DURBAN, SOUTH AFRICA – Adolescents who were perinatally infected with HIV have a high prevalence of selected psychiatric disorders that impede their adherence to antiretroviral therapy, Claude Ann Mellins, PhD, reported at the 21st International AIDS Conference.
Those psychiatric diagnoses were predictive of viremia over the ensuing 2-3 years in a new analysis from the ongoing Child and Adolescent Self-Awareness and Health (CASAH) study, according to Dr. Mellins, professor of medical psychology at Columbia University, New York, and codirector of CASAH.
The clinical implications of the CASAH findings are clear, she added. “Assessing and treating specific categories of psychiatric and substance abuse problems may enhance efforts to improve adherence and prevent poor health outcomes in these adolescents and young adults, who are especially vulnerable due to their very challenging circumstances,” Dr. Mellins said.
CASAH is a longitudinal study of perinatally HIV-infected and perinatally HIV-exposed but uninfected New York City youth. They were enrolled during 2003-2008, when they were 9-16 years old. They and their caregivers undergo detailed psychosocial interviews every 12-18 months. The goal is to identify risk factors as well as protective factors influencing their behavioral health outcomes, the clinical psychologist explained.
She reported on 179 perinatally infected adolescents who were at least 13 years old at the first of their three interviews conducted over a 2.7-year period. Of note, 53% of them met Diagnostic Interview Schedule for Children (DISC-IV) criteria for one or more psychiatric diagnoses at all three time points. The pattern of psychopathology was somewhat different from that previously described in adults with HIV, who have been studied much more extensively than perinatally infected teens.
“Much of the literature on adults has focused on depression and mood disorders as predictors of poor health outcomes. Our data suggest that among youth, disruptive behavioral disorders – things like [attention-deficit/hyperactivity disorder], conduct disorder, or oppositional defiant disorder – may be just as important, if not more so. Substance abuse was also a critical factor,” Dr. Mellins said.
In a cross-sectional multivariate logistic regression analysis, a behavior disorder diagnosed at the first interview was associated with a 2.57-fold increased likelihood of contemporaneous viremia as evidenced by a plasma HIV RNA viral load greater than 1,000 copies/mL, and with a threefold increased likelihood of self-reported missed doses of antiretroviral medications during the previous week.
Anxiety disorder was the most common psychiatric diagnosis at the initial interview, followed by disruptive behavior disorder and substance use disorder. A diagnosis of any psychiatric disorder at the time of the first interview was associated with a significantly increased risk of viremia across the next 2.7 years. Forty-seven percent of subjects had viremia at 2.7 years of follow-up, reflective of chronic suboptimal medication adherence.
She noted that the pattern of psychiatric disorders in perinatally infected patients shifts between adolescence and young adulthood.
“By the time perinatally infected adolescents become young adults, I will say that anxiety and mood disorders become much more prevalent. But the number of psychiatric problems actually goes down by young adulthood,” according to Dr. Mellins.
Indeed, in another CASAH analysis she presented at AIDS 2016, this one involving 136 perinatally infected young adults and 86 perinatally exposed but uninfected controls, the vast majority living in impoverished communities, there was no difference between the two groups in rates of psychiatric or substance use disorders, although the 27% prevalence of substance use disorders is higher than that found in the age-matched general population.
Eighty-four percent of the perinatally infected 18- to 28-year-olds had graduated from high school, 94% were in a stable housing situation, 59% were currently working or in school, 54% were paying rent, and 95% reported ever being in a romantic relationship. Rates were similar in the perinatally exposed but uninfected group with the exception that these individuals were less likely to be paying rent.
“In spite of substantive risks, there is a relatively large portion of both groups with positive behavioral health outcomes, achieving normative young adult transition milestones. We need to understand why. Identification of protective factors conferring resilience can inform evidence-based prevention efforts, which are critical given the staggering numbers of children and young adolescents worldwide affected by HIV who will be transitioning to adulthood,” she said.
Dr. Mellins said the CASAH findings constitute a persuasive argument in favor of integrating mental health as a component of HIV care.
“Young people don’t always go to mental health appointments that are separate from medical care, so integrating mental health as a component of HIV care might be one of the most effective ways to identify and treat mental health problems in infected youth while simultaneously improving medication adherence and health outcomes,” Dr. Mellins said.