Anxiety Disorders Among Children And Adolescents Living With HIV: Prevalence, Risk Factors And Impact On Negative Outcomes In The Chaka Project Noeline Nakasujja;MBChB. Mmed.Psych, PhD Head, Dept of Psychiatry, School of Medicine College of Health Sciences, Makerere University

CHAKA CHildren and Adolescents in KAmpala and Masaka, Uganda (CHAKA) PI –Eugene Kinyanda Mental Health Project, MRC/UVRI Uganda Research Unit on AIDS/ MRC-DFID African Leadership Award

CHAKA General Objective To understand psychiatric disorders and neuro-cognitive disorder among children and adolescents with HIV (CA-HIV) in Uganda

Outline of the Presentation: Background Objectives Methodology Results Discussion Limitations

Why HIV, anxiety and children?

Children (<15 years) estimated to be living with HIV  2014 Eastern Europe & Central Asia 17 000 [14 000 – 19 000] North America and Western and Central Europe 3300 [2200 – 4700] Middle East & North Africa 13 000 [10 000 – 16 000] Caribbean 13 000 [11 000 – 15 000] Asia and the Pacific 200 000 [180 000– 230 000] Sub-Saharan Africa 2.3 million [2.2 million – 2.5 million] Latin America 33 000 [29 000 – 40 000] Total: 2.6 million [2.4 million – 2.8 million]

Background Globally, 2.1 million children and adolescent are living with HIV 80% in sub-Saharan Africa (UNAIDS, 2015) Uganda children and adolescents with HIV:150,000 (UNAIDS, 2012) Access to effective ART ensuring survival of perinatally infected children into adolescence and adulthood (Louw et al, 2016) These HIV infected children and adolescents (CA- HIV) are at risk of emotional and behavioural problems (Louw et al, 2016)

Pre-ART era, children < 15 years, 51% had significant psychological distress (SRQ-25; ≥6) (Musisi & Kinyanda, 2009) Adolescents aged 6-18 years, at least one psychiatric disorder 48.8%on the MINI KID (Kamau et al, 2012) USA & Puerto Rico, youth aged 6-17 years, symptom and impairment criteria of the CASI-4R, at least one PD, 17% (Gadow et al, 2010, Nachman et al, 2012))

HIV + adolescents (6-18 years) in Kenya, PD by Mini-Kid: MDD 17 HIV + adolescents (6-18 years) in Kenya, PD by Mini-Kid: MDD 17.8%, social phobia 12.8%, specific phobia 7.1%, panic disorders 5.8%, agoraphobia 2.6%, separation anxiety disorder 2.6% (Kamau et al, 2012) Diagnostic Interview Schedule for Children (DISC-IV), anxiety disorders 49%, Mood disorders 7.3% (Mellin et al, 2009)

Objectives: To describe the prevalence of anxiety disorders and its predictors among CA-HIV To describe the risk factors for anxiety disorders among CA-HIV in the Chaka Project

Methodology CHAKA cohort of 1,336 children/adolescent- caregiver dyads with HIV recruited at 4 HIV care facilities (2 urban, 2 rural) The AIDS Support Organisation clinic and The Uganda Cares clinic Joint Clinical Research Centre, clinic and Nsambya Homecare Department In this study, Children defined as 5-11 years, Adolescents as being 12-17 years Assessments undertaken by trained psychiatric nurses & Psychiatric Clinical Officers

Anxiety assessment: Anxiety disorders: generalised anxiety disorder, specific phobia, panic attack, somatic symptom disorder, social anxiety disorder (social phobia), separation anxiety disorder

Psychiatric Assessments Child and adolescent psychiatric disorder Child & Adolescent Symptom Inventory-5 (CASI-5) (caregiver) Youth Self Report Symptom Inventory-4 (8-11 yrs) Youth Inventory 4R (12-17 yrs)

Psychosocial factors: Life time trauma events (A) 2 questions, 1 physical trauma, 1 sexual trauma Negative life events (last 6 months) (A) 2 questions, parents separated, parents very ill HIV felt stigma (last 12 month) (A) Using the Brief HIV Stigma Scale-5 items Child-caregiver relationship (asked caregiver) (CA) . Using the Child-Caregiver Relationship Inventory (4q)

Biological & Clinical factors: Wong-Baker faces (Pain) (C & A) Worst HIV clinical stage ever attained (C & A) Current HIV clinical symptoms (WHO pediatric clinical staging (child) Current HIV clinical symptoms (WHO clinical staging) (adolescent) CD4 nadir (C & A) Current CD 4 count (baseline, 6 months, 12 months) (C & A) HIV Viral load (baseline, 12 months (C & A)

Statistical Methods Considered items that occur “often” or “very- often” - used for prevalence Problem deemed clinically significant if it interferes with functioning “often” or “very often” Score for each problem 0 (never) to 3 (very often) – used for alternative risk factor analysis to increase power

Statistical Methods Bivariate analyses for associations between socio-demographic factors, vulnerability factors and stress factors Multivariable logistic regression model fitted based on stress vulnerability model to choose relevant predictors (backward elimination)

Demographic characteristics Variable Level Anxiety disorders (n=284) n (%) Test Statistic (P-value) Study Site Urban (n=684) Rural (n=655) 154 (22.5%) 130 (19.9%) Χ2 = 1.42 (P=0.23) Sex Male (n=638) Female (n=699) 130 (20.4%) 154 (22.0%) Χ2 = 0.55 (P=0.46) Age group Children (n=855) Adolescents (n=484) 204 (23.9%) 80 (16.5%) Χ2 = 9.94 (P=0.002) Religion Christian (n=1058) Muslim (n=273) Others/missing (n=8) 218 (20.6%) 65 (23.8%) 1 (12.5%) Χ2 = 1.70 (P=0.43) Tribe Baganda (n=967) Non-Baganda (n=370) 212 (21.9%) 72 (19.5%) Χ2 = 0.97 (P=0.32) Child lives with Both parent (n=354) Mother only (n=417) Father only (n=95) Grandparents (n=258) 94 (26.6%) 86 (20.6%) 15 (15.8%) 47 (18.2%) 42 (19.5%) Χ2 = 9.55 (P=0.05)

Test Statistic (P-value) Family Structure Variable Level Anxiety disorders (n=284) n (%) Test Statistic (P-value) Mother of child alive Yes (n=948) No/do not know (n=391) 217 (22.9%) 67 (17.1%) Χ2 = 5.49 (P=0.02) Father of child alive Yes (n=960) No/do not know (n=379) 217 (22.6%) 67 (17.7%) Χ2 = 3.95 (P=0.05) Born premature Yes (n=20) No/do not know (n=835) 7 (35.0%) 197 (23.6%) Χ2 = 1.40 (P=0.24) Child attending special education Yes (n=30) No (n=1274) 8 (26.7%) 273 (21.4%) Χ2 = 3.47 (P=0.18) Family has enough food Yes (n=660) No (n=191) 153 (23.2%) 51 (26.7%) Χ2 = 1.01 (P=0.32) Socio-economic index mean(Std) Disorder (n=204) No disorder n=651) 4.48 (1.8) 4.17 (1.8) F=4.70 (P=0.03)

Test Statistic (P-value) Factor Level (N=899) Anxiety disorders (n=284) n (%) Test Statistic (P-value) Viral load (copies/mL) <1000 1000-9999 ≥10,000 190 (23.8%) 16 (18.2%) 40 (20.5%) Χ2 = 2.11 (P=0.35) HIV felt stigma none (n=1240) some-1 and above (n=99)   272 (21.9%) 12 (12.1%) Χ2 = 5.28 (P=0.02)

Pattern and prevalence of anxiety disorders Psychiatric Disorder (n=1337) Meet symptom criteria only n (%) Impairing psychiatric symptoms n (%) Meet criteria for DSM-5 n (%) Any anxiety disorder 284 (21.2%)   Generalized Anxiety Disorder 22 (1.6%) 54 (4.0%) 10 (0.8%) Specific Phobia 191 (14.3%) Panic Disorder 36 (2.7%) Post-traumatic stress disorder 64 (4.8%) Social Anxiety 37 (2.8%) 56 (4.2%) 11 (0.8%) Separation Anxiety 76 (5.7%) 57 (4.3%) 25 (1.9%)

Pattern and prevalence of anxiety disorders

Likelihood Ratio P-value Logistic model for factors associated with anxiety Factor Level aOR 95% Confidence Limits Likelihood Ratio P-value Sex of child Male Female 1 1.19 Reference (0.90 ; 1.57) 0.22 Age of child Per 5 year increase 0.80 (0.64 ; 0.996) 0.046 Caregiver Education level No formal Primary Secondary Higher 0.66 0.99 1.04 (0.39 ; 1.14) (0.72 ; 1.35) (0.65 ; 1.66) 0.50 Caregiver positive on self-report qu’re No Yes 1.95 (1.43 ; 2.67) <0.001 Child has any depression 2.05 (1.26 ; 3.34) 0.004 Child has othe PD e.g ADHD,ODD 3.04 (1.80 ; 5.14)

Discussion Caregiver depression & psychological distress (Louw et al, 2016; Lentoor et al, 2016; Betancourt et al, 2015) HIV stigma (Dow et al, 2016) Low socio-economic status (Betancourt et al, 2015) Non epidemiologic sample Quality of care hypothesis (Lund et al 2010)

Summary of Findings: 21.2 % prevalence of any anxiety disorder Risk factors included : young age, living with distressed caregiver Quality of care hypothesis 10/8/2017 5th IAS Conference

Acknowledgments Jonathan Levin Richard Mpango Soraya Seedat, Tatiana Salisbary Catherine Abbo Vikram Patel Kinyanda Eugene