Association of Substance Use Disorders with Engagement in Care and Mortality among a Clinical Cohort of People with HIV in Washington, DC

White and Gray Matter Changes are Associated With Neurocognitive Decline in HIV Infection

OBJECTIVE

To investigate the relationship between neurocognitive deficits and structural changes on brain magnetic resonance imaging in people living with HIV (PLWH) with good virological control on combination antiretroviral therapy, compared with socioeconomically matched control participants recruited from the same communities.

METHODS

Brain magnetic resonance imaging scans, and clinical and neuropsychological data were obtained from virologically controlled PLWH (viral load of <50 c/mL and at least 1 year of combination antiretroviral therapy) and socioeconomically matched control participants. Magnetic resonance imaging was carried out on 3 T scanner with 8-channel head coils and segmented using Classification using Derivative-based Features. Multiple regression analysis was performed to examine the association between brain volume and various clinical and neuropsychiatric parameters adjusting for age, race, and sex. To evaluate longitudinal changes in brain volumes, a random coefficient model was used to evaluate the changes over time (age) adjusting for sex and race.

RESULTS

The cross-sectional study included 164 PLWH and 51 controls, and the longitudinal study included 68 PLWH and 20 controls with 2 or more visits (mean 2.2 years, range 0.8-5.1 years). Gray matter (GM) atrophy rate was significantly higher in PLWH compared with control participants, and importantly, the GM and global atrophy was associated with the various neuropsychological domain scores. Higher volume of white matter hyperintensities were associated with increased atherosclerotic cardiovascular disease risk score, and decreased executive functioning and memory domain scores in PLWH.

INTERPRETATION

These findings suggest ongoing neurological damage even in virologically controlled participants, with significant implications for clinical management of PLWH. ANN NEUROL 2024;95:941-950.

A Latent Class Analysis of Substance Use and Longitudinal HIV RNA Patterns Among PWH in DC Cohort

People with HIV (PWH) with substance use disorders (SUD) have worse health outcomes than PWH without SUD. Our objective was to characterize substance use patterns and their impact on longitudinal HIV RNA trajectories among those enrolled in an observational study of PWH in care in Washington, DC. Substance use by type (alcohol, cannabis, opioid, stimulant, hallucinogen, inhalant, sedative) was used to identify shared patterns of substance use using Latent Class Analysis (LCA). A multinomial logistic regression model evaluated the association between the resulting substance use classes and the membership probability in longitudinal HIV RNA trajectory groups. There were 30.1% of participants with at least one substance reported. LCA resulted in a three-class model: (1) Low-Level Substance Use, (2) Opioid Use, and (3) Polysubstance. The Opioid and Polysubstance Use classes were more likely to have a mental health diagnosis (45.4% and 53.5%; p < 0.0001). Members in the Opioid Use class were older (median age of 54.9 years (IQR 50.3-59.2) than both the Polysubstance and Low-Level Substance Use Classes (p < 0.0001). There were 3 HIV RNA trajectory groups: (1) Undetectable, (2) Suppressed, and (3) Unsuppressed HIV RNA over 18 months of follow-up. The probability of being in the unsuppressed HIV RNA group trajectory when a member of the Opioid Use or Polysubstance Use classes was 2.5 times and 1.5 times greater than the Low-Level Substance Use class, respectively. The Opioid Use and Polysubstance Use classes, with higher-risk drug use, should be approached with more targeted HIV-related care to improve outcomes.

Housing, HIV outcomes, and related comorbidities in persons living with HIV in Washington, DC

Housing instability can hinder the ability of people with HIV (PWH) to maintain engagement in care, adhere to antiretroviral (ART) regimens, and achieve viral suppression. This analysis examined the association between housing instability and HIV outcomes, as well as the association between housing status and substance use disorders, mental health disorders, and sexually transmitted infections. Multivariable logistic regressions were performed using data from the DC Cohort, a longitudinal cohort of PWH. Among 8622 PWH, unstably housed PWH were significantly more likely to be prescribed ART (aOR: 1.4; 95%CI: 1.1, 1.8) yet were significantly less likely to be virally suppressed (aOR: 0.6; 95%CI: 0.5, 0.8). Unstably housed PWH were also significantly more likely to have a substance use or mental health disorder, which may inhibit PWH's ability to achieve viral suppression. Efforts to end the HIV epidemic should address housing to ensure treatment is optimized for key populations.

Racial, ethnic, and age disparities in the association of mental health symptoms and polysubstance use among persons in HIV care

We characterized polysubstance use burden and associations with mental health problems across demographic subgroups of PWH. In 2018-2020, as part of a primary care-based intervention study, PWH in care at three medical centers in Kaiser Permanente Northern California were screened for depression (PHQ-9≥10), anxiety (GAD-2≥3), and substance use (Tobacco, Alcohol, Prescription medication, and other Substance use [TAPS]≥1 per substance). We used Poisson regression to estimate prevalence ratios (PRs) comparing polysubstance use prevalence (TAPS≥1 for ≥2 substances) between PWH with positive screens for depression or anxiety vs. neither, among all PWH, and stratified by race/ethnicity and age (restricted to men), adjusting for sociodemographics, CD4, and HIV load. Screened PWH (N = 2865) included 92% men, 56% White, 19% Black, and 15% Hispanic PWH, with a median age of 55 years. Overall, polysubstance use prevalence was 26.4% (95% CI 24.9%-28.1%). PWH with depression or anxiety (n = 515) had an adjusted polysubstance use PR of 1.26 (1.09-1.46) vs. PWH with neither (n = 2350). Adjusted PRs were 1.47 (1.11-1.96), 1.07 (0.74-1.54), and 1.10 (0.85-1.41) among Black, Hispanic, and White men, respectively. Adjusted PRs did not differ by age group. Interventions should consider jointly addressing mental health and substance use problems and potential drivers, e.g. stigma or socioeconomic factors.

Joint effects of substance use disorders and recent substance use on HIV viral non-suppression among people engaged in HIV care in an urban clinic, 2014-2019

AIMS

To estimate the joint effects of substance use disorder (SUD) and recent substance use on human immunodeficiency virus (HIV) non-suppression.

DESIGN

Retrospective clinical cohort study with repeated observations within individuals.

SETTING

Baltimore, Maryland, United States.

PARTICIPANTS

1881 patients contributed 10 794 observations.

MEASUREMENTS

The primary independent variable was the combination of history of SUD and recent substance use. History of SUD was defined as any prior International Classification of Diseases 9/10 code for cocaine or opioid disorder. Recent substance use was defined as the self-report of cocaine or non-prescribed opioid use on the National Institute of Drug Abuse-modified Alcohol, Smoking and Substance Involvement Screening Test or clinician-documented cocaine or opioid use abstracted from the medical record. The outcome was viral non-suppression, defined as HIV RNA >200 copies/mL on the first viral load measurement within 1 year subsequent to each observation of substance use. We adjusted for birth sex, Black race, age, HIV acquisition risk factors, years in care and CD4 cell count. In secondary analyses, we also adjusted for depressive, anxiety and panic symptoms, cannabis use and cannabis use disorder.

FINDINGS

On their first observation, 31% of patients had a history of an SUD and 18% had recent substance use. Relative to no history of SUD and no recent substance use, the 1-year fully adjusted risk difference (RD) for viral non-suppression associated with cocaine and opioid use disorder and recent substance use was 7.7% (95% CI = 5.3%-10.0%), the RD was 5.5% (95% CI = 1.2%-9.7%) for history of cocaine use disorder without recent substance use, and the RD was 4.6% (95% CI = 2.7%-6.5%) for recent substance use without a SUD.

CONCLUSIONS

Substance use and substance use disorders appear to be highly prevalent among, and independently associated with, viral non-suppression among people with HIV.

Sex stratification of the trends and risk of mortality among individuals living with HIV under different transmission categories

We retrospectively examined 33,142 persons living with HIV (PLWH) in Taiwan from a nationwide database to assess sex-stratified trends and risk of all-cause mortality under different transmission categories from 1984 to 2016. Overall, 61.25% were men who have sex with men (MSM), 14.37% were men who have sex with women (MSW), 18.32% were male persons who inject drugs (M-PWID), 3.30% were women who have sex with men (WSM), and 2.74% were female PWID (F-PWID). All-cause mortality (per 100 person-years) among heterosexual people and PWID was higher in men (4.04 and 3.39, respectively) than in women (2.93 and 2.18, respectively). In each sex-stratified transmission category, the all-cause mortality reduced substantially from 1984–1996 to 2012–2016, but evolved distinctly from 2007–2011 to 2012–2016. Since 2007–2011, the decline in all-cause mortality has slowed notably in the groups with sexually transmitted HIV, but has increased in PWID, surpassing even that among groups with sexually transmitted HIV in 2012–2016. PLWH with sexually transmitted HIV had lower risks of all-cause mortality than PWID, regardless of sex. Sex and transmission category did not interact significantly on all-cause mortality. Understanding the reasons for the distinct evolving trends of all-cause mortality in each transmission category serves as a reference for developing strategies to reduce mortality in PLWH in Taiwan further.