous intraepithelial lesion (HSIL) in human immunodeficiency virus (HIV)-infected adolescents is unknown. We examined the risk of developing HSIL among adolescents with and without HIV infection. METHODS: HIV-infected (n = 172) and -uninfected (n = 84) girls aged 13-18 years who were participating in a multicenter study of primarily horizontally acquired HIV infections in adolescents (Reaching for Excellence in Adolescent Health Care) and who did not have HSIL on cytologic examination at study entry or at the first follow-up visit were followed at 6-month intervals. HIV-uninfected girls were recruited for comparison in a 2:1 ratio (HIV infected:HIV uninfected). The primary outcome was cytologic diagnosis of HSIL confirmed by expert review. RESULTS: Incidence of HSIL by the end of follow-up was higher for HIV-infected girls than for HIV-uninfected girls (21.5% vs. 4.8%, respectively). In multivariate analysis, use of hormonal (either estrogen/progesterone oral combination or medroxyprogesterone acetate intramuscular) contraceptives, high cervical mucous concentrations of interleukin (IL)-12, a positive HPV test, and persistent low-grade squamous intraepithelial lesion (LSIL) were significantly associated with the development of HSIL. CONCLUSIONS: The incidence of HSIL was alarmingly high in HIV-infected adolescent girls. However, when other predictors were considered in multivariate analysis, HIV status was not retained in the model. The heightened risk for HSIL associated with persistent LSIL underscores the need to closely monitor HIV-infected adolescents with LSIL. The risk for HSIL associated with high concentrations of IL-12 may be suggestive of a local immune dysregulation. The role of hormonal contraception as a risk factor deserves further investigation.     

Cognitive Impairment and Psychiatric Morbidity in HIV+ Zambians with New-Onset Seizure

A prospective cohort study of new-onset seizure in people with human immunodeficiency virus (HIV) in Zambia is ongoing to determine the incidence of subsequent epilepsy and risk factors for epileptogenesis in this population. At enrollment, we evaluated this cohort for cognitive impairment and psychiatric morbidity. Over 50% of participants had cognitive impairment and significant psychiatric morbidity. Most participants had advanced HIV disease based on CD4+ T-cell count and World Health Organization stage, but we found no association between cognitive impairment or psychiatric morbidity and HIV disease staging.