In the current era of combination antiretroviral therapy, women living with HIV (HIV-infected) have opportunities for long-term survival given adequate adherence to treatment and care. Mother-to-child transmission of HIV dramatically declined with use of antiretroviral drugs during pregnancy.1 Despite these advances, the HIV epidemic in women persists, and their offspring are delivered with in utero HIV exposure.2 Although risk for HIV infection is increasingly associated with heterosexual transmission rather than drug use,3 HIV continues to disproportionately affect women living in low-income urban communities affected by substance use and violence. In addition, complications and risks associated with HIV remain, including psychiatric disorder and substance use disorder (SUD),4–9 that may prevent women from actualizing the full benefits of current treatment opportunities.
Risks for psychiatric disorder and SUD among HIV-infected women are related to a complex interplay of genetic, biological, and psychosocial factors. Neurochemical changes during pregnancy and postpartum and HIV disease complications, including chronically activated inflammatory pathways, confer risk for depression.10–13 HIV-infected women often have personal histories of trauma, experience acute and chronic stress, and face the challenges of managing HIV-related health problems while raising children in complex environments, often with uncertain resources and inadequate support.14–18 Psychiatric disorder and SUD, if present, may increase the risk for inconsistent utilization of antiretroviral treatment (ART), poor adherence, inadequate virological suppression, and HIV disease progression.19–25 Of particular concern are persistent psychiatric disorder or SUD that are undiagnosed or untreated, placing women at heightened risk for role function impairment, morbidity, and mortality. Similarly, their children may be at risk for negative developmental effects and mental health problems related to parental psychiatric illness and its effect on parenting.26–30
In the era of ART, few studies have longitudinally examined psychiatric functioning and substance use among HIV-infected mothers. Few have focused on mothers of children who are HIV exposed but uninfected, that is, the majority of children currently born to women living with HIV in the United States. Given the ramifications of psychiatric disorder and SUD on health outcomes and linkage with HIV transmission behaviors, understanding the mental health needs of women in the current era may be critical for efforts to improve their health and ability to care for children and reduce transmission to others. The goals of this investigation were as follows: (1) to estimate the prevalence of psychiatric disorder and SUD among HIV-infected mothers of children with perinatal HIV exposure, but without HIV infection, and a cohort of HIV-uninfected mothers from the same communities; (2) to estimate the incidence, remission, and persistence of psychiatric disorder and SUD among a subset of HIV-infected mothers with 2 psychiatric and substance use evaluations completed 1–3 years apart; and (3) to identify key demographic and biopsychosocial correlates of prevalent, incident, remitted, and persistent psychiatric disorder and SUD among HIV-infected mothers. We hypothesized that psychiatric disorders are more prevalent among mothers living with HIV compared with mothers without HIV infection and that disorders are more likely to persist for mothers with health limitations.
Eligible participants included HIV-infected birth mothers whose children were enrolled in the Static and Dynamic cohorts of the Surveillance Monitoring for ART Toxicities (SMARTT) study, a longitudinal investigation of the biological and psychosocial effects of perinatal HIV exposure conducted at 22 sites in the United States. Sites were predominantly urban and included hospitals/clinics in Northeastern, Midwestern, Southern, and Western regions of the United States and in Puerto Rico. Mothers and children attended study visits coinciding with the children’s birthdays (±3 months) at 1–3, 5, 7, 9, 11, and 13 years of age from 2007 to 2010 and at ages 1–3, 5, 9, and 13 years of age from 2010 forward. In 2010–2011, funding became available for 9 of 22 SMARTT research sites to enroll and evaluate at one study visit a community comparison group of HIV-unexposed children of ages 1, 3, 5, or 9 years and their HIV-uninfected mothers. Children and mothers were evaluated near the time of the child’s birthday.
Birth mothers in both groups completed at least 1 valid psychiatric and substance use evaluation, the Client Diagnostic Questionnaire (CDQ).31 Institutional review boards at participating sites approved the study; written informed consent was obtained for adult and child participation.
Psychiatric disorders and SUDs were assessed with the CDQ,31 a psychiatric screening tool that was adapted from the PRIME-MD,32 a well-validated screening tool for assessing psychiatric disorders and SUDs in primary care settings. The CDQ was developed and validated for persons affected by HIV and was administered to mothers by a psychologist, in either English or Spanish, depending on the primary language of the mother. The CDQ-based diagnosis of “any disorder” was the primary focus of this analysis, given the strong association of mental health problems and substance use among persons living with HIV, and has the strongest validity data relative to either psychiatric disorder or SUD alone or any of the individual disorders. Sensitivity, specificity and overall accuracy of the CDQ were 91%, 78%, and 85%, respectively.31 For both groups of mothers at initial interview, we examined the prevalence of any psychiatric disorder and SUD and each specific disorder. Psychiatric disorders included major depressive disorder, other depressive disorder, panic disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), and psychosis; SUD included alcohol abuse and drug abuse. We also examined the prevalence of comorbid or co-occurring psychiatric and SUDs. For HIV-infected mothers with an initial CDQ and a repeat CDQ 1–3 years later, we identified incident, remitting, or persisting psychiatric disorders and SUDs.
Maternal health characteristics, including functional limitations (eg, fatigue, difficulty with mobility or difficulty with work-related tasks), psychosocial information, and demographic factors of interest were collected at study entry and during follow-up through maternal interview. Maternal cognitive functioning was measured with the Wechsler Abbreviated Scale of Intelligence (WASI)33 that provides a Full Scale Intelligence Quotient. The WASI and CDQ were administered according to standardized procedures.
Demographic and maternal characteristics were summarized by HIV status. CDQ and WASI evaluations were reviewed, and those considered invalid were excluded from the analyses. Estimates of the prevalence of psychiatric disorders and SUDs among HIV-infected mothers at each time of measurement [initial (time 1) and follow-up at 1-year, 2-year, or 3-year visits (time 2)] and among HIV-uninfected mothers at their 1 interview were identified. Fisher's exact tests and 2-sample t tests were conducted as appropriate to compare prevalence of disorders between HIV-infected and HIV-uninfected mothers using the initial CDQs completed by both groups.
HIV-infected mothers who completed CDQs at times 1 and 2 were included in the analysis of incidence, remission, and persistence of psychiatric disorders and SUDs. Summary statistics were obtained for the prevalence of psychiatric disorders and SUDs in the following categories: (1) no disorders at time 1 or time 2; (2) any disorder at time 1 but none at time 2 (remitted); (3) no disorder at time 1 but any disorder at time 2 (incident); and (4) any disorder at time 1 and time 2 (persistent). For the last category, the specific disorder at each time point could differ. Using Fisher's exact tests, 2 comparisons of the prevalence of psychiatric disorders and SUDs were made to examine the representativeness of the sample as follows: one with HIV-infected mothers who were ineligible for the longitudinal cohort (because they were not due for a follow-up CDQ) and one with mothers who missed their follow-up CDQ.
All valid CDQ evaluations completed by HIV-infected mothers were included to identify biopsychosocial characteristics associated with the presence of any psychiatric disorder and SUD. Generalized estimating equation models were constructed to account for correlations between responses for each mother. To identify correlates of persistent and incident psychiatric disorders and SUDs, we compared mothers with any disorder at both time 1 and time 2 and mothers without a disorder at time 1 and any disorder at time 2 to mothers with no disorder at either evaluation. Ordinary logistic regression models were fit to evaluate the associations of persistent and incident disorders with demographic and biopsychosocial correlates. To better understand correlates associated with remission and persistence of disorders, we conducted additional analyses comparing those with persistent and remitted disorders. Sensitivity analyses adjusting for site effects were conducted for all outcome analyses.
Our primary analyses were conducted using combined psychiatric disorders and SUDs as the outcome. Univariable analyses were first conducted to evaluate the unadjusted associations between the outcome and each demographic and biopsychosocial covariate. Covariates with P < 0.1 from the univariable analyses were retained in the final multivariable model to estimate the adjusted associations with psychiatric disorders and SUDs. In the multivariable models, the time interval (in months) between 2 CDQs was included as an a priori decision, regardless of the significance in univariable analyses. For multivariable models, missing indicators were created for covariates with >5% missing data. Adjusted odds ratios, 95% confidence intervals, and P values were obtained from the multivariable models. Results with P < 0.05 were considered significant. All analyses were based on data submitted as of January 1, 2012.
Sensitivity analyses were conducted using only psychiatric disorder (without SUD) as the outcome. Additionally, sensitivity analyses adjusting for site effect were conducted to account for potential differences in CDQ results across research site regions. The 22 research sites were grouped into 4 geographic regions (Puerto Rico, Northeastern/Midwestern states, Southern states, Western states), and this variable was added to the multivariable models fitted in the primary analyses. The adjusted associations of psychiatric disorder and SUD with all characteristics, after adjusting for site effect, were compared with the associations in the primary analyses.
As of January 1, 2012, a total of 1350 HIV-infected mothers were expected to complete a CDQ. Among them, 1230 (91%) completed 1 or more CDQs. Reasons for missed evaluations were identified for 101 of 120 mothers and included lack of time or non-English or non-Spanish primary language and unavailable translation. Of the 1230 completed CDQs, 7 (<1%) were considered invalid, largely due to poor comprehension of questions. Thus 1223 of 1230 HIV-infected mothers (91%) were included in the analyses of the prevalence of psychiatric disorders and SUDs. In addition, completed CDQs were available from 128 HIV-uninfected mothers.
Among the 1223 HIV-infected mothers with an initial CDQ, 775 were expected to complete 1 or more additional CDQs. Among these 775 mothers, 689 (89%) mothers completed a second CDQ within 1–3 years of the first interview and were included in analyses of persistence, incidence, and remission of psychiatric disorders and SUDs. Reasons for exclusion (n = 86) included a missed follow-up CDQ (n = 52), primarily due to lack of time, or CDQ completion outside of the 1-year to 3-year window (n = 34). As compared with mothers in the longitudinal cohort for determination of incident, remitted, and persistent disorders (n = 689), mothers who were not eligible for the longitudinal cohort (second CDQ not expected, missed the second CDQ or completed the CDQ outside of the 1-year to 3-year retest interval specified for these analyses; n = 534) were more likely to screen positive for drug abuse disorder at study entry (P = 0.02), whereas mothers who were expected to complete but missed the second CDQ (n = 52) more often screened positive at entry for depressive disorder (P = 0.03) and drug abuse disorder (P = 0.03).
HIV-infected mothers were more likely to be older, of Hispanic ethnicity, and have annual household income ≤$20,000 compared with HIV-uninfected mothers. HIV-infected mothers more often reported use of tobacco and illicit drugs during pregnancy, had more functional limitations and health problems, and had lower Full Scale Intelligence Quotient scores. They were less likely to be high school graduates or currently employed than HIV-uninfected mothers (Table 1).
Prevalence of Psychiatric and SUDs
Figure 1 summarizes the prevalence of psychiatric disorders and SUDs among both groups of mothers at their initial CDQ. Thirty-five percent of both HIV-infected and HIV-uninfected mothers had any disorder, including psychiatric disorder and/or SUD. Psychiatric disorders were identified among 32% of HIV-infected mothers and 31% of HIV-uninfected mothers; SUDs were identified among 9% of both groups. After adjusting for sociodemographic variables, no significant differences were observed between HIV-infected and HIV-uninfected mothers for prevalence of any individual psychiatric disorder or SUD. Comorbid psychiatric disorders and/or SUD were reported by 15% of HIV-infected mothers and 13% of HIV-uninfected mothers. Among HIV-infected mothers with SUD, 64% of mothers reported co-occurring psychiatric disorders.
PTSD was the most prevalent disorder in both groups, with 23% of HIV-infected mothers and 21% of HIV-uninfected mothers meeting screening criteria at the initial CDQ. Witnessing violence (combat experience, saw people in family harming one another, saw someone assaulted/seriously injured/killed) was the most frequently reported traumatic event by both groups of mothers (see Table S1, Supplemental Digital Content, http://links.lww.com/QAI/A490). HIV-infected mothers reported witnessing violence less often than HIV-uninfected mothers (44% vs. 55% P ≤ 0.01). HIV-infected mothers had more direct personal experience with violence as they more often reported experiencing physical abuse during childhood (24% vs. 14%, P = 0.01) and sexual assault during adulthood (14% vs. 6%, P = 0.01).
Pattern of Changes in Psychiatric and SUDs Among Mothers With HIV
Table 2 shows the distribution of the pattern of changes in psychiatric disorders and SUDs among HIV-infected mothers who completed initial and follow-up CDQs. The mean interval between evaluations was 18 months. Nearly half (48%) of mothers screened positive for any psychiatric disorder or SUD at either evaluation time (incident disorder + remitting disorder + persisting disorder/689). Among HIV-infected mothers with no disorder at the initial evaluation (no disorder + incident disorder = 451), 21% (93/451) had an incident disorder during follow-up. Among mothers with disorders at their initial evaluation (remitting disorder + persisting disorder = 238), 61% (145/238) had persistent disorders and 39% (93/238) had remitted disorders at follow-up. Comorbid psychiatric disorders and/or SUD were reported by 23% of mothers with incident disorders and 20% with remitted disorders. Among mothers with persistent disorders, comorbid disorders were reported by 57% at time 1 and 48% at time 2. Seventeen percent of HIV-infected mothers reported receiving mental health treatment (medication and/or therapy) for psychiatric and/or SUD either at the time of evaluation or within the past six months as follows: 4.5% at time 1, 7% at time 2, and 5.5% at both time points.
Factors Associated With Presence, Incidence, and Persistence of Psychiatric Disorders and SUDs Among HIV-Infected Mothers
Table 3 presents the univariable and multivariable associations of demographic and biopsychosocial characteristics of interest with the presence of any current psychiatric disorder or SUD among HIV-infected mothers. In the multivariable model, mothers who were younger than 35 years, single parents, and those who had 1 or more functional limitations had higher odds of screening positive for any disorder, compared with mothers without those characteristics. Not surprisingly, mothers who self-reported alcohol or illicit substance use during pregnancy also had higher odds of screening positive for any current psychiatric disorder or SUD. However, sensitivity analyses conducted to identify factors associated with the presence of psychiatric disorders only (excluding SUD) among women with HIV infection at study entry (n = 1223) revealed that the use of illicit substance during pregnancy (P = 0.04) was significantly associated with the presence of any current psychiatric disorder.
As shown in Table S2 (see Supplemental Digital Content, http://links.lww.com/QAI/A490), mothers who reported 1–2 functional limitations as compared with no limitations had higher odds of incident disorders (vs. no disorders at either time point). Lower annual household income and 1 or more functional limitations were associated with higher odds of persistent disorders (vs. no disorders at either time point), as were alcohol or illicit substance use during pregnancy. When comparing mothers with persistent and remitted disorders, no significant associations were observed with demographic or psychosocial characteristics, although the presence of multiple functional limitations, lower income, and illicit substance use during pregnancy were marginally associated with persistent disorders (data not shown).
Sensitivity analyses to identify correlates of persistent psychiatric disorders only (excluding SUD) in the longitudinal analyses revealed that using alcohol during pregnancy (P = 0.01) was associated with higher odds of persistent psychiatric disorders. Additionally, mothers with 1 or 2 functional limitations at the time of the initial evaluation more often developed a new psychiatric disorder than mothers who had no functional limitation. Including research site in the adjusted models had no effect on the findings observed in the primary analyses.
Psychiatric and SUDs among mothers with HIV infection are of great concern due to their impact on mothers’ own health and quality of life and the health and psychological well-being of their children. In our investigation, psychiatric disorder and SUD among HIV-infected mothers were more prevalent than among adults in general and nonpregnant women in large scale US population surveys,34,35 but rates were similar to those observed among our comparison group of HIV-uninfected mothers recruited from the same medical centers. Among all diagnostic categories assessed in this study, PTSD was the most prevalent disorder for both HIV-infected (23%) and HIV-uninfected mothers (21%), with notably higher rates than those observed in the general adult population (9.7%),35 but similar to estimates in previous studies of US HIV-infected women.16
Our results indicate that almost half of mothers living with HIV in this longitudinal sample had a psychiatric disorder or SUD at some time during the period of study. Further, psychiatric disorder or SUD persist among many mothers; 61% of mothers with disorders at the initial evaluation presented with a disorder at both time points, although the specific disorder may have changed. More than half of mothers with persistent disorders had comorbid disorders at their initial evaluation, especially PTSD, anxiety, and depression, in varying combinations, which may adversely affect adherence and retention in HIV care and contribute to the persistence of disorders. Of additional concern, among mothers with no disorders at their initial evaluation, 21% experienced an incident disorder, which underscores the dynamic nature of psychiatric conditions and the need for ongoing screening and evaluation and provision of easily accessible services.
A number of biopsychosocial characteristics were associated with prevalent, incident, and persistent psychiatric disorder and SUD in mothers with HIV infection. Mothers who were younger or single parents were more likely to have a disorder and mothers with lower family income were more likely to have persistent disorders compared with those with no disorder. Functional limitations, such as fatigue and difficulty with mobility or work-related tasks, were also strongly associated with prevalent, persistent and incident disorders, regardless of whether psychiatric disorders were examined independently or in conjunction with SUDs. Although we were unable to ascertain whether functional limitations were due to complications of HIV, the debilitating effects of either psychiatric and/or substance abuse disorders, or their interaction, prior research suggests that functional limitations predict negative effect,17 possibly due to individuals’ difficulty meeting home and occupational demands and other associated stressors. The presence of functional limitations was the single factor that distinguished mothers with incident disorders from those who had no disorders during follow-up; similarly, the presence of functional limitations was marginally related to the presence of persistent disorders vs. remitted disorders during follow-up.
Mothers in our cohort experienced high rates of trauma. Compared with HIV-uninfected mothers, mothers with HIV infection were more likely to report physical abuse during childhood and sexual assault during adulthood while those without HIV were more likely to have witnessed violence. Although type of trauma was not the primary outcome of interest in this study, these significant differences are noteworthy. Both sexual trauma (which is interpersonal and deeply intimate by nature) and childhood physical abuse (which is often perpetrated by a parent or family member who is simultaneously considered a source of safety or a primary attachment figure) may be more likely to affect victims’ self-esteem, emotional regulation, and ability to form healthy relationships.36 Physical abuse in early childhood may also alter brain responses to mild or high stress in adulthood37and may predispose adults with this history to mental health problems and elevated adult sexual risk behavior. Similarly, in the context of multiple risk factors and chronic illness among mothers with HIV infection, the experience of sexual assault in adulthood may further compromise self-care, health management, and health outcomes.16,38 Trauma recovery services may be particularly helpful to women with such histories to prevent recurrence of victimization and reduce the risk of intergenerational trauma in their family systems.39,40
Maternal histories of alcohol or illicit substance use during pregnancy were relatively infrequent (10%) but not absent in this study. Although previous analyses of a smaller cohort of HIV-infected mothers from this cohort41 suggested that self-report of substance use in pregnancy was fairly reliable, it remains possible that some mothers underreported substance use, due to social desirability bias or mothers’ concerns about reports to child-protective services. Still, this finding suggests that maternal report of alcohol or illicit substance use during pregnancy may have value in predicting SUD prevalence and persistence and, if this finding is confirmed by future studies, have clinical value in identifying women who are at particularly high risk and need additional or more intensive mental health follow-up.
Despite high rates of disorders observed in this study, we found low utilization of mental health services and substance use treatment for those in need, even among mothers with persistent disorders. Psychiatric disorder and SUD, if left untreated, may exacerbate mothers’ health problems and prevent adequate health-promoting behavior while treatment or recovery may provoke parallel improvement in specific indicators of immunity.20 Referrals for appropriate intervention were standard of care at all study sites. In light of limited reported treatment, however, we speculate that stigma associated with HIV and/or mental health and substance use treatment, and practical and structural barriers (eg, cost, lack of transportation or childcare, inflexible work hours) or cultural factors (eg, language differences and level of acculturation) may be critical limitations to utilization of appropriate mental health services or substance use treatment. More research is needed to understand the low rates of service use among women of childbearing age and among women living with HIV specifically and to develop interventions and policies to promote participation. Moreover, multiple studies have now recommended integrated HIV, mental health and substance use treatment, as women living with HIV may be more likely to initiate and maintain mental health services and/or substance abuse treatment if these services were included in their routine medical care.6,42,43
This investigation is one of the largest studies to date to examine longitudinal data on mothers with HIV in the era of ART. It is, however, not without limitations. Although the demographic characteristics of our study cohort were representative of the US population of mothers with HIV, the fact that both HIV-infected and HIV-uninfected mothers were from convenience samples introduces enrollment bias, which potentially limits our ability to generalize the findings to all mothers with HIV. Our comparison group of HIV-uninfected mothers was evaluated only once, due to funding limitations, precluding identification of incident, remitted, and persistent disorders and thus the potential impact of HIV on women’s psychological health. Given the primary focus of SMARTT on child outcomes, detailed information on the past psychiatric and HIV disease histories of the mothers was unavailable and thus we could not evaluate potential confounding factors, such as maternal nadir CD4 count or treatment history. Finally, although the CDQ is validated for identifying psychiatric disorder and SUD in primary care settings and among those affected by HIV, it is a screening instrument and insufficient for definitive clinical diagnoses, including diagnosis of bipolar disorder or antisocial personality disorder, which sometimes co-occur with SUDs.
Nonetheless, the results of this study have important implications for programs and policy. Systematic screening, diagnosis, and early treatment of psychiatric disorder and SUD should be key components of comprehensive HIV care for women, with periodic reassessment for those at highest risk, such as younger mothers, those with limited resources, and those with functional limitations. Access to evidence-informed treatment for psychiatric disorder and SUD, and trauma recovery might be essential to preempt the development or escalation of mental illness and its consequences for mothers and their families. The psychological, societal, cultural, and institutional barriers to access mental health care must be identified and eliminated.
The authors thank the children and families for their participation in Pediatric HIV/AIDS Cohort Study (PHACS) and the individuals and institutions involved in the conduct of PHACS. Harvard University School of Public Health (Principal Investigator: George Seage; Project Director: Julie Alperen) and the Tulane University School of Medicine (HD052104, 3U01HD052104-06S1) (Principal Investigator: Russell Van Dyke; Co-Principal Investigator: Kenneth Rich; Project Director: Patrick Davis). Data management services were provided by Frontier Science and Technology Research Foundation (Principal Investigator: Suzanne Siminski), and regulatory services and logistical support were provided by Westat, Inc (Principal Investigator: Julie Davidson). The following institutions, clinical site investigators, and staff participated in conducting PHACS SMARTT in 2012, in alphabetical order—Baylor College of Medicine: William Shearer, Mary Paul, Norma Cooper, Lynette Harris; Bronx Lebanon Hospital Center: Murli Purswani, Emma Stuard, Anna Cintron; Children's Diagnostic and Treatment Center: Ana Puga, Dia Cooley, Patricia Garvie, Deyana Leon, Doyle Patton; Ann and Robert H. Lurie Children’s Hospital of Chicago: Ram Yogev, Margaret Ann Sanders, Kathleen Malee, Scott Hunter; New York University School of Medicine: William Borkowsky, Sandra Deygoo, Helen Rozelman; St. Jude Children's Research Hospital: Katherine Knapp, Kim Allison, Megan Wilkins; San Juan Hospital/Department of Pediatrics: Midnela Acevedo-Flores, Lourdes Angeli-Nieves, Vivian Olivera; SUNY Downstate Medical Center: Hermann Mendez, Ava Dennie, Susan Bewley; Tulane University Health Sciences Center: Russell Van Dyke, Karen Craig, Patricia Sirois; University of Alabama, Birmingham: Marilyn Crain, Newana Beatty, Dan Marullo; University of California, San Diego: Stephen Spector, Jean Manning, Sharon Nichols; University of Colorado Denver Health Sciences Center: Elizabeth McFarland, Emily Barr, Robin McEvoy; University of Florida/Jacksonville: Mobeen Rathore, Kristi Stowers, Ann Usitalo; University of Illinois, Chicago: Kenneth Rich, Lourdes Richardson, Delmyra Turpin, Renee Smith; University of Medicine and Dentistry of New Jersey: Arry Dieudonne, Linda Bettica, Susan Adubato; University of Miami: Gwendolyn Scott, Claudia Florez, Elizabeth Willen; University of Southern California: Toinette Frederick, Mariam Davtyan, Maribel Mejia; University of Puerto Rico Medical Center: Zoe Rodriguez, Ibet Heyer, Nydia Scalley Trifilio. Note: The conclusions and opinions expressed in this article are those of the authors and do not necessarily reflect those of the National Institutes of Health or US Department of Health and Human Services.
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