Mental Health Problems in Adolescents With HIV: Overview & Expert Interview

Substantially less mental health research has been conducted in young adults and adolescents compared with adults, and such evidence is especially sparse in resource-limited settings.¹ Noting that the burden of illness may be particularly pronounced in children and adolescents living with HIV, the authors of a recent review examined the available literature regarding mental health care access, treatment outcomes, and the role of mental health problems in the transition from pediatric to adult care in this patient population.¹

Selected findings from the review are highlighted below.

• Mental health disorders including depression and anxiety are more common among perinatally HIV-infected adolescents vs those who are not infected. Adolescents infected with HIV have a greater risk for psychiatric hospitalizations compared with those not infected with HIV.
• A large cohort study found that 61% of perinatally-exposed youth (both infected and uninfected) had psychiatric disorders other than substance use.² Among HIV-positive adolescents involved in a 2000 US study, 53% had been diagnosed with psychiatric disorders and 44% had chronic depression.³
• High rates of depression have also been observed in HIV-infected children and adolescents in Kenya (17.8%), Malawi (18.9%), and Rwanda (25.0%).⁴
• There is a need for research comparing HIV-infected youth with other groups such as perinatally-exposed but uninfected youth and matched controls with no history of exposure.
• Some studies suggest a higher prevalence of mental health problems in female vs male HIV-infected youth, although results have been mixed overall.
• Mental health issues may interfere with indicators of successful transition from pediatric to adult care, such as taking ownership of medical care and adhering with medication and clinic visits.
• In general, there are few mental health treatment facilities devoted to children and adolescents.
• In the Adolescent Impact Study conducted in 3 US cities (n=164), 31% of HIV-infected adolescents demonstrated psychopathology.⁵ However, nearly one-third of the patients reporting clinical symptoms did not receive care despite the availability of psychiatric medications, hospitalizations, counselling, or psychotherapy.
• Treatment access may be even lower for marginalized populations, with one study showing that black HIV-infected youth were less likely to receive mental health care than non-black youth.⁶

“Our review emphasizes the need for mental health issues to be addressed proactively for all HIV-infected youth and integrated into their overall HIV care,” the authors concluded.

To further explore the mental health challenges facing adolescents living with HIV, as well as treatment implications and additional research needs, Infectious Disease Advisor interviewed Sarah M. Wood, MD, MSHP, instructor of pediatrics at the University of Pennsylvania Perelman School of Medicine, Philadelphia, and attending physician in the division of adolescent medicine at Children’s Hospital of Philadelphia.

Infectious Disease Advisor: What are some of the unique mental health challenges affecting adolescents with HIV?

Dr Wood: Mental health and HIV are highly interconnected. When you look across a range of chronic illnesses in adolescents and young adults, such as diabetes or cystic fibrosis, rates of depression tend to be higher in [people with] those [diseases than] among the general adolescent population. This is certainly the case with HIV, where studies of adolescents and young adults living with HIV have demonstrated rates of depression that are much higher than in uninfected youth.

However, there are several unique characteristics of the relationship between mental health and HIV. For young people who acquire HIV through sex or injection drug use in adolescence, mental health may play a role in transmission risk, as depression is highly associated with lower condom use and higher rates of having multiple partners. After HIV diagnosis, mental illness, including depression, increases the risk for nonadherence to antiretroviral therapy and acts as a barrier to staying engaged in HIV care. Overall, the downstream effect of depression in youth living with HIV is increased morbidity and mortality.

On the flip side, HIV itself may increase the risk for depression. There is a growing body of research demonstrating that the neuropathogenic effects of HIV on the developing central nervous system may increase the risk for mental illness in adolescence and adulthood. My early research showed that adolescents with perinatally-acquired HIV who had early AIDS diagnoses were at higher risk for mental illness and cognitive impairment in adolescence.⁷ This is of particular concern in young people with perinatally-acquired HIV in resource-limited settings like sub-Saharan Africa, who may have had unchecked central nervous system viral replication earlier in life.

Last, one highly important and unique challenge for youth living with HIV is stigma. Unfortunately, HIV-related stigma is still a stark reality for many youth living with HIV and can cause hesitance to disclose their HIV status to friends, family, or partners. This can lead to limited social support in managing one’s HIV-related health care, including mental health care. The resulting isolation is a feedback loop that further increases stigma.

Infectious Disease Advisor: How do such issues affect the care of these patients?

Dr Wood: Depression commonly acts as a barrier to achieving optimal health status for a young person living with HIV. We are really fortunate to live in an era when HIV is a highly manageable condition. With antiretroviral therapy, my expectation is that my patients will live long, healthy, and productive lives. However, that end goal depends on young people being able to both adhere to daily antiretroviral medication and stay engaged in HIV care so that they don’t have interruptions in treatment.

Depression is a known barrier to both of these care goals. Individuals with depression have a shorter time to HIV treatment failure and are more likely to be lost to follow-up.⁸ Adolescents are already less likely than adults to be HIV tested, receive antiretroviral therapy, be linked with HIV care, stay in HIV care, and have a suppressed viral load. My research demonstrates that youth living with HIV have high rates of treatment failure, up to 20% per year, even after initially achieving suppression of their HIV virus.⁹ These data suggest that young people living with HIV are likely more vulnerable to the impact of mental illness than older adults, since they already experience worse care outcomes with respect to HIV infection. These data underscore the need to assure that mental health is integrated into HIV care for young people living with HIV.

Infectious Disease Advisor: How should these issues be addressed (screening, treatment, etc.) by clinicians, as well as by healthcare systems at large?

Dr Wood: To address mental health in youth living with HIV, the first step is improving our ability to identify youth at risk for mental illness through screening. Currently, the US Preventative Services Task Force recommends screening for major depressive disorder in all adolescents age 12 to 18 years, irrespective of HIV status. As HIV care providers, we see our patients every 3 months, so we have an opportunity to screen regularly. At Children’s Hospital of Philadelphia, we screen all patients for depression, anxiety, and substance abuse at entry to care and at each visit.

However, screening alone doesn’t change the course of mental health conditions. Integrating health systems so that treatment for depression can occur in the same setting as HIV treatment is also critical. When on-site treatment for mental health conditions isn’t available, assuring linkage to mental health treatment through a medical case management model has also been shown to be effective. It is also important to ensure that youth living with HIV have uninterrupted access to insurance to cover mental health care, so that they can readily access treatment.

Infectious Disease Advisor: What should be the focus of future research in this area?

Dr Wood: Future areas for research include identifying optimal strategies for mental health and substance abuse treatment in adolescents living with HIV and better understanding of the neuropathogenesis of depression in youth living with HIV. Despite how common depression is in this population, there are few studies on how to best treat youth living with HIV. One recent study from the Adolescent Trials Network demonstrated that a 24-week cognitive behavioral therapy-based intervention plus pharmacotherapy was effective in reducing depressive symptoms.

In addition, there is some evidence that interventions to increase social support and reduce stigma may complement traditional depression therapies in youth living with HIV. It is also important to understand how the virus itself affects the developing brain to build strategies that can better protect the brain from the effects of HIV replication in the central nervous system.

References

1. Vreeman RC, McCoy BM, Lee S Mental health challenges among adolescents living with HIV. J Int AIDS Soc. 2017;20(Suppl 3):21497.
2. Mellins CA, Brackis-Cott E, Leu C-S, et al. Rates and types of psychiatric disorders in perinatally human immunodeficiency virus-infected youth and seroreverters. J Child Psychol Psychiatry. 2009;50(9):1131-1138.
3. Pao M, Lyon M, D’Angelo LJ, Schuman WB, Tipnis T, Mrazek DA. Psychiatric diagnoses in adolescents seropositive for the human immunodeficiency virus. Arch Pediatr Adolesc Med. 2000;154(3):240-244.
4. Marhefka SL, Lyon M, Koenig LJ, et al. Emotional and behavioral problems and mental health service utilization of youth living with HIV acquired perinatally or later in life. AIDS Care. 2009;21(11):1447-1454.
5. Whiteley LB, Brown LK, Swenson R, Kapogiannis BG, Harper GW. Mental health care among HIV infected youth in medical care: disparities and equalities. J Int Assoc Provid AIDS Care. 2014;13(1):29-34.
6. Wood SM, Shah SS, Steenhoff AP, Rutstein RM, The impact of AIDS diagnoses on long-term neurocognitive and psychiatric outcomes of surviving adolescents with perinatally acquired HIV. AIDS. 2009;23(14):1859-1865.
7. Pence BW, Mills JC, Bengtson AM, Association of increased chronicity of depression with HIV appointment attendance, treatment failure, and mortality among HIV-infected adults in the United States. JAMA Psychiatry. 2018;75(4):379-385.
8. Wood SM, Lowenthal E, Lee S, Ratcliffe SJ, Dowshen N, Longitudinal viral suppression among a cohort of adolescents and young adults with behaviorally acquired human immunodeficiency virus. AIDS Patient Care STDS. 2017;31(9):377-383.
9. Brown LK, Kennard BD, Emslie GJ, Adolescent Trials Network for HIV/AIDS Interventions, Effective treatment of depressive disorders in medical clinics for adolescents and young adults living with HIV: a controlled trial. J Acquir Immune Defic Syndr. 2016;71(1):38-46.