Longitudinal study of emerging mental health concerns in youth perinatally infected with HIV and peer comparisons.

Based on studies conducted throughout the world, it is now well established that youth with perinatal HIV infection (PHIV) experience relatively high rates of psychopathology.1–5 This is not unexpected as psychiatric symptoms in adults are not only implicated in HIV disease transmission6 but also associated with less than optimal strategies for managing child behavior7 and evidence moderate to high heritability.8,9 There is also fairly compelling evidence indicating HIV contributes to neurocognitive impairment,10–13 and treatment with antiretroviral drugs is onerous14 and may result in a range of annoying somatic symptoms.15,16 Thus, over and above the challenges of coping with a chronic illness17 associated with considerable negative social stigma, youth with PHIV are vulnerable to a number of biological and environmental risk factors.18–20 In addition to the obvious need to provide adequate care, the mental health concerns of youth with HIV have additional implications for clinicians. For example, psychiatric symptoms are associated with risky sexual behaviors and disease transmission,1,18,19,21–24 substance use,19,25,6 poor adherence to pharmacotherapy,27–31 and HIV illness parameters,13 but relations among these variables are complex and may vary as a function of study population characteristics.32 What is much less clear is the role of HIV infection or its attendant therapies in either contributing to or exacerbating emotional and behavioral problems. There are a handful of studies with appropriate comparison samples that have examined this topic, most of which have used cross-sectional designs. For example, Mellins et al33 found 3- to 8-year-old children with PHIV did not differ in the severity of caregiver ratings of emotional behavioral problems from HIV-exposed but uninfected peers. However, in a later study Mellins et al34 also examined rates of psychiatric disorders in the past year in older youth (aged 9–16 years) with HIV versus controls recruited from 4 medical centers. Here, they found a significantly higher overall rate of psychiatric disorders assessed with a structured interview in youth with PHIV (61%) versus exposed but uninfected peers (49%); however, group differences were not significant for specific disorders with the exception of attention-deficit hyperactivity disorder (ADHD) (18 and 8%, respectively). Recently, we reported on 319 youth with PHIV and 256 peers who were HIV-exposed or living in house-holds with at least 1 HIV-infected family member (peer comparisons). Participants were recruited from 29 sites in the United States and Puerto Rico.35 Youth with PHIV were relatively healthy, and almost all youth were currently receiving antiretroviral therapy. Many youth with PHIV (27%) and peer comparisons (26%) were rated (either self- or caregiver report) as having psychiatric problems that interfered with academic or social functioning, and the percentage of youth in both groups with the symptoms of specific disorders was clearly higher than the general population. Moreover, youth with PHIV had higher lifetime rates of special education (44%/32%) and interventions for emotional or behavioral problems (37%/22%) than uninfected peers, suggesting that lifetime rates of mental health concerns may actually be higher in youth with PHIV. In a related report about the same sample,36 we found several HIV illness parameters including lower nadir and entry CD4% associated with psychiatric illness, particularly conduct disorder (CD), as well as poorer quality of life and social and academic performance, suggesting that either the virus or severe immune suppression may have an effect on these functions. Collectively, the findings of these controlled, primarily cross-sectional studies support earlier reports of mental health concerns in youth with PHIV and identify several potential risk factors; however, they generally do not address the incidence of psychiatric conditions or changes in symptom or treatment status over time, relative to an appropriate comparison group, all of which help illustrate the scope of clinical management concerns. This study expands on our prior research by characterizing (a) the incidence of emerging psychiatric symptoms in youth with PHIV and peer comparisons during a 2-year time interval, (b) predictors of emerging symptoms (demographic, psychosocial, and HIV illness variables), and (c) rates of pharmacotherapy for emerging symptoms in these 2 groups of youth. This is one of the first published studies to address these topics using a controlled, prospective, longitudinal design with a relatively large, geographically representative sample of youth with PHIV, most of whom were treated with highly active antiretroviral therapy (HAART).