Results from a recent study suggest that HIV severity is associated with the severity of some mental health problems and academic, cognitive, and social impairments in teens born with HIV.

The researchers noted that this study alone does not allow conclusions to be drawn about the causes of the associations identified in the study. However, they argued that their results suggested that certain developmental and academic problems are common in children and teens with HIV, even well-controlled HIV.

“Low CD4 percentage at a young age and high viral load at specific ages were associated with worse social and academic functioning,” said Dr. Sharon Nachman, a professor of pediatrics at Stony Brook University in New York and lead author of the study, in correspondence with The AIDS Beacon.

“It was not just one low CD4 percentage or one high viral load that we are talking about, but rather sustained low CD4 percentage and sustained high viral loads that really did the most damage,” she added. “Current measures of HIV (current CD4 percentage and viral load) don’t really tell the story of how that child’s brain is doing, since so many of the kids on study had excellent virologic and immunologic control at the time they entered the study.”

The authors also noted that mental health and coping issues of children’s primary caregivers likely influence their parenting ability, regardless of the caregivers’ HIV status. This could potentially affect treatment adherence and viral outcomes in the children.

According to the study authors, it is important to understand the relationship between the severity of psychiatric symptoms in HIV-positive youth and HIV severity and type of highly active antiretroviral therapy (HAART). They argued that behavioral and cognitive problems are related to social and academic difficulties as well as risky sexual behavior and greater risk of HIV transmission.

The study authors also noted that in a previous study they conducted, HIV-positive children and teens were more likely to receive medication or other interventions for psychological problems than children who were exposed to HIV before birth but not infected. They speculated that their findings may be due to effects of HIV or HAART on behavioral problems in children with HIV.

In this two year-long study, researchers aimed to assess psychiatric symptoms and cognitive, social, and academic performance as well as quality of life in youth born with HIV. They also monitored the children’s disease severity and HAART regimens to find any link between these and psychiatric symptoms or other impairments.

The study included 319 children between the ages of six and 17 who were born in the United States or Puerto Rico. Just over half (51 percent) were male, and 62 percent were 12 years old or older at the time of the study.

Most children in the study (74 percent) had current CD4 percentages (a measure often used in children rather than CD4, or white blood cell, count) of 25 percent or greater at the beginning of the study. More than half (59 percent) had undetectable viral loads (amount of HIV in the blood), defined in this study as less than 400 copies per milliliter.

Most participants (81 percent) were on HAART at the start of the study. All participants had recent or past exposure to Sustiva (efavirenz) which is a non-nucleoside reverse transcriptase inhibitor that, according to the study authors, may be linked with psychiatric problems.

Half of the participants lived with their HIV-positive mother, and 70 percent had one or more additional HIV-positive people in the home.

Results showed that a third of teens born with HIV qualified as having at least one of four main categories of psychiatric disorders: attention-deficit/hyperactivity disorder (ADHD), depression, disruptive behavior disorder or conduct disorder, and anxiety.

Disruptive behavior disorders are characterized by behaviors like temper tantrums, physical aggression, excessive argumentativeness, stealing, and other forms of defiance or resistance to authority.

In addition, 54 percent of children whose primary caregivers had at least one psychiatric disorder also had at least one psychiatric disorder themselves. Thirty-one percent of children whose primary caregivers did not have a psychiatric disorder had at least one disorder.

Findings regarding measures of HIV severity and the severity of psychiatric symptoms were mixed. For instance, a lower initial CD4 percentage was linked with more severe conduct disorder symptoms but with less severe depression symptoms.

A higher initial viral load was associated with more severe depression symptoms but also with less severe ADHD symptoms. Greater HIV disease severity, such as a previous AIDS-related infection, was linked with less severe ADHD symptoms.

Older age at the nadir CD4 percentage (the lowest percentage of CD4 cells since HIV infection) was associated with more severe disruptive behavior disorder, and youth with a lower nadir CD4 percentage and younger age at peak HIV viral load had lower quality of life. According to the study authors, these findings suggest that poorer immune system performance or control of HIV virus at different ages affects different brain functions.

Youth with a lower nadir CD4 percentage had impaired social function, and those with higher peak viral load in addition to lower nadir CD4 percentage took longer to process information.

The researchers found little evidence for an association between specific HAART regimens and severity of psychiatric symptoms.

However, there was some evidence for an association between less severe ADHD symptoms and a HAART regimen containing a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor.

Exposure to Sustiva was associated with impaired working memory but with better academic performance. Five or more years of HAART was associated with better social functioning but lower information processing speeds; however, the exact effects differed slightly depending on HAART regimen. Youth with at least five years of protease inhibitor exposure had poorer social functioning and impaired working memory.

For more information, please see the study in the Archives of Pediatric and Adolescent Medicine (abstract).