Elizabeth Brackis-Cott

Patterns of HIV Status Disclosure to Perinatally HIV-Infected Children and Subsequent Mental Health Outcomes

Increasing numbers of perinatally HIV-infected children are surviving into their teens and beyond. Research and clinical reports suggest that many HIV-infected children, particularly those younger than 13 years, do not know they are HIV infected owing to parental concerns about the impact on their mental health. This study examines patterns of HIV status disclosure to 77 perinatally HIV-infected ethnic minority children (aged 3–13 years), and explores the association between knowledge of HIV status and emotional and behavioral outcomes. The majority of children in this study (70%) did not know their HIV status. On average, children who knew their HIV status were older and tended to have lower CD4%. Child knowledge of HIV status was not associated with gender, ethnicity, caregiver education, parent–child relationship factors, type of placement (biological vs adoptive), or other health status indicators. As hypothesized, HIV status disclosure to infected children did not result in increased mental health problems. There was a statistical trend for children who knew their HIV status to be less depressed than children who did not know. Also, greater social disclosure (e.g. communication of child’s status to family and friends) was found when the child had an AIDS diagnosis or lower CD4%, as well as when the caregiver was HIV negative, African American and not the child’s biological parent. In conclusion, pediatric HIV infection remains a highly stigmatized issue that is difficult to discuss with the infected child and others. Yet, contrary to the beliefs of many caregivers, disclosure did not result in increased mental health problems.

Rates and types of psychiatric disorders in perinatally human immunodeficiency virus-infected youth and seroreverters.

BACKGROUND The purpose of this study was to examine 1) the prevalence of psychiatric and substance use disorders in perinatally HIV-infected (HIV+) adolescents and 2) the association between HIV infection and these mental health outcomes by comparing HIV+ youths to HIV exposed but uninfected youths (HIV-) from similar communities. METHODS Data for this paper come from the baseline interview of a longitudinal study of mental health outcomes in 9-16 year old perinatally HIV-exposed youths (61% HIV+) and their caregivers. Three hundred forty youths and their primary adult caregivers were recruited from four medical centers and participated in separate individual interviews. Youth psychiatric disorder was assessed using the caregiver and youth versions of The Diagnostic Interview Schedule for Children (DISC-IV). RESULTS According to caregiver or youth report, a high percentage of HIV+ and HIV- youths met criteria for a non-substance use psychiatric disorder, with significantly higher rates among the HIV+ youths (61% vs. 49%, OR = 1.59; CI = 1.03,2.47; p < .05). The most prevalent diagnoses in both groups were anxiety disorders (46% for total sample) which included social phobia, separation anxiety, agoraphobia, generalized anxiety disorder, panic disorder, obsessive- compulsive disorder, and specific phobias. One quarter of the sample met criteria for a behavioral disorder (ADHD, conduct disorders, and oppositional defiant disorders), with ADHD being most prevalent. HIV+ youths had significantly higher rates of ADHD (OR = 2.45; CI = 1.20, 4.99, p < .05). Only 7% of youths met criteria for a mood disorder and 4% for a substance abuse disorder. Several caregiver variables (caregiver type and HIV status) were also associated with both child HIV status and mental health outcomes. CONCLUSIONS Our data suggest that HIV+ youths are at high risk for mental health disorders. Further longitudinal research is necessary to understand the etiology, as well as potential protective factors, in order to inform efficacy-based interventions.

Psychiatric disorders in youth with perinatally acquired human immunodeficiency virus infection

Background: Clinical reports from the United States indicate substantive mental health problems in perinatally human immunodeficiency virus (HIV)-infected youth that pose substantial barriers to optimizing their health. This pilot study explores rates and types of psychiatric and substance use disorders, as well as emotional and behavioral functioning in perinatally HIV-infected children and adolescents. Methods: Forty-seven perinatally-infected youths (9–16 years of age) and their primary caregivers recruited from a pediatric HIV clinic were interviewed using standardized assessments of youth psychiatric disorders and emotional and behavioral functioning, as well as measures of health and caregiver mental health. Results: According to either the caregiver or child report, 55% of youths met criteria for a psychiatric disorder. The most prevalent diagnoses were anxiety disorders (40%), attention deficit hyperactivity disorders (21%), conduct disorders (13%), and oppositional defiant disorders (11%). However, the majority of caregivers and children scored in the normative range on the symptom questionnaires on emotional and behavioral functioning. None of the demographic or child health variables or measures of caregiver mental health was significantly associated with presence of a child psychiatric disorder. There was an association between caregiver mental health and child emotional and behavioral functioning. Conclusions: Standardized assessments of mental health identified very high rates of psychiatric disorders, primarily in the anxiety and behavioral domains, in this sample of youth with perinatal HIV infection. Mental health interventions should be integrated into medical care to help members of this highly vulnerable population optimize their health and well-being.

Substance Use and Sexual Risk Behaviors in Perinatally Human Immunodeficiency Virus-Exposed Youth: Roles of Caregivers, Peers and HIV Status

PURPOSE To examine the association between sexual risk behaviors and substance use, as well as the impact of caregiver characteristics and perceived peer norms among perinatally HIV-exposed but uninfected and perinatally HIV-infected youth. METHODS Using baseline data from a multisite study of psychosocial behaviors in perinatally HIV-exposed urban youth (N = 340; 61% HIV+; 51% female; aged 9-16 years). We conducted interviews with youth-caregiver dyads. Using hierarchical logistic regression, we explored the association between lifetime sexual risk behaviors, cigarettes, alcohol, marijuana, other drug use, caregiver relationship characteristics and peer influence. RESULTS Cigarettes, alcohol, and marijuana were significantly associated with HIV sexual risk behavior; no youth reported other drug use. After accounting for peer norms, the relationship between substance use and risky sexual behaviors was somewhat diminished. Irrespective of substance use, perception that more peers were involved in risky sex was associated with sexual risk behavior. Caregiver relationship characteristics had no effect on the association between substance use and risky sexual behavior. In all analyses, we found no effect across HIV status. CONCLUSIONS Regardless of HIV status, perinatally exposed youth who use substances are more likely to engage in sexual risk behaviors. Although the current study shows that peer influence on risky sexual behavior is more robust, caregivers are still important. The pediatric and adolescent HIV community must develop multilevel prevention initiatives that target youth, their peers, and their families.

The impact of perinatal HIV infection on older school-aged children's and adolescents' receptive language and word recognition skills.

Perinatally HIV-infected youths are reaching adolescence in large numbers. Little is known about their cognitive functioning. This study aims to describe and compare the receptive language ability, word recognition skills, and school functioning of older school-aged children and adolescents perinatally HIV infected (HIV-positive) and perinatally HIV-exposed but uninfected (seroreverters; HIV-negative). Participants included 340 youths (206 HIV-positive, 134 HIV-negative), 9-16 years old, and their caregivers. Youths completed the Peabody Picture Vocabulary Test, Third Edition (PPVT-III) and the Reading Subtest of the Wide Range Achievement Test, Third Edition (WRAT-3). Caregivers were interviewed regarding demographic characteristics and school placement of youths. Medical information was abstracted from medical charts. Both groups of youths scored poorly on the PPVT-III and WRAT-3 with about one third of youths scoring in less than the 10th percentile. The HIV-positive youths scored lower than the seroreverters (M = 83.8 versus 87.6, t = 2.21, p = 0.028) on the PPVT-III and on the WRAT-3 (M = 88.2 versus 93.8, t = 2.69, p = 0.008). Among the HIV-positive youths, neither CD4+ cell count, HIV RNA viral load or Centers for Disease Control and Prevention (CDC) classification were significantly associated with either PPVT-III or WRAT-3 scores. However, youths who were taking antiretroviral medication had lower WRAT-3 scores than youths not taking medication (M = 95.03 versus 86.89, t = 2.38, p = 0.018). HIV status remained significantly associated with PPVT-III and WRAT-3 standard scores after adjusting for demographic variables. Many youths had been retained in school and attended special education classes. Findings highlight poor language ability among youths infected with and affected by HIV, and the importance of educational interventions that address this emerging need.

Mental Health of Early Adolescents from High-risk Neighborhoods: The Role of Maternal HIV and Other Contextual, Self-Regulation, and Family Factors

OBJECTIVES To examine the effect of maternal HIV infection, as well as other individual, family, and contextual factors on the mental health of inner-city, ethnic minority early adolescents. METHODS Participants included 220 HIV-negative early adolescents (10-14 years) and their mothers, half of whom were HIV-infected. Individual interviews were conducted regarding youth depression, anxiety, externalizing and internalizing behaviour problems, as well as a range of correlates of youth mental health guided by a modified version of Social Action Theory, a theoretical model of behavioral health. RESULTS Although the HIV status of mothers alone did not predict youth mental health, youth knowledge of mothers HIV infection and mothers overall health were associated with worse youth mental health outcomes, as were contextual, self-regulation, and family interaction factors from our theoretical model. CONCLUSIONS There is a need for family-based mental health interventions for this population, particularly focusing on parent-child relationships, disclosure, and youth self-esteem.

Communication About HIV and Risk Behaviors Among Mothers Living With HIV and Their Early Adolescent Children

Little is known about how mothers living with HIV communicate to their children about HIV risk. The current study explored communication between mothers and children about prevention and risk behaviors, the impact of maternal HIV infection and child knowledge of HIV, and concordance in reports from mothers and their children. The sample comprised 220 mothers and their early adolescent children (10-14 years old) who resided in socioeconomically disadvantaged, urban neighborhoods. Mothers living with HIV were more likely to report discussing HIV and had more frequent related discussions compared to those mothers not living with HIV. Overall, children with mothers living with HIV reported greater comfort discussing sex- and drug-related topics than did those with noninfected mothers. The findings are discussed in terms of implications for family-based HIV prevention programs.

Current Life Concerns of Early Adolescents and Their Mothers: Influence of Maternal HIV.

Focus group discussions were conducted with inner-city ethnic minority families with regard to current life concerns, mother/child communication of concerns, and the influence of maternal HIV on both of those issues. Participants included early adolescents who were HIV-negative and their mothers (one-half were HIV-positive and one-half HIV-negative). Early adolescents were most concerned about sexual activity, pregnancy, safety and violence, and drugs. Early adolescents whose mothers were HIV-positive were concerned additionally with their mothers’ sickness and death, adult responsibilities, stigma and ostracism, and an even greater uncertainty about their futures. Mothers’ concerns for their children included safety and violence, sexual activity, drugs, and parenting. Mothers who were HIV-positive also were concerned about their own HIV-related issues of stigma, disclosure, becoming ill, and children assuming adult roles. Although early adolescents and mothers reported talking to each other about concerns, the quality of those discussions was unclear. Implications for family-based HIV prevention interventions are discussed.

Adapting a Family-Based HIV Prevention Program for HIV-Infected Preadolescents and Their Families: Youth, Families and Health Care Providers Coming Together to Address Complex Needs

Summary This article describes a family-based HIV prevention and mental health promotion program specifically designed to meet the needs of perinatally-infected preadolescents and their families. This project represents one of the first attempts to involve perinatally HIV-infected youth in HIV prevention efforts while simultaneously addressing their mental health and health care needs. The program, entitled CHAMP+ (Collaborative HIV Prevention and Adolescent Mental Health Project-Plus), focuses on: (1) the impact of HIV on the family; (2) loss and stigma associated with HIV disease; (3) HIV knowledge and understanding of health and medication protocols; (4) family communication about puberty, sexuality and HIV; (5) social support and decision making related to disclosure; and (6) parental supervision and monitoring related to sexual possibility situations, sexual risk taking behavior and management of youth health and medication. Findings from a preliminary evaluation of CHAMP+ with six families are presented along with a discussion of challenges related to feasibility and implementation within a primary health care setting for perinatally infected youth.

Predicting the Onset of Sexual and Drug Risk Behaviors in HIV-Negative Youths with HIV-Positive Mothers: The Role of Contextual, Self-Regulation, and Social-Interaction Factors

HIV-negative, inner-city adolescents with HIV-infected parents are considered to be at high risk for acquiring HIV themselves. Using a modified theory of health behavior, this study examined the effects of maternal HIV infection and psychosocial variables on the onset of sexual and drug risk behavior in 144 HIV-negative adolescents with and without HIV-positive mothers. Adolescents and their mothers were interviewed when the youths were 10–14 years old and again when they were 13–19 years old. By follow-up, 42% of youths reported the onset of vaginal sex (vs 5% at baseline). Marijuana and alcohol use increased from 6 and 38%, respectively, at baseline to 25 and 60% at follow-up. Among those reporting risk behaviors, 40--50% reported onset prior to 14 years. Youth and family psychosocial variables, but not maternal HIV status, were associated with risk behaviour outcomes.