The Impact of Perinatal HIV Infection on Older
School-Aged Children’s and Adolescents’ Receptive
Language and Word Recognition Skills
Elizabeth Brackis-Cott, Ph.D.,1Ezer Kang, Ph.D.,2,3Curtis Dolezal, Ph.D.,1
Elaine J. Abrams, M.D.,2,3and Claude Ann Mellins, Ph.D.1
Perinatally HIV-infected youths are reaching adolescence in large numbers. Little is known about their cognitive
functioning. This study aims to describe and compare the receptive language ability, word recognition skills, and
school functioning of older school-aged children and adolescents perinatally HIV infected (HIV-positive) and
perinatally HIV-exposed butuninfected(seroreverters;HIV-negative). Participants included340youths(206HIV-
positive, 134 HIV-negative), 9–16 years old, and their caregivers. Youths completed the Peabody Picture Vo-
cabulary Test, Third Edition (PPVT-III) and the Reading Subtest of the Wide Range Achievement Test, Third
Edition (WRAT-3). Caregivers were interviewed regarding demographic characteristics and school placement of
youths. Medical information was abstracted from medical charts. Both groups of youths scored poorly on the
PPVT-III and WRAT-3 with about one third of youths scoring in less than the 10th percentile. The HIV-positive
youths scored lower than the seroreverters (M¼83.8 versus 87.6, t¼2.21, p¼0.028) on the PPVT-III and on the
WRAT-3 (M¼88.2 versus 93.8, t¼2.69, p¼0.008). Among the HIV-positive youths, neither CD4þcell count,
HIV RNA viral load or Centers for Disease Control and Prevention (CDC) classification were significantly
associated with either PPVT-III or WRAT-3 scores. However, youths who were taking antiretroviral medication
had lower WRAT-3 scores than youths not taking medication (M¼95.03 versus 86.89, t¼2.38, p¼0.018). HIV
status remained significantly associated with PPVT-III and WRAT-3 standard scores after adjusting for demo-
graphic variables. Many youths had been retained in school and attended special education classes. Findings
highlight poor language ability among youths infected with and affected by HIV, and the importance of edu-
cational interventions that address this emerging need.
reaching adolescence in large numbers. For example, in New
York City, more than 67% of living persons diagnosed with
HIV infection before 13 years of age are currently 13 years of
age or older.1These youths are primarily ethnic minorities
living in impoverished, urban communities who contend
with multiple stressors that place them at risk for poor cog-
nitive functioning (e.g., exposure to substances in utero, at-
tendance atschoolsin‘‘poorperformance districts,’’comorbid
behavioral problems, inconsistent school attendance because
of poor health or health care appointments). From the be-
ith the advent of antiretroviral treatment
(ART), children living with perinatal HIV infection are
ginning of the epidemic, there have been consistent findings
of significant neurologic, developmental, cognitive, and lan-
guage deficits in HIV-infected (HIV-positive) infants and
age perinatally HIV-infected children present with significant
learning problems affecting their academic performance, de-
velopmental milestones, and ability to function indepen-
dently.7However, little is known about the cognitive
functioning, reading ability, or school performance of peri-
natally HIV-infected adolescents. One study by Kullgren and
colleagues8that included adolescents found cognitive, adap-
tive, as well as behavioral delays in HIV-positive youths
compared to normative samples. Unfortunately, their sample
of 67 youths ranged in age from 3–16 years with a mean of 6.7
1HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University, New York, New York.
2Department of Pediatrics, Harlem Hospital Center, New York, New York.
3College of Physicians & Surgeons, Columbia University, New York, New York.
AIDS PATIENT CARE and STDs
Volume 23, Number 6, 2009
ª Mary Ann Liebert, Inc.
years. Similarly, Jeremy and colleagues8afound poor neu-
ropsychological functioning in HIV-positive children and
adolescents (4 months to 17 years) compared to established
norms and that neuropsychological functioning was worse
for children with higher viral loads. However, a limitation of
the study was the author’s inability to look at specific age
groups and the lack of an appropriate control group. Bisiacchi
and colleagues8bcompared a sample of 29 perinatally HIV-
infected children and adolescents and 13 seroverters (6–15
years), and found significant differences in executive func-
tions in HIV-positive children compared to seroreverters.
Also despite the documentation of longer lifespan among
perinatally HIV-infected youth, little has been published on
the school experiences of older HIV-positive children and
adolescents. Mialky and colleagues8cfound that among 85
school-age children (5–18 years, mean¼9.9 years), 85% were
attending public schools, 3% were in private schools, and 2%
were home schooled. Five children were attending special
education classes at the time of the study, 23.5% had repeated
at least one grade, and 52% were receiving some special ser-
vices in their school such as resource room (n¼10), physical
therapy (n¼5), tutoring (n¼4), speech therapy (n¼3), and
accelerated courses (n¼2).
As children transition to early and middle adolescence, it
becomes increasingly clear that language and reading skills
are the critical building blocks for literacy and future aca-
demic success9–12with an important transition from ‘‘learning
to read and reading to learn.’’13Poor educational achieve-
ment, including delayed reading and language skills in youth
perinatally infected with HIV may have implications for their
ability to understand their illness and its treatment, to adhere
sexual and=or drug risk behaviors.14–16For example, studies
of HIV-positive adults have found that those who were cog-
nitively compromised or had low levels of health literacy had
greater difficulty with adherence, particularly when the reg-
imen was complex.15–16aAs perintally HIV-infected youths
age and assume more responsibility for their own health care,
they too will require a degree of health literacy that, if not
present, may seriously impede their capacity to effectively
manage their disease.
In summary, although there are a number of studies
demonstrating neurocognitive and language deficits in HIV-
positive infants and young children, particularly in the do-
main of expressive language.17–19The data on preadolescents
and older adolescents are limited. The few studies that exist
cover too large an age range, do not focus on adolescents, or
do not have appropriate control groups. Moreover, the lan-
guage and reading skills of HIV-positive adolescents have not
specifically been described. It is unclear whether early dis-
crepancies between HIV-positive and HIV-negative children
persists over time or whether they might be diminished with
age and improved health. Such information will be helpful to
plan psychoeducational interventions for the growing pop-
ulation of older, perinatally HIV-infected youths. Using
baseline data from Project CASAH (Child and Adolescent
Self-Awareness and Health Study), one of the largest U.S.-
based studies of psychosocial determinants of behavior in a
sample composed of both perinatally HIV- infected youths
and perinatally HIV-exposed, but uninfected youths (seror-
everters; HIV-negative) with similar age and demographic
backgrounds, the goal of this study is to conduct secondary
data analysis using two brief screening tools to describe and
compare the receptive vocabulary skills, word decoding
ability, and school achievement in both groups.
Participants and procedures
Participants include 206 perintally HIV-infected older
school-aged children and adolescents and 134 seroreverters,
legal capacity to consent for the child’s participation. Both
adolescents who had and had not been formally told of their
HIV status were included. During the study recruitment pe-
riod (2003–2007), of 443 eligible participants, 11% refused
contact with the research team and 6% could not be contacted
by the study coordinators. Of 367 (83% of 443) approached to
participate in the study 340 caregiver=youth dyads (93% of
367) enrolled. New York State confidentiality laws preclude
data collection on families who refused participation. Parti-
cipants were recruited from four urban medical centers in
New York City. Two sources of data were collected: (1)
caregiver and youth interviews and (2) medical chart ab-
stractions for HIV-positive youth. Caregivers and children
were interviewed simultaneously but separately during two
60- to 90-minute sessions (approximately 1 month apart).
Among the 340 caregiver=youth dyads enrolled, 96% com-
pleted both interview sessions. Since the data for this analysis
were derived from the second interview session the study
cohort included 325 caregiver=youth dyads.
This study received local Institutional Review Board ap-
proval and was compliant with the Health Insurance Port-
ability and Accountability Act (HIPAA) of 1996. All
caregivers provided written informed consent for themselves
and youths and youths provided written assent. Monetary
reimbursement for time and transportation was provided.
Child receptive language ability and word recognition
The Peabody Picture Vocabulary Test (PPVT-III), is a
widely used, well-validated test of receptive language abili-
ties.20The examiner reads each word aloud; the child chooses
which of four pictures best illustrates the word. Standard
between the total score of the PPVT-III and the Full Scale IQ
(r¼0.90) and Verbal IQ scores (r¼0.91) from the Wechsler
Intelligence Scale for Children.20The PPVT-III was also vali-
dated using the Kaufman Adolescent and Adult Intelligence
Test.20The Wide Range Achievement Test (WRAT-3)21mea-
sures the development of reading, spelling, and arithmetic
skills for individuals ages 5–75 years. For this study, we used
the reading subtest of the WRAT-3, which focuses on specific
coding skills: Reading—recognizing and naming letters and
pronouncing printed words. The child is asked to read up to
42 words aloud. Standard scores range from 45–155. The in-
formation presented in the technical manual provides ade-
quate psychometric properties of the WRAT-3.21
caregiver age, gender, ethnic identity, education, work status
of caregiver, as well as family income.
Caregivers were asked about child and
416BRACKIS-COTT ET AL.
about school placement of youth (regular education class
versus special education class), and whether the youth had
ever skipped a grade, been held back, suspended or expelled.
Caregivers were asked
Child health status.
HIV RNA viral load (copies per milliliter), and clinical disease
category according to CDC classification system for the clos-
est date to the research interview were obtained through
medical record abstraction for the HIV-positive youths. Based
on variation in assay methodology all viral load 100,000 or
more copies per milliliter were coded as 100,000 copies per
milliliter and all values 400 or less copies per milliliter were
coded as undetectable. In addition, caregivers ofHIV-positive
youths were asked whether their child was taking anti-
HIV-positive youths and seroreverters were compared on
demographic variables, PPVT-III, WRAT-3, and school-related
characteristics. w2tests were used for dichotomous and cat-
egorical variables, and t tests were used for continuous
variables. Variables such as age and education have been
categorized for presentation in the tables, but were retained
in their original continuous form for t test analyses. In ad-
dition, multivariate regression analyses were conducted to
test the association between HIV status and PPVT-III=-
WRAT-3 standard scores while adjusting for demographic
The vast majority of demographic variables were similar
between HIV-positive youths and seroreverters including
child race=ethnicity, age, gender, and grade in school (Table
1). Significantly fewer HIV-positive youths were living with a
birth parent (36% versus 70%; w2¼36.9, p<0.001), and thus,
by definition, an HIV-positive caregiver (31% versus 69%;
w2¼42.9, p<0.001). Also, HIV-positive youths had older
caregivers than seroreverters (t¼?2.54, p¼0.01).
Among the HIV-positive youths, the mean CD4þcell count
was 602 (median¼572, standard deviation [SD]¼317) and
only 10% had CD4þless than 200cells=mm3. The median HIV
RNA viral load was 3150 copies per milliliter (mean¼14,722;
SD¼25,516); 34% had undetectable viral loads (?400 copies
per milliliter) and only 5% had viral load values 100,000 or
more copies per milliliter. The majority of HIV-positive
youths were taking antiretroviral medications (84%).
Receptive language ability
Among the total sample, the mean PPVT-III standard score
was85.3(Table 2). PPVT-IIIpercentile scores ranged from less
than 1st to 96th percentile; 60% of all youths scored below
average (<25th percentile) and 37% scored less than 10th
percentile. Among the HIV-positive youths, the mean stan-
dard score was 83.9 and PPVT-III percentile scores ranged
from less than 1st to 96th percentile. Sixty-two percent scored
below average (<25th percentile) and 39% scored less than
10th percentile. Among the seroreverters, the mean PPVT-III
from less than 1st to 86th percentile. Fifty-six percent of the
seroreverters scored below average (<25th percentile) and a
third (34%) scored less than 10th percentile. The HIV-positive
youths scored significantly lower (M¼83.8) than the seror-
everters (M¼87.6) on the PPVT-III (t¼2.21, p¼0.028).
Among the full sample, the mean WRAT-3 score was 90.5
and WRAT-3 percentile scores ranged from less than 1st
to100th percentile. Half of youths (49%) scored below average
(<25th percentile) and 28% scored less than 10th percentile.
Among HIV-positive youths, the mean WRAT-3 score was
88.3 and WRAT-3 percentile scores ranged from less than 1st
to 97th percentile. Half of the HIV-positive youths (54%)
scored below average (<25th percentile) and a third (33%)
scored less than 10th percentile. Among the seroreverters, the
mean WRAT-3 score was 93.8 and WRAT-3 percentile scores
ranged from less than 1st to 100th percentile. Forty percent
Table 1. Characteristics of Youths and Their Primary
Caregivers by Child HIV Status
n (% of 325)
n (% of 196)
n (% of 129)
Relationship to childa
149 (46)61 (31) 88 (68)
HIV-positive vs. HIV-negativeap<0.001;bp<0.05.
Due to missing data, some values do not sum to the total Ns listed.
Due to rounding, percentages may not sum to 100.
LANGUAGE ABILITY OF HIV-POSITIVE YOUTH AND SEROREVERTERS417
scored below average (<25th percentile) and 21% scored less
than 10th percentile. The HIV-positive youths scored signifi-
cantly lower (M¼88.2) than the seroreverters (M¼93.8) on
the WRAT-3 (t¼2.69, p¼0.008). For both the PPVT-III and
the WRAT-3, the full range of scores was represented and
normally distributed with no extreme outliers.
Associations between demographics,
health status, and ability
Correlations, t tests, and analyses of variance (ANOVAs)
assessed the associations between PPVT-III and WRAT-3
standard scores and all demographic variables in Table 1.
Males and youths in higher grades had higher PPVT-III
scores; younger youths had higher scores on the WRAT-3. All
other analyses were not statistically significant. Among HIV-
positive youths, none of the health status variables obtained
from medical charts (CD4þcount, viral load, CDC classifica-
tion) were significantly associated with either PPVT-III or
WRAT-3 scores; all correlation coefficients were close to zero.
However, youths who were taking antiretroviral medication
had lower WRAT-3 scores than youths not taking medication
(M¼95.03 versus 86.89, t¼2.38, p¼0.018). In regression an-
alyses, HIV status remained significantly associated with
PPVT-III and WRAT-3 standard scores after adjusting for
child’s gender, household income, caregiver education, child
race=ethnicity, and whether the caregiver was the child’s bi-
ologic parent (Table 3).
Over a third of the youths (35%) in both groups (37% of
HIV-positive, 32% of HIV-negative) had been retained in
school, 33% were currently attending special education clas-
ses (37% of HIV-positive versus 28% of HIV-negative) and
47% had a history of special education placement (52% HIV-
positive, 39% HIV-negative, w2¼4.77, p<0.05; Table 4).
Across groups, special education placement was most fre-
quently attributed to problems with reading or math.
Our sample of perinatally HIV-infected and exposed
youths scored poorly on measures of language functioning:
37% scored less 10th percentile on the PPVT-III and 28%
scored less than 10th percentile on the WRAT-3. Poor scores
are suggestive of poor verbal ability including limited vo-
cabulary and lack of basic skills needed for reading. In addi-
tion, large numbers of youths were academically retained
(35%) and placed in special education classes (47%). Overall,
Table 2. PPVT and WRAT Scores by Child HIV Status
Mean standard score (SD)b
Mean percentile score (SD)
Mean standard score (SD)c
Mean percentile score (SD)c
aNote. 2 youths refused to complete the WRAT-3.
HIV-positive vs. Seroreverters;bp<0.05;cp<0.01.
PPVT, Peabody Picture Vocabulary Test; WRAT-3, Wide Range Achievement Test, Third Edition; SD, standard deviation.
Table 3. Multivariate Regression Models Predicting Cognitive Functioning among HIV-Positive
and HIV-Negative Adolescents
PPVT - III WRAT - 3
b (SE)p b (SE)p
Gender (1¼male, 2¼female)
Caregiver years of education
Caregiver is biologic parent (0¼no, 1¼yes)
Child HIV status (0¼HIV-negative, 1¼HIV-positive)
aReference category¼African American.
PPVT, Peabody Picture Vocabulary Test; WRAT-3, Wide Range Achievement Test, Third Edition; SE, standard error.
418 BRACKIS-COTT ET AL.
the performance of this cohort of perinatally HIV-exposed
youths was well below age expectations. HIV-positive
youths’ performance was statistically worse as compared to
the seroreverters on both measures of reading and language
ability and the HIV-positive youths were more likely to have
attended special education classes. Our data suggest that in-
fected youths continue to have learning problems at higher
than expected rates as they age and enter adolescence.
Because HIV remains a stigmatized disease and teachers
are rarely disclosed to about a child’s status, it will be im-
portant for medical doctors working with this population to
be aware of how HIV influences youths’ ability to function in
school. The stress of living with a chronic stigmatized illness
coupled withasense ofeducational failureplaces youths with
HIV at further risk for behavioral and health problems. For
example, poor language skills may limit youths’ ability to
understand their illness and compromise their ability to ad-
here to challenging medication regimens.15,16Conversely, bet-
ter cognitive functioning, particularly in the verbal domain,
may operate as a protective factor against early sexual activity
during adolescence, whereas lower intelligence may be a risk
factor.14Furthermore, our school-based findings that large num-
ber of these youths are being retained in school and attending
special education classes further demonstrates how these peri-
natally HIV infected and affected youths are struggling.
It is noteworthy to report that, among the HIV-positive
youths, delays were not associated with most recent CD4þ
count or viral load. Previous studies that found viral load to be
unrelated to cognitive test scores, speculated that the lack of
association with viral load might be due to the fact that viral
biomedical markers only reflect current health status and do
not necessarily represent past medical history which may have
included long periods of illness, immune suppression and ac-
tive viremia. Furthermore, cognitive functioning may be indi-
rectly related to disease severity, for example with increased
number of absences from school among sicker children. Our
finding that youths who were currently taking antiretroviral
therapy had lower scores on the WRAT-3 could be explained
by sicker children being more likely to be prescribed medica-
tion or conversely could be related to side effects of the medi-
cations.25This finding needs more thorough analysis and
assessment to fully understand the association, however, such
analysis is beyond the scope of this investigation.
Although HIV-positive youths had significantly lower
scores on both measures of language and reading ability, it is
important to note that 34% of seroreverters scored less than
10th percentile on the PPVT-III and 21% scored less than 10th
percentile on the WRAT-3. By definition, these youths are
living with an HIV-positive parent or have already lost a
parent to death. In addition to dealing with the stressors of
inner city living, these youths are often caretakers for their
parents andisolated due totheir ‘‘family secret,’’often leading
to behavior problems or symptoms of anxiety or depres-
sion.26–30Similar to the HIV-positive youths, seroreverters are
living in impoverished, urban communities in poor perfor-
mance school districts. Unfortunately, HIV-exposed but un-
infected youths are often difficult to identify, as they are
typically not followed in specialized HIV care clinics. HIV-
positive youths are more likely to have regular contact with
medical, mental health, and social service providers to help
families navigate systems to get the services they need, but
HIV-negative youths are less likely to benefit from such ser-
vices. There is no sign that the numbers of uninfected, but
HIV-affected children are diminishing, as HIV disease con-
tinues to spread in women of child-bearing age. Our data
suggest that seroreverters may be at risk for poor outcomes
given the association between cognitive functioning and risk
behaviors31,32that can in turn lead to sexually transmitted
diseases (STDs), pregnancy, and behaviorally acquired HIV
disease. Medical providers treating seroreverters may be in a
unique position to identify youths who are struggling and
There are a number of limitations to this study that should
be considered when interpreting our results. Participants
were recruited from HIV primary care clinics in New York
City and findings may not generalize to perinatally HIV-
exposed youths in other settings. Also, although we attempted
to recruit both groups from similar communities based on the
demographics of pediatric HIV disease, other factors (e.g.,
differential rates of study refusal or access to services) may
have altered the group effects. Due to issues of confidentiality
and HIPAA, no data were collected on participants who re-
fused to participate or who were not approached. Nor were
level of acculturation in general, all of which could account for
some of the findings. In addition, Project CASAH is study of
psychosocial determinants of youth risk and resilience, with a
Table 4. School-Related Characteristics for HIV Infected and Uninfected Youth
n (% of 325)
n (% of 196)
n (% of 129) School-related characteristics
Currently in school (yes)
Ever held back in school (yes)
Currently in special education class
Ever attended special education class (yes)a
Reason for special education placement ever
n (% of 153)
n (% of 101)
n (% of 52)
HIV-positive vs. HIV-negative;ap<0.05.
LANGUAGE ABILITY OF HIV-POSITIVE YOUTH AND SEROREVERTERS419
particular interest in mental health and thus included limited
measurement of cognitive or academic functioning that could
be administered in a short time. The WRAT-3 has limited va-
as there is a difference between one’s ability to successfully
decode words and comprehend text. It also remains to be seen
how well suited the PPVT-III, while highly correlated with
overall IQ in typically developing children, is as a proxy for
overall IQ or general verbal ability in those with learning dif-
ficulties or general developmental delays. More thorough
evaluation of cognitive functioning would be helpful in
strengthening our findings. Notwithstandingtheselimitations,
youths infected with and affected by HIV, and highlights the
importance of educational interventions that address this
emerging need. As this population ages, further research
should continue to examine the relationship between markers
of disease severity, related psychosocial factors, and cognitive
functioning and attempt to clarify specific cognitive domains
including motor functioning, executive skills, and information
programs can be developed and incorporated into ongoing
care for this population.
This research was supported by a grant from the National
Institute of Mental Health (R01-MH63636; Principal In-
vestigator: Claude Ann Mellins, Ph.D.), and by a center grant
from the National Institute of Mental Health to the HIV
Center for Clinical and Behavioral Studies at NY State Psy-
chiatric Institute and Columbia University (P30-MH43520;
Principal Investigator: Anke A. Ehrhardt, Ph.D.)
Author Disclosure Statement
No competing financial interests exist.
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