The HIV-Infected Adolescent

HIV-infected adolescents represent a unique, yet diverse, population requiring specialized medical and psychosocial HIV care. Perinatally infected and behaviorally infected adolescents often have differing therapeutic needs, but may share common difficulties, including medication nonadherence, high-risk sexual behavior, psychosocial stressors, and concomitant psychiatric disorders. Addressing these needs within a culturally sensitive framework and in the context of a population-specific approach to treatment is paramount to optimizing care. Harm reduction for this group to maximize their health and limit HIV transmission to others is also critical with respect to the rising incidence of newly diagnosed HIV-positive adolescents. Implementing a formal, multidisciplinary program that involves individual youths and their families for improved transition to adult HIV care will afford such adolescents a better chance for a healthy adulthood.     

A primary care level algorithm for identifying HIV-infected adolescents in populations at high risk through mother-to-child transmission

Objective To present an algorithm for primary‐care health workers for identifying HIV‐infected adolescents in populations at high risk through mother‐to‐child transmission. Methods Five hundred and six adolescent (10–18 years) attendees to two primary care clinics in Harare, Zimbabwe, were recruited. A randomly extracted ‘training’ data set (n = 251) was used to generate an algorithm using variables identified as associated with HIV through multivariable logistic regression. Performance characteristics of the algorithm were evaluated in the remaining (‘test’) records (n = 255) at different HIV prevalence rates. Results HIV prevalence was 17%, and infection was independently associated with client‐reported orphanhood, past hospitalization, skin problems, presenting with sexually transmitted infection and poor functional ability. Classifying adolescents as requiring HIV testing if they reported >1 of these five criteria had 74% sensitivity and 80% specificity for HIV, with the algorithm correctly predicting the HIV status of 79% of participants. In low‐HIV‐prevalence settings (<2%), the algorithm would have a high negative predictive value (≥99.5%) and result in an estimated 60% decrease in the number of people needing to test to identify one HIV‐infected individual, compared with universal testing. Conclusions Our simple algorithm can identify which individuals are likely to be HIV infected with sufficient accuracy to provide a screening tool for use in settings not already implementing universal testing policies among this age‐group, for example immigrants to low‐HIV‐prevalence countries.     

The “moral career” of perinatally HIV-infected children: revisiting Goffman's concept

HIV-infected children usually live in vulnerable situations, experiencing discrimination and stigma commonly felt by other people living with HIV/AIDS. The present study aims to analyse primary socialisation of HIV-infected children and adolescents recruited from a public health service in Rio de Janeiro (Brazil) as a social process that shapes a new generation of stigmatised and vulnerable persons. Research was informed by an interactionist perspective, focusing on key aspects of HIV-infected children and adolescents life histories under the conceptual frame of Erving Goffman's theories regarding “moral careers”. Goffman defines the making of a moral career as the process through which a person learns that she/he possesses a particular attribute, which may lead her/him to be discredited by members of the surrounding society. We have identified aspects of life histories of HIV-vertically infected children and adolescents for each aspect of “moral career” as described by Goffman, relating them to as family structure, the experience of living HIV within the family, and the position and family role of a given subject. The patterns of “moral career” proposed by Goffman in 1963 were useful in identifying components of HIV-related stigma among children and adolescents. These include gender and social disadvantages, difficulty in coping with a child with a potentially severe disease, orphanhood, abandonment, adoption and disclosure of one's HIV serostatus. Primary socialisation of HIV-infected children and adolescents is a key piece of the complex HIV/AIDS-labelling process that could be targeted by interventions aiming to decrease stigma and marginalisation. Health care workers and stakeholders should be committed to ensuring education and guaranteeing the legal rights of this specific population, including the continuous provision of quality health care, full access to school and support to full disclosure of HIV diagnosis.     

HIV serostatus disclosure and lived experiences of adolescents at the Transition Clinic of the Infectious Diseases Clinic in Kampala, Uganda: a qualitative study

Most studies on HIV serostatus disclosure and adolescents focus on whether, how and when to disclose to adolescents their HIV diagnosis. Fewer studies have examined HIV serostatus disclosure by adolescents who know they are infected with HIV. This study presents qualitative data examining HIV serostatus and treatment disclosure practices and concerns of young people living with HIV in Uganda and the extent to which they are satisfied with current norms around HIV serostatus and treatment disclosure. We conducted two focus groups and interviewed 20 HIV-infected young people aged 15-23 receiving HIV care and treatment at the Transition Clinic in Kampala. Respondents perceived disclosure as a relationship encompassing both communication and self-conduct. Adolescents employed unique strategies to disclose their HIV status, notably joking to "test the waters" and emotionally prepare the other person before later disclosing in a more serious manner. Findings reinforce the idea that HIV disclosure is a process, not a one-time event. Interviewees anticipated both positive and negative outcomes of disclosure, including financial and emotional support, stigma, discrimination and rejection. They described a sense of violation of their autonomy when confidentiality was breached by third party disclosure, and also expressed fear of emotional distress for their loved ones. Although adolescents yearned to be in control of information about their HIV status and treatment, they have little space to call their own, and privacy is often compromised, especially because in traditional African settings, young people are considered to be dependents under the full responsibility of caregivers. Further exploration of disclosure outcomes and strategies specific to adolescents can help better tailor interventions towards youth. Antiretroviral therapy programmes should consider counselling for caretakers to appreciate and respect the privacy and disclosure concerns of their HIV-infected children.     

AIDS in Brazilian children: history, surveillance, antiretroviral therapy, and epidemiologic transition, 1984-2008

We present a systematic review of historical, political, and epidemiologic aspects of AIDS in Brazilian children. Over 25 years, Brazil has developed different strategies to control AIDS in children. Three revisions of criteria for defining AIDS cases in children and nine national guidelines on antiretroviral therapy administration for management of HIV infection were published. These guidelines represent important progress, including aspects of HIV/AIDS surveillance, antiretroviral treatment, opportunistic conditions, prophylaxis, and laboratory testing. Brazil has significantly expanded access to free therapy with different classes of antiretroviral drugs. Initially focusing on treatment for HIV and opportunistic conditions, the scope of treatment guidelines gradually expanded to comprehensive health care for children and adolescents. From 1996 to 2008, the number of AIDS cases and deaths in children has been reduced by 67% and 65%, respectively, as a result of different strategies to prevent mother-to-child transmission of HIV and highly active antiretroviral therapy administration to infected children. Improved morbidity, mortality, and survival of Brazilian children with AIDS demonstrate clear benefits of adopting a policy of free and universal access to antiretroviral drugs associated with comprehensive care. However, important issues remain to be resolved, mainly concerning social, operational, and regional inequalities in coverage and quality of care, and epidemiological surveillance in different regions of the country. This broad review shows that the overall situation of pediatric AIDS in Brazil represents an incomplete process of epidemiologic and demographic transition, with the coexistence of old and new clinical and epidemiologic challenges.     

Peripheral blood mononuclear cell markers in antiretroviral therapy-naive HIV-infected and high risk seronegative adolescents. Adolescent Medicine HIV/AIDS Research Network.

OBJECTIVE: To examine potential hematologic and immunologic markers for healthy adolescents and for adolescents infected with HIV. DESIGN: The REACH Project (Reaching for Excellence in Adolescent Care and Health) of the Adolescent Medicine HIV/AIDS Research Network (AMHARN) recruits HIV-infected and high-risk HIV-uninfected adolescents, aged at least 13 but less than 19 years. The study evaluates biomedical and behavioral features of HIV infection as observed while under medical care for HIV infection and adolescent health. METHODS: Blood samples were collected from HIV-infected and HIV-uninfected subjects at 16 clinical sites. Cell phenotypes were determined using standard single, dual or three-color flow cytometry. RESULTS: This report includes data at enrollment for 94 HIV-positive adolescents who had never received antiretroviral therapy (ART) (mean age, 17.4 +/- 1.0 years for males and 16.5 +/- 1.3 years for females) and 149 HIV-negative adolescents (mean age, 16.7 +/- 1.2 years for males and 16.6 +/- 1.2 years for females); this is the antiretroviral therapy-naive subset drawn from 294 HIV-positive and 149 HIV-negative adolescents enrolled in the REACH Cohort. The total leukocyte count was significantly reduced in the HIV-positive females in comparison with the HIV-negative females (P < 0.001). There was a reduction in natural killer cells (P < 0.05) in HIV-positive females (mean, 140.6 +/- 104.2 x 10(6) cells/l) in comparison with HIV-negative females (184.3 +/- 142.5 x 10(6) cells/l), whereas no differences were found between the two groups of males. The reduction in the total CD4 cell count in HIV-positive males and females in comparison with the HIV-negative subjects was the consequence of a decrease in both the naive CD4 and memory CD4 components. There was a striking increase in the mean number of CD8 memory cells in HIV-positive compared with HIV-negative adolescents, and a corresponding increase in the percentage of these cells. In contrast, naive CD8 cells were present in increased numbers but their percentage was decreased. CONCLUSIONS: These studies of adolescents provide normative data for high-risk healthy adolescents as well as baseline immunologic data for a cohort of ART-naive HIV-positive adolescents. This comparison suggests that this untreated, recently infected group had relatively intact immunologic parameters.     

Community beliefs,HIV stigma,and depression among adolescents living with HIV in rural Uganda

The availability of and increased access to antiretroviral therapy (ART) has significantly reduced the morbidity and mortality associated with HIV. As a result, perinatally infected youth are increasingly able to reach adolescence. There is limited information about the psychosocial challenges facing adolescents living with HIV (ALWH) in rural settings of sub-Saharan Africa. We sought to understand psychosocial challenges facing ALWH in rural Uganda and their effects on mental health and HIV treatment outcomes. We conducted 5 focus group discussions and 40 one-on-one in-depth interviews in Mbarara, Uganda with adolescents (aged 13–17 years) and adult women caregivers. All interviews were audio-recorded, transcribed directly into English, and coded using thematic analysis to identify themes related to psychosocial adversities and mental health. Adversities faced by adolescents included negative community perceptions (perceived aggression, presumed early mortality), HIV stigma (enacted and internalized), vulnerability factors (loss of parents, poverty), and health challenges (depression, ART non-adherence). In the conceptual model that emerged from the findings, negative community perceptions (about perceived aggression or presumed early mortality) predisposed ALWH to experience enactments and internalization of stigma that led to depression and ART non-adherence. The data also identified several protective factors, including counselling, family and religious support, and timely serostatus disclosure. Interventions to correct community misperceptions about HIV can potentially reduce stigma and thereby improve physical and mental health outcomes of ALWH.     

Clearinghouse: youth and HIV

This bibliography lists articles related to treating HIV in young patients. Topics include treatment of dissociation in young men who have been infected as a result of sexual abuse; development of youth-based treatment approaches; attitudes and risk behavior of young mothers with HIV; and specific prevention programs for adolescents with HIV. Contact information is included.     

Correction of facial lipoatrophy using autologous fat transplants in HIV-infected adolescents

Objectives

Antiretroviral therapy has dramatically improved the survival of HIV‐infected children. Nevertheless, side effects comparable to those found in adults have been encountered, such as facial lipoatrophy, which can have a negative impact on the self‐esteem of otherwise healthy adolescents. Cosmetic surgical procedures in adolescents raise psychological issues which need to be specifically addressed and which have never been previously reported in this population. We evaluated the patient satisfaction, safety and cosmetic results of HIV‐infected adolescents who experienced autologous fat transplants for the correction of facial lipoatrophy.

Methods

We report the results of plastic surgery using autologous fat transplants (Coleman's Lipostructure^?) in six HIV‐infected adolescents with facial lipoatrophy: three boys and three girls, aged 14–19 years.

Results

The quantity of reinjected fat on each side of the face varied from 5 to 12 mL within a single procedure. All the patients reported being satisfied or very satisfied with the cosmetic results and reported a positive impact on their daily life.

Conclusions

With well‐trained surgeons and carefully selected indications, corrective surgery of facial lipoatrophy in HIV‐infected adolescents can provide immediate and long‐lasting benefits in terms of physical appearance and psychological wellbeing, and should be considered as a component of comprehensive care.

     

Psychosocial profile of HIV-infected adolescents in a Southern US urban cohort

We undertook a retrospective medical chart review of HIV-infected adolescents referred to a Southern US urban comprehensive adolescent HIV clinic between 1992 and 2003 to describe the psychosocial profile of adolescents infected with HIV via high-risk behaviours.Ninety-one adolescents (59 females, 32 males, 95% African-American, median age 17 years) were identified. Common reasons for initial HIV testing included routine prenatal screening (20%), clinical symptoms suggestive of HIV (20%), and recognized risk-related behaviours (20%). Findings included a history of unstable housing in the previous year (27%), running away (29%), knowing someone with HIV (36%), parental substance abuse (reported by youth, 46%), parental abandonment/neglect (30%), high substance use rates (marijuana 33%, tobacco 27%), current/prior STDs (60%), and involvement with the juvenile justice system or incarceration (41%). Sexual abuse/assault was reported by 41%. Previous depression was reported in 15% with approximately half reporting prior hospitalization. An additional 12% of the cohort had current clinical depressive symptoms. We conclude that infections with HIV via high-risk behaviours during adolescence occur in youth with multiple psychosocial stressors. Targeted prevention efforts to reduce these underlying stressors may decrease new adolescent infection. HIV-infected youth are best served in a comprehensive care environment with immediate access to medical care, social work, and psychology/psychiatry services.     

Growing up in a world with AIDS: social advantages of having AIDS in Brazil

Could HIV/AIDS become a positive factor for a child's life? This contradiction is explored in this paper based on anthropological fieldwork and research in Brazil. I used participant observation and informal interviewing both with children living with HIV/AIDS and uninfected street children to obtain qualitative data. Brazil is known as a country leader in social responses towards the AIDS epidemic. Not only has access to antiretroviral medications been assured, but also a series of help networks guarantee that the human rights of HIV-infected people be respected. Children and adolescents benefit equally from these social gains. As such, many children born to HIV-positive women have reached adolescence and have 'normal' lives. This article explores the life experiences of children and adolescents infected by HIV and compares them to the life experiences of street children. Even though the AIDS epidemic is linked to death, infected children and adolescents dream about their lives and futures. Contradictorily, street children, who have not acquired the virus and are considered healthy from a biological stand point, have no prospective plans and answer without hope to questions about the future.     

Thymic volume, T-cell populations, and parameters of thymopoiesis in adolescent and adult survivors of HIV infection acquired in infancy

OBJECTIVES: Antiretroviral therapy has significantly prolonged the lifespan of children who acquire HIV infection in infancy, but the impact of HIV on thymus-mediated maintenance of T lymphocytes has not been studied. To examine the long-term effects of HIV infection in childhood on thymopoiesis, thymic volume and parameters of thymic function from clinically stable adolescents and young adults with HIV infection acquired in infancy were compared with those from uninfected controls. METHODS: Thymic volume was determined using three-dimensional reconstruction and volumetric analysis of non-contrast enhanced computed tomography images of the upper chest. The degree of fat involution was assessed using a semiquantitive scoring system. CD4 and CD8 T cell populations and T cell receptor recombination excision circles (TREC) concentrations in peripheral blood lymphocytes were measured in all subjects. RESULTS: Twenty youths (aged 17.6 +/- 2.5 years) with HIV infection acquired perinatally (n = 18) or by neonatal transfusion (n = 2) were enrolled whose HIV plasma viral load had been undetectable for a median of 3.1 years, along with 18 seronegative healthy young adults (aged 20.6 +/- 1.3 years). HIV infected subjects and controls had indistinguishable CD4 T cell counts, thymus volumes (20.5 versus 15.8 cm), thymic index scores, and TREC values. Thymic volume correlated with the number and percentage of CD4 T lymphocytes in the control group and with the number of TREC in CD4 lymphocytes in the HIV infected group. CONCLUSIONS: Long term survivors of pediatric HIV infection appear to have retained or recovered thymic volume and thymic activity approximating uninfected youths.     

Impact of Condom Use and Standardized Sexually Transmitted Disease Treatment on HIV Prevention Among Men Who Have Sex with Men in Hunan Province: Using the Asian Epidemic Model

Abstract We evaluated the HIV/AIDS epidemic among men who have sex with men (MSM) in Hunan Province using the Asian Epidemic Model (AEM) and explored the impact of both condom use and standardized STD treatment on HIV prevention programs. The AEM was used to estimate HIV infection under four different scenarios: (1) condom use among MSM maintained at the 2005 level, (2) condom use among MSM improved since 2005, (3) the sexually transmitted infection (STI) prevalence rate among MSM maintained at the 2008 level, and (4) the STI prevalence rate among MSM improved since 2008. Compared with the rate of condom use at the 2005 level among MSM, if the rate of condom use had continuously improved, the number of new infections would have been reduced by 79.1% and the number of people living with HIV and AIDS would decrease by more than 8600 by 2020 and the cumulative number of new infections would have been reduced by 63.6% since 2006 while the number of new HIV infections among females would decline from 2015 with a drop of over 35% by 2020. When compared with the projection based on an unchanged rate of STI infection, the number of new HIV infections would decrease by 49.4% by 2020, and the decreased number of people living with HIV and AIDS would be more than 4000. The total number of 5200 newly infected HIV cases could be reduced from 2006 to 2020 and the number of newly infected HIV cases among the general female population would be reduced by 15.4%. With both the increased rate of condom use and standardized STD treatment for the MSM population in Hunan Province, the spread of HIV infection in both MSM and the general female population would decrease.     

Barriers to Medication Adherence in Behaviorally and Perinatally Infected Youth Living with HIV

The study explored barriers to antiretroviral medication adherence in perinatally and behaviorally HIV infected adolescents and young adults in a cross-sectional, multisite sample. The study included a subset of a convenience sample from a cross-sectional analysis. Participants were youth with HIV ages 12–24 who were prescribed HIV medication and reported missing medication in the past 7 days (n = 484, 28.4 % of protocol sample). The top barriers were similar for perinatally and behaviorally infected youth, but perinatally infected youth reported significantly more barriers. Forgetting, not feeling like taking medication and not wanting to be reminded of HIV infection were the most common barriers reported. Number of barriers was significantly correlated with percent of doses missed, viral load, and psychological distress for perinatally infected youth and with doses missed, psychological distress, and substance use for behaviorally infected youth. Interventions to improve adherence to HIV medications should not only address forgetfulness and choosing not to take medications, but also consider route of infection.     

HIV infection in the elderly

In the US, an estimated 1 million people are infected with HIV, although one-third of this population are unaware of their diagnosis. While HIV infection is commonly thought to affect younger adults, there are an increasing number of patients over 50 years of age living with the condition. UNAIDS and WHO estimate that of the 40 million people living with HIV/AIDS in the world, approximately 2.8 million are 50 years and older. With the introduction of highly active antiretroviral therapy (HAART) in the mid-1990s, survival following HIV diagnosis has risen dramatically and HIV infection has evolved from an acute disease process to being managed as a chronic medical condition. As treated HIV-infected patients live longer and the number of new HIV diagnoses in older patients rise, clinicians need to be aware of these trends and become familiar with the management of HIV infection in the older patient. This article is intended for the general clinician, including geriatricians, and will review epidemiologic data and HIV treatment as well as provide a discussion on medical management issues affecting the older HIV-infected patient.     

Knowledge about HIV/AIDS, the perceived risks of infection and sources of information of Asian-Indian adolescents born in the USA

This study examined the extent and specificity of knowledge about HIV/AIDS, the most used sources of information and the usefulness of these sources among Asian-Indian adolescents who were born in the USA and whose parents emigrated from India. Although 86% knew that having unsafe sex with a person infected with HIV could transmit HIV, 47% did not know that sharing a razor with an HIV-positive person could do so, and a significant proportion believed that donating blood (27%) and taking blood tests (14%) could transmit HIV. Television was the most used source of information, but school programmes on HIV/AIDS were considered the most useful source. The results indicated that to be effective, HIV/AIDS prevention programmes must assess the gap in scientific knowledge and beliefs, and clarify misconceptions, reinforce school programmes to present clear messages about the transmission of HIV/AIDS and utilize television to reach adolescents.