IACAPAP Textbook of Child and Adolescent Mental Health

PSYCHIATRY & PEDIATRICS

Chapter

I.3

HIV/AIDS
ADDRESSING THE MENTAL HEALTH NEEDS OF AFFECTED CHILDRENAND FAMILIES

Tami D Benton, Anusha Lachman & Soraya Seedat
Tami D Benton MD
The Children’s Hospital ofPhiladelphia & Universityof Pennsylvania School of
Medicine, USA
Conflict of interest: nonereported

Anusha Lachman MBChB,
DCH, FCPsych, MMed
(Psych), Cert Child Psych,
MPhil
Tygerberg Adolescent
Psychiatric Unit & Stellenbosch
University, Cape Town, South
AfricaConflict of interest: nonereported

Soraya Seedat MBChB,
MMed (Psych), PhD
Department of Psychiatry,Stellenbosch University, CapeTown, South Africa‘Amelia, 13, (right) and her sister Mamdiuana, 7, inside the door of their house near Mombane (Mozambique). The
sisters now live alone, with the support of their community after both of their parents died of AIDS. Community supportfor HIV/AIDS orphans has become a priority for many communities. Leaders quickly realized that the effects of HIV
related illness are felt by entire communities - not only those who are infected with the disease. As a result, community
responses to the pandemic are necessary.’
Image and text: Andy Clark, PhotoSensitive

Conflict of interest: research
grants from the National
Institutes of Health and fromseveral pharmaceuticalcompanies (Lundbeck,
GlaxoSmithKline, and AstraZeneca), speaker honoraria
from Pfizer, Servier, Dr
Reddy’s, Sanofi-Aventis, andEli-Lilly.

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2013. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Benton TD, Lachman A, Seedat S. HIV/AIDS. Addressing the mental health needs of affected children andfamilies.. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Childand Adolescent Psychiatry and Allied Professions 2013.

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IACAPAP Textbook of Child and Adolescent Mental Health

AIDS: acquired immune deficiency syndrome.
AIDS-defining clinical condition: a list of diseases
associated with AIDS (published by theUnited States Center for Disease Control
and Prevention, CDC).
ARTs: antiretroviral drugs, term used to describe all
medications used to treat HIV disease.
CCR5 antagonists: antiretroviral medications
that bind to the CCR5 receptor on CD4
cells and prevent the HIV virus fromentering lymphocytes, thus interfering with
infectivity.
CD4: a glycoprotein found on the surface of helper
T-cells which is a receptor for the HIV virus.

Nucleoside reverse transcriptase inhibitors(NRTIs): antiretroviral drug class thatblocks reverse transcriptase of an HIV
enzyme and thus inhibits replication of the
HIV virus.
Progressive HIV-1 encephalopathy: a progressive
neurological condition resulting fromadvanced HIV infection or AIDS,
characterized by memory loss, slowed
movements, and behavioral changes.
Protease inhibitors: class of antiretroviral
medications that blocks activation of an
HIV protease enzyme involved in thesynthesis of new viral particles.

Reverse-transcriptase inhibitors (RTIs): a classof antiretroviral drugs that inhibit theactivity of reverse transcriptase, a viral DNA
polymerase that is required for replication of
Fusion inhibitors: class of antiretroviral medications
HIV and other retroviruses.
that prevent the HIV virus from fusing
Cytotoxic T-lymphocytes (CTLs): killer T-cells that
destroy cells infected by a virus.

with CD4+ cells, thus interfering withreplication.

HAART: highly active antiretroviral therapy.
HIV: human immunodeficiency virus infection.
HIV infects and destroys T-cells, eventuallyleading to an acquired immune deficiency
syndrome (AIDS).
HIV-1 disease: the most prevalent strain of humanimmunodeficiency virus.

Viral load (VL): The amount of HIV in a sampleof blood. Viral load (VL) is reported as thenumber of HIV RNA copies per milliliter ofblood. An important goal of antiretroviraltherapy is to suppress a person’s VL to an
undetectable level—a level too low for thevirus to be detected by a VL test.
Viremia: presence of virus in the blood.

HIV-associated dementia (also known as AIDS
dementia complex, HIV dementia, and HIV
encephalopathy) is a rapidly progressive
dementia associated with HIV infection
and characterized by cognitive deficits in avariety of domains.
HIV-positive: refers to individuals who are infectedwith the HIV virus. HIV-positive denotes
the confirmed presence of an HIV infection.
Integrase inhibitors: antiretroviral medications thatprevent viral DNA from integrating with theCD4 cell’s DNA thus preventing replicationof the HIV virus.
Non-nucleoside reverse transcriptase inhibitors(NNRTIs): antiretroviral drug class thatblocks reverse transcriptase of an HIV
enzyme by binding to a different site thanthe NRTI’s, but also results in inhibition ofviral replication.

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Click on the figure to accessa comprehensive glossary of
HIV/AIDS relevant terms

2

IACAPAP Textbook of Child and Adolescent Mental HealthProgress in HIV/AIDS prevention and treatment over the last twenty years
has been remarkable. A disease that initially resulted in rapid mortality
has now become a chronic condition. So much so that an adolescentdiagnosed with HIV can expect to live 60 years or more and will be more likely
to succumb to diseases of aging such as heart disease rather than to their HIV
infection (Insel, 2012). The HIV/AIDS pandemic has severely impacted themental health of children and families worldwide. The World Health Organization(WHO) estimates that about 34 million people were living with HIV by theend of 2010 (WHO, 2011). Many of those affected are women and children.
These data, though alarming, do not begin to reflect the impact of this illness onchildren, families and communities. HIV/AIDS is a biopsychosocial disease whose
impact extends far beyond its physical symptoms. Stigma, social and economic
factors, and political environment contribute to the burden of HIV/AIDS.
Reports describing rates of new cases and the prevalence of HIV infection inform
our understanding of the reach of this illness but they do not capture its actual
burden. The number of HIV cases is not proportional to the impact of this illness.
Efforts to identify cases, to treat HIV and prevent its progression—and in many
instances, to decrease the number of new cases—have been effective. However,
we have only begun to understand the mental health effects of HIV on children,
adolescents and their families. Furthermore, recognition and treatment for thosewith the double stigma associated with HIV and mental illness has lagged far
behind our knowledge about the HIV virus itself. In this chapter, we will describe
what is known about psychiatric and neurologic comorbidities associated withHIV disease, psychosocial sequela of the illness in industrialized and in developing
nations, and current evidence-based interventions for young people and families
coping with this illness.

EPIDEMIOLOGY
Despite significant advances in the prevention, detection and treatment
of HIV, millions of men, women and children worldwide continue to be newly
infected (see Table I.3.1). While the number of new cases is declining, they remain
alarmingly high. Approximately 2.5 million adults and children acquired HIV in
2011, 20% lower than the global estimates of new infections reported in 2001.
Children accounted for approximately 330,000 of these new cases, a decline of
24% since 2009. At the end of 2011, 0.8% of adults aged 15-49 were living with
HIV, with considerable variation across regions (see Table I.3.2). The sharpest
declines in newly acquired HIV have occurred in the Caribbean and Sub-SaharanAfrica. Sub-Saharan Africa, however, accounts for 69% of individuals living with
HIV. Despite the continued reduction in new cases of HIV globally, some regions
have trended towards higher rates: a 35% increase in HIV infections were observedin the Middle East and North Africa since 2001, reflecting an increase from 27,000
new cases to 37,000 new cases through 2011 (UNAIDS, 2012).

Perinatal infection
Success in the reduction of new HIV infections has occurred principally
through the prevention of transmission from mother to child; a 43% decline invertical transmission has occurred since 2003. Sub-Saharan Africa—the region

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Drs Luc Montagnier, fromthe Pasteur Institute, France(top) and Robert Gallo, fromthe National Cancer Instituteof the US are credited withthe discovery of HIV. Luc
Montagnier was awarded the2008 Nobel Price in Physiology
or Medicine.
Photos: Wikimedia Commons

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Table I.3.1 Prevalence of HIV and new infections in adults and children
RegionLiving with HIV(prevalence)

Newly Infected withHIV (incidence)

Sub-Saharan Africa

23.5 million

1.8 million

Middle East and North Africa

300,000

37,000South and South-East Asia

4 million

280,000

East Asia

830,000

89,000Oceania

53,0002,900

Latin America

1.4 million

83,000

Caribbean

230,000

13,000Eastern Europe and CentralAsia

1.4 million

140,000

Western and Central Europe

900,000

30,000

North America

1.4 million

51,000Global34 million

2.5 million

Source: UNAIDS (2012)burdened with more than 90% of the children with HIV globally—saw a 24%
reduction in new cases from 2009 to 2011. Declines have also been achieved in
the Caribbean, Oceania, Asia, Latin America, Eastern Europe and Central Asia.
There has been no reduction in newly infected children in the Middle East andNorth Africa (UNAIDS, 2012).
Prenatal detection of HIV-infected women and highly active antiretroviraltherapies (HAARTs) have produced significant reductions in new cases ofcongenitally acquired HIV. Use of HAARTs has resulted in decreased mortality
in children acquiring HIV through vertical transmission. In many countries,
children who were born with HIV are living into young adulthood and many are
working, pursuing higher education and starting their own families (Donenberg& Pao, 2005).

Youth
New infections are highest among older adolescents and young adults.
Young women account for more than 60% of all young people living with HIV
worldwide. This number is even higher in Sub Saharan Africa (71%). In 2010,
adolescents aged 15-24 accounted for 42% of new HIV infections in people 15
years and older. Globally, women in the 15-24 years age group are infected attwice the rate of young men and account for 22% of all new HIV infections and
31% of new infections in Sub Saharan Africa. While new infections remain high,there has been progress in 21 of 24 countries that report HIV prevalence, especiallyin sub Saharan Africa. Women and girls are disproportionally burdened by HIV
disease in part related to gender inequality and gender based violence in many
countries. For example, rates of forced sex among adolescent girls younger than 15
years have been estimated at 11% to 48% globally (UNICEF, 2011).

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HIV virus.
Hardin Library for the Health
Sciences, University of Iowa, US.
http://hardinmd.lib.uiowa.edu/
cdc/948.html

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IACAPAP Textbook of Child and Adolescent Mental Health

Table I.3.2 Prevalence of HIV in people aged 15-24 years according toregion (%)
RegionWomen

Men

Sub-Saharan Africa

3.1

1.3

Middle East and North Africa

<0.1

<0.1

South and South-East Asia

0.1

0.1

East Asia

<0.1

<0.1

Oceania0.1

0.1

Latin America

0.1

0.2

Caribbean

0.6

0.3

Eastern Europe and Central Asia

0.5

0.7

Western and Central Europe

<0.1

0.1

North America

0.2

0.3

Global0.6

0.3

Source: UNAIDS (2012)

Deaths due to HIV
More than 20 million people are estimated to have died from HIV/AIDS
since the discovery of the virus in 1981 (UNAIDS, 2004). The number of deaths
related to AIDS began to decline during the 1st decade of the 21st century due togreater public education, a decline in new infections, and broader availability of
antiretroviral drugs. The rate of AIDS-related deaths continues to decline. In
2011, 1.7 million people died from AIDS-related causes worldwide comparedwith 2.3 million in 2005 (UNAIDS, 2012). With access to antiretroviral drugs,
AIDS has become a chronic condition, even in poorly resourced, hyper-endemicareas (UNAIDS, 2012).

MECHANISM OF INFECTION
Mother to child transmission of HIV can occur through pregnancy, delivery,
and through breast milk. Transmission between individuals can occur throughtransfusions—advances in the detection of HIV in blood products has resulted
in substantial transfusion-related reductions in transmission (CDC, 2011)—
needle sharing or sexual contact. A decline in perinatal transmission of HIV has
occurred globally due to efforts by international agencies—focusing on routine
testing for HIV among pregnant women and treatment with antiretroviral drugs
prepartum, intrapartum and during breast feeding (see box). Current guidelines
recommending routine voluntary testing in all healthcare settings for individuals
aged 13 to 64 years and annual testing of at risk individuals and their sex partners
should further decrease new cases of HIV infection.
The mechanism of viral infection is well known. Following exposure, theHIV virus infects helper T-cells, replicating in the peripheral blood and lymphoidorgans. Cytotoxic T-lymphocytes that recognize the virus are generated in an effort

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Table I.3.3 CDC classification of AIDS defining illness in pediatric populations
Age-related CD4 values<11 months(% CD4+)12-35 months(% CD4+)36-59
months(% CD4+)>5 years(absolute
number per mm2
or % CD4+)

None or not
significant

>35

>30

>25

>500

Mild

30-35

25-30

20-25

350-499

Advanced

25-29

20-24

15-19

200-349

Severe

<25

<20

<15

<200 or <15%HIV-associatedimmunodeficiency

Source: WHO (2006).

Mother to baby transmission
HIV testing is recommended for all pregnant women. HIV can be transmitted from an
HIV-positive woman to her child during pregnancy, labor, or by breastfeeding. In Europe andthe US, about 15% to 20% of babies born to HIV-positive women who are not taking anti-HIV
drugs are infected. Fewer than 2% of babies are infected if the mother is taking HIV medication.
Because HIV can be transmitted through breast milk, initial recommendations suggested
that women infected with HIV should not breastfeed their babies. However, recently the WHO
has produced guidelines for breastfeeding by HIV infected mothers that will optimize healthy
survival of their children. These guidelines recommend breastfeeding for women who arereceiving effective antiretroviral medications and who do not have alternatives available forfeeding their infants.
Although the risk is very low, HIV can also be transmitted to a baby through food thatwas previously chewed (pre-chewed) by a mother or caretaker infected with HIV. To be safe,babies should not be fed pre-chewed food. HIV cannot be transmitted through casual contact,such as hugging and closed-mouth kissing. HIV also cannot be transmitted by items such as
toilet seats, door knobs, or dishes used by a person infected with HIV.
Women who are receiving an antepartum combination antiretroviral drug regimen
should continue this regimen as much as possible during labor and before delivery, including
scheduled cesarean delivery. Intravenous zidovudine should be administered near delivery
to HIV-infected women with HIV RNA ≥400 copies/mL (or unknown HIV RNA), regardless ofantepartum regimen or mode of delivery. IV zidovudine is not required for HIV-infected women
receiving a combination ARV regimens who have HIV RNA <400 copies/mL near delivery. For
women who have received antepartum ARV drugs but have suboptimal viral suppression neardelivery (that is, HIV RNA >1,000 copies/mL), scheduled cesarean delivery is recommended.

Click on the image to accessthe WHO infant feeding
guidelines.

Women whose HIV status is unknown who present in labor should undergo rapid HIV
antibody testing. If the results are positive, a confirmatory HIV test should be done as soon as
possible and maternal (IV zidovudine)/infant (combination antiretroviral prophylaxis) antiretroviraldrugs should be initiated pending results of the confirmatory test. If the confirmatory HIV test is
positive, infant antiretroviral drugs should be continued for 6 weeks. If the test is negative, theinfant ARV drugs should be stopped.
For some HIV-infected mothers (e.g., those who did not received anti-HIV medications
during pregnancy or have a viral load greater than 1,000 copies/mL) a caesarean delivery at
38 weeks of pregnancy (2 weeks before the due date) can reduce the risk of mother to-childtransmission. Either 6 weeks of zidovudine alone or zidovudine in combination with otheragents is recommended for infants born to mothers reciving IV zidovudine at delivery.
Source: AIDS Info

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Figure I.3.1 Stages of HIV infection (Source: Aids.Gov)

to kill viral particles. The initial viremia following infection is experienced as a flulike syndrome by the infected individual. The cytotoxic T-lymphocytes generated
at the start of the infection reduce the viremia and induces an asymptomatic phase(clinical latency) that can last for years. Eventually, however, the immune systemdeteriorates with increased viremia and an acquired immune deficiency syndrome(AIDS) develops. When the helper T-lymphocyte count falls below 200 cells/ml
or one AIDS defining condition occurs, a diagnosis of AIDS is made.
Taking antiretroviral medications can significantly slow the progressionof HIV infection to AIDS, thus early detection is critical to effective treatment.
New and evolving technologies allow earlier, faster and more accurate detectionof the HIV virus. Rapid diagnostic tests using saliva can provide screening resultsin as a little as 20 minutes. Serum samples however, are still required to confirm
the presence of HIV infection, generally by detecting the virus or its antibody,
2-12 weeks after the initial infection (see Box). When vertically acquired HIV issuspected in infants, HIV antibody detection cannot be used to make a diagnosis
of HIV. Virologic testing—to identify antibodies to the virus, DNA and RNA
polymerase chain reaction—are made within 48 hours of birth, at 1-2 months
and at 3-6 months to distinguish the infant’s antibodies from maternal antibodies,
which should decline over time. Criteria for defining AIDS in the pediatricpopulation are similar to those for adults with some exceptions (Caldwell et al,1994). An alternative classification system has been developed for infants exposed
to HIV whose status remains to be determined (Table 1.3.4).

NEUROLOGIC EFFECTS
The primary targets for HIV infection of the central nervous system are
the microglia and macrophages. HIV’s neurotoxic effects are thought to result
primarily from its ability to induce inflammatory factors that cause neuronal cell
damage and eventual death. The late effects of the neuronal cell damage and death
result in the HIV-associated dementia observed among adults infected with HIV.
Two types of encephalopathy have been described in children and adolescents withHIV with CNS involvement:
Progressive HIV-1 encephalopathy, characterized by the classic triad of(a) acquired microcephaly, (b) delay or loss of developmental milestones (motor,
cognitive and language) and (c) pyramidal tract motor deficits.

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Testing for HIV
The most common HIV
test is the HIV antibody
test. Generally it takes
the body about 3 months
from the time of infection to
produce enough antibodies
to be detected by an HIV
antibody test (for somepeople, it can take up to 6
months). The time period
between infection and theappearance of detectable
HIV antibodies is called thewindow period. Because
HIV antibodies are notdetectable yet, the HIV
antibody test is not usefulduring the window period.
The plasma HIV RNA
test (also called a viralload test) can detect
HIV in a person’s blood
within 9 days of infection,
before the body develops
detectable HIV antibodies.
The plasma HIV RNA test
is recommended when
recent infection is very
likely—for example, soonafter a person has had
unprotected sex with apartner infected with HIV.
Results of both tests are
generally available within a
few days.
Source: AIDS Info

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Figure I.3.2
Computed tomographyscan of an 11-year-old
child with progressive
encephalopathy
secondary to HIV
infection showing
diffuse atrophy andbilateral calcificationsin the basal ganglia
Source http://www.rihes.cmu.
ac.th/Ped_HIV/06-cli_present/
s4_09.html

A static encephalopathy involves no insidious deterioration of attained
milestones and is characterized by significantly delayed development andacquisition of new skills at a much slower rate than would be anticipated basedon the child’s age. These children may display cognitive abilities ranging from
low-average to markedly impaired. A subset of HIV-positive children has been
observed to display mild neurocognitive deficits with average overall intellectual
functioning but with specific learning problems, language and visuomotor deficits,
attention dysregulation, and socio-emotional impairment.

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IACAPAP Textbook of Child and Adolescent Mental HealthAt the beginning of the epidemic, severe progressive encephalopathy was
the presentation in 50% to 90% of children born with HIV; however, improved
treatment has altered this pattern (Tardieu et al, 2000). Recent estimates of HIV
encephalopathy presenting with brain atrophy, cognitive delays and motor deficits
among infected children are in the range of 13% to 23% (Tardieu et al, 2000).
Radiologic findings associated with HIV encephalopathy include calcifications in
the basal ganglia, global brain atrophy, enlarged ventricles and cortical sulci (seeFigure I.3.2). Evidence further suggests that higher viral loads are associated withmore severe cerebral atrophy (Brouwers et al, 2000).
The presentation of HIV infection of the nervous system is influenced bymultiple interacting variables including duration of the illness, its severity andtreatment. The pattern depends on the stage of brain development when infection
occurs. Neurocognitive developmental delays may be due to multiple factors
such as the direct effect of HIV, antiretroviral drugs toxicity, or psychologicaland socioeconomic factors (Willen, 2006). Many infected children may have no
medical symptoms and their developmental progress may be more influenced bypoverty and a lack of resources than the infection itself. For those presenting withbehavioral and developmental symptoms, the specific etiology of these symptoms
is often unclear. The determination of whether a child’s neuro-behavioral deficit isrelated to HIV—as opposed to other environmental, social or medical reasons—iscritical because of its implications for treatment.
Evaluating neurologic symptoms in the context of HIV requires considering
many factors. Globally, the social context of many HIV positive children includes
poverty, low socioeconomic status, lack of resources, and family losses interactingwith environmental stressors and neglect. Low levels of maternal literacy,
poor quality of interaction between caregivers and child, low birth weight andanemia are often more frequent in HIV-positive children (Brown et al, 2000). In
developing countries, zinc deficiency, malnutrition, childhood encephalopathies
such as cerebral malaria, and bacterial meningitis contribute an added burden.
In areas heavily impacted by HIV, like sub Saharan Africa, few studies haveexamined other risks for neurologic disease, thus restricting the ability to draw
firm conclusions regarding risk (Abubakar et al, 2008). The lack of measures ofchildhood neurocognitive outcomes standardized for Africa—and low-income
countries in general—and insufficiently sensitive measures further limit thescreening for deficits. This is especially important given data suggesting that some of
the behavioral and emotional deficits present in HIV-positive children were notedamong HIV-negative children who were living in the same social environment(Mellins et al, 2003).

Patterns of neurocognitive dysfunction
Untreated HIV infection in children has been associated with cognitive,
motor, language, and psychological developmental deficits (Smith et al, 2006).
Risk factors for CNS involvement in children include the timing of infection,
advanced maternal disease at delivery, rapid progression with early advanced
immune impairment. In the absence of antiretroviral treatment, children with afast progression and a more aggressive illness are likely to die before the age of 2
years, a much more common event in resource limited settings.

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Neuro-pathogenesis
The pattern of the disease depends on the stage of brain development when
HIV infection occurs. As highlighted already, neurocognitive developmental delays
may be due to the direct effect of HIV, antiretroviral toxicity, or psychologicaland socioeconomic factors (Willen, 2006). Neurological and developmental
signs are often markers of HIV disease in infants and may precede other signs ofdisease progression. HIV infection in children impacts on an immature brain andmanifests itself as a static or progressive HIV encephalopathy. A difference between
adult and child (especially children under 1 year of age) is that CNS disease fromHIV in children occurs more often before there is significant immunosuppression.
As a result of improved treatment, children are surviving into adolescenceand neurocognitive deficits are now being noted. Adolescence is a critical period
for brain development, nerve myelination and synaptic pruning—neural processes
crucial for higher order functions (e.g., efficient information processing, decision
making). The HIV virus affects subcortical white matter and frontostriatal systems
that are important for the regulation of emotions and behavior, increasing the riskin adolescence of impaired decision making, poor impulse control, risky sexual
behavior, and aggression. For perinatally infected youth exposed to early severe
HIV, the psychosocial ramifications of the illness—including stigma, disclosureof HIV status to others, and the missed academic and social opportunities—maysignificantly impact on mental health outcomes. In low resource settings, this isoften compounded by other factors such as poverty, exposure to violence, substanceabuse, neighborhood gangs, parental psychiatric and substance use disorders,adjustment to parental illness and death, caretaking transitions, orphanhood, andfamily disintegration (Mellins & Malee, 2013).
Children are living longer, but often they do so with severe developmental
delay or disability due to HIV encephalopathy. Children require motor skills tomaintain levels of confidence and independence in daily activities and to interact
with peers. Cognitive growth and social maturation have both been associatedwith motor skill development (Hilburn et al, 2010). Prevention of encephalopathy
through early initiation of high CNS-penetrating HAART regimens is thetreatment of choice (Violari et al, 2008). In poorly resourced settings where accessto antiretrovirals is limited, developmental problems associated with HIV should
be recognized and managed as early as possible.

Click on the picture to accessthe lecture “HIV: Manifestationsof Disease” by Lisa HightowWeidman, MD (51:22)

Although the HIV-associated dementia found in adults has not been welldescribed in adolescents, recent case studies describing dementia in adolescentssuggest that this syndrome may be observed more frequently in the future(Scharko et al, 2006). Among adults, HIV associated dementia presents as
subcortical dementia, a clinical syndrome characterized by slowing of cognition,
memory disturbances, difficulty with complex intellectual tasks such as problem
solving, visuospatial abnormalities, and disturbances of mood. Deterioration inattention, executive functioning and working memory have been associated withthe progressive frontocortical thinning found in HIV-associated dementia. For
adolescents, prevention of CNS disease requires adherence to antiretroviral therapy,
which can be challenging for them. Poor adherence to antiretrovirals, which canrequire multiple doses daily, can lead to resistance, higher viral loads, and increased
susceptibility to CNS infection. Among adolescents who acquire HIV disease

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IACAPAP Textbook of Child and Adolescent Mental Healththrough risky behaviors or transfusions, antiretrovirals have prolonged survival.
However, adolescents living longer with HIV are more likely to experience CNS
sequela including attention, memory and cognitive processing deficits. Similar
to adults, adolescents who develop AIDS show late neurocognitive changes with
progressive bradykinesia, spasticity, and hallucinations (Watkins et al, 2000).

Antiretroviral therapies and neurocognitive outcomes
Highly active antiretroviral therapies and progressive HIV-1 encephalopathy
Evidence suggests that progressive HIV-1 encephalopathy is a potentiallyreversible complication with a high probability of neurobiological improvement.
However, the literature disagrees regarding treatment. Though early initiation of
HAARTs is considered to be neuroprotective, there is a high risk of relapse inpatients with arrested encephalopathy if viral control is lost (Joska et al, 2010).
There are higher rates of residual cognitive and scholastic deficits in children withprevious diagnosis of progressive HIV-1 encephalopathy. Their IQ scores tend
to improve but still remain lower than in the general population, than in HIVnegative children born to HIV-positive mothers (perinatally exposed but notinfected), and lower than in HIV-negative children.
Highly active antiretroviral therapies in school aged children
Puthanakit et al (2010) have shown that school-aged HIV-positive children
have lower cognitive functioning than age matched HIV-exposed and HIV-negative
children. Long term treatment with HAARTs does not bring about improvement
in baseline cognitive functioning despite virologic control and normal immune
indices (normal CD4 counts). HIV positive children perform more poorly incognitive tests regardless of stage of disease, immune status or medication (Van
Loon, 2009). Thus, early initiation of HAART in infants and young children
should be considered in order to preserve neurocognitive functioning.
Long term effects on cognitive functioning
Despite the overall benefits of HAARTs, their long term efficacy in reducing
neurocognitive deficits remains to be demonstrated. Worldwide prevalence ofneurocognitive impairment has been only marginally affected by widespread use
of HAARTs. There have been few studies from low and middle income countriesof the effects of antiretroviral initiation on neurocognitive outcomes in perinatally
infected children and adolescents. Evidence to date from Thailand, Cambodia andSouth Africa suggests a failure of improvement of cognitive functions following
antiretroviral initiation, even with virologic suppression and immunologicalrecovery (Laughton et al, 2013). Benefits and reversal of deficits also varysignificantly between individuals. The severity of cognitive impairment at thetime of HAART initiation seems to be the strongest predictor of persistent deficits
despite long-term HAART (Tozzi et al, 2007).

PSYCHIATRIC SYMPTOMS IN CHILDREN AND
ADOLESCENTS WITH HIV/AIDS
The WHO recommends treatment for mental health conditions in individuals
who are HIV-positive. To that end, recognition of psychiatric symptoms among
young people at risk for HIV infection and those already infected is extremely

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IACAPAP Textbook of Child and Adolescent Mental Healthimportant. Psychiatric illness may be a predisposing factor for HIV infection ora perpetuating factor for risky behaviors in HIV infected youth. HIV infection
can also occur as a consequence of the psychiatric disorder itself. Psychiatrically illadolescents are more likely to become sexually active at a younger age, to engage
in unprotected intercourse, to have multiple sexual partners, to have history of
sexually transmitted diseases, to use drugs or alcohol and less likely to use condoms(Donenberg & Pao, 2005; Brown et al, 2000).
As with neurologic symptoms, recognition of psychiatric disorders iscomplicated by multiple interacting factors. Symptoms may occur as a result of
direct or indirect effects of the virus upon the CNS, genetic factors, opportunistic
infections, prenatal substance exposure, poor nutrition, limited access to medical
treatment, and other psychosocial and environmental factors. Other aspects that
may impact on the presentation of behavioral symptoms in youth living with HIV
include the fact that most live in distressed areas affected by poverty, violence,family conflict, substance use or in low income countries with limited access tocare.
Estimates of the prevalence of psychiatric disorder in youth infected
perinatally or who acquired HIV infection vary widely, with clinic-based reportssuggesting high rates of mental health problems (Gaughan et al, 2004). Children
with lower CD4 nadir counts (the lowest CD4 cell count measured after HIV
infection), higher viral loads, and AIDS-defining diagnoses seem to be at a higher
risk of poorer neurodevelopmental and cognitive outcomes, underscoring the needfor earlier initiation of antiretroviral treatment. Scharko and colleagues (2006)
reviewed published studies of psychiatric diagnosis among perinatally infected
youth; they found high rates of ADHD (29%), anxiety disorders (24%) anddepression (25%). However, the authors note that studies had serious limitations
such as small sample sizes, differing diagnostic methods, a variety of ages and lackof a control group. Other studies have also found high rates of psychiatric disorder,
ranging from 48% to 61% (Wood et al, 2009, Mellins et al, 2009). However,a controlled study of behavioral problems in perinatally infected children foundrates of behavioral problems that did not differ from those of a control group ofchildren who were perinatally exposed but not infected with HIV, suggesting thatthe observed behavioral problems were not the result of HIV infection (Mellins etal, 2003).
In one of the few studies using a structured diagnostic interview to obtain
psychiatric diagnosis, Pao and colleagues (2000), examined a sample of 34 HIV
positive adolescents attending an urban clinic. The investigators found very highrates of lifetime psychiatric diagnosis with 68% meeting criteria for depression,
59% for substance abuse and 29% for conduct disorder. However, the majority
had a psychiatric disorder preceding their HIV diagnosis, with approximately halfof them having a current affective disorder.
Studies of psychiatric diagnosis among children in low income nations are
scarce, and the few existing studies are hampered by small sample sizes and the useof diagnostic instruments that have not been validated in those settings. However,studies in children infected with HIV suggest higher rates of psychiatric symptoms.
One study from Kenya examining psychiatric syndromes among congenitally

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IACAPAP Textbook of Child and Adolescent Mental Health‘One of the most effective waysof getting a message out to yourtarget audience is to print it loudand clearly on the back of at-shirt. That’s what these young
Kenyans have done, “HIV/AIDS- chill and live longer” is theirmessage; it’s an abstinence
message, which they feel is one
tool that should be employed intheir community.’
Text and image: Patti Gower,
PhotoSensitive

acquired HIV infected children and adolescents reported overall rates of 48%
for any disorder (major depression, social phobia, oppositional defiant disorder,
and ADHD) with 25% having more than one diagnosis (Kamau et al, 2012). A
Ugandan study of HIV positive adolescents found high rates of anxiety, depression,
somatization and mania (Musisi & Kinyanda, 2009). Studies are emerging fromSouth Africa and India which show associations between psychosocial factors and
HIV/AIDS (Collins et al, 2006). Studies in Brazil found high rates of psychiatric
symptomatology among adolescents seeking HIV testing who were HIV-positive(Bassols et al, 2007). While more research is needed, current data suggests there
is a high prevalence of psychiatric disorders among children infected perinatally or
through other mechanisms, pointing to the need for screening, early identificationand treatment. Mellins et al’s (2003) finding that behavior problems observed inperinatally infected youth were no different than in youth exposed to HIV but notinfected highlights the challenges faced when making diagnosis of mental healthconditions in the context of HIV disease. It is notable that there have been few
studies of evidence-based mental health interventions in perinatally infected youth
and no published randomized controlled trials of treatment for specific psychiatricdisorders in this population.

TREATMENT OF HIV
Effective treatments for HIV infection have transformed the lives ofindividuals living with HIV throughout the world, in developed and developing
nations. The neurologic sequela of HIV infection that occurred at the beginningof this epidemic are now observed much less frequently. The encephalopathy
that develops with progression of HIV disease can be prevented or reversed with
HAARTs (McCoig et al, 2002; Brouwers et al, 1990)

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Click on the picture to accessthe US Office of AIDS Research
Advisory Council guidelines forthe use of antiretroviral agents.

13

IACAPAP Textbook of Child and Adolescent Mental Health

Antiretroviral treatment is based on the use of six major classes of medication,
determined by their mechanisms for fighting the HIV virus:
•
•
•
•
•
•

Nucleoside reverse transcriptase inhibitors (NRTIs)
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Protease inhibitors
Fusion inhibitors
CCR 5 antagonists, andIntegrase inhibitors.

Highly active antiretroviral therapy disrupts the HIV virus ability to infectand reproduce by interrupting its mechanisms of infection at more than one site,thus decreasing the virus’ effectiveness. Use of three or more HAARTs from atleast two different drug classes is recommended to maximize therapeutic benefits(OARAC).

Adherence
Though effective, there are many challenges associated with adherence to
HIV treatment. Failure to completely adhere to treatment regimens can result intreatment failure and the development of resistance to medication, particularly aproblem for adolescents (Williams et al, 2006). HAART regimes, though simplified
by the development of combination pills, remain complicated by the need to takemedication several times a day, significant side effects, and interactions with othermedications, especially psychotropic drugs, and food items that could interferewith their effectiveness. HAARTs can also exacerbate the symptoms initially. For
example, nucleoside reverse transcriptase inhibitors (NRTIs) have been reported
to exacerbate progressive encephalopathy and neuropathy (Tamula et al, 2003;
Church et al, 2001).
Optimal benefit of treatment requires nearly 100% compliance.
Inconsistent adherence can result in drug resistance, increasing viral loads andprogression to AIDS (Feingold et al, 2000). In developing nations, the presence of
psychiatric illness has been shown to negatively impact adherence to antiretrovirals(Murphy et al, 2005). A systematic review examining the relationships between
mental illness and HIV disease in adults did not find similar relationships between
mental disorder (depression) and adherence to ARTs (Nachega et al, 2004). A
south African study found that fear of rejection, stigma and violence by a sexual
partner to be associated with less than 95% adherence to HAARTs (Nachega etal, 2004). Studies examining adherence among HIV-positive adolescents who
were not congenitally infected have found an association between the presenceof depression and poor adherence to antiretrovirals (Donenberg & Pao, 2005;
Murphy et al, 2005). Studies of children perinatally infected with HIV found that
non-adherence increased with increasing age, female gender, detectable viral load,
recent stressful life events, failing a grade, and the presence of depression or anxiety(Williams et al, 2006). In summary, factors found to reduce adherence amongchildren and adolescents include increasing age, complexity and palatability of thetreatment regimen, symptomatic HIV disease, caregivers’ mental health, family
belief systems, disclosure status, and family social support (Dodds et al, 2003;
Wiener et al, 2004). There are a number of successful evidence-based interventions

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Without proper treatment, halfof the 370,000 children newly
infected with HIV in 2010 will
die before they reach theirsecond birthday. But very
few medicines are designed
and adapted specifically forchildren, and are affordable andpractical to use in the places
where they live. Click on the
figure to watch a podcast by
Doctors without Borders
discussing these issues,particularly as they refer to very
young children (under 3 yearsof age), from the size of thepills to taste and affordability(13:51).

14

IACAPAP Textbook of Child and Adolescent Mental Healthfor improving antiretroviral adherence for adults and youth using behavioral
approaches (Rotheram-Borus et al, 2001a).

Impact of antiretroviral treatment
Antiretroviral therapy in children is associated with enhanced survival,
improved neurocognitive function, reduction in the incidence of opportunistic
infections, and better quality of life. Yet, despite the initiation of antiretroviraltreatment, children with HIV continue to fall behind their HIV non-infected
peers in terms of growth and development. Clinical trial data in high, middle andlow income countries have confirmed the immunologic and virologic benefits ofantiretroviral drugs (Ciaranello et al, 2009).
There is a higher risk of death and disease progression in infancy than in
adulthood and it is well known that CD4 counts and viral load are poor predictorsof disease progression in infants. The results of the CHER trial demonstrated
that early treatment with antiretrovirals reduced mortality by 76% and HIV
progression by 75% (Violari et al, 2008). This resulted in a change in guidelines,
now recommending that all HIV infected children under 12 months of age receive
antiretrovirals immediately. These guidelines present particular challenges in low
income countries where access to care after birth is limited and where there is alack of early infant testing, mother to child transmission prevention programs,
and monitoring of treatment. Providing antiretrovirals to infants in resource poor
countries demands a holistic approach that goes beyond the simple administrationof pills.

TREATMENT OF PSYCHIATRIC SYMPTOMSTreating psychiatric symptoms in the context of HIV disease requires acareful assessment and consideration of the interacting organic and psychosocial
factors contributing to an individual’s presentation (Brown et al, 2000). For
example, differentiating the medical symptoms of HIV disease from depressive
symptoms manifesting as somatic concerns or symptoms of depression itself can bedifficult (Benton, 2008). Furthermore, cultural factors influence the psychologicalresponse to HIV infection (Ponton & Lees, 1998). As mentioned earlier in thischapter, HIV-positive youth may exhibit depression, attention deficits, mania, andeven psychotic symptoms resulting in distress, resistance to taking or poor adherence
to antiretroviral treatment, and disregard for safe sex behaviors (Lightfoot et al,2005). Thus, treatment of psychiatric symptoms may alleviate distress, improveadherence to treatment and overall functioning.

Psychosocial interventions
While most controlled psychological and behavioral therapy studies havefocused upon HIV prevention in developing nations, some treatment studies
suggest that evidence based psychotherapies that are effective for non-medically ill
individuals can be effective for mental conditions in HIV-positive persons as well
(Donenberg & Pao, 2005; Olatunji et al, 2006). Studies suggest that psychosocial
and behavioral treatments that utilize a wide variety of interventions including
social support, interpersonal therapy, CBT, and behavioral stress management inindividual or group formats are effective in both adults and adolescents (Olatunji
et al, 2006; Harding et al, 2011). A systematic review of adults and adolescents with

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IACAPAP Textbook of Child and Adolescent Mental HealthHIV concluded that individual, family and group-based treatments all demonstrated
efficacy in improving coping, family functioning and in reducing psychologicaldistress and social isolation. The interventions were effectively delivered in an
individual or group format—particularly relevant for resource poor countries(Harding et al, 2011). A study in Uganda tested the efficacy of interpersonal
psychotherapy for depression in rural communities with high HIV prevalence andhigh AIDS related mortality. In this study, 30 villages were randomized to 16
weeks of interpersonal psychotherapy or a control condition. The results showedsignificant reductions in depressive symptoms for the intervention group whencompared with controls, suggesting that evidence based interventions are feasible
in communities with limited resources and few mental health professionals (Bolton
et al, 2003). Among pediatric populations, family focused mental health services
have been found useful for improving family functioning, reducing social isolationand increasing utilization of other support services (Brown et al, 2000), reducing
problem behaviors and emotional distress (Rotheram-Borus et al, 2001a).
Substantial data support the efficacy of behavioral interventions forthe prevention of HIV transmission among adults and youth. More than 144
interventions have demonstrated efficacy in randomized controlled trials conductedin both high income and resource poor nations (Rotheram-Borus et al, 2009).
For HIV-positive adolescents, prevention programs usually focus on adherence
to medication and lifestyle changes, prevention of transmission, improved selfcare and quality of life, partnering with medical providers, managing medicationside effects, disclosure, and positive health behaviors (Rotheram-Borus et al, 1995;
1998; 2001a; 2001 b).

Using psychotropic medication
Limited data exist regarding medication treatment for psychiatric symptoms
in children and adolescents infected with HIV. Recommendations are largely
empirical and mostly extrapolated from adult studies (Evans et al, 2005). However,caution is warranted when prescribing any psychotropic medication to HIVpositive youth who are using antiretrovirals. Both HAARTs and psychotropics arelargely metabolized by the 3A4 and 2D6 enzymes of the cytochrome (CYP) p450
system with the subsequent high potential for drug interactions. As a result, bloodlevels of antiretrovirals and psychotropic medications may be increased, decreased
or both, by inhibition or induction of these enzymes. Certain antiretrovirals are
known to have a particular impact and to pose risks for individuals with HIV. The
protease inhibitors, especially ritanovir, are potent inhibitors of 3A4 and to a lesser
extent 2D6. Efavirenz is a potent inducer of CYP 3A4, decreasing plasma levels ofother medications that are metabolized by this pathway.

HIV-positive individuals tend to
be more sensitive to the side
effects of pychotropic drugs andoften respond to lower doses.

Some of the antiretrovirals can also cause psychiatric symptoms. The mostconcerning in this regard is efavirenz. Early reports suggested that sudden onsetof suicidal ideation and depression were potential side effects. Reports further
suggest that more than 50% of individuals using efavirenz might experience
depression, suicidal ideation, vivid nightmares, anxiety, insomnia, psychosis,
cognitive dysfunction and antisocial behavior. More recent data suggests that vivid
dreams and vestibular dysfunction were much more frequent with efavirenz thanin patients treated with a triple nucleoside regimen. However, these unwanted
effects were transient and resolved within 4 weeks (Ferrando, 2013)

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IACAPAP Textbook of Child and Adolescent Mental Health

Table I.3.4 Common interactions between antiretroviral drugs andpsychotropic medications
Drug

Interaction

Citalopram

Fluoxetine andfluvoxamine

Paroxetine
Sertraline•

Lopinavir/ritonavir (ritonavir increases
citalopram levels)•

Increase levels of amprenavirdelavirdine,efavirenz, indinavir, opinavir/ritonavir,
nelfinavir, ritonavir, saquinavir.
Nevirapine decreases fluoxetine levels••

Lopinavir/ritonavir (ritonavir increases
paroxetine levels)•

Lopinavir/ritonavir (ritonavir increases
sertraline levels)

When considering psychotropic use in the context of pediatric HIV andantiretroviral tretament, clinicians must examine factors beyond the presenting
behavioral complaint. A thorough psychiatric and psychosocial assessment
including ascertaining developmental factors, environmental issues, and socialand family circumstances must occur. Recent stressors must also be elucidated.
Collateral information from school, primary care providers, specialists, counselors
and family members must be obtained before reaching diagnostic conclusions.
Neurologic disorders must also be evaluated as a potential cause of behavioral
symptoms and as a risk factor for medication side effects. A thorough review of theantiretroviral regimen should identify potential precipitants of behavioral changes.

Click on the picture to accessdetailed information about HIV
drug interactions.

Given the absence of evidence to guide the prescribing of psychotropic
medication in this population, caution is warranted. When choosing medicationand dosing, the clinician should consider Tanner stage, body weight and bodymass index, as well as the child’s medical condition. Medications should beselected taking into consideration their side effect profiles, starting with the lowest
therapeutic dose, and titrating gradually to minimize adverse effects. HIV-positive
individuals tend to be more sensitive to side effects and often respond to lower
doses (Benton, 2010).

Mood disorders
Depression and bipolar disorder increase in frequency from childhood toadolescence among HIV-positive and HIV-negative youths (Geller et al, 2002;
Lewinsohn et al, 1993). Criteria for a depression diagnosis in adolescents who are
HIV-positive are the same as for adolescents who are not HIV-positive. However,making a diagnosis of depression is complicated in the young person with HIV
by the overlap of the vegetative symptoms of depression with HIV symptoms
themselves or side effects of antiretroviral treatment. Symptoms common in
depression such as fatigue, anorexia, anhedonia and other somatic complaints
may also suggest progression of HIV disease. Clinical assessment must include anevaluation of worsening medical status, poor adherence to antiretrovirals resulting

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IACAPAP Textbook of Child and Adolescent Mental Healthin drug resistance, and recent stressors (e.g., adjustment disorders) or grief due tothe loss of family members or friends.
SSRIs are the most commonly used antidepressants for young people livingwith HIV; they are the antidepressants of choice due to their efficacy in adolescentsand their favorable side effect profile. Although no data exist supporting
differential efficacy among the SSRIs, fluoxetine has the strongest evidence baseand is approved in the US and other countries for treatment of depression inchildren older than 8 years of age (Emslie et al, 1997). Tricyclic antidepressantshave not been shown to be superior to placebo in controlled trials in youth andare toxic, particularly in overdose. Other agents commonly used for the treatment
of depression in the context of HIV disease include mirtazapine due to its safety
profile and lesser risks for drug interactions. Mirtazapine has been helpful forsleep and in promoting weight gain although controlled trial data is still lacking.
Similar to other groups with depression, careful monitoring of the emergence ofsuicidal ideation is warranted (Benton, 2010). The prevalence of bipolar disorders
in HIV-positive youth has not been systematically studied and recommendations
for treatment are based on current pediatric and adult treatment guidelines.

Attention deficit hyperactivity disorder
While high prevalence rates of attention deficit hyperactivity disorder in
HIV infected youth have been reported (Mellins et al, 2009; Scharko, 2006), few
medication treatment trials exist among HIV-positive youth. Psychostimulants arewell studied in youth with ADHD who are not medically ill, being the treatment ofchoice for this disorder in those who are HIV-positive also. Efficacy of stimulantsfor ADHD in HIV-positive youth has not been studied, even though they arecommonly prescribed in this population. The current practice is that children
who exhibit ADHD symptoms in the context of HIV disease can be treated withstimulant medication at the recommended dosages for non-HIV-positive children.
Because stimulant medications have few drug-drug interactions, they are relatively
safe in combination with antiretrovirals.

Pediatric HIV: The realityof a neglected disease.
Click on the figure to watch
a video clip discussing someof the problems facing thetreatment of young children with
HIV in low income countries(4:42).

Anxiety disorders
High rates of anxiety disorder have been reported among HIV-positive
youth, however, prevalence of specific disorders is unclear (Mellins et al, 2009).
Social phobias, specific phobias, separation anxiety, agoraphobia, panic disorder,
and obsessive compulsive disorder have been reported in this population as well as
high rates of comorbidity with other psychiatric conditions (Mellins et al, 2009).
As with other anxiety disorders, treatment should be initiated when symptoms
interfere with normative functioning. Cognitive and behavioral therapies havedemonstrated efficacy in children and adolescents for the treatment of anxiety andshould be the first line of treatment for HIV-positive youth with anxiety disorders(Brown et al, 2000). SSRIs should be considered for anxiety disorders that do notrespond to behavioral interventions.
Another source of anxiety for HIV-positive children and adolescents relates
to medical procedures occurring during treatment for their illness. Distraction
techniques and psychotherapies have been helpful, often used in conjunction withbenzodiazepines in low doses, such as lorazepam. Clonazepam has also been used
for children with more prolonged anxiety. However, benzodiazepines may cause

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IACAPAP Textbook of Child and Adolescent Mental Healthsedation and behavioral disinhibition, especially in patients with CNS disease orother cognitive effects of HIV disease or its treatment and should be monitored
closely. Antihistamines are commonly used for calming anxiety or sedation foranxious children, but are not recommended for the treatment of anxiety. The
anticholinergic properties of antihistamines may worsen delirium.

Post-traumatic stress disorder
The epidemiology of HIV in industrialized and low income nations
increases the risk of exposure to trauma in youths. For example, the majority ofperinatally exposed youth in the US live in inner cities where stress, poverty, andtrauma are endemic (Havens et al, 2008). Both traumatic events and medical
procedures further increase the risk for post-traumatic stress disorder or traumaticstress (Stuber et al, 2003). This is very relevant given the association between
trauma exposure and adherence to safe sex practices and to antiretroviral treatment
for HIV-positive youth (Radcliffe et al, 2006). In a study examining PTSD andpost-traumatic stress in 30 HIV-positive adolescents and young adults, rates of
PTSD ( 13%) and post-traumatic stress syndrome (23%) were high in response
to being diagnosed with HIV infection, but even higher when examining othertraumatic events occurring among the same young people, giving further support
to the impact of ongoing trauma in the lives of HIV-positive youth (Radcliffe etal, 2006).
Trauma focused cognitive behavioral therapies have been found to beeffective for PTSD symptoms. Medications may be helpful for some youth;
however, empirical support for medication use is weak (Foa et al, 2000)

Delirium
The clinical presentation of delirium in adolescents is similar to adults.
Impaired attention and responsiveness, disorientation, confusion, affective lability,
alterations in level of consciousness, and sleep disturbance can be present. Althoughparanoia, perceptual disturbances and memory impairment are less common inyounger children, the diagnostic criteria for delirium are applicable across thelifespan. In most cases of pediatric delirium the etiology is a medical condition or
medication (Turkel & Tavare, 2003).
Treatment consists of strategies to maintain orientation and environmental
cueing. Pharmacologic treatment for delirium in HIV infection relies primarily
on second generation antipsychotic agents in low dose. Adverse effects of the
antipsychotics, including extrapyramidal, are limited; both typical and second
generation antipsychotic agents are equally efficacious. Lorazepam causes aworsening of delirium with disinhibition, ataxia, confusion and oversedation,suggesting that benzodiazepines should not be used for delirium in this population(Ferrando, 2013).

Click on the picture to viewa lecture on ‘Pediatric HIV
Prevention, care and treatment
in Lesotho’ by Lindy C
Fenlason MD, from the Baylor
International Pediatric AIDS
Initiative (BIPAI) (48:17).

OTHER PSYCHOSOCIAL FACTORS AFFECTING
TREATMENT FOR FAMILIES AFFECTED BY HIV/AIDS
Bereavement
UNICEF reports that 15.2 million children had been orphaned by AIDS
worldwide by 2005 and that 13.7 million children had lost one or both parents

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IACAPAP Textbook of Child and Adolescent Mental Healthto AIDS in South Africa alone. The number of orphans is predicted to reach 2.3
million by 2020 (Dorrington et al, 2005). Parental loss poses further mental healthrisks for the children and adolescents left behind. Evidence suggests that children
who have been orphaned by HIV/AIDS have multiple risks for poor outcomes
including poor medical care and nutrition. Further, orphaned children aged 16
to 24 show lower educational achievement, are more likely to be abused and havehigher rates of HIV (Cluver et al, 2007). In addition, children and adolescentswith HIV often face the dual misfortune of living with their own life-limiting
illness and facing the death of loved ones (Roth et al, 1994). Frequently, the loss
multiplies the burden because of HIV disease. The stigma and secrecy commonlysurrounding death by HIV/AIDS may complicate the grieving process by depriving
these youngsters of the support they need and by reinforcing a sense of shameabout their parents’ death. Disclosure of an AIDS-related cause of death may resultin stigmatization, shaming by family members, and ostracism and teasing by peers,thus interfering with the grieving process and further impairing a child’s ability tocope with the loss (Siegel & Gorey, 1994).
In addition to the loss, extended family members are often counted upon toprovide care and support for the remaining children. The impact of orphanhood
has been most profoundly experienced in low income nations. It is estimated thatabout 9% of children in Sub-Saharan Africa have lost at least one parent to HIV/AIDS during the 1990’s (Monasch & Boerma, 2004). In most cases, the extended
family assumes the roles of caretaking, shouldering the financial and emotionalburden of caring for these children with multiple medical and emotional needs(Earls et al, 2008). Further, longitudinal studies suggest that both HIV/AIDS inorphans and in their caregivers predicts increased rates of depression, anxiety, andposttraumatic stress symptoms in HIV/AIDS orphans years later, highlighting theneed to focus interventions on infected youth and their caregivers (Cluver et al,2012).

Disclosure
Reasons influencing the decision to tell a child or adolescent their HIVpositive status are complex. Cultural issues, misperceptions and misinformation
about the disease—by relatives, teachers, health care providers, and thecommunity—are all factors impacting on the disclosure (Bakeera-Kitaka et al,2008). Additionally, disclosure of a child’s HIV status may also reveal the HIV
status of the parents, who may experience stigma and discrimination themselves asa result (Pinzon-Iregui et al, 2013).
The WHO, the American Academy of Pediatrics (AAP, 1999) and theInternational Center for AIDS Care and Treatment Programs (Abrams et al,2004) have endorsed disclosure to older children (10 years of age or older) of
their HIV status (see box). These organizations have also published guidelines
to assist clinicians and families who are struggling with this complicated issue.
Despite these recommendations, most studies about disclosure worldwide suggestthat many HIV-positive children and adolescents are unaware of their HIV status(Pinzon-Iregui et al, 2013). The proportion of children who know their HIV
status is lower in low and middle income countries (20.4%) when compared withindustrialized countries (43.1%) (Pinzon-Iregui et al, 2013; Vreeman et al, 2010).
For example, one study in Thailand found that only 1 in 5 HIV infected youths

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Click on the figure to accessthe WHO Guideline on HIV
Disclosure Counseling forChildren up to 12 Years of Age.

20

IACAPAP Textbook of Child and Adolescent Mental Health

Image: Patti Gower, PhotoSensitive

between the ages of 5-16 years had been told of their HIV diagnosis (Boon-Yasidhi
et al, 2005).
The ambivalence of caretakers and providers to disclose a child’s HIV status
is fueled by realistic concerns about the potential consequences of disclosure.
Some of the reasons commonly cited for failure to disclose are fear of emotional
trauma to the child, fear that the child is too young to understand and cannot
keep a secret, fear of disclosure to others because of the stigma, that children do
not express interest in knowing, and caregivers not knowing how to initiate thediscussion (Domek, 2010). Pinzon-Iregui et al (2013) provide a comprehensive
review of disclosure practices globally. The most commonly cited fear was that of
psychological trauma to the child. Further complicating this issue are the conflicting
results of studies examining disclosure. Some studies report higher self-esteem,
promotion of trust, improved adherence to treatment, and better health and wellbeing (Mellins et al, 2002). Studies further suggest that disclosure may decrease
psychological distress and depression and improve the overall mental health ofcaregivers compared with those who do not disclose (Wiener et al, 1998). Other
studies have suggested that disclosure may increase distress and contribute toanxiety, depression, and behavioral problems (Tubman et al, 2003). However, mosthave found a positive association between disclosure and quality of adherence toantiretroviral treatment (Vreeman et al, 2010). Children’s knowledge of their HIV
status has been associated with lower CD4 counts and viral loads, lower likelihoodof being classified as non-adherent (Vreeman et al, 2010), better adherence to

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IACAPAP Textbook of Child and Adolescent Mental Health

WHO (2011) recommendations about disclosure of HIV status tochildren*
•

•

•

•

Children should be told their HIV positive status; younger children
should be told their status incrementally to accommodate their
cognitive skills and emotional maturity, in preparation for full
disclosure (strong recommendation, low quality of evidence).
Children should be told the HIV status of their parents or
caregivers; younger children should be told this incrementallyto accommodate their cognitive skills and emotional maturity(conditional recommendation, low quality of evidence)
The decision on who will disclose to the child should be guided by
the intent to improve/promote the child’s welfare and minimize therisk to his or her well-being and to the quality of the relationshipbetween child and parent/caregiver (conditional recommendation,
absence of evidence)
Initiatives should be put in place to enforce privacy protection andinstitute policy, laws and norms that prevent discrimination andpromote tolerance and acceptance of people living with HIV. Thiscan help create environments where disclosure of HIV status iseasier (strong recommendation, low quality of evidence).

*6 to 12 years of age.

Click on the image to accessthe education resources of the
Baylor International Pediatric
AIDS Initiative.

WHO (2011) Guideline on HIV Disclosure Counselling for Children up To 12 Years of Age. WHO Press,
Geneva, Switzerland

antiretroviral treatment (Blasini et al, 2004), and decreasing vulnerability to risky
behaviors (Bakeera-Kitaka et al, 2008).
A well planned discussion about a child’s HIV status can have many benefits.
Ideally, the discussion should occur in a structured setting with coordination
between parents or caregivers and their health care team. The information should
be conveyed to the child in a developmentally appropriate, socio-culturally
sensitive way. Parents and caregivers must also be prepared for the child’s reaction
to the disclosure. Children may not respond immediately but have a delayed
reaction, which can range from no signs of distress to severe distress. Caregivers
must also keep in mind that most children and adolescents adjust and learn to copewith their illness (Weiner et al, 2003).

Disclosure to adolescents
Disclosure to adolescents who are HIV-positive is even more complicated.
Adolescents are beginning to make decisions about sexual activity, other risk
behaviors such as experimentation with drugs and planning about their future
including relationships and parenting. Realistic concerns about rejection by peers
can impact an adolescents’ willingness to adhere to antiretroviral treatment andsafe sex practices to avoid raising suspicion about their HIV status. It is essentialthat adolescents know their HIV status and understand its treatment in orderto maximize their health-promoting behaviors and decrease risk of transmission.
Disclosure and open discussion about their illness can enhance adolescents’
acceptance of guidance, support and skills needed to cope with their illness(Benton, 2011).

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IACAPAP Textbook of Child and Adolescent Mental Health

Disclosure of parental HIV status
Another unique issue for HIV-positive youth concerns parental HIV status
and parental disclosure of their HIV status. Reasons for parents to disclose areoften for parental custody planning and the moral imperative of doing the rightthing for their child (Pilowsky et al, 2000). Studies of the impact of maternal
disclosure of HIV status upon youth have produced conflicting results. Somestudies suggest increased behavioral problems and distress, increased sexual
risk taking and substance use, while others suggest no effect on psychological
functioning. A positive parent child relationship appears to be a better predictor ofa child or adolescent’s response to disclosure than the act of disclosing (Donenberg& Pao, 2005).

An AIDS free world is within ourreach.

CONCLUSIONS
Progress is being made towards the global vision of a world in which AIDS
has been eliminated. Reduction in new cases worldwide, decreasing mother-childtransmission, and increased access to antiretroviral treatment strongly suggest that
UNAIDS’ vision for zero new HIV infections and zero AIDS related deaths isachievable. Antiretroviral treatments have been successful in prolonging lives andtransforming AIDS into a chronic disease.
Increasing data continue to demonstrate the effectiveness of antiretroviraltreatment. The discrepancies between effective antiretroviral treatment and low
rates of viral suppression can be partially explained by behavioral factors. Even themost effective treatments are useless if the patient does not take the medication.
Achieving an AIDS free generation will require universal testing integrated into
primary medical care so that everyone knows their status, treating those who
are found to be positive and ensuring that individuals remain engaged in theirtreatment, adhere to recommendations and remain in HIV care (Cohen et al,2011).
Treatment for mental health conditions in these patients requires a similar
approach in HIV-positive individuals as in other groups: early detection, early
treatment and patient engagement. Both HIV and psychiatric disorder require
behavior changes before treatment success is possible. Effective behavioral
interventions in the context of HIV/AIDS and its treatment can be lifesaving.
The best treatment approach for children and adolescents with HIV/AIDS
involves multidisciplinary, integrated care that includes pediatric AIDS care,mental health care, outreach, case management providing linkages to services, anda comprehensive continuum of care within the primary care setting. Although
this treatment approach is recommended, access to such programs is limited inindustrialized countries and to a much greater extent in low income countries
where mental health services are much more limited or non-existent. This has
been recognized by the WHO, which has developed a five part series of training
materials and resources for integrating mental health care with HIV care (Collins
et al, 2010).
An AIDS free world is within our reach but not without addressing themental health needs of individuals at risk of becoming infected with HIV, those
who are already infected, and the families of HIV-positive individuals. Recognizing

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IACAPAP Textbook of Child and Adolescent Mental Healthpsychiatric disorders, treating them, and being able to intervene in a culturally
sensitive and cost effective way in low income countries will be essential to prevent
transmission of HIV and improve the lives of young people living with HIV/AIDS.

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