Psychiatric Considerations in Children and Adolescents with HIV/AIDS

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Epidemiology

Despite tremendous progress in our understanding of the HIV virus, its mode of transmission, and treatments to prevent its progression, HIV disease continues to be pandemic. Worldwide, an estimated 4.8 million people became newly infected in 2003 and more than 20 million people have died since the first cases of acquired immune deficiency syndrome (AIDS) were identified in 1981.1 An estimated 1,106,400 persons in the United States were living with HIV infection, with 21% undiagnosed and unaware

Etiology of HIV/AIDS infection among youth

Infected mothers transmit HIV during pregnancy or delivery, or through breast milk. Person to person transmission occurs through blood contacts such as transfusions or needle sharing; or through sexual contact with an infected partner. Transmission through blood products is rare in the United States but prevalent in some other countries. Perinatal transmission of HIV has been significantly reduced by the implementation of voluntary routine prenatal screening for HIV implemented by the CDC in

Neurologic effects of HIV infection

HIV primarily infects microglia of the central nervous system and macrophages. Its neurotoxic effects are thought to result primarily from the virus's ability to induce inflammatory factors that result in neuronal cell damage and death. In the adult population, the late effects of the neuronal cell damage presents as HIV-associated dementia (HAD). In children and adolescents, 2 types of encephalopathies may be seen: (1) a progressive encephalopathy characterized by acquired microcephaly, loss

Psychiatric syndromes in children and adolescents with HIV disease

The recognition of psychiatric syndromes in HIV-uninfected adolescents and in HIV+ adolescents, and the use of available interventions when recognized are extremely important. A large body of evidence supports the associations between adolescents with mental health conditions and the greater risk for HIV transmission. Psychiatrically ill adolescents are more likely to be sexually active at an early age, to engage more often in unprotected intercourse, to have multiple sexual partners,21, 22 to

Treatment

Recommendations for pharmacologic treatment of psychiatric disorders in HIV-infected youth are largely empirical.5 Data obtained from adults suggest that medications commonly used to treat psychiatric symptoms in nonmedically ill individuals, including psychostimulants, antidepressants, and antipsychotic medications, are useful for the treatments of those disorders in the medically ill, including those who are HIV+.32

However, when choosing to use psychotropic medications, careful consideration

Mood disorders: depression and bipolar disorder

The prevalence of depressive disorders increases in frequency from childhood to adolescence for HIV-negative (HIV−) and HIV+ populations.29 The presentation of depression in adolescents who are HIV+ is similar to adult populations. As in adults, depressed mood and irritability of at least 2 weeks' duration are criteria. Complicating this diagnosis of depression in the HIV+ child or adolescent, however, is the overlap between the vegetative symptoms of depression and the symptoms of the medical

Attention-deficit/hyperactivity disorder

Several studies suggest high rates of ADHD in HIV-infected youths,24, 40 though few studies have examined the use of psychotropic medications in this group. The efficacy of psychostimulants for the treatment of ADHD in nonmedically ill populations is well validated, and is the pharmacotherapeutic treatment of choice for this disorder. Although commonly prescribed in HIV+ children, few studies exist that examine dosage or efficacy in the HIV+ population.

Empirical data suggest initiating

Anxiety disorders

Anxiety disorders appear to be common among HIV+ youths, frequently comorbid with other psychiatric disorders. Social and specific phobias, separation anxiety disorders, agoraphobia, generalized anxiety, panic, and obsessive compulsive disorders have been reported, but the prevalence rates of specific anxiety disorders are unclear.26 When present in HIV+ youth and significant enough to interfere with normative function, cognitive and behavioral therapies are indicated. The use of SSRIs and TCAs

Posttraumatic stress disorder

The epidemiology of HIV in United States women increases the risk of exposure to trauma for youth living with HIV. The majority of perinatally exposed youths live in inner cities where stress, poverty, and trauma are prevalent.41 Trauma related to traumatic events and trauma related to medical procedures place HIV+ youth at risk for posttraumatic stress disorder (PTSD) and/or traumatic stress.42 The evidence further suggests that trauma exposure may adversely affect adherence to treatment

Delirium and dementia

The evidence suggests that delirium in the pediatric population presents with the same clinical picture as that of adults, and that the DSM-IV diagnostic criteria are applicable across the lifespan. Impairments in attention, responsiveness, levels of consciousness, orientation, confusion, affective lability, and sleep disturbance are present in pediatric patients with delirium, although paranoia, perceptual disturbances, and memory impairment are less common in younger children. The most common

Adherence

Current treatments for HIV/AIDS use antiretroviral medications. Four classes of medications, each with different mechanisms of action, are used in combination with a protease inhibitor to prevent the entry, replication, and cell destruction caused by HIV: nucleoside analogue reverse transcriptase inhibitors (NRTIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), fusion inhibitors, and protease inhibitors. These medications require multiple day dosing, have unpleasant side effects,

Summary

Youths infected with HIV are living longer. While most are doing well, many struggle with the burden of their illness and the demands of living with this chronic condition. The focus of our efforts must be prevention of new HIV infections. The recognition and treatment of psychiatric conditions for adolescents who are HIV− and for those who are HIV+ are an important component of this effort.

Psychiatric conditions are increasingly recognized among HIV+ youths who were born with their HIV disease

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  • Cited by (14)

    • Depression among Youth Living with HIV/AIDS

      2019, Child and Adolescent Psychiatric Clinics of North America
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      A regular assessment of cognitive functioning, adherence to medications, lifestyle, and safer sex practices should be included. Alcohol and drug use should be assessed as risk factors for unsafe sexual activity and poor health outcomes.51 One potential challenge for child and adolescent psychiatrists treating YLWHA is acknowledging any discomfort with inquiring about sexual behaviors with high-risk teens, both HIV infected and uninfected.

    • Abundance of psychiatric morbidity in perinatally HIV infected children and adolescents with comparison to their HIV negative sibling

      2016, Neurology Psychiatry and Brain Research
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      The Human Immunodeficiency Virus (HIV) epidemic was identified in 1980 & since then it has become a global challenge for the psychological health of the young children of HIV infected mothers. The report reveals that more than 22 million people have perished from this disease, and it is today the seventh-leading cause of death in the United States (Benton, 2010). Several countries in South East Asia also experience a sharp rise in HIV infection in the last decade which has not been focused very much (Suguimoto et al., 2014).

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