Characteristics of Study Participants
HIV-infected subjects (n = 319) and controls (n = 256) were comparable by gender, race and ethnicity, experience with previous-year life stressors, and the proportion of caregivers self-reporting psychological symptoms. However, HIV-infected children were older than controls (62% ≥12 years of age versus 42%, respectively), less likely to live with biological parents (43% vs 76%, respectively), and more likely to live in households with higher socioeconomic status, as measured by household income and primary caregiver education. Of the controls, 174 (68%) were in the PHE subgroup and 82 were in the LWH subgroup; 96% of the PHE subgroup also lived with an HIV-positive person and >30% of both control subgroups lived with an HIV-positive sibling ().
P1055: Demographic Characteristics at Study Entry According to HIV Status and for HIV-Uninfected Subgroups
The PHE and LWH control subgroups were comparable in gender, whether caregivers were biological parents, reported emotional problems, education, and income.
However, the subgroups differed in age (LWH median age: 13 years, similar to the HIV-positive group, versus PHE: 10 years of age) and race/ethnicity. Of the 3 study subgroups, more families of LWH children (79%) had previous-year life stressors compared with either HIV-positive or PHE children (64% each; P < .001). Also, more LWH children had caregivers who met psychiatric cutoffs (21%) compared to 12%–13% for the HIV-positive and PHE groups (P = .09; ).
At study entry, 81% of the HIV-infected youth were taking highly active antiretroviral treatment (HAART), defined as ≥3 antiretroviral medications from ≥2 classes, whereas only 8% were not taking antiretroviral medications. Approximately one quarter (23%) was defined as Centers for Disease Control and Prevention class C, almost 75% had CD4% values of ≥25%, and almost 60% had undetectable HIV RNA levels at study entry ().
Psychiatric Symptoms and Impairment
Perinatally HIV-infected and control youth had a similar prevalence of psychiatric symptoms (61% of each group had at least 1 condition). Similar percents across groups (14%–18%) reported impairment or clinically significant impairment in at least 1 condition (). However, LWH controls reported more conduct disorder problems (7.5%) than either HIV-positive or PHE controls (each ~1%, 3-way unadjusted comparison; P = .006).
Prevalence of Selected Psychiatric Conditions and Impairment According to HIV Infection Status and Perinatal HIV-Exposure Status for Controls
Children with HIV were more likely than controls to have received psychotropic medications and behavioral interventions, but the latter result varied by control subgroup (). For example, 12% of controls and 23% of HIV-positive children had received psychiatric medication before study entry (P < .001; ), a trend that held across age categories (for children ≥10 years of age; ) and medication classes (SSRIs, stimulants; data not shown). SSRIs were primarily given to adolescents (≥12 years of age), whereas stimulants were given across all age groups (data not shown). For behavioral interventions, the LWH subgroup reported as high a rate (24%) as the HIV-positive group (27%), both higher than for the PHE subgroup (14%, 3-way comparison; P = .003; ).
Percent of HIV-infected and uninfected participants who received treatment for emotional and behavioral problems.
P1055: Psychiatric Interventions According to HIV Status and Control Subgroup
Percent of HIV-positive (n = 319) and control (n = 256) children who were treated in the past or currently with medication for emotional and behavioral problems by 2-year age groups and overall. P values are shown if they are <.05.
Of the 104 participants who ever took a psychotropic agent, 90% had taken 1 or 2 drugs in a regimen, and only 21% had lifetime experience with >2 drugs. Medications taken by at least 5 children included: methylphenidate (n = 59), amphetamine salts (n = 32), atomoxetine (n = 13), risperidone (n = 13), sertra-line (n = 12), fluoxetine (n = 12), and bupropion (n = 6). Thirteen percent of the 292 HIV-infected children who were on antiretroviral medications at study entry were simultaneously taking psychotropic medications.
Rates of specific behavioral interventions were comparable for the HIV-infected and control groups, ranging from <15% (special diets, hospitalization), 30% to 50% (tutoring, group counseling, behavior modification, family counseling), to >80% (individual counseling) ().
Behavioral Interventions by Study Group
Treatment Stratified According to Psychiatric Condition
More HIV-positive children with clinically significant ADHD (76% of 37) received treatment compared with controls (50% of 28; P = .04; ). For the 3-way subgroup comparisons, among those with clinically significant impairment (HIV-positive group [n = 55], PHE group [n = 27], and LWH group [n = 15]), there were no differences in the percentages reporting lifetime psychiatric medication use (PHE group: 37%, LWH group: 20%, HIV-positive group: 40%; P = .41). However, fewer PHE controls with impairment still reported behavioral treatment (30%) than either the HIV-positive (57%) or LWH controls (60%; P = .05).
Percent of HIV-positive and control children with clinically significant impairment who received behavioral or medication treatment. aSeparation or general anxiety. P values < .10 are shown for unadjusted comparison.
Predictors of Behavioral Interventions and Treatment With Psychiatric Medication
After controlling for gender, age, race/ethnicity, and caregiver education, perinatally HIV-infected youth had 4 to 13 times the odds of having treatment with antidepressant medication compared with controls, depending on the analysis (odds ratio [OR]: 3.9, any symptoms; OR: 4.3, ADHD; OR: 13.1, aggression; OR: 7.4, mood disorders; OR: 4.4, anxiety; ). HIV-infected children also had higher odds than controls of having been treated with stimulants; after adjusting for ADHD symptoms (OR: 2.5), aggression (OR: 2.4), or mood disorders (OR: 2.1). The association between HIV-positive status and increased odds of intervention also held when age was controlled for in fine-grained categories ( shows unadjusted data). The effect of HIV status on treatment sometimes was moderated by other factors. For example, within the younger ADHD-symptomatic group, HIV-infected children had half the odds as controls of having received medications, a result that countered the general trend (; interaction data not shown).
Adjusted ORs for Psychiatric Interventions Associated With Psychiatric Symptom Cutoffs
Impairment As a Predictor of Treatment Intervention
The multivariable logistic regression analyses of associations between HIV status, impairment, and treatment outcomes supported the main results with only a few differences. For analyses of aggression and anxiety disorders, HIV-infected children with impairment had equal or lower odds of treatment than corresponding controls rather than higher ones (data not shown). For example, ~32% of controls with clinically significant aggression received stimulants compared with 10% of HIV-infected participants.
Caregiver Versus Child Self-Report and Age Effects
The odds of the child receiving treatment were more than twice as high when caregivers reported compared with when the child alone reported. For example, the odds of treatment were >4 times as high when caregivers compared with children reported mood disorder symptoms (). Our multivariable analysis also showed that adolescents had higher odds of behavioral interventions and antidepressant medication use compared with younger-aged children ().