Claude A. Mellins1, Elaine J. Abrams 2, Curtis Dolezal1, Resilience in Perinatally HIV-Infected and Perinatally HIV-Exposed Adolescents and Young Adults Growing Up in High-risk Environments Claude A. Mellins1, Elaine J. Abrams 2, Curtis Dolezal1, Patricia Warne1 , Katherine S. Elkington1, Amelia Bucek1, Cheng-Shiun Leu1, Jeannette Raymond1, Stephanie Benson1 1HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY; 2ICAP, Columbia University Mailman School of Public Health, New York, NY 21st International AIDS Conference, Durban, South Africa Abstract # TUAB0101 No conflicts of interest to report

“Few were expected to live more than two or three years.” (Dee, 2005) Pediatric HIV in the U.S. “Few were expected to live more than two or three years.” (Dee, 2005) 1980s 1994 Today

Adolescents and Young Adults “That is why I stopped the ART” (Dahab et al., 2008)

Young Adulthood Childhood Adolescence Young Adulthood Adulthood

Child & Adolescent Self-Awareness and Health (CASAH) R01-MH069133 (PI: Mellins) Longitudinal study following perinatally HIV-infected (PHIV+) and perinatally HIV-exposed but uninfected (PHIV-) youth. Originally recruited (2003-2008) when the youth were 9 – 16 yrs from 4 major medical centers in New York City. Youth and their caregivers participated in psychosocial and behavioral interviews every 12- 18 months with medical chart data on PHIV+ youth. Goals: Throughout adolescence and young adulthood Examine impact of PHIV on Behavioral Health (mental health, substance use, sexual behavior, adherence to treatment). Identify risk and protective factors related to behavioral health and developmental milestones. Today I am presenting data from Project CASAH funded by NIMH is Longitudinal study following perinatally HIV-infected (PHIV+) and perinatally HIV-exposed but uninfected (PHIV-) youth Originally recruited (2003-2008) when the youth were 9 – 16 yrs from 4 major medical centers in New York City . Youth and their caregivers have participated in psychosocial and behavioral interviews every 12- 18 months with medical chart data on PHIV+ youth Goals: Examine behavioral health (mental health, substance use, sexual behavior, adherence to treatment) Identify risk and protective factors related to behavioral health problems throughout adolescent/ young adult development

Methods Psychosocial snapshot of both PHIV+ and PHIV- participants at FU5 – when youth are 18 - 28 years old Behavioral Health Problems (YA DISC-IV, Fisher et al., 2006 ) Psychiatric Disorder in the past 12 months (Mood, Anxiety, Disruptive Behavior) Substance Abuse Disorder in the past 12 months History of incarceration Young Adult Transition Milestones (CASAH questionnaire) High school graduate, GED, or in 12th grade if 18 years Currently working or in school Stable housing Paying rent Ever in a romantic relationship Sexual risk (condomless sex past 3 mos) (ACASI; Dolezal et al.) HIV RNA Viral Load (VL) and CD4+ cell counts (medical charts) Today I am going to present a very brief snapshot of what this cohort looks like when they are between the ages of 18 and 27 at their fifth follow- up interview.   Present a few behavioral health problems including whether or not they presented with any psychiatric disorder (we assessed a full range of mood, anxiety and behavioral disorders) ; any substance abuse disorder, including alcohol, marijuana, other drugs) and history of incarceration – using youth reports on a well validated full psychiatric interview- the DISC But we also examined 5 normative young adult transition milestones for this age group – including graduation from high school or its equivalent; currently working or in school, stable housing, whether they are contributing rent or income to housing and whether they have ever been in a romantic relationship.

Data Analysis Descriptive statistics generated to describe distribution of Behavioral Health Problems Achievement of transition milestones Chi square test / ANOVA used to examine the association of Behavioral Health Problems (0,1, 2+ problems) with HIV status, demographic characteristics Achievement of transition milestones (# milestones: 0- 5) Sexual behavior (absence of condomless sex, past 3 mos) (PHIV+ only) HIV biomarkers (VL < 1000 copies/mL; CD4 > 200 cells/mm3) Descriptive statistics on Behavioral Health and transition milestones, Polytimous Regression to compare youth with 0 Behavioral Health Problems compared to youth with 1 or 2+ problems   HIV status and demographic differences; then to see if associated with achievement of milestones, absence of sexual risk behavior- condomless sex Among PHIV+ Youth –better viral suppression and immune function

Demographics N= 207 (128 PHIV+ and 79 PHIV-) PHIV+ PHIV- Mean Age (Range: 18-28) 23 22 Gender (% female) 56% 54% Ethnicity (% Latino) 47% 51% Race (% Black/African American) 72% 66% Mean Household Income $18,000 $14,000   Very briefly- these youth are in their early 20s on average, evenly distributed by gender, primarily African America and latino- reflecting the HIV epidemic in women and children in NY Majority raised by a female caregiver, over half of whom were birth parents, typically an HIV+ mother with PHIV+ youth less likely to have been raised by a birth parent, typically an HIV+ mother and the majority of both groups were living below poverty line in NYC

Behavioral Health Problems 20% of 18-26 yr olds had a mental health condition, past year (SAMHSA, 2014) 17% of 18-25 yr olds had substance dependence /abuse, past year (SAMHSA, 2014) This first slide looks at 3 Behavioral Health problems- with the darker pink representing PHIV+ and light pink PHIV- Slightly over a quarter of both groups presented with any non-substance abuse psychiatric disorder, with anxiety and mood most prevalent- while clearly this needs attention, the rates are not that much higher than national norms in which 20% of young adults 18-28 had a mental health condition in the past year In terms of Substance abuse- ¼-1/3 of the youth are presenting with a substance abuse disorder- these rates are high- national data suggests about 17% of youth 18-25 have an alcohol or illicity drug dependence or abuse disorder in the past year And 7-13% have ever been incarcerated- What is important to note here is that PHIV+ youth are not presenting with more problems than the negative youth, if anything there is a trend for them to be less likely to have the problem, and that in spite of this risks I presented- the majority are not presenting with each of these problems What I will say here is that inspite of signficant biopsychossocial risks- the majority have not had a psych or SU disorder in the past 12 months nor have they ever been in carcerated with no group differences, if anyhting PHIV+ youth look slightly better- over 70% of both groups did not meet criteria fro a psychiatric disorder, 75% of PHIV + and nearly 70% of PHIV- youth did not meet critear for alcohol or any kind of substance abuse disorder, and 90% have never been incarcerated

Concurrent Behavioral Health Problems Over half of PHIV+ and PHIV- youth had no behavioral health problems No psychiatric disorder, substance use disorder, or history of incarceration PHIV+ youth were not more likely to have concurrent problems than PHIV- youth (trend for them to be less likely to have 2+ problems). Over 50% of both groups do not have any of these problems   About 1/3 have only 1 problem Less than quarter have 2 or more PHIV+ youth are not at any more risk for having problems, infact there is a trend for them to be less likely to have co-morbid problems

Adult Transition Milestones Current Relationship: ~50% Working: 39% PHIV-, 41% PHIV+ In School: 34% PHIV-, 26% PHIV+ Living rent-free with family: 71% PHIV-, 38% PHIV+ *=p<.001

Number of Transition Milestones Achieved %s add up to 99 and 101 due to rounding. Here are actual values: PHIV-: 10.1, 39.2, 39.2, 10.1, 1.3 PHIV+: 26.6, 37.5, 28.1, 7.8

Sex Behaviors, Biomarkers Sex Behavior, Past 3 Months PHIV+ PHIV- Sexually active No condomless sex * # sex partners 70% 66% M = 1 76% 56% *p<.05 PHIV+ VL and CD4 % VL < 1000 copies/ml 65% CD4 >200 cells/mm3 81%

Comparison of Youth with 0, 1, and 2+ Behavioral Health Problems   0 Problems 1 Problem 2+ Problems p-value1 Age (% < 22) 64% 57% 36% 0.02* No condomless sex; 3mos 71% 54% 52% 0.03* PHIV+ Only: Viral Load (% ≤ 1000) 79% 55% 42% 0.01* CD4 count (% > 200) 87% 82% 58% 0.08+ Mean milestones achieved 3.77 3.62 3.87 0.42 Association of BHO with transition milestones is not here Lastly when we looked at the youth with 0 behavioral health problems compared to youth with 1 or 2+ problems   They were not more likely to achieve more milestones interestingly- but They were more likely to report no incidence of condomless sex in the past 3 months, and to have better health problems- more had VL < 1000 and CD4 > 200- With similar results when we used different cut fofs 1=p-value of chi square test for categorical variable and ANOVA for continuous variables *=p<.05 +=p<.10

SUMMARY PHIV+ and PHIV- young adults are from challenging circumstances and at high risk for multiple behavioral health problems. Data from when our cohort was 18-28 years suggests that, in spite of substantive risks, there is a relatively large portion of both groups with positive behavioral health outcomes, achieving normative young adult transition milestones. Young adults with no behavioral health problems were more likely to report better condom use and, among PHIV+, to have better immune function and viral suppression. We identified psychiatric and substance use disorders, with rates of substance abuse disorders higher than national data indicate. However, PHIV+ young adults were not worse off than their uninfected peers, with a trend for them to do better in some areas. We need to understand WHY? This is a lot of text. Break up into 2 slides?

CONCLUSIONS Next steps are to use our full longitudinal data to look at a larger range of Behavioral Health Problems and Transition Milestones the individual, social and structural factors across adolescence that serve protective roles for those doing well, including the service systems that support PHIV+ youth. Our data suggested the integration of mental health, substance use and biomedical services are needed, but other financial and social needs may also need to be considered. We see this as a critical juncture for more broadly defined prevention efforts given the staggering numbers of children and young adolescents worldwide affected by HIV who will be transitioning to adulthood. Lets learn from those who defy the odds! For bullet 2- comment on scafolding + youth may have gotten and benefits that may help them transition that affected youth todate may not have

THANK YOU to the CASAH Team, Participants and Funder Research Staff: Stephanie Benson, B.A. Amelia Bucek, M.P.H. Jeannette Raymond, B.A. Jenna Reyes, B.A. Karina Santamaria, M.P.H. Amy Weintraub, B.A. Thank you to all of our research participants. Investigators: Elaine Abrams, M.D. Mahrukh Bamji, M.D. Laurie Bauman, Ph.D. Curtis Dolezal, Ph.D. Katherine Elkington, Ph.D. Cheng-Shiun Leu, Ph.D. Mary McKay, Ph.D. Patricia Warne, Ph.D. Andrew Wiznia, M.D.