Medical nonadherence in pediatric HIV: Psychosocial risks and intersection with the child protection system for medical neglect

Nonadherence to antiretroviral treatment has serious health implications for HIV-infected children, at times warranting referral to child protective services (CPS). The current study of 134 children with perinatally acquired HIV infection aimed to investigate rates of treatment adherence and CPS involvement, multilevel variables associated with nonadherence, and the manner in which these risks operated together in the prediction of adherence outcomes. Risk factors for nonadherence were grouped on the basis of confirmatory factor models, and factor score regression was carried out to determine which factors were uniquely predictive of adherence. A series of indirect effects models were then tested in order to examine how these factors operated together in the prediction of adherence. Results showed that almost half of the sample demonstrated suboptimal adherence to treatment, and in one-fifth, CPS was involved for medical neglect. Caregiver Health, Caregiver Involvement, Caregiver Acceptance, and Child Adaptation were predictive of nonadherence, and together explained 54% of the variance in treatment adherence. There were significant indirect effects of Caregiver Health on adherence that operated through Caregiver Involvement and Child Adaptation and an indirect effect of Caregiver Involvement on adherence through Child Adaptation. Findings extend current literature that has independently linked various factors predictive of medical adherence in pediatric HIV by showing separate but simultaneous associations with nonadherence and unique pathways to adherence involving multilevel risks. Healthcare and child welfare implications are discussed.