CD4 indications) combination antiretroviral therapy. Infants in the early therapy group had improved overall and locomotor scores using the Griffiths Mental Development test compared to the delayed group (Laughton et al., 2009). Even in the era of combination antiretroviral therapy, neurological manifestations still present serious challenges for children.

Adherence and Behavioral Challenges

As previously discussed, treatment adherence is a challenge among HIV-infected populations, and is problematic because of the potential of viral mutations resulting in resistance to antiretrovirals. Although children share many of the structural and social barriers to adherence as adults, adherence can be particularly challenging in children due to (1) the frequency of doses or (2) the number of pills to administer per dose, which can create a burden on caregivers who are responsible for ensuring very young children receive their treatment. Furthermore, the treatments available in liquid form are often not palatable. In addition, many perinatally infected children aging into adolescence demonstrate independence and rebellion via nonadherence.

Other behavioral issues associated with adolescence, including sexual debut, have been studied in perinatally infected children. Surprisingly, in one U.S. study, 40 percent of perinatally infected youth ages 9 to 16 reported having unprotected sex (Mellins et al., 2009). Pregnancies have also begun to occur in perinatally infected young women. In the PACTG 219C cohort, 38 of 638 girls became pregnant (6 percent, first pregnancy rate of 18.8/1,000 person years). Thirty-two of these resulted in live births; 29 were HIV uninfected, 1 was HIV infected, and 2 were of unknown status (Brogly et al., 2007).

There is a growing body of literature examining the mental health status of perinatally HIV-infected children. However, isolating the role of HIV infection remains difficult because many of the risk factors associated with mental health disorders overlap with those for HIV (e.g., poverty, disrupted home life, history of mental illness, substance abuse) (Jeremy et al., 2005). Rigorous study designs using validated instruments are just beginning to become available. Mellins et al. (2009) have demonstrated that infected children have greater risk of developing any psychiatric condition, predominantly attention deficit hyperactivity disorder, compared to uninfected control subjects. No differences in risk for developing anxiety or mood disorders or substance abuse were observed. The presence of a mental health disorder was associated with sex and drug use risk behaviors. The use of psychotropic medications is common in HIV-infected youth, with approximately one third receiving some medications in 2003, most commonly antidepressants, stimulants, and antipsychotics (Wiener et al., 2006).

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