Adolescents with a past history of AIDS-defining illness are more likely to have cognitive or psychiatric problems than adolescents with HIV without a history of AIDS, US researchers report in the September 10th edition of AIDS.
The findings have significant implications not just for the developed world, but also for countries like South Africa, where the number of perinatally infected adolescents is expected to double by 2020.
The study, carried out among HIV-positive adolescents receiving treatment at the specialist HIV clinic of the Children’s Hospital of Philadelphia, focussed on perinatally infected adolescents aged 11 and over, currently receiving care at the clinic.
Previous studies have shown significant cognitive impairment in infants and children with HIV with a history of AIDS, but the authors say theirs is the first study to explore the issue in adolescents who have been infected with HIV since birth.
One hundred and seventy-two patients born before 1995 and therefore theoretically eligible for review received treatment at the clinic up to September 2006, of which 23% died and 26% transferred care to another clinic. Eighty-one adolescents were eligible for review in this study, with a median age of 15 years.
Forty-seven per cent had a prior history of AIDS-defining illness (a CDC category C diagnosis), and nearly half of this group had a history of multiple AIDS-defining illnesses. There was no significant difference between this group and adolescents with a prior history of AIDS in current CD4 percentage, nor in the proportions who took a HAART regimen of at least three drugs as their first regimen.
The study examined the following factors:
- Intelligence, measured by the Weschler Intelligence Scale for Children. Intelligence scores fell within the average range for children.
- Psychiatric illness as diagnosed by a psychiatrist and confirmed by a clinical psychologist. 48% had psychiatric illness and 18.5% of all patients had multiple psychiatric diagnoses.
- Learning disability, defined as impairment in at least one area of learning, confirmed by psychometric testing. 42% had been diagnosed with a learning disability and 38.5% were receiving specialised learning support.
- Mood disorder (30% had a mood disorder)
- Attention deficit hyperactivity disorder (18% had ADHD).
Multivariate logistic regression analysis, in which the researchers controlled for the effects of age at ART initition, showed a strong relationship between a prior history of AIDS and psychiatric and neurocognitive disorders. The investigators were unable to control for prematurity, maternal drug use, maternal antiretroviral use or suboptimal adherence to HAART, all of which may have contributed to neurocognitive impairment.
Adolescents with a history of AIDS were 19 times more likely to have experienced multiple psychiatric diagnoses (adjusted odds ratio 19.3 (95% confidence interval 2.3 – 162.6, p=0.001), three times more likely to have been diagnosed with a mood disorder (95% CI 1.1-10, p=0.023), four times more likely to have received mental health treatment (95% CI 1.3-13, p=0.042) and four times more likely to have a learning disability (95% CI 1.5-11.1, p=0.014).
Adolescents with AIDS also had a significantly lower full-scale intelligence quotient (FSIQ) (-12.1, 95% CI -18.7 – 5.5, p=0.002), placing them in the below-average range. 21% of those with a prior AIDS diagnosis fell into the `lower-extreme` category on the FSIQ scale. The relationship between AIDS diagnosis and lower FSIQ score remained significant when adolescents with a history of HIV-related progressive encephalopathy were excluded from the analysis.
Receipt of antiretroviral treatment prior to an AIDS diagnosis did not affect the risk of psychiatric or neurocognitive disorder: an AIDS diagnosis at any point was associated with poorer outcomes.
The authors say that “although early HIV-related CNS toxicity may be a cause of psychiatric illness, the emotional and social upheaval associated with severe HIV infection likely plays a significant role … These data suggest that HIV-infected adolescents, regardless of the severity of HIV disease, may require significant behavioural, psychiatric and educational support services as they transition into adulthood.”
They conclude: “Early ART, initiated before the onset of symptomatic HIV disease, may be warranted to protect the developing CNS in infants and children with HIV.”
Wood S et al. The impact of AIDS diagnoses on long-term neurocognitive and psychiatric outcomes of surviving adolescents with perinatally acquired HIV. AIDS 23, 1859-1865, 2009.