Sexual Abuse and Sexually-Transmitted HIV/AIDS in Jamaican Children and Adolescents Aged 6-19 Years

Introduction: Risk factors and outcomes of sexually-acquired human immunodeficiency virus infection were characterized in Jamaican children and adolescents. Methodology: Management was carried out by multidisciplinary teams in Infectious Diseases clinics during August 2003 through February 2019 using modified World Health Organization HIV criteria. Results: There were 78 clients, aged 6 to 19 years, with females:males = 4:1 (p < 0.05). Sexual-initiation occurred in 60%, 47 before < 16 years (median 13 years, with four < 10 years; females:males = 7:1). Sexual-initiation preceded HIV diagnosis in all cases (median 2 years). Secondary education 93% (69/77) and living with non-parental relatives 17% (13/78) were associated with early sexual-initiation (p < 0.042); as was later imprisonment in 6% (3/52). Other sexually transmitted infections 36% (19/53) were associated with sexual-initiation ≥ 16 years (p < 0.01). Risks for ongoing HIV-transmission included infrequent condom use 74% (39/53), body-piercings 50% (24/48), illicit drug use 37% (28/76), tattoos 36% (19/52), transactional sex 14% (7/53) and pregnancy 56% of girls. 77% (59/77) had Centres for Diseases Control’s Category A HIV infection; 82% (61/75) initiated anti-retroviral therapy; 75% (56/75) had first-line drugs, with helper T lymphocyte counts ≥ 500 cells/μL in 61% (48/78) and HIV viral load of < 1,000 copies/μL in 63% (40/64). Complications included dermatological 39% (20/52), respiratory 25% (13/52) and neurological 15% (8/52). Early sexual initiation was associated with depression 43% (33/76; p < 0.004) and suicidal attempt or ideation 23% (18/77; p < 0.096). Four (5%) died. Conclusions: Sexually transmitted HIV/AIDS in children and adolescents should preempt prompt medical, legal and psychosocial interventions.

We describe the clinical epidemiology and outcomes of a cohort of children and adolescents with sexually-acquired HIV-infection at two urban JaPPAAIDS Child and Adolescent Infectious Disease clinics. We determined their socio-demographic factors, the behaviors contributing to HIV-acquisition and ongoing transmission, clinical manifestations and outcomes. Results were shared with stakeholders to facilitate patient advocacy and guide national policy.

Methodology
This study characterized children and adolescents with sexually-acquired HIV within the Greater Kingston Metropolis, who were enrolled prospectively in the JaPPAAIDS clinics at the University Hospital of the West Indies (UHWI) and the Comprehensive Health Center, during August 2003 to February 2019 [25][26][27][28][29].
Management was by a multidisciplinary team of pediatricians, psychologist, social worker and a research nurse manager. Reporting occurred to the National AIDS Program, the Child Development Agency and Center for Investigation of Sexual Offences and Child Abuse [35].
A list of all patients with sexually-acquired HIV was obtained from the JaPPAAIDS clinics' databases. Medical records were reviewed and those aged < 24 years included. A data extraction sheet recorded information, without personal identifiers, on demographics, risky behaviors, clinical status and ART. Complications secondary to HIV/AIDS and its treatment were abstracted. Clients with vertically transmitted and transfusion-related HIV infection were excluded.
Descriptive analyses were performed. Data were analyzed using the Statistical Program for Social Sciences (SPSS version 20). Comparisons were made between two groups, using Students t test for normally distributed parametric data. Chi-square test was used for categorical variables. Statistical significance was taken at p < 0.05. Research was conducted according to the Helsinski Declaration and approval was granted from the Ethics Committees of the University of the West Indies, Jamaican Ministry of Health and South East Regional Health Authority.
The clinical data revealed the majority (77%) were classified as CDC Category A, i.e. mild HIV infection (Table 3). Antiretroviral therapy had started in 82%, most (75%) of whom were on first-line therapy. The last documented helper T lymphocyte cell (CD4) count was ≥ 500 cells/μL in 50%, with 45% of patients having an HIV viral load of < 1,000 copies/mL. Consistent adherence to ART's was reported in 32% of those treated, although for 49% adherence was classified as "sometimes" (Table 3).
We report that 74% of this cohort had engaged in unprotected sex with only 25% reporting consistent condom usage [5,[19][20][21][22][23][24]. Acquisition of condoms by healthy Jamaican teens is discouraged as they may be seen as promiscuous [38]. Decreased sexual pleasure and insistence on condom use is viewed negatively by partners and fidelity maybe questioned. In the USA, coitarche before age 14 years is reportedly associated with condom use in 68% of females and 80% of males [8]. Caribbean surveys identified 56% of girls and 79% of boys engaging in sexual activity before age 14 years; 38% of those aged 13 to 15 years, denied using a condom at last sexual intercourse [10]. Among sexually-active Jamaican high-schoolers, prevalence of condom use during last sex act was 52% [6].
Transactional sexual intercourse in 14% of this cohort was self-initiated for monetary and materialistic gain, a known risk for child sexual abuse and HIVinfection [19]. Transactional sexual initiation of teens may also result from parental exploitation, for income generation to support the household [19]. A high proportion of Jamaican girls, aged 10 to 19 years are having sex with older men for financial gain [7]. Teens are limited in decision-making, negotiating condom use and are at high risk for physical abuse. Transactional sex is stigmatized and illegal in the Caribbean [12]. Among sexually-experienced adolescents, many males had their first sexual experience with a commercial sex worker, or a casual friend.
This study of sexually HIV-infected youth reports a female:male predominance of 4:1 overall, and increased to > 7:1 for those aged < 16 years. A similar gender disparity has been observed globally and in South Africa [1,39]. As adolescents are given "syndromic-STI-management" and not tested routinely for HIV in Jamaica, this suggests the larger problem of undiagnosed asymptomatic sexually HIV-infected youth [12]. Thirty seven percent of the cohort was diagnosed with an STI-coinfection, similar to 33% in Gellert's series [21]. Gonococcal infections are linked with subsequent HIV infection for both sexes [40]. Adolescents attending an STI clinic in Jamaica, had repeated STI's (33%), teenage pregnancy (13%), HIVcoinfection (1.2%) and syphilis (1.2%) [16]. Here, 60% of our HIV-infected girls were pregnant, the higher proportion potentially reflecting their identification during antenatal screening.
Drug-use was commonly reported in 37% of this HIV-infected population. Alcohol consumption in large quantities increases high-risk sexual behaviors, including unprotected sex, multiple sexual partners, sex with high-risk partners and transactional sex [14]. Among Jamaican high-schoolers, lifetime prevalence of alcohol use was 64%, while 22% consumed alcohol, or used drugs before their last sexual intercourse [13].
Body-piercing and tattoos occurred in 50% and 37%, respectively. This industry is unregulated in Jamaica and the Caribbean and the link to HIVtransmission is challenging to establish because these clients are also sexually-active [41].
While most of our HIV-infected children and teens lived with parents, others reported unstable living environments and frequent movement between family and friends, which has been significantly associated with HIV-acquisition among underage clients elsewhere [19]. HIV-related stigma makes social support more essential and increases the need for family support and a good parent-child relationship. Half of the respondents in a Sub-Saharan African survey highlighted the importance of community support for HIV-infected adolescents, fostering acceptance, healthy decisions and adherence to ART's [42]. "Eve for Life" in Jamaica supports social and psychological aspects of adolescent girls living with, or at risk for HIV. Though most clients in our study were enrolled in secondary schools approximately half were "dropouts", due to financial instability, school truancy, misconduct and expulsions, with high unemployment rates.
Seventy seven percent of the HIV-infected youth in our study were categorized as CDC category A. Half of the cohort had CD4 cells/μL count of ≥ 500 and an acceptable HIV viral load, with 82% on ART. Optimal ART adherence correlated with HIV viral load < 1,000 copies/mL in 48%. Non-adherence correlated positively with missing appointments and increasing age of the child in JaPPAIDS clinics [17]. As teens assume autonomy, adherence diminishes leading to increase in drug resistance, exposure to multiple ART regimes and frequent drug-related and clinical complications. Many had dermatological, neurological, respiratory and other complications reflecting immune-compromised states and unlike other series, we report HIV-related deaths [18][19][20][21][22][23][24].
Adverse psychological effects of sexually-acquired HIV were apparent with 23% of our study population having suicidal attempts/ideation and 43% having clinical depression. Sexually-abused children are also recognized to have these adverse psychological effects [43,44]. Early and ongoing psychological intervention is therefore needed in HIV-infected teens. Psychologists, social workers and the Nurse Managers in JaPPAAIDS clinics provide an outlet for teens to talk about ongoing problems and offer emotional support.
The WHO's seven principles to prevent violence against children and adolescents could be enforced [45]. These include implementation and enforcement of laws, establishing appropriate norms and values, providing a safe environment with parental/caregiver support, establishing income and economic strengthening, providing response and support services, and education and life skills.

Conclusions and recommendations
We report Jamaican children and adolescents who contracted HIV through unprotected sexual contact, including through childhood sexual exploitation/violence. Inconsistent condom use, transactional sex and drug-use were reported, associated with HIV acquisition as well as onward transmission. These children and adolescents exhibited difficulty coping with their illness, psychological maleffects, non-adherence and HIV-attributable morbidity and mortality.
Measures must be implemented to prevent child sexual abuse and sexually-transmitted HIV in children and youth. Thorough medico-legal investigations must be done and perpetrators prosecuted. Victims must be managed appropriately, referred to the oversight legal agencies, linked to treatment and care and assisted to cope with their illness and engage in safe sexual practices. Hospital and also the Comprehensive Health Center, respectively. This project is dedicated to the vulnerable children and adolescents reported here, whose lives we would hope have mostly been impacted for positive change through interventions and the treatment and care they obtained in their challenging journey.
The JaPPAAIDS Clinics have been funded through the years by multiple sources, including the Elizabeth Glaser Pediatric AIDS Foundation, United States' National Institutes of Child Health and Human Development, Global Fund for AIDS, Tuberculosis and Malaria, the University of the West Indies, the Jamaican Ministry of Health, Clinton Health Access, United National Children's Educational Fund, UNAIDS and others. This paper represents the Doctorate in Pediatric Medicine thesis for Dr Kadine Orrigio. It was an invited oral, platform presentation at the "First Caribbean Congress on Health in Adolescents and Youth", sponsored by PAHO/WHO, at the Hyatt Hotel, Trinidad, October, 2019.

Authors' contributions
Dr Kadine Orrigio contributed to all aspects of the development of this paper, which was the subject of her doctoral thesis, which she wrote and was accepted , in support of her Doctorate in Pediatric Medicine Degree from the University of the West Indies, Mona Campus, Jamaica, W.I. Prof Russell Pierre, Dr Diahann Gordon-Harrison and Dr Kaye Lewis O'Connor -revised several reiterations of the manuscript and made relevant comments into its editorial content. Dr Georgiana Gordon-Strachan -analyzed the data, performed statistical tests, revised several reiterations of the manuscript and made relevant comments into its editorial content. Prof Celia Christie -originated the idea for the thesis and the manuscript, supervised Dr Orrigio's DM thesis and rewrote all versions of the paper resulting in the final published manuscript. She is the Corresponding and Senior Co-author.