D e p re s s i o n a m o n g Yo u t h

Living with HIV/AIDS

Tami D. Benton, MDa,*, Warren Yiu Kee Ng, MD, MPHb,1, Denise Leung, MD
c
,
Alexandra Canetti, MDd, Niranjan Karnik, MD, PhDe

KEYWORDS
 Depression  Pediatric HIV/AIDS  Behaviorally acquired HIV
 Vertically acquired HIV  Congenital HIV  Adolescent HIV

KEY POINTS
 Despite advances in the detection and treatment of human immunodeficiency virus/AIDS
globally, adolescents continue to be disproportionately affected, with human immunode-
ficiency virus becoming increasingly a disease of adolescence.
 Depression is prevalent among human immunodeficiency virus-positive youths, serving
as a risk factor for nonadherence, risky sexual behaviors, low viral suppression, and pro-
gression to AIDS.
 Depression is a risk factor for becoming human immunodeficiency virus positive, affecting
decision making about sexual encounters, adherence to safe sex practices, and use of
substances during sexual contacts.
 Current evidence-based pharmacotherapies and psychotherapies for depression are
effective for depression for human immunodeficiency virus-positive youth, but medica-
tions may require attention to drug interactions.

Human immunodeficiency virus (HIV) disease is increasingly a disease of adoles-

cence. The most recent estimates by the Centers for Disease Control and Preven-
tion (CDC) indicate that 25% of new HIV diagnoses in the United States occurred

Disclosure Statement: The authors have nothing to disclose.

a
Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Penn-
sylvania, 3440 Market Street, Suite 400, Philadelphia, PA 19104, USA; b Division of Child and
Adolescent Psychiatry, Columbia University Irving Medical Center, New York Presbyterian
Hospital/Columbia University Medical Center, 635 W 165th St, #EI 610, New York, NY 10032,
USA; c Child and Adolescent Pediatric Psychiatry Community Services, Division of Child and
Adolescent Psychiatry, Columbia University Irving Medical Center, 3959 Broadway, MSCH 6N
615A, New York, NY 10032, USA; d Special Needs Clinic and School Based Mental Health Pro-
gram, Columbia University Irving Medical Center, 622 West 168th St, VC4 East, New York, NY
10032, USA; e Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush
University Medical Center, 1645 West Jackson Blvd., Suite 600, Chicago, IL 60612, USA
1
Present address: 635 West 165th Street, EI#610, New York, NY 10032.
* Corresponding author.
E-mail address: bentont@email.chop.edu

Child Adolesc Psychiatric Clin N Am 28 (2019) 447–459

https://doi.org/10.1016/j.chc.2019.02.014 childpsych.theclinics.com
1056-4993/19/ª 2019 Elsevier Inc. All rights reserved.
448 Benton et al

Abbreviations
ART Antiretroviral therapy
ATN Adolescents trials network
CBT Cognitive-behavioral therapy
CDC Centers for disease control and prevention
COMB Combination treatment of cognitive-behavioral therapy and medication
management algorithm
HIV Human immunodeficiency virus
PHIV- Youth born without HIV from HIV-infected mothers
PHIV1 Perinatally infected persons with HIV
YLWHA Youth living with HIV and AIDS.

among 13- to 24-year-olds.1 Fortunately, with advances in antiretroviral treatments

(ART), youth living with HIV and AIDS (YLWHA) can live long healthy lives, provided
that they have effective medications and adhere to treatment guidelines. Without
consistent and effective ART use, YLWHA are at risk for poor viral control,
increased risk of viral transmission, poor medical outcomes, and decreased quality
of life.2,3 YLWHA have high rates of psychiatric disorders, including depression.
Therefore treating depression is critical to physical health and preventing HIV dis-
ease progression and transmission.3 Depression among YLWHA has been associ-
ated with decreased adherence to ART, decreased treatment engagement,
increased substance use, unsafe sex practices, and poor viral suppression.4–6
Furthermore, the presence of depression among adolescents, both YHWHA and
HIV uninfected, increases the risks for sexually transmitted infections including
HIV. In this article, we review the complex interplay between youth, HIV, and
depression, and how child and adolescent psychiatrists can best care for this
vulnerable population through prevention and interventions.

PREVALENCE OF HUMAN IMMUNODEFICIENCY VIRUS AMONG YOUTH

Progress in HIV detection and treatments have transformed an infection, once

considered fatal, into a chronic disease. Those who acquire HIV disease either
congenitally or behaviorally, are much more likely to die of illnesses related to aging,
rather than those related to AIDS. ARTs have significantly improved the quality of life
and health status of youths infected with HIV. Although HIV continues to be
pandemic worldwide, efforts in the United States have been successful in reducing
new cases of HIV infections. The CDC estimates that annual HIV infections have
decreased by 24% among youth overall from 2010 through 2015. Although incident
cases of HIV infection decreased by 19% in the United States over the last decade,
there was an 87% increase in new infections among subsets of 13- to 24-year-olds1
who currently account for 21% of all new HIV infections.7 Among those newly
infected cases identified in 2016, sexual and ethnic minority groups were dispropor-
tionally represented, with 81% of those new infections occurring among gay/
bisexual men who classified themselves as African American (54%) or Hispanic/
Latino (25%).8
A further analysis of the data provided by the CDC from 2011 through 2015 for
YLWHA are alarming. Of the 60,300 known cases of adolescents living with HIV in
the United States, 51% of those individuals were undiagnosed, the highest rate of un-
diagnosed HIV infection among any age group. Of those diagnosed, only 41%
received any treatment for HIV disease, and only 31% were retained in HIV care. Viral
suppression, the key requirement for the prevention of progression of HIV disease to
 Youth Living with HIV and Depression 449

AIDS, was achieved in only 27% of those receiving care—the lowest rate of viral sup-
pression for any age group. YYLWHA accounted for 8% of new AIDS diagnosis and
100 deaths in 2015.1,8

DEPRESSION AS A RISK FACTOR FOR HUMAN IMMUNODEFICIENCY VIRUS

INFECTION

Behaviors typically initiated during adolescence such as sexual and substance use
experimentation are factors imposing risk for sexually transmitted diseases for
youths, including HIV disease. Adolescence is also the developmental phase during
which the rates of mood disorders, specifically depression, begin to increase,
creating the perfect storm for HIV risk. Recent epidemiologic data from the National
Comorbidity Survey found lifetime prevalence rates of depression among adoles-
cents of 11% and 12 month prevalence rates of 7.5%.9 Furthermore, evidence sug-
gests that youth with mental health conditions are more likely to have a history of early
sexual debut and higher rates of sexually transmitted diseases than youths without
psychiatric conditions.10 It is well-documented that depression increases risk for
acquiring HIV disease because youth who are depressed engage in risk behaviors,
including unsafe sexual practices, are less likely to use condoms11 and more likely
to use substances.12 Depression and low self-esteem have been associated with
low contraceptive use, sexually active peers, permissive sexual attitudes, and high
pregnancy risks.13,14 Internalizing symptoms associated with depression have
been linked to limited ability to make decisions about safe sex with partners,
decreased assertiveness, and low perceived self-efficacy in sexual relationships.15
Personal attributes have also been implicated in adolescent HIV risk behaviors
including cognitions about HIV/AIDS, affect dysregulation, mental health conditions,
sexual abuse, and personality traits.16
In a recent study examining how depression and substance use interacted to pre-
dict risky sexual behaviors and sexually transmitted diseases among a population of
African American female adolescents, investigators found that 40% of the 701 youths
between the ages of 14 and 20 years reported significant depression on the Center for
Epidemiologic Studies Depression Scale screener, and that 64% had reported sub-
stance use in the 90 days before the assessment.17 In this study, depression was
associated with recently incarcerated partner involvement, sexual sensation seeking,
unprotected sex, and an incident sexually transmitted infection over the study period,
suggesting that this population might benefit from future prevention efforts targeting
the intersection of depression and substance use.

DEPRESSION AMONG YOUTH LIVING WITH HUMAN IMMUNODEFICIENCY VIRUS/

ACQUIRED IMMUNE DEFICIENCY SYNDROME

Depression is more prevalent among HIV1 youth (21%–50%) compared with their
peers, regardless of their mode of infection (congenital or behavioral).18,19 Although
there are similarities between the mental health needs of both populations, there
are also significant differences that impact their psychosocial environments, treatment
experiences, and treatment needs.

BEHAVIORALLY ACQUIRED HUMAN IMMUNODEFICIENCY VIRUS

Depression contributes to increased morbidity and mortality for YLWHA. Depression

is a risk factor for HIV infection and interferes with adherence to medical treatments
and safe sex practices that prevent further transmission of the virus.20–22 Depression
450 Benton et al

is associated with increased health care costs and poor health outcomes for these
youth23
In one multisite study examining a sample of YLWHA receiving medical care through
adolescent medicine clinics as part of the Adolescents Trials Network (ATN), a sample
of 2032 YLWHA (ages 12–24 years) were assessed across 20 sites using a computer-
ized audio assisted self-interview and the Brief Symptom Inventory to assess mental
health symptoms. These assessments were administered to youths who had acquired
HIV congenitally and behaviorally. The sample was composed of 33% females and
67% males with mean age of 20.3 years. Overall, 18% of youth reported clinically sig-
nificant symptoms on the Brief Symptom Inventory. YLWHA with behaviorally ac-
quired infection compared with congenital infection had twice the odds (21% vs
10.8%) of reporting clinically significant symptoms. Psychological symptoms were
significantly higher for those who acquired HIV behaviorally (21%) compared with
congenitally (10.8%).24
Pao and colleagues18 studied YLWHA in an adolescent clinic using the Structured
Clinical Interview for Axis I Disorders in the Diagnostic and Statistical Manual of Mental
Disorders, 4th edition, to evaluate 34 HIV1 adolescents (mean age, 18.5 years)
attending an urban clinic for current and lifetime rates of psychiatric disorders. High
prevalence rates of lifetime psychiatric disorders among the sample were identified,
with 68% having met criteria for depression during their lifetimes in addition to high
rates of substance abuse (59%) and conduct disorder (29%). The investigators found
that 44% met criteria for major depression and that the majority of the sample had a
psychiatric diagnosis before their HIV diagnosis. In another study examining 147
HIV1 young women ages 13 to 24 years (mean age, 20.6) using the National Institutes
of Mental Health diagnostic interview schedule to assess specifically for depression,
investigators found that 10% met the criteria for a major depressive disorder.25
Another study examined 174 HIV1 youths ages 13 to 24 years old receiving medical
treatment in a primary care clinic, using a diagnostic questionnaire adapted for the pri-
mary care setting to screen for mental health conditions and violence, followed by a
clinical diagnostic interview (Diagnostic and Statistical Manual of Mental Disorders,
4th edition). Among that sample, 15% met criteria for a major depressive disorder.26
Other studies have reported high rates of depressive disorders using psychological
symptom inventories.20–23,25 Taken together, these studies suggest higher prevalence
rates of depressive disorders among YLWHA than the general adolescent population.
In a more recent study, Walsh and colleagues,27 in a retrospective review of a clin-
ical database obtained through a subspecialty clinic studied 130 YLWHA who were
screened for depression with the 9-item Patient Health Questionnaire 9/Patient Health
Questionnaire A and substance use with the CRAFFT (Car, Relax, Alone, Forget,
Friends, Trouble) screening tool. Twenty-four percent of the sample screened positive
for depression risk. Those youths who acquired HIV behaviorally were more likely to
endorse self-harm/suicidal thoughts than those with congenital transmission.

CONGENITALLY ACQUIRED HUMAN IMMUNODEFICIENCY VIRUS

Youth born with HIV congenitally are also called perinatally infected (PHIV1) and
represent a population with unique characteristics related to the combined epidemics
of HIV and substance use in the United States in the early 1980s and 1990s. PHIV1
were primarily from ethnic minority, socioeconomically disadvantaged families
affected by the high prevalence of substance abuse, psychiatric disorders, and
trauma within inner cities.28 With the successful prevention of HIV infection from
mother to infant (vertical) transmission, the administration of zidovudine, the use of
 Youth Living with HIV and Depression 451

elective caesarean sections, and the effective implementation of prenatal screening,

the eradication of perinatal HIV infection has become a reality within the United
States.29,30 These successes have led to a cohort that has aged into adolescence
and early adulthood with new challenges and realities, including treatment adherence
and psychiatric disorders.31
These youth and long-term survivors have contributed to our understanding of the
developmental issues unique to HIV and the genetic, social, cultural, and environ-
mental vulnerabilities and factors. Having grown up contributing to the development
of pediatric HIV treatment guidelines, they experienced more illnesses, hospitaliza-
tions, and adversities. The stigma related to the societal climate surrounding HIV/
AIDS early in the epidemic contributed to the psychosocial and psychological chal-
lenges. Given the unique experiences and risks, it is not surprising that
PHIV1 youth had greater psychiatric disorders and vulnerabilities compared with their
peers.32
Although adherence to ART is critical to life, health, and physical well-being, mental
health issues are often adherence barriers. Nonadherence to ART and mental health
problems were the most frequent combination of adherence challenges with 23% of
PHIV1 youth in 1 study.33 With the onset of adolescence, mood disorders and depres-
sion emerge, further complicating the developmental and psychosocial challenges. In
another study, PHIV1 youth with depression had greater odds for nonadherence at
different time points over 2 years.34 Depression, a common barrier to adherence for
adults living with HIV/AIDS, is also significant for PHIV1 youth. From the patient
perspective, depression was identified as a barrier for more than 15% of participants
across all age groups from children to adults. However, 26% of adolescents identified
depression as a barrier in an international systematic review.35
Mellins and colleagues36 compared PHIV1 youth and HIV-negative youth from
households affected by an HIV-infected parent or caregiver and tried to isolate the
unique contributions of HIV from the contextual factors of genetics, biology, environ-
ment and socioeconomic factors. Project (Child and Adolescent Self Awareness and
Health Study) is one of the largest US-based longitudinal studies specifically exam-
ining the behavioral health outcomes of PHIV1 youth compared with youth born
without HIV from HIV-infected mothers (PHIV- youth). A longitudinal cohort of 280
youth with 166 PHIV1 and 114 PHIV- youth aged 9 to 16 years at baseline in New
York City has shed some light on the contributions of HIV to psychiatric sequelae.36
The PHIV1 youth reported more use of mental health services (38% vs 23%;
P 5 .032), but both groups had a high prevalence of psychiatric disorders, with
69% meeting criteria for at least 1 psychiatric disorder. Among these youth, 22% of
youth had another psychiatric disorder. In this study, PHIV1 youth were three times
more likely to report a mood disorder (odds ratio, 3.16; P 5 .02). PHIV1 youth with
a psychiatric disorder including depression or dysthymia were more likely to use sub-
stances with an odds ratio of 4.0 (P 5 .01). The risk factors for behavioral health
sequelae included family vulnerability for substance abuse and psychiatric disorders,
bereavement, discrimination, poverty, inadequate housing, and exposure to
trauma.16,36
Another multisite study, IMPAACT (International Maternal Pediatrics Adolescent
AIDS Clinical Trials Group), also found a high prevalence with 61% of PHIV1 and
HIV-negative youth from HIV affected families having a psychiatric diagnosis. Among
319 PHIV1 youth and 256 controls aged 6 to 17 years, 17% of the PHIV1 youth were
diagnosed with a mood disorder, including major depressive disorder, bipolar mood
disorder, and dysthymia, with an odds ratio of 7.4. This study also demonstrated
that PHIV1 youth were more likely to receive medication (23% vs 12%; P<.001)
452 Benton et al

and mental health treatment, including both behavior and medication interventions
(37% vs 22%; P<.001) compared with the PHIV- youth.37
Another exacerbating factor to psychiatric disorders among PHIV1 youth was the
severity of the HIV disease. HIV/AIDS disease progression is associated with a wors-
ening of psychiatric and neurocognitive disorders. A study compared 81 PHIV1 youth
with an AIDS-defining diagnosis using CDC class C classification, compared with
youth with less severe HIV disease, 60% were more likely to have a psychiatric diag-
nosis compared with 37%. They were also more likely to receive psychiatric medica-
tion (31% vs 14%), have a mood disorder (42% vs 21%), or have a psychiatric
hospitalization (26% vs 7%). PHIV1 youth with greater HIV disease severity with a
CD4 count of less than 25% versus 25% or greater had a 19% probability of depres-
sion symptoms compared with 8%.38 PHIV1 youth have a high prevalence of depres-
sion and other psychiatric disorders. Similar to peers who acquire HIV behaviorally,
depression can impact the success of medical treatment and ART therapy, further
worsening their health and mental health outcomes and quality of life.

TREATMENT FOR DEPRESSION IN THE CONTEXT OF HUMAN IMMUNODEFICIENCY

VIRUS AND ACQUIRED IMMUNE DEFICIENCY SYNDROME

There is increasing recognition that the identification and treatment of depressive dis-
orders is critical to effective medical outcomes for YLWHA. ARTs have effectively
increased life expectancy for YLWHA, decreased new infections, and improved the
quality of life for individuals impacted by HIV and their caregivers.4,5,39 The importance
of this recognition is further magnified by emerging evidence that depression is asso-
ciated with an increase in the mortality rate among HIV1 women40 and with disease
progression in HIV1 men.41 Making a diagnosis of depression, however, can be
complicated by the complex developmental, biologic, psychological, and social cir-
cumstances associated with this illness in youth, resulting in psychiatric symptoms
that are often unrecognized and untreated.42
In the context of HIV infection, the diagnosis of depressive disorders can be even
more challenging because many vegetative symptoms of depression (eg, fatigue
and insomnia most commonly, as well as pain and appetite loss) are observed in
many patients throughout the course of their HIV illness, even when depression is
not present. However, in both the early and late phases of HIV disease, these symp-
toms correlate more closely with a mood disorder (when present) than with clinical
correlates of infection. The prominence of diminished mood in the morning coupled
with anhedonia should alert clinicians to the presence of a major depressive disorder
and should help to distinguish it from demoralization or an adjustment disorder. Clin-
ical detection of depressive symptoms is even more important given a well-
documented decrease in adherence to ARTs in the context of depression. Fortunately,
recent studies have shown that the treatment of depressive symptoms in patients with
HIV infection improves psychosocial functioning and quality of life.43,44
Adherence to ART is a complex health behavior that is influenced by the drug
regimen, patient and family factors, and the patient–provider relationship.35,45 There
have been a dearth of studies examining effective treatment interventions for
YLWHA46 and strategies have been based on current practice guidelines for treating
youth, adult studies, and previously used algorithms. Several studies have demon-
strated that treatment addressing the issues unique to YLWHA—including stigma,
medical symptoms, poverty, and alienation from families—are critical to treatment
success.
 Youth Living with HIV and Depression 453

It is important to be aware of the social determinants of mental health disparities that

exist in the access for mental health care for YLHA. A study by Whiteley and col-
leagues46 found that psychiatrically symptomatic black youth living with HIV were
less likely than their symptomatic nonblack peers to receive mental health care and
psychiatric medications.

USING MEDICATION AND PSYCHOTHERAPY TO TREAT DEPRESSION IN YOUTH

LIVING WITH HUMAN IMMUNODEFICIENCY VIRUS/ACQUIRED IMMUNE
DEFICIENCY SYNDROME

There is evidence to support combined treatment using psychotherapy and medica-

tion management to address the symptoms of depression in general. Evidence from
the ATN has reinforced the efficacy of combined treatment for depressive symptoms
in YLWHA. A study led by Brown and colleagues2 at 4 ATN sites involving 44 partic-
ipants showed the effectiveness of a structured approach to combination treatment
of cognitive-behavioral therapy (CBT) and medication management algorithm
(COMB) in significantly lowering depressive symptoms based on the Quick Inventory
for Depression Symptoms scale compared with patients who were administered treat-
ment as usual. Those in COMB were significantly more likely to respond (Quick Inven-
tory for Depression Symptoms-SR >50% decrease from baseline; 85% vs 20%;
P<.001) at 24 weeks with the pattern maintained at week 48 (88% vs 33%;
P<.001).2 In addition, those in COMB were more likely to receive psychotherapy
than treatment as usual (95% vs 45%; P<.001) and to attend more sessions over
the 24-week period (12.6 sessions vs 5.0 sessions; P<.001).2
In the ATN trials, a structured medication algorithm was formulated based on the
current practice parameters for depression, data from adult and adolescent depres-
sion trials, and previously used algorithms. Of note, the CBT delivered during this trial
was specifically tailored to YLWHA, addressing topics such as medical symptoms,
poverty, stigma, and alienation from families. The ATN used health and wellness
CBT to reduce depression, improve adherence, and promote mental health. A mixed
deficits and strength model decreased negative mood and cognitions of youth while
enhancing strengths, positive experience, mood, and cognitions.47 Stage 1 of the
treatment involved engagement in treatment, with psychoeducation being provided
on the cooccurrence of depressive illness and HIV infection, treatment options,
rapport building, and an explanation of the CBT model for treatment of depression.
Motivational interviewing skills were also used to give patients insight, knowledge,
and skills to strengthen their own motivation for change. Stage 2 emphasized a
decrease in symptoms by teaching core CBT skills to target any remaining depressive
symptoms. Stage 3 included achieving and maintaining wellness strategies and life-
style changes to extend recovery. Other investigators have used multisystemic ther-
apy, an intensive family- and community-based treatment program, to improve
antiretroviral adherence and health outcomes in pediatric patients.48
The use of medications to treat depression in YLWHA continues to remain primarily
empirical. Unlike the adult population, there are no studies comparing the efficacy of
antidepressants including the selective serotonin reuptake inhibitors in YLWHA or how
to proceed after only a partial or no response to medications.2 Clinicians treating
depression in YLWHA have generally followed current practice parameters on treating
adults with HIV while incorporating adolescent depression treatment guidelines and
being cognizant of drug-drug interactions (Table 1). Among the selective serotonin re-
uptake inhibitors, fluoxetine, imipramine, sertraline, and paroxetine have evidence
from double-blind trials of being effective in treating major depressive disorder in
454 Benton et al

Table 1
Medication interactions with antiretroviral medications

Medication Interactions with ARTs

Tricyclic The tricyclic antidepressants have been shown to have increased plasma
antidepressants levels when taken with ritonavir, sometimes requiring dosage
adjustments. As such, it is recommended that tricyclic antidepressant
blood levels should be monitored when being used concurrently with
ritonavir.
Selective Ritonavir increase the levels of sertraline and citalopram. Fluoxetine and
serotonin fluvoxamine are decreased by nevirapine. Fluoxetine and fluvoxamine
reuptake increase the levels of amprenavir, delaviridine, efavirenz, indinavir,
inhibitors lopinavir/ritonavir, nelfinavir, ritonavir, and saquinavir.
Trazodone Darunavir, indinavir, lopinavir/ritonavir, and ritonavir has the potential to
increase the side effects of Trazodone which include nausea, dizziness,
hypotension, and syncope.
St John’s Wort Decreases in indinovir levels have been reported with the administration
(Hypericum of St John’s Wort.
perforatum)

Data from Dubé B, Benton T, Cruess DG, et al. Neuropsychiatric manifestations of HIV infection and
AIDS. J Psychiatry Neurosci 2005;30(4):237–46.

adults with HIV.49 Table 2 lists the medications that have approval from the US Food
and Drug Administration to treat major depression in children and adolescents50 and
Table 3 lists those approved to treat bipolar 1 depression in children and adolescents.
An important consideration in selecting an antidepressant medication is the side effect
profile and drug-drug interactions with ART, because they can negatively impact the
quality of life and medication adherence; conversely, medication side effects can also
be used to mitigate HIV-related symptoms such as fatigue, insomnia, and weight loss.

Table 2
Medications approved by the US Food and Drug Administration to treat major depression in
children and adolescents

Antiretroviral Effects
Age Dosage (Most Commonly
Medication (y) (mg/d) Metabolized Used Antiretrovirals)
Escitalopram 12 10–20 Liver extensively —
CYP450: 2C19
(primary), 2D6,
3A4 substrate
Fluoxetine 8 10–20 Liver, CYP450: Levels decreased
2C19 (primary) by nevirapine
substrate Fluoxetine increases
levels of amprenavir,
delaviridine, efavirenz,
indinavir, lopinavir/ritonavir,
nelfinavir, ritonavir,
and saquinavir

Adapted from Centers for Medicare and Medicaid Services. Antidepressant Medications: U.S. Food
and Drug Administration-approved indications and dosages for use in pediatric patients. Available
at: https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-
Education/Pharmacy-Education-Materials/Downloads/ad-pediatric-dosingchart.pdf. Accessed May
11 2016.
 Youth Living with HIV and Depression 455

Table 3
Medications approved by the US Food and Drug Administration to treat bipolar depression

Antiretroviral Effects
Age Dosage (Most Commonly
Medication (y) (mg/d) Metabolized Used Antiretrovirals)
Olanzapine/ 10 3/25–12/50 Olanzapine: liver Levels decreased by
fluoxetine extensively; CYP450 nevirapine
1A2, 2D6 (minor), Fluoxetine increases
2C19 (substrate) levels of amprenavir,
Fluoxetine: liver, delaviridine, efavirenz,
CYP450: 2C19, indinavir, lopinavir/ritonavir,
(primary) substrate nelfinavir, ritonavir,
and saquinavir

Adapted from Centers for Medicare and Medicaid Services. Antidepressant Medications: U.S. Food
and Drug Administration-approved indications and dosages for use in pediatric patients. Available
at: https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-
Education/Pharmacy-Education-Materials/Downloads/ad-pediatric-dosingchart.pdf. Accessed May
11 2016.

It is also important to inquire about and monitor the use of nontraditional agents used
to treat depressive symptoms such as St John’s Wort owing to their impact on ART
treatment efficacy.6

SUMMARY

Tremendous progress has been made in reducing new HIV/AIDS cases in the United
States. Screening, early detection, rapid testing, and early ARTs have been effective in
preventing transmission and prolonging health. HIV disease is now a chronic health
condition and YLWHA who are receiving treatment are living longer and healthier lives.
Although many youth are doing well, studies suggests that this is not true for all pop-
ulations of adolescents affected by HIV, especially ethnic minority youth. Adolescents
continue to have higher rates of undiagnosed and untreated infections and, for those
in treatment, they have the lowest rates of viral suppression required to prevent the
progression to AIDS.
YLWHA have a high prevalence of depression and other psychiatric conditions, and
the presence of depression impacts the success of medical treatment and ART ther-
apy, worsening both their physical health and mental health outcomes. Depression is
also a risk for acquiring the HIV virus and for transmitting the virus to others. Child and
adolescent psychiatrists play an important role in preventing new infections for ado-
lescents with depression by identifying and treating the depression and other psychi-
atric conditions that place youth at risk. Child and adolescent psychiatrists are also
ideally prepared to evaluate the adolescent’s adherence to treatment recommenda-
tions, to assess for risky sexual practices and behaviors that place them at risk, to
make recommendations about safe sex practices or treatments, and to connect
them with appropriate physical health providers or other interventions.
The psychiatric evaluation of YLWHA requires a comprehensive biopsychosocial
assessment that includes multiple informants involved in the youth’s care, including
caregivers, schools, and other agencies. Inclusion of this care team will contextualize
the presenting symptoms and allow for the anticipation of health care challenges. A
discussion and treatment plan at a developmentally appropriate level that includes
the youth, care team, and supportive others acknowledges the importance of their
sense of autonomy, independence, and confidentiality. The disclosure of the youth’s
456 Benton et al

HIV status, when, to whom, and how the disclosure occurs is an important component
unique to YLWHA. A comprehensive assessment must also include stressors that are
common for YLWHA such as loss of family or friends who may be HIV infected,
changes in health status, or other psychosocial challenges. A regular assessment of
cognitive functioning, adherence to medications, lifestyle, and safer sex practices
should be included. Alcohol and drug use should be assessed as risk factors for un-
safe sexual activity and poor health outcomes.51
One potential challenge for child and adolescent psychiatrists treating YLWHA is
acknowledging any discomfort with inquiring about sexual behaviors with high-risk
teens, both HIV infected and uninfected. Direct questions should be asked about the
adolescents’ sexual behaviors, the role and meaning of sexual relationships, the use
of condoms, the context for sexual activities and sexual attitudes, beliefs and behaviors
of their peers, and the quality of their peer and partner relationships. The initiation of
these discussion in the context of a therapeutic relationship conveys the importance
of the adolescent’s concerns and the therapists concerns about safety, and provides
a forum for discussion that the adolescent might use to gain awareness of their own
sexual practices, and to increase motivation for engaging in safer sexual practices.52
Treatment studies for YLWHA, suggest that interventions used to treat depression
for all adolescents are effective for youth living with HIV, although the best outcomes
occur when treatments are modified to recognize and integrate challenges unique to
youth living with HIV/AIDS. YLWHA with their complex risks and vulnerabilities benefit
from comprehensive and integrated psychiatric treatment coordinated with their HIV
medical care. Integrated treatment teams can best address the multiple barriers
and challenges that YLWHA encounter.
Despite considerable progress, HIV remains a significant health risk for adolescents,
and depression heightens that risk. Child and adolescent psychiatrists have an impor-
tant role to play in curbing this epidemic for youth by identification and treatment of
depression and other mental health conditions to reduce risks for new infections
and increase HIV treatment adherence, treatment success, safer sex practices, and
overall quality of life.

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