Association of Syndemic Unhealthy Alcohol Use, Smoking, and Depressive Symptoms on Incident Cardiovascular Disease among Veterans With and Without HIV-Infection

Convergence between Cardiometabolic and Infectious Diseases in Adults from a Syndemic Perspective: A Scoping Review

Objective. Synthesize the approaches used to study the convergence between cardiometabolic and infectious diseases in adults from a syndemic perspective based on the scientific evidence available to date worldwide. Methods. Scoping review that follows the recommendations of the PRISMA statement. The protocol was registered in INPLASY202150048. The search for studies was carried out in MEDLINE, LILACS, Web of Science and Scopus. Results. Since the COVID-19 pandemic, there has been an increase in studies in the field of convergence between cardiometabolic and infectious diseases from a syndemic perspective, but only three studies were classified as true syndemics. There are weaknesses in the adherence to the elements of the syndemic theory, given a low incorporation of population measurements, and until now it has not been possible to find convincing empirical evidence that supports the bio-bio interface. Quantitative methods predominated through models focused on "sum scores". Conclusions. Future studies should comprehensively address the elements of syndemics, review discrepancies between additive analyses versus other modeling, and incorporate the influence of large-scale social forces. The lack of these aspects distances studies from the notion of syndemic, bringing them closer to comorbidity or multimorbidity approaches.

Cardiovascular Disease Risk Factor Control in People With and Without HIV

BACKGROUND

Management of hypertension, dyslipidemia, diabetes and other modifiable factors may mitigate the cardiovascular disease (CVD) risk in people with human immunodeficiency virus (HIV, PWH) compared with people without HIV (PWoH).

METHODS

This was a retrospective cohort study of 8285 PWH and 170 517 PWoH from an integrated health system. Risk factor control was measured using a novel disease management index (DMI) accounting for amount/duration above treatment goals (0% to 100% [perfect control]), including 2 DMIs for hypertension (diastolic and systolic blood pressure), 3 for dyslipidemia (low-density lipoprotein, total cholesterol, triglycerides), and 1 for diabetes (HbA1c). CVD risk by HIV status was evaluated overall and in subgroups defined by DMIs, smoking, alcohol use, and overweight/obesity in adjusted Cox proportional hazards models.

RESULTS

PWH and PWoH had similar DMIs (80%-100%) except for triglycerides (worse for PWH) and HbA1c (better for PWH). In adjusted models, PWH had an elevated risk of CVD compared with PWoH (hazard ratio [HR], 1.18; 95% confidence interval [CI], 1.07-1.31). This association was attenuated in subgroups with controlled dyslipidemia and diabetes but remained elevated for PWH with controlled hypertension or higher total cholesterol. The strongest HIV status association with CVD was seen in the subgroup with frequent unhealthy alcohol use (HR, 2.13; 95% CI, 1.04-4.34).

CONCLUSIONS

Control of dyslipidemia and diabetes, but not hypertension, attenuated the HIV status association with CVD. The strong association of HIV and CVD with frequent unhealthy alcohol use suggests enhanced screening and treatment of alcohol problems in PWH is warranted.

Implications of vascular depression for successful cognitive aging in HIV Disease

Although older adults with HIV are at high risk for mild neurocognitive disorders, a subset experience successful cognitive aging (SCA). HIV is associated with an increased risk of vascular depression (VasDep), which can affect cognitive and daily functioning. The current study examined whether VasDep impedes SCA among older adults with HIV. 136 persons with HIV aged 50 years and older were classified as either SCA+ (n = 37) or SCA- (n = 99) based on a battery of demographically adjusted neurocognitive tests and self-reported cognitive symptoms. Participants were also stratified on the presence of vascular disease (e.g., hypertension) and current depression as determined by the Composite International Diagnostic Interview and the Depression/Dejection scale of the Profile of Mood States. A Cochran-Armitage test revealed a significant additive effect of vascular disease and depression on SCA in this sample of older adults with HIV (z = 4.13, p <.0001). Individuals with VasDep had the lowest frequency of SCA+ (0%), which differed significantly from the group with only vascular disease (30%, OR = 0.04, CI = 0.002,0.68)) and the group with neither vascular disease nor depression (47% OR = 0.02, CI = 0.33,0.001). Findings were not confounded by demographics, HIV disease severity, or other psychiatric and medical factors (ps > 0.05). These data suggest that presence of VasDep may be a barrier to SCA in older adults with HIV disease. Prospective, longitudinal studies with neuroimaging-based operationalizations of VasDep are needed to further clarify this risk factor's role in the maintenance of cognitive and brain health in persons with HIV disease.

HIV and an Ageing Population-What Are the Medical, Psychosocial, and Palliative Care Challenges in Healthcare Provisions

The continuing increase in patient numbers and improvement in healthcare provisions of HIV services in the UK, alongside the effectiveness of combined antiretroviral therapy (cART), has resulted in increasing numbers of the ageing population among people living with HIV (PLWH). It is expected that geriatricians will need to deal with many older people living with HIV (OPLWH) as life expectancy increases. Therefore, geriatric syndromes in OPLWH will be similar to the normal population, such as falls, cognitive decline, frailty, dementia, hypertension, diabetes and polypharmacy. The increase in the long-term use of cART, diabetes, dyslipidaemia and hypertension may lead to high prevalence of cardiovascular disease (CVD). The treatment of such conditions may lead to polypharmacy and may increase the risk of cART drug-drug interactions. In addition, the risk of developing infection and cancer is high. OPLWH may develop an early onset of low bone mineral density (BMD), osteoporosis and fractures. In this review, we have also provided potential psychosocial aspects of an ageing population with HIV, addressing issues such as depression, stigma, isolation and the need for comprehensive medical and psychosocial care through an interdisciplinary team in a hospital or community setting. OPLWH have a relatively high burden of physical, psychological, and spiritual needs and social difficulties, which require palliative care. The holistic type of palliative care that will improve physical, emotional and psychological wellbeing is discussed in this review.

Syndemic trajectories of heavy drinking, smoking, and depressive symptoms are associated with mortality in women living with HIV in the United States from 1994 to 2017

BACKGROUND

Heavy drinking, smoking, and depression are common among people with HIV. Little is known about the co-occurring, synergistic effect of having two or more of these conditions long-term -a sustained syndemic - on mortality among women with HIV (WWH).

METHODS

Data from 3282 WWH of the Women's Interagency HIV Study from 1994 to 2017 were utilized. National Death Index review identified cause of death (n=616). Sustained syndemic phenotypes were based on membership in high-risk groups defined by group-based trajectory models of repeated self-reported alcohol use, smoking, and depressive symptoms and their co-occurrence. Cox proportional hazard models estimated associations of sustained syndemic phenotypes with all-cause, non-AIDS, and non-overdose mortality, adjusting for age, race/ethnicity, education, enrollment wave, illicit drug use, and time-varying HIV viral load and CD4+ T-cell count.

RESULTS

WWH were 58% Black and 26% Hispanic, with a mean baseline age of 36.7 years. Syndemic phenotypes included zero (45%, n=1463), heavy drinking only (1%, n=35), smoking only (28%, n=928), depressive symptoms only (9%, n=282), and 2+ trajectories (17%, n=574). Compared to zero trajectories, having 2+ trajectories was associated with 3.93 times greater all-cause mortality risk (95% CI 3.07, 5.04) after controlling for confounders and each high-risk trajectory alone. These findings persisted in sensitivity analyses, removing AIDS- and overdose-related mortalities.

CONCLUSIONS

Clustering of 2+ conditions of heavy drinking, smoking, and depression affected nearly one in five WWH and was associated with higher mortality than zero or one condition. Our findings underscore the need for coordinated screening and parsimonious treatment strategies for these co-occurring conditions.

Implications of Vascular Depression for Successful Cognitive Aging in HIV disease

Introduction

Although older adults with HIV are at high risk for mild neurocognitive disorders, a subset experience successful cognitive aging (SCA). HIV is associated with an increased risk of vascular depression (VasDep), which can affect cognitive and daily functioning. The current study examined whether VasDep impedes SCA among older adults with HIV.

Methods

136 persons with HIV aged 50 years and older were classified as either SCA+ (n=37) or SCA- (n=99) based on a battery of demographically adjusted neurocognitive tests and self-reported cognitive symptoms. Participants were also stratified on the presence of vascular disease (e.g., hypertension) and current depression as determined by the Composite International Diagnostic Interview and the Depression/Dejection scale of the Profile of Mood States.

Results

A Cochran-Armitage test revealed a significant additive effect of vascular disease and depression on SCA in this sample of older adults with HIV (z=4.13, p<.0001). Individuals with VasDep had the lowest frequency of SCA+ (0%), which differed significantly from the group with only vascular disease (30%, OR=0.04, CI=0.002,0.68)) and the group with neither vascular disease nor depression (47% OR =0.02, CI=0.33,0.001). Findings were not confounded by demographics, HIV disease severity, or other psychiatric and medical factors (ps>.05).

Discussion

These data suggest that presence of VasDep may be a barrier to SCA in older adults with HIV disease. Prospective, longitudinal studies with neuroimaging-based operationalizations of VasDep are needed to further clarify this risk factor's role in the maintenance of cognitive and brain health in persons with HIV disease.

Elevated frequency and everyday functioning implications of vascular depression in persons with HIV disease

Depression and cardiovascular disease are common and associated with one another in HIV disease. This study aimed to determine the frequency and everyday functioning implications of the clinical syndrome of vascular depression among people living with HIV (PLWH). Participants in this cross-sectional study included 536 PLWH and 272 seronegative individuals who completed a biomedical and psychiatric research evaluation. Vascular depression was operationalized as the current presence of: 1) two or more vascular conditions; and 2) depression as determined by a normative elevation on the Depression/Dejection subscale of the Profile of Mood States or a diagnosis of Major Depressive Disorder per the Composite International Diagnostic Interview. Everyday functioning was measured by both self- and clinician-rated activities of daily living. A logistic regression model showed that HIV was associated with a three-fold increased risk of vascular depression, independent of potential confounding factors. A second logistic regression model within the PLWH sample showed that PLWH with vascular depression had significantly greater odds of dependence in everyday functioning as compared to PLWH with either vascular disease or depression alone. The elevated frequency of vascular depression in PLWH is consistent with the vascular depression hypothesis from the late-life depression literature. The high rate of functional dependence among PLWH with vascular depression highlights the clinical importance of prospective work on this syndrome in the context of HIV disease.

The Use of Biomarkers to Guide Precision Treatment for Tobacco Use

This review summarizes the evidence to date on the development of biomarkers for personalizing the pharmacological treatment of combustible tobacco use. First, the latest evidence on FDA-approved medications is considered, demonstrating that, while these medications offer real benefits, they do not contribute to smoking cessation in approximately two-thirds of cases. Second, the case for using biomarkers to guide tobacco treatment is made based on the potential to increase medication effectiveness and uptake and reduce side effects. Next, the FDA framework of biomarker development is presented along with the state of science on biomarkers for tobacco treatment, including a review of the nicotine metabolite ratio, electroencephalographic event-related potentials, and other biomarkers utilized for risk feedback. We conclude with a discussion of the challenges and opportunities for the translation of biomarkers to guide tobacco treatment and propose priorities for future research.

Context, COVID-19 and comorbidities: exploring emergent directions in syndemics and HIV research

PURPOSE OF REVIEW

The purpose of this review is to identify themes across articles that aimed to explore HIV-related syndemics in 2020 and 2021 and to discuss their implications for research on syndemics.

RECENT FINDINGS

We identified 189 articles on syndemics between 2020 and 2021. Key themes across studies included COVID-19; mental health and psychosocial challenges; substance use; socio-structural factors; protective factors; and methodological approaches. COVID-19's implications for HIV syndemic research were discussed. Mental health and substance use research largely examined linkages with sexual practices or reduced HIV care retention. Researchers examined associations between socio-structural variables (e.g. poverty) and elevated HIV exposure, reduced HIV testing and poorer health. Concepts of water insecurity and 'ecosyndemics' were also raised, as was the importance of attending to noncommunicable diseases and comorbidities. Most studies did not assess interactions between health conditions, signalling the need for methodological grounding in the foundational concepts of syndemic theory.

SUMMARY

Most studies recommended that HIV prevention and care research attend to the interplay between poor mental health, substance use and multidimensional violence. Increased attention to structural factors, particularly exacerbated poverty in the COVID-19 pandemic, is required. Research can identify protective factors to harness to advance HIV prevention and care.