HIV infection and the central nervous system: a primer

Short-term exposure to HIV Tat induces glial activation and changes in perineuronal nets

Despite widespread use of combination antiretroviral therapy (cART), there remains a subset of individuals who display cognitive impairment broadly known as HIV-associated neurocognitive disorder (HAND). Interestingly, HIV-infected cells continuously release the HIV-1 protein Tat even in the presence of cART. Persistent exposure to Tat is proposed to increase both neuroinflammation and neurotoxicity. In vitro evidence shows that matrix metalloproteinases (MMPs) are among the neuroinflammatory molecules induced by Tat, which are known to disrupt specialized neuronal extracellular matrix structures called perineuronal nets (PNNs). PNNs predominantly surround parvalbumin interneurons and help to buffer these cells from oxidant stress and to independently increase their excitability. In order to better understand the link between short-term exposure to Tat, neuroinflammation, and PNNs, we explored the direct effects of Tat on glial cells and neurons. Herein, we report that in mixed glial cultures, Tat directly increases the expression of proinflammatory molecules, including MMP-9. Moreover, direct injection of Tat protein into mouse hippocampus increases the expression of astrocyte and microglia markers as well as MMP-9. The number of PNNs is decreased following Tat exposure, followed later by decreased numbers of hippocampal parvalbumin-expressing neurons. In older mice, Tat induced significant increases in the gene expression of proinflammatory molecules including markers of gliosis, MMPs and complement system proteins. Taken together, these data support a direct effect of Tat on glial-derived MMP expression subsequently affecting PNNs and neuronal health, with older mice more susceptible to Tat-induced inflammation.

An evaluation of the moderating effects of routine and busyness on the relationship between prospective memory and everyday functioning in older persons with HIV disease

INTRODUCTION

People living with HIV (PLWH) often experience difficulties in everyday functioning, which can arise in part from deficits in the strategic/executive aspects of prospective memory (PM). Using Suchy's Contextually Valid Executive Assessment (ConVExA) framework, this study sought to determine whether the contextual factors of busyness and routine moderate the relationship between the strategic/executive aspects of PM and everyday functioning in older PLWH.

METHODS

Participants in this cross-sectional analysis were 145 PLWH aged 50 years and older who had completed the Martin and Park Environmental Demands (MPED) questionnaire of routine and busyness, the performance-based Cambridge Test of Prospective Memory, and self-report measures of activities of daily living (ADLs) and cognitive symptoms in daily life.

RESULTS

Multiple regression analyses covarying for relevant comorbidities showed that higher levels of busyness - but not routine - were associated with more frequent cognitive symptoms in daily life. Neither busyness nor routine interacted with PM in association with cognitive symptoms. However, routine and a strategic/executive measure of PM interacted in predicting ADLs; specifically, the association between time-based PM and ADLs was stronger in persons with higher levels of routine in their daily lives. Parallel analyses with less executively-demanding event-based PM were null and small.

CONCLUSIONS

Overall, findings provided mixed - and unexpected - evidence for the associations between contextual factors (i.e. routine and busyness), everyday functioning, and PM in this sample of older adults with HIV disease. Results and clinical implications are interpreted and discussed in the framework of the ConVExA model.

Apathy in persons living with HIV disease: A systematic narrative review

BACKGROUND

Apathy was identified as a feature of HIV early in the epidemic; however, there are no systematic reviews of the diverse literature on the sociodemographic and clinical correlates of apathy in HIV disease.

METHODS

The current study adopted a hybrid systematic-narrative review methodology in which we used PRISMA guidelines to identify, summarize, and critique peer-reviewed, empirical studies of apathy in HIV disease in the era of combination antiretroviral therapy.

RESULTS

A total of 34 studies of apathy in persons living with HIV (PLWH) were identified. Findings across these studies showed that apathy was reliably related to the structure of grey and white matter pathways commonly implicated in apathy, poorer everyday functioning, education, and other neuropsychiatric symptoms (e.g., depression). Apathy was not reliably associated with age, sex, race/ethnicity, cognition, and clinical markers of HIV disease.

LIMITATIONS

The current review does not provide rigorous quantitative estimates of clinical correlates of apathy, and the exclusion criteria of non-English and non-peer reviewed publications introduces risk of bias and Type I error.

CONCLUSIONS

Apathy occurs at higher rates in PLWH and is linked to neuroanatomical differences, as well as negative outcomes for everyday functions, aspects of neurocognition, and neuropsychiatric symptoms. As such, apathy is an important component to consider in the clinical assessment, diagnosis, and management of neurocognitive disorders in PLWH. Future work is needed to replicate existing findings with larger sample sizes and longitudinal designs, examine apathy as a multi-dimensional construct, and develop evidence-based treatments for apathy in PLWH.

The relationship between synaptodendritic neuropathology and HIV-associated neurocognitive disorders is moderated by cognitive reserve

We examined whether cognitive reserve moderated the relationship between neurodegeneration and cognition in 67 postmortem persons with HIV (PWH) who were cognitively assessed within 1 year of death. Cognitive reserve was measured via the Wide Range Achievement Test-4 reading subtest (WRAT4). Synaptodendritic neurodegeneration was based on densities of synaptophysin and microtubule-associated protein 2 immunohistochemical reactivity in frontal cortex, and categorized as minimal, moderate, or severe (tertile-split). T-Scores from 15 cognitive tests were averaged into a global cognitive T-score. Among those with low cognitive reserve (based on WRAT4 median split), the moderate neurodegeneration group showed cognition that was poorer than the minimal neurodegeneration group and comparable to the severe neurodegeneration group. Among those with high cognitive reserve, the moderate neurodegeneration group showed cognition comparable to the minimal neurodegeneration group and better than the severe neurodegeneration group. High cognitive reserve may buffer against cognitive impairment among PWH with moderate, but not severe, neurodegeneration.

Lower prospective memory is associated with higher neurocognitive dispersion in two samples of people with HIV: A conceptual replication study

OBJECTIVES

People living with HIV (PLWH) often experience deficits in the strategic/executive aspects of prospective memory (PM) that can interfere with instrumental activities of daily living. This study used a conceptual replication design to determine whether cognitive intraindividual variability, as measured by dispersion (IIV-dispersion), contributes to PM performance and symptoms among PLWH.

METHODS

Study 1 included 367 PLWH who completed a comprehensive clinical neuropsychological test battery, the Memory for Intentions Test (MIsT), and the Prospective and Retrospective Memory Questionnaire (PRMQ). Study 2 included 79 older PLWH who completed the Cogstate cognitive battery, the Cambridge Prospective Memory Test (CAMPROMPT), an experimental measure of time-based PM, and the PRMQ. In both studies, a mean-adjusted coefficient of variation was derived to measure IIV-dispersion using normative T-scores from the cognitive battery.

RESULTS

Higher IIV-dispersion was significantly associated with lower time-based PM performance at small-to-medium effect sizes in both studies (mean r s  = -0.30). The relationship between IIV-dispersion and event-based PM performance was comparably small in magnitude in both studies (r s  = -0.19, -0.20), but it was only statistically significant in Study 1. IIV-dispersion showed very small, nonsignificant relationships with self-reported PM symptoms in both samples (r s < 0.10).

CONCLUSIONS

Extending prior work in healthy adults, these findings suggest that variability in performance across a cognitive battery contributes to laboratory-based PM accuracy, but not perceived PM symptoms, among PLWH. Future studies might examine whether daily fluctuations in cognition or other aspects of IIV (e.g., inconsistency) play a role in PM failures in everyday life.

DExD/H-box helicases in HIV-1 replication and their inhibition

Antiretroviral therapy (ART) reduces human immunodeficiency virus type 1 (HIV-1) infection, but selection of treatment-refractory variants remains a major challenge. HIV-1 encodes 16 canonical proteins, a small number of which are the singular targets of nearly all antiretrovirals developed to date. Cellular factors are increasingly being explored, which may present more therapeutic targets, more effectively target certain aspects of the viral replication cycle, and/or limit viral escape. Unlike most other positive-sense RNA viruses that encode at least one helicase, retroviruses are limited to the host repertoire. Accordingly, HIV-1 subverts DEAD-box helicase 3X (DDX3X) and numerous other cellular helicases of the Asp-Glu-x-Asp/His (DExD/H)-box family to service multiple aspects of its replication cycle. Here we review DDX3X and other DExD/H-box helicases in HIV-1 replication and their inhibition.

Preliminary Validity of a Telephone-Based Neuropsychological Battery in a Consecutive Series of Persons with HIV Disease Referred for Clinical Evaluation

OBJECTIVE

The COVID-19 pandemic necessitated use of remote assessments by clinical neuropsychologists. Telehealth was particularly important for vulnerable groups, including persons living with HIV (PLWH); however, limited internet access can be a serious barrier to care. This study examined the preliminary validity of a telephone-based neuropsychological assessment in a clinical sample of PLWH.

METHOD

A consecutive series of 59 PLWH were assessed via telephone at an HIV clinic in the southern U.S. between April 2020 and July 2022. The battery included auditory-verbal neuropsychological tests of memory, attention, and executive functions, and questionnaires assessing self-reported mood and activities of daily living (ADL).

RESULTS

Study measures demonstrated acceptable internal consistency. PLWH demonstrated worse neuropsychological performance compared with expectations derived from the normal curve and an HIV-seronegative adult sample (N = 44). PLWH assessed via telephone demonstrated similar impairment rates to that of a consecutive series of PLWH (N = 41) assessed in-person immediately prior to the pandemic. Higher telephone-based global neuropsychological scores were related to younger age, more education, better fund of knowledge, White race/ethnicity, fewer medical conditions, and fewer depression symptoms. Global neuropsychological impairment was strongly and independently associated with greater dependence in ADL domains, particularly for instrumental activities.

CONCLUSIONS

Although telephone-based approaches to neuropsychological assessment are not ideal, these data provide support for the feasibility, internal consistency, and preliminary validity of this method in a consecutive clinical series of PLWH. The direct comparability of telephone-based and in-person neuropsychological assessments remains to be determined by prospective, counterbalanced study designs examining both PLWH and seronegative individuals.

Factor Structure of the Memory for Intentions Test (MIsT): A Conceptual Replication in Older Adults and People with HIV Disease

OBJECTIVE

The Memory for Intentions Test (MIsT) is a clinical measure of prospective memory that has strong evidence for convergent, discriminative, and ecological validity. This study uses a conceptual replication design to evaluate the latent structure of the MIsT in two parallel samples who commonly experience prospective memory deficits: older adults and people living with HIV disease.

PARTICIPANTS AND METHODS

Study participants included 303 people with HIV disease (ages 18-67) and 267 community-dwelling older adults (ages 50-91). Confirmatory factor analyses of the MIsT were conducted separately in each sample. We evaluated a one-factor model, as well as three two-factor models with the MIsT items loading onto each factor based on cue type, delay interval, or response modality.

RESULTS

The one-factor model provided the best (and most parsimonious) fit to the data in both study samples. All two-factor models also demonstrated good fit statistics, although correlations between the two factors in each model were high and none of the two-factor models provided a significantly better fit than the one-factor model.

CONCLUSIONS

Results of this conceptual replication study provide support for a robust factor structure of the MIsT across older adults and people with HIV disease. A total score for the MIsT provides the most parsimonious solution, although available evidence and theory also support the potential use of subscales (e.g., cue type). Future studies of the MIsT would be useful to determine its psychometrics in different clinical populations and across demographic factors (e.g., race/ethnicity).

Neurological soft signs and brain morphology in people living with HIV

Neurological soft signs (NSS) are a common feature of severe psychiatric disorders such as schizophrenia but are also prevalent in organic brain diseases like HIV-associated neurocognitive disorder (HAND) or Alzheimer’s disease. While distinct associations between NSS, neurocognition, and cerebral regions were demonstrated in schizophrenia, these associations still have to be elucidated in HIV. Therefore, we investigated 36 persons with HIV of whom 16 were neurocognitively healthy and 20 were diagnosed with HAND. NSS were assessed using the Heidelberg scale. NSS scores were correlated with gray matter (GM) using whole brain voxel-based morphometry. Results showed significantly elevated NSS in the HAND group when compared to the neurocognitively healthy with respect to NSS total score and the subscores “orientation” and “complex motor tasks”. While the two groups showed only minor, non-significant GM differences, higher NSS scores (subscales “motor coordination”, “orientation”) were significantly correlated with GM reduction in the right insula and cerebellum (FWE-corrected). Our results corroborate elevated NSS in HIV+ patients with HAND in contrast to cognitively unimpaired patients. In addition, cerebral correlates of NSS with GM reductions in insula and cerebellum were revealed. Taken together, NSS in this patient group could be considered a marker of cerebral damage and neurocognitive deficits.

Multimodal Investigation of Neuroinflammation in Aviremic Patients With HIV on Antiretroviral Therapy and HIV Elite Controllers

BACKGROUND AND OBJECTIVES

The presence of HIV in the CNS has been related to chronic immune activation and cognitive dysfunction. The aim of this work was to investigate (1) the presence of neuroinflammation in aviremic people with HIV (PWH) on therapy and in nontreated aviremic PWH (elite controllers [ECs]) using a translocator protein 18 kDa radioligand; (2) the relationship between neuroinflammation and cognitive function in aviremic PWH; and (3) the relationship between [¹¹C]-PBR28 signal and quantitative MRI (qMRI) measures of brain tissue integrity such as T1 and T2 relaxation times (rts).

METHODS

[¹¹C]-PBR28 (standard uptake value ratio, SUVR) images were generated in 36 participants (14 PWH, 6 ECs, and 16 healthy controls) using a statistically defined pseudoreference region. Group comparisons of [¹¹C]-PBR28 SUVR were performed using region of interest-based and voxelwise analyses. The relationship between inflammation, qMRI measures, and cognitive function was studied.

RESULTS

In region of interest analyses, ECs exhibited significantly lower [¹¹C]-PBR28 signal in the thalamus, putamen, superior temporal gyrus, prefrontal cortex, and cerebellum compared with the PWH. In voxelwise analyses, differences were observed in the thalamus, precuneus cortex, inferior temporal gyrus, occipital cortex, cerebellum, and white matter (WM). [¹¹C]-PBR28 signal in the WM and superior temporal gyrus was related to processing speed and selective attention in PWH. In a subset of PWH (n = 12), [¹¹C]-PBR28 signal in the thalamus and WM regions was related to a decrease in T2 rt and to an increase in T1 rt suggesting a colocalization of increased glial metabolism, decrease in microstructural integrity, and iron accumulation.

DISCUSSION

This study casts a new light onto the role of neuroinflammation and related microstructural alterations of HIV infection in the CNS and shows that ECs suppress neuroinflammation more effectively than PWH on therapy.

Neurocognitive performance differences between black and white individuals with HIV disease are mediated by health literacy

Objective:Health disparities are evident for Black Americans with HIV disease, who are disproportionally affected by the epidemic in the United States. The current study investigated whether the higher rates of neurocognitive impairment in Black Americans with HIV disease may be at least partly attributable to health literacy, which is a potentially modifiable factor. Method: Participants were 61 White and 25 Black participants (ages 27-70) with HIV disease who were enrolled in studies at an urban academic center in Southern California. Neurocognitive function was assessed by an age-adjusted global score from the Cogstate battery. Health literacy was measured by a composite score derived from the Rapid Estimate of Adult Literacy in Medicine, Newest Vital Sign, and 3-Brief. Results: Bootstrap confidence interval mediation analyses showed that health literacy was a significant mediator of the relationship between race and neurocognition; that is, there were no direct ethnoracial differences in neurocognition after accounting for health literacy. A follow-up model to confirm the directionality of this association demonstrated that neurocognition was not a significant mediator of the relationship between race and health literacy. Conclusions: Low health literacy may contribute to the higher rates of neurocognitive impairment for Black Americans with HIV disease. Future studies might examine the possible mechanism of this mediating relationship (e.g., access to health information, health behaviors, socioeconomics) and determine whether culturally tailored interventions that improve health literacy also confer broader brain health benefits for Black Americans with HIV disease.

A pilot study of cognition and creativity among persons with HIV disease referred for neuropsychological evaluation

Creativity can help people to innovate, overcome obstacles, and successfully navigate challenges in daily life. Some aspects of creativity rely on the prefrontostriatal loops and executive functions, which can be compromised in persons with HIV (PWH). This pilot study examined whether neuropsychological functioning plays a role in creativity in PWH. A consecutive series of 41 PWH who were referred to an urban neuropsychology clinic in southeastern Texas were enrolled. Participants completed the Abbreviated Torrance Test for Adults (ATTA) to measure creativity, from which standardized creativity scores of fluency, originality, elaboration, and flexibility were derived. Participants also completed several measures of everyday functioning and a brief clinical neuropsychological battery measuring executive functions, motor skills, memory, and visuoconstruction. Global neuropsychological functioning showed a large, positive association with ATTA creativity performance that did not vary meaningfully by creativity domain and was independent of premorbid IQ. ATTA creativity scores were not associated with any measure of everyday functioning. Findings from this pilot study suggest that higher levels of neuropsychological functioning may support multiple dimensions of creativity in adults with HIV disease. Future studies might examine whether creativity moderates the association between HIV-associated neurocognitive impairment and various health behaviors (e.g., adherence, appointment attendance).

Chronic SSRI treatment reverses HIV-1 protein-mediated synaptodendritic damage

HIV-1 infection affects approximately 37 million individuals, and approximately 50% of seropositive individuals will develop symptoms of clinical depression and/or apathy. Dysfunctions of both serotonergic and dopaminergic neurotransmission have been implicated in the pathogenesis of motivational alterations. The present study evaluated the efficacy of a SSRI (escitalopram) in the HIV-1 transgenic (Tg) rat. Behavioral, neurochemical, and neuroanatomical outcomes with respect to HIV-1 and sex were evaluated to determine the efficacy of chronic escitalopram treatment. Escitalopram treatment restored function in each of the behavioral tasks that were sensitive to HIV-1-induced impairments. Further, escitalopram treatment restored HIV-1-mediated synaptodendritic damage in the nucleus accumbens; treatment with escitalopram significantly increased dendritic proliferation in HIV-1 Tg rats. However, restoration did not consistently occur with the neurochemical analysis in the HIV-1 rat. Taken together, these results suggest a role for SSRI therapies in repairing long-term HIV-1 protein-mediated neuronal damage and restoring function.

A Clinical Pilot Study of Spaced Retrieval Practice with a Self-Generation Booster to Improve Health-Related Memory in Persons With HIV Disease

Objective

Spaced retrieval practice (SRP) and self-generation are among the most replicated and effective mnemonic strategies in the cognitive psychology literature, but their benefits have not yet been realized in healthcare settings. This study used a randomized, between-subjects design to examine the hypothesis that SRP with a self-generation booster can improve memory for health-related information among clinically referred persons with HIV (PWH), who often have difficulty acquiring new health knowledge.

Method

A consecutive series of 41 PWH referred to a county-funded urban neuropsychology clinic were enrolled. Participants were randomly assigned to learn four statements about the treatment of a mock infectious disease in either a massed study control condition (n = 20) or an SRP condition (n = 21) in which they received two distributed free recall training tests supplemented with self-generation for missed items. The primary outcome was participants’ free recall of the four treatment statements after a 20-minute delay filled with nonverbal tests.

Results

PWH participants in the SRP condition were four times more likely than controls to recall at least one treatment statement at the 20-minute delay. SRP was not related to post-test recognition or health-related decision-making performance but was associated with moderately better self-efficacy for decision-making.

Conclusions

Findings from this pilot study show the potential of SRP with a self-generation booster to improve learning and memory for health-related information among PWH in clinic.

Viral Pandemics of the Last Four Decades: Pathophysiology, Health Impacts and Perspectives

The twenty-first century has witnessed some of the deadliest viral pandemics with far-reaching consequences. These include the Human Immunodeficiency Virus (HIV) (1981), Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) (2002), Influenza A virus subtype H1N1 (A/H1N1) (2009), Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (2012) and Ebola virus (2013) and the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) (2019-present). Age- and gender-based characterizations suggest that SARS-CoV-2 resembles SARS-CoV and MERS-CoV with regard tohigher fatality rates in males, and in the older population with comorbidities. The invasion-mechanism of SARS-CoV-2 and SARS-CoV, involves binding of its spike protein with angiotensin-converting enzyme 2 (ACE2) receptors; MERS-CoV utilizes dipeptidyl peptidase 4 (DPP4), whereas H1N1 influenza is equipped with hemagglutinin protein. The viral infections-mediated immunomodulation, and progressive inflammatory state may affect the functions of several other organs. Although no effective commercial vaccine is available for any of the viruses, those against SARS-CoV-2 are being developed at an unprecedented speed. Until now, only Pfizer/BioNTech's vaccine has received temporary authorization from the UK Medicines and Healthcare products Regulatory Agency. Given the frequent emergence of viral pandemics in the 21st century, proper understanding of their characteristics and modes of action are essential to address the immediate and long-term health consequences.

Priming Astrocytes With HIV-Induced Reactive Oxygen Species Enhances Their Trypanosoma cruzi Infection

Introduction: Trypanosoma cruzi is an intracellular protozoa and etiological agent that causes Chagas disease. Its presence among the immunocompromised HIV-infected individuals is relevant worldwide because of its impact on the central nervous system (CNS) causing severe meningoencephalitis. The HIV infection of astrocytes – the most abundant cells in the brain, where the parasite can also be hosted – being able to modify reactive oxygen species (ROS) could influence the parasite growth. In such interaction, extracellular vesicles (EVs) shed from trypomastigotes may alter the surrounding environment including its pro-oxidant status.

Methods: We evaluated the interplay between both pathogens in human astrocytes and its consequences on the host cell pro-oxidant condition self-propitiated by the parasite – using its EVs – or by HIV infection. For this goal, we challenged cultured human primary astrocytes with both pathogens and the efficiency of infection and multiplication were measured by microscopy and flow cytometry and parasite DNA quantification. Mitochondrial and cellular ROS levels were measured by flow cytometry in the presence or not of scavengers with a concomitant evaluation of the cellular apoptosis level.

Results: We observed that increased mitochondrial and cellular ROS production boosted significantly T. cruzi infection and multiplication in astrocytes. Such oxidative condition was promoted by free trypomastigotes-derived EVs as well as by HIV infection.

Conclusions: The pathogenesis of the HIV-T. cruzi coinfection in astrocytes leads to an oxidative misbalance as a key mechanism, which exacerbates ROS generation and promotes positive feedback to parasite growth in the CNS.

Prospective memory and spontaneous compensatory mnemonic strategy use in the laboratory and daily life in HIV-associated neurocognitive disorders

INTRODUCTION

Older adults with HIV-associated neurocognitive disorders (HAND) are at high risk for deficits in the resource-demanding, strategic aspects of prospective memory (PM) that can adversely affect health outcomes. This study examined the frequency and correlates of spontaneous compensatory strategy use during a laboratory-based PM task and its associations with the use of mnemonic strategies in daily life.

METHOD

Participants included 53 older adults with HAND, 89 older persons with HIV without HAND, and 62 seronegatives who completed the Cambridge Prospective Memory Test (CAMPROMPT), on which the type, frequency, and quality of their compensatory strategy use was quantified. Participants also completed self-report measures of PM symptoms and the frequency of mnemonic compensatory strategy use in daily life.

RESULT

There were no significant group-level effects on strategy use during the CAMPROMPT. Persons with HAND had moderately lower time-, but not event-based PM scores. Higher compensatory strategy use was strongly associated with better PM, particularly for time-based cues. Moreover, higher compensatory strategy use on the CAMPROMPT was associated with more frequent general mnemonic strategy use in daily life, and specifically with more frequent use of internal PM strategies (e.g., visualization) for medication adherence.

CONCLUSION

Spontaneous compensatory mnemonic strategy use can support PM performance among older adults with HAND in the laboratory. Strategy use in the laboratory may be a marker for the extent to which older adults with HAND use other compensatory strategies to support memory in their daily life. Future studies may examine whether compensatory mnemonic strategies can be taught and used to support PM in the daily lives of older persons with HIV disease.

Prevalence and Risk Factors of HIV-Associated Neurocognitive Disorders in Rural Southwestern Uganda

Advances in treatment of HIV have dramatically improved survival rates; HIV-associated neurocognitive disorders (HAND), however, remain highly prevalent and continue to represent a significant public health problem, especially in resource-limited settings. We completed a cross-sectional study to describe the prevalence and risk factors for HAND in rural Southwestern Uganda AIDS Support Organization Centers. After securing ethical clearance from relevant bodies, 393 participants were screened for HAND using the International HIV Dementia Scale. A cutoff score of ≤10 and a significance level of p ≤ .05 were set. More than half of the 393 participants (n = 229, 58.23%) screened positive for HAND. The associated risk factors were gender (odds ratio [OR] 0.54, p = .017), peasant farming (OR 1.70, p = .04), and older age (OR 1.03, p = .019). HIV-associated neurocognitive disorder remains one of the major complications of HIV despite improvement in antiretroviral therapy and life expectancies.

Circulatory Astrocyte and Neuronal EVs as Potential Biomarkers of Neurological Dysfunction in HIV-Infected Subjects and Alcohol/Tobacco Users

The diagnosis of neurocognitive disorders associated with HIV infection, alcohol, and tobacco using CSF or neuroimaging are invasive or expensive methods, respectively. Therefore, extracellular vesicles (EVs) can serve as reliable noninvasive markers due to their bidirectional transport of cargo from the brain to the systemic circulation. Hence, our objective was to investigate the expression of astrocytic (GFAP) and neuronal (L1CAM) specific proteins in EVs circulated in the plasma of HIV subjects, with and without a history of alcohol consumption and tobacco smoking. The protein expression of GFAP (p < 0.01) was significantly enhanced in plasma EVs obtained from HIV-positive subjects and alcohol users compared to healthy subjects, suggesting enhanced activation of astrocytes in those subjects. The L1CAM expression was found to be significantly elevated in cigarette smokers (p < 0.05). However, its expression was not found to be significant in HIV subjects and alcohol users. Both GFAP and L1CAM levels were not further elevated in HIV-positive alcohol or tobacco users compared to HIV-positive nonsubstance users. Taken together, our data demonstrate that the astrocytic and neuronal-specific markers (GFAP and L1CAM) can be packaged in EVs and circulate in plasma, which is further elevated in the presence of HIV infection, alcohol, and/or tobacco. Thus, the astroglial marker GFAP and neuronal marker L1CAM may represent potential biomarkers targeting neurological dysfunction upon HIV infection and/or alcohol/tobacco consumption.

Poor Self-efficacy for Healthcare Provider Interactions Among Individuals with HIV-Associated Neurocognitive Disorders

Two factors that influence HIV health behaviors and therefore may contribute to gaps in the HIV treatment continuum are poor health-related self-efficacy and HIV-associated neurocognitive disorders (HAND). However, the relationship between HAND and self-efficacy has not been assessed. In an HIV sample, 91 individuals with intact cognition (HAND-) and 40 individuals with HAND (HAND+) were administered a measure of self-efficacy for healthcare interactions with providers. Participants with HAND had significantly lower scores on this measure, which were correlated with poorer episodic and semantic memory performance, as well as self-reported memory symptoms in daily life. Findings suggest that neurocognitive impairment, and particularly memory dysfunction, may play an important role in self-efficacy for healthcare interactions in HIV. Further examination of the interplay between HAND and self-efficacy is warranted as these two factors may be important for the public health goal of identifying targets for improving access, delivery, and maintenance of HIV care.

The Role of Brain Derived Neurotrophic Factor in HIV-Associated Neurocognitive Disorder: From the Bench-Top to the Bedside

Human immunodeficiency virus (HIV)-associated neurocognitive disorder (HAND) remains prevalent in the anti-retroviral (ART) era. While there is a complex interplay of many factors in the neuropathogenesis of HAND, decreased neurotrophic synthesis has been shown to contribute to synaptic degeneration which is a hallmark of HAND neuropathology. Brain derived neurotrophic factor (BDNF) is the most abundant and synaptic-promoting neurotrophic factor in the brain and plays a critical role in both learning and memory. Reduced BDNF levels can worsen neurocognitive impairment in HIV-positive individuals across several domains. In this paper, we review the evidence from pre-clinical and clinical studies showing the neuroprotective roles of BDNF against viral proteins, effect on co-morbid mental health disorders, altered human microbiome and ART in HAND management. Potential applications of BDNF modulation in pharmacotherapeutic, cognitive and behavioral interventions in HAND are also discussed. Finally, research gaps and future research direction are identified with the aim of helping researchers to direct efforts to make these BDNF driven interventions improve the quality of life of patients living with HAND.

Impaired Neurocognitive Performance and Mortality in HIV: Assessing the Prognostic Value of the HIV-Dementia Scale

This study examined whether global HIV-associated neurocognitive impairment (NCI), assessed with the HIV-Dementia Scale (HDS), predicted mortality in an ethnically diverse sample of 209 HIV-positive adults. Participants were predominantly in the mid-range of illness at baseline, and followed over 13-years. At baseline, 31 (15%) participants scored in the NCI range (HDS ≤ 10); 58 (28%) died during follow-up. Baseline NCI was significantly associated with earlier mortality (HR = 2.10, 95% CI [1.10-4.00]) independent of sociodemographic and HIV disease-related covariates. Less errors on the antisaccade task, an index of executive/attention control, was the only HDS subtest predicting earlier mortality (HR = 0.72, 95% CI [0.58-0.90]). In the absence of an AIDS-defining condition, NCI, particularly in the executive/attention domain, is an independent prognostic marker of mortality in a diverse HIV-positive cohort. These findings highlight the clinical utility of brief cognitive screening measures in this population.

Cross-talk between microglia and neurons regulates HIV latency

Despite effective antiretroviral therapy (ART), HIV-associated neurocognitive disorders (HAND) are found in nearly one-third of patients. Using a cellular co-culture system including neurons and human microglia infected with HIV (hμglia/HIV), we investigated the hypothesis that HIV-dependent neurological degeneration results from the periodic emergence of HIV from latency within microglial cells in response to neuronal damage or inflammatory signals. When a clonal hμglia/HIV population (HC69) expressing HIV, or HIV infected human primary and iPSC-derived microglial cells, were cultured for a short-term (24 h) with healthy neurons, HIV was silenced. The neuron-dependent induction of latency in HC69 cells was recapitulated using induced pluripotent stem cell (iPSC)-derived GABAergic cortical (iCort) and dopaminergic (iDopaNer), but not motor (iMotorNer), neurons. By contrast, damaged neurons induce HIV expression in latently infected microglial cells. After 48-72 h co-culture, low levels of HIV expression appear to damage neurons, which further enhances HIV expression. There was a marked reduction in intact dendrites staining for microtubule associated protein 2 (MAP2) in the neurons exposed to HIV-expressing microglial cells, indicating extensive dendritic pruning. To model neurotoxicity induced by methamphetamine (METH), we treated cells with nM levels of METH and suboptimal levels of poly (I:C), a TLR3 agonist that mimics the effects of the circulating bacterial rRNA found in HIV infected patients. This combination of agents potently induced HIV expression, with the METH effect mediated by the σ1 receptor (σ1R). In co-cultures of HC69 cells with iCort neurons, the combination of METH and poly(I:C) induced HIV expression and dendritic damage beyond levels seen using either agent alone, Thus, our results demonstrate that the cross-talk between healthy neurons and microglia modulates HIV expression, while HIV expression impairs this intrinsic molecular mechanism resulting in the excessive and uncontrolled stimulation of microglia-mediated neurotoxicity.

Neurocognitive dysfunction in HIV-infected youth: investigating the relationship with immune activation

BACKGROUND

HIV-infected individuals are at increased risk of neurocognitive impairment compared to the general population. Studies suggest that, despite combination antiretroviral therapy (cART), HIV infection causes immune activation which results in neural damage; however, few data exist in HIV-infected youth.

METHODS

HIV-infected youth 8-26-years-old on cART with virological suppression were prospectively enrolled along with healthy controls. Neurocognitive performance was assessed by age-appropriate Wechsler Intelligence Scales. Soluble and cellular markers of T-lymphocyte and monocyte activation were measured by ELISA and flow cytometry, respectively.

RESULTS

45 HIV-infected subjects and 21 controls were enrolled. Markers of T-cell and monocyte activation were higher in the HIV-infected subjects compared to controls, but proportions of inflammatory and patrolling monocytes were similar. Although there were no significant differences in neurocognitive scores between the HIV-infected and control groups, scores were low-average for four of five testing domains for the HIV-infected subjects and average for all five in the controls, and % of HIV-infected subjects with scores classified as 'low average' or below was higher than in the controls. Variables most associated with neurocognitive performance among HIV-infected subjects included activated CD4⁺ T-cells (% CD4+CD38+HLA-DR), monocyte activation (soluble CD14), HIV duration, age and sex.

CONCLUSIONS

HIV-infected youth on cART with virological suppression show subtle evidence of neurocognitive impairment compared to healthy controls, and increased immune activation appears to play a role. Additional studies are needed to develop strategic interventions beyond cART to potentially improve neurocognitive performance and/or minimize further impairment in this vulnerable population. ClinicalTrials.gov Identifier: NCT01523496.

The Glucocorticoid Receptor Is a Critical Regulator of HIV Latency in Human Microglial Cells

We have developed models of HIV latency using microglia derived from adult human patient brain cortex and transformed with the SV40 T large and hTERT antigens. Latent clones infected by HIV reporter viruses display high levels of spontaneous HIV reactivation in culture. BrainPhys, a medium highly representative of the CNS extracellular environment, containing low glucose and 1% FBS, reduced, but did not prevent, HIV reactivation. We hypothesized that spontaneous HIV reactivation in culture was due to the expression of pro-inflammatory genes, such as TNF-α, taking place in the absence of the natural inhibitory signals from astrocytes and neurons. Indeed, expression and secretion of TNF-α is strongly reduced in HIV-latently infected microglia compared to the subset of cells that have undergone spontaneous HIV reactivation. Whereas inhibitors of NF-κB or of macrophage activation only had a short-term silencing effect, addition of dexamethasone (DEXA), a glucocorticoid receptor (GR) agonist and mediator of anti-inflammation, silenced the HIV provirus in a long-term, and shRNA-mediated knock-down of GR activated HIV. DEXA also decreased secretion of a number of cytokines, including TNF-α. Chromatin immunoprecipitation analysis revealed that DEXA strongly increased GR occupancy at the HIV promoter, and reduced histone 3 acetylated levels. Moreover, TNF-α expression inhibitors in combination with DEXA induced further HIV silencing and increased the histone 3 lysine 27 tri-methylated epigenetic mark of repression at the HIV promoter region. We conclude that GR is a critical repressor of HIV transcription in microglia, and a novel potential pharmacological target to restrict HIV expression in the CNS.

White matter microstructure among perinatally HIV-infected youth: a diffusion tensor imaging study

We evaluated white matter microstructure integrity in perinatally HIV-infected (PHIV) youths receiving cART compared to age- and gender-matched healthy youths through DTI metrics using voxel-based morphometry (VBM). We investigated 14 perinatally HIV-infected patients (age 17.9 ± 2.5 years) on cART and 17 healthy youths (HC) (age 18.0 ± 3.0 years) using a 3T MRI scanner. Four DTI-derived metrics were fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD). Statistical analysis was done with voxel-based analysis of covariance (ANCOVA), with age and gender as covariates. Region-of-interest secondary analyses in statistically significant regions were also performed. Regional increases in FA in the PHIV youths were found in left middle frontal gyrus, right precuneus, right lingual gyrus, and left supramarginal gyrus. Increased MD was found in the right precentral gyrus while decreased MD was found in the white matter of the right superior parietal lobule and right inferior temporal gyrus/fusiform gyrus. Regions of increased/decreased RD overlapped with regions of increased/decreased MD. Both increased and decreased AD were found in three to four regions respectively. The regional FA, MD, RD, and AD values were consistent with the voxel-based analysis findings. The findings are mostly consistent with previous literature, but increased FA has not been previously reported for perinatally HIV-infected youths. Potentially early and prolonged therapy in our population may have contributed to this new finding. Both toxicity of antiretroviral therapy and indolent infection must be considered as causative factors in the DTI metric changes that we have observed.

Calendaring and alarms can improve naturalistic time-based prospective memory for youth infected with HIV

Individuals with HIV disease often evidence deficits in prospective memory (PM), which interfere with daily functioning and increase the risk of suboptimal health behaviours. This study examined the benefits of simple encoding and cueing supports on naturalistic time-based PM in 47 HIV-positive young adults. All participants completed a naturalistic time-based PM task in which they were instructed to text the examiner once per day for seven days at a specified time. Participants were randomised into (1) a Calendaring condition in which they created a calendar event in their mobile telephone for the specified texting time; (2) an Alarm condition in which they programmed an alarm into their mobile telephone for the specified texting time; (3) a Combined calendaring and alarm condition; and (4) a Control condition. Participants in the Combined condition demonstrated significantly better naturalistic PM performance than participants in the Control and Calendaring conditions. Findings indicate that HIV-positive young people may benefit from a combined calendaring and alarm supportive strategy for successful execution of future intentions in daily life.

Persistent EcoHIV infection induces nigral degeneration in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-intoxicated mice

The widespread use of antiretroviral therapy for treatment of human immunodeficiency virus (HIV) infections has dramatically improved the quality and duration of life for HIV-positive individuals. Despite this success, HIV persists for the life of an infected person in tissue reservoirs including the nervous system. Thus, whether HIV exacerbates age-related brain disorders such as Parkinson's disease (PD) is of concern. In support of this idea, HIV infection can be associated with motor and gait abnormalities that parallel late-stage manifestations of PD including dopaminergic neuronal loss. With these findings in hand, we investigated whether viral infection could affect nigrostriatal degeneration or exacerbate chemically induced nigral degeneration. We now demonstrate an additive effect of EcoHIV on dopaminergic neuronal loss and neuroinflammation induced by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine intoxication. HIV-1-infected humanized mice failed to recapitulate these EcoHIV results suggesting species-specific neural signaling. The results demonstrate a previously undefined EcoHIV-associated neurodegenerative response that may be used to model pathobiological aspects of PD.

Correlation between Lymphocyte CD4 Count, Treatment Duration, Opportunistic Infection and Cognitive Function in Human Immunodeficiency Virus-Acquired Immunodeficiency Syndrome (HIV-AIDS) Patients

BACKGROUND:

Human immunodeficiency virus (HIV) infection is an epidemic worldwide, despite the marked benefits of antiretroviral therapy (ARV) in reducing severe HIV-associated dementia. A milder form of neurocognitive disorders are still prevalent and remain a challenge.

AIM:

This study aimed to determine the correlation between plasma cluster of differentiation 4 (CD4) lymphocyte, duration of ARV treatment, opportunistic infections, and cognitive function in HIV-AIDS patients.

METHODS:

A cross-sectional study involving 85 HIV-AIDS patients was conducted at Adam Malik General Hospital Medan, Indonesia. All subjects were subjected to physical, neurologic examination and Montreal Cognitive Assessment-Indonesian Version (MoCA-INA) to assess cognitive function and measurement of lymphocyte CD4 counts.

RESULTS:

Out of the 85 subjects evaluated, the proportion concerning sexes include 52 males (61.2 %) and 33 females (38.8%). The mean age was 38.53 ± 9.77 years old. There was a significant correlation between CD4 lymphocyte counts and MoCA-INA score (r = 0.271, p = 0.012), but there was no significant correlation between duration of ARV treatment and MoCA-INA score. There was also no difference in MoCA-INA score based on the presence of opportunistic infection.

CONCLUSION:

Lymphocyte CD4 count was independently correlated with cognitive function in HIV-AIDS patients.

Scaling Synapses in the Presence of HIV

A defining feature of HIV-associated neurocognitive disorder (HAND) is the loss of excitatory synaptic connections. Synaptic changes that occur during exposure to HIV appear to result, in part, from a homeostatic scaling response. Here we discuss the mechanisms of these changes from the perspective that they might be part of a coping mechanism that reduces synapses to prevent excitotoxicity. In transgenic animals expressing the HIV proteins Tat or gp120, the loss of synaptic markers precedes changes in neuronal number. In vitro studies have shown that HIV-induced synapse loss and cell death are mediated by distinct mechanisms. Both in vitro and animal studies suggest that HIV-induced synaptic scaling engages new mechanisms that suppress network connectivity and that these processes might be amenable to therapeutic intervention. Indeed, pharmacological reversal of synapse loss induced by HIV Tat restores cognitive function. In summary, studies indicate that there are temporal, mechanistic and pharmacological features of HIV-induced synapse loss that are consistent with homeostatic plasticity. The increasingly well delineated signaling mechanisms that regulate synaptic scaling may reveal pharmacological targets suitable for normalizing synaptic function in chronic neuroinflammatory states such as HAND.

Deficient Emotion Processing is Associated with Everyday Functioning Capacity in HIV-associated Neurocognitive Disorder

OBJECTIVE

Emotion processing has received little research focus in HIV, but emerging evidence suggests that abilities such as facial affect discrimination may be features of HIV-associated neurocognitive disorder (HAND). The present study hypothesized that individuals with HAND would evidence an emotion processing deficit relative to cognitively unimpaired individuals with HIV and seronegative comparison participants on a task assessing these abilities. Moreover, it was expected that this deficit would be significantly associated with social aspects of everyday functioning.

METHOD

To explore these hypotheses, 37 HIV+ individuals with HAND, 46 HIV+ without HAND, and 38 HIV-seronegative comparison participants were administered the CogState Social Emotional Cognition Task (SECT) and the UCSD Performance-based Skills Assessment-Brief (UPSA-B).

RESULTS

Results revealed that the HAND group was more likely to have impaired accuracy and slower reaction time relative to the comparison groups on the SECT task. In fact, individuals with HAND were almost 10 times more likely to be impaired on emotion processing accuracy than HIV+ without HAND. Among individuals with HIV, accuracy (but not reaction time) was independently related to a functional capacity measure tapping social ability, but not to a similar measure without a social component (UPSA-B Communication and Finances subscales, respectively).

CONCLUSIONS

These results suggest that disruption of emotion processing may be an important feature of HAND that has clinical value as an independent predictor of real-world activities that involve social components. Future research should prospectively investigate this relationship, which may inform of intervention strategies for improving everyday functioning.

Monoacylglycerol lipase inhibitor JZL184 prevents HIV-1 gp120-induced synapse loss by altering endocannabinoid signaling

Monoacylglycerol lipase (MGL) hydrolyzes 2-arachidonoylglycerol to arachidonic acid and glycerol. Inhibition of MGL may attenuate neuroinflammation by enhancing endocannabinoid signaling and decreasing prostaglandin (PG) production. Almost half of HIV infected individuals are afflicted with HIV-associated neurocognitive disorder (HAND), a neuroinflammatory disease in which cognitive decline correlates with synapse loss. HIV infected cells shed the envelope protein gp120 which is a potent neurotoxin that induces synapse loss. Here, we tested whether inhibition of MGL, using the selective inhibitor JZL184, would prevent synapse loss induced by gp120. The number of synapses between rat hippocampal neurons in culture was quantified by imaging clusters of a GFP-tagged antibody-like protein that selectively binds to the postsynaptic scaffolding protein, PSD95. JZL184 completely blocked gp120-induced synapse loss. Inhibition of MGL decreased gp120-induced interleukin-1β (IL-1β) production and subsequent potentiation of NMDA receptor-mediated calcium influx. JZL184-mediated protection of synapses was reversed by a selective cannabinoid type 2 receptor (CB2R) inverse agonist/antagonist. JZL184 also reduced gp120-induced prostaglandin E2 (PGE2) production; PG signaling was required for gp120-induced IL-1β expression and synapse loss. Inhibition of MGL prevented gp120-induced synapse loss by activating CB2R resulting in decreased production of the inflammatory cytokine IL-1β. Because PG signaling was required for gp120-induced synapse loss, JZL184-induced decreases in PGE2 levels may also protect synapses. MGL presents a promising target for preventing synapse loss in neuroinflammatory conditions such as HAND.

Visualisation of future task performance improves naturalistic prospective memory for some younger adults living with HIV disease

Human immunodeficiency virus (HIV) disease is commonly associated with deficits in prospective memory (PM), which increase the risk of suboptimal health behaviours, like medication non-adherence. This study examined the potential benefits of a brief future visualisation exercise during the encoding stage of a naturalistic PM task in 60 young adults (aged 19-24 years) with HIV disease. Participants were administered a brief clinical neuropsychological assessment, which included a standardised performance-based measure of time- and event-based PM. All participants were also given a naturalistic PM task in which they were asked to complete a mock medication management task when the examiner showed them the Grooved Pegboard Test during their neuropsychological evaluation. Participants were randomised into: (1) a visualisation condition in which they spent 30 sec imagining successfully completing the naturalistic PM task; or (2) a control condition in which they repeated the task instructions. Logistic regression analyses revealed significant interactions between clinical neurocognitive functions and visualisation. HIV positive (HIV+) participants with intact retrospective learning and/or low time-based PM demonstrated observable gains from the visualisation technique, while HIV+ participants with impaired learning and/or intact time-based PM did not evidence gains. Findings indicate that individual differences in neurocognitive ability moderate the response to visualisation in HIV+ young adults. The extent to which such cognitive supports improve health-related PM outcomes (e.g., medication adherence) remains to be determined.

Subclinical executive function impairment in children with asymptomatic, treated phenylketonuria: A comparison with children with immunodeficiency virus

In this study we compared the neuropsychological profile of phenylketonuria (PKU) and human immunodeficiency virus (HIV) to examine the specificity of the executive function (EF) impairment reported in these two patologies. A total of 55 age-matched children and adolescents were assessed, including 11 patients with PKU, 16 patients with HIV and 28 healthy controls, underwent a neuropsychological assessment. Although neither the PKU nor the HIV group scored below the normative ranges, both groups showed lower scores in neuropsychological tests engaging EFs than controls. In addition, compared to patients with PKU the HIV group performed significantly worse in the Trail-Making Test A, Corsi Span and Verbal Fluency. These findings suggest that EF impairments in PKU (a) are limited to EFs (i.e., working memory and attentional shifting), (b) are not simply due to generalized processing speed deficits and

How I treat patients with HIV-related hematological malignancies using hematopoietic cell transplantation

Hematopoietic cell transplantation (HCT) has now been shown to be safe and effective for selected HIV-infected patients with hematological malignancies. Autologous HCT is now the standard of care for patients with HIV-related lymphomas who otherwise meet standard transplant criteria. Limited data also support use of allogeneic HCT (alloHCT) in selected HIV-infected patients who meet standard transplant criteria. We recommend enrolling patients in clinical trials that offer access to CCR5Δ32 homozygous donors, if available. HIV-infected patients requiring HCT may also be considered for participation in trials evaluating the activity of gene-modified hematopoietic stem cells in conferring resistance to HIV infection. To be considered for HCT, patients must have HIV infection that is responsive to combination antiretroviral therapy (cART). Careful planning for the peri-HCT management of the cART can avoid risk of significant drug interactions and development of cART-resistant HIV. In general, we recommend against the use of boosted proteasome inhibitors and nonnucleotide reverse transcriptase inhibitors in the cART regimen, in favor of nucleoside reverse transcriptase inhibitors and integrase inhibitors (without cobicistat). After HCT, patients must be closely monitored for development of opportunistic infections (OI), such as cytomegalovirus. Prevention of OI should include prophylactic and pre-emptive antimicrobials.

HIV-associated synaptic degeneration

Human immunodeficiency virus (HIV) infection induces neuronal injuries, with almost 50% of infected individuals developing HIV-associated neurocognitive disorders (HAND). Although highly activate antiretroviral therapy (HAART) has significantly reduced the incidence of severe dementia, the overall prevalence of HAND remains high. Synaptic degeneration is emerging as one of the most relevant neuropathologies associate with HAND. Previous studies have reported critical roles of viral proteins and inflammatory responses in this pathogenesis. Infected cells, including macrophages, microglia and astrocytes, may release viral proteins and other neurotoxins to stimulate neurons and cause excessive calcium influx, overproduction of free radicals and disruption of neurotransmitter hemostasis. The dysregulation of neural circuits likely leads to synaptic damage and loss. Identification of the specific mechanism of the synaptic degeneration may facilitate the development of effective therapeutic approaches to treat HAND.

Verbal episodic memory profiles in HIV-Associated Neurocognitive Disorders (HAND): A comparison with Huntington's disease and mesial temporal lobe epilepsy

HIV-associated neurocognitive disorders (HAND) commonly feature verbal episodic memory impairment historically characterized by a retrieval deficit, consistent with a classic "subcortical" presentation; however, there are hints of a subtle shift toward a more "cortical" memory profile characterized by a primary encoding deficit. The current study evaluated this possibility by comparing the pattern of HAND-associated verbal episodic memory deficits to those of traditional "subcortical" (i.e., Huntington's disease; HD) versus "cortical" (i.e., left temporal lobe epilepsy with mesial temporal sclerosis; L-MTLE) profiles. Seventy-seven individuals with HAND, 47 individuals with HD, 21 individuals with L-MTLE, and 45 healthy participants were administered the California Verbal Learning Test - 2^nd Edition (CVLT-II). CVLT-II profiles were classified as reflecting a primary encoding deficit, retrieval deficit, or a normal profile. Among participants with a deficit profile, the HAND group showed the highest rates of retrieval versus encoding profiles (71% vs. 29%), followed by HD (59% vs. 41%), L-MTLE (46% vs. 54%), and healthy (50% vs. 50%) groups. While significant profile heterogeneity was observed across clinical groups, findings suggest that HIV-associated verbal episodic memory impairments are most consistent with a traditional "subcortical," retrieval deficit profile, consistent with the primary frontostriatal neuropathogenesis of HIV disease.

Increased Immune Activation and Exhaustion in HIV-infected Youth

BACKGROUND

Immune activation and exhaustion drive several comorbidities and disease progression in HIV-infected adults; however, they are not well studied in HIV-infected youth. Thus, this study sought to examine levels of immune activation and exhaustion in this population, investigate associated HIV- and non-HIV-related variables and compare results with a matched healthy control group.

METHODS

HIV-infected youth 8-25 years of age on stable antiretroviral therapy with an HIV-1 RNA level <1000 copies/mL were enrolled, along with matched healthy controls. We measured T-cell and monocyte immune activation and exhaustion markers in cryopreserved peripheral blood mononuclear cell and plasma samples.

RESULTS

A total of 136 subjects (80 HIV+: 66% male; 91% black) were enrolled. Markers of CD4+ and CD8+ T-cell activation were higher in the HIV-infected group versus controls [mean % CD4+CD38+HLA-DR+ and CD8+CD38+HLA-DR+ = 2.2 versus 1.5 (P=0.002) and 4.9 versus 2.2 (P<0.0001), respectively], as were exhausted CD4+ and CD8+ T-cells [mean % CD4+CD38+HLA-DR+PD-1+ and CD8+CD38+HLA-DR+PD-1+ = 1.0 versus 0.5 (P<0.0001) and 1.6 versus 0.7 (P<0.0001), respectively]. There were no differences in proportions of inflammatory or patrolling monocytes between groups (P>0.05); however, soluble CD14 was higher in HIV-infected compared with controls (1.6 versus 1.4 µg/mL; P=0.01). Current CD4 count, low-density lipoprotein cholesterol and age were the variables most associated with CD4+ and CD8+ T-cell activation.

CONCLUSIONS

CD4+ and CD8+ T-cell immune activation and exhaustion are higher in HIV-infected youth compared with matched controls, while monocyte subpopulations are not altered despite a high soluble CD14 level. The clinical significance of the increased immune activation and exhaustion should be further explored.

The role of neuropsychology in UK pediatric HIV care: Relevance to clinical practice and research

There has been a dramatic improvement in the survival of children with perinatally-acquired HIV (PHIV) following the introduction of effective treatment in 1990s. The care for children living with PHIV is now focused on more accurately understanding the effects of both HIV and HIV treatment on the developing body and brain. An evaluation of current HIV neuroimaging, and neurocognitive research, when combined with clinical experience in the area of HIV, could help to inform United Kingdom (UK) PHIV service provision. This paper argues that an understanding from a neuropsychological perspective will help these young people to optimize their health, quality of life, and future functioning. The aim of the paper is to bring together research and clinical understanding of HIV and its treatment effects on the developing brain, together with an understanding of other potential neurological risk factors. It is argued here that there is a need for targeted neuropsychology assessment and preventative interventions, supported by clinical and preliminary research on the neurocognitive effects of HIV and its treatments.

An Update of the Review of Neuropsychological Consequences of HIV and Substance Abuse: A Literature Review and Implications for Treatment and Future Research

Neuropyschological dysfunction, ranging from mild cerebral indicators to dementia has been a consistent part of the medical picture of HIV/AIDS. However, advances in medical supervision, particularly as a result of antiretroviral (ARV) treatment, have resulted in some mitigation of the neuropsychological effects of HIV and necessitate re-evaluation of the pattern and nature of HIV-related cognitive or mental deficits. The associated enhancements in morbidity and mortality that have occurred as a result of ARV medication have led to a need for interventions and programs that maintain behaviors that are healthy and stop the resurgence of the risk of HIV transmission. Risk factors such as mental illness and substance use that may have contributed to the initial infection with HIV still need consideration. These risk factors may also increase neuropsychological dysfunction and impact observance of prevention for treatment and recommendations. Explicitly, a better comprehension of the role of substance use on the progression of HIV-related mental decline can enlighten management and evaluation of persons living with HIV with concurrent disorders of substance use. This review provides a summary of the neurophyschology of substance use and HIV and the existing research that has looked at the effects of both substance use and HIV disease on neurophyscological function and suggestions for future research and treatment.

Regional Cerebral Gray Matter Volume in HIV-Positive Patients with Executive Function Deficits

PURPOSE

To evaluate whether human immunodeficiency virus (HIV)-positive patients with and without executive functions deficits and healthy control subjects differ on cortical thickness and subcortical brain structures volume in vivo.

METHODS

In total, 34 HIV-positive patients with executive functions deficits were compared with 13 HIV-positive patients without executive functions deficits and 19 gender-, age-, and education-matched control subjects. Executive functions impairments were classified by performance on the Wisconsin card sorting test. T1 3-dimensional magnetization prepared rapid gradient echo-weighted imaging was performed using a 1.5 Tesla (magnetic resonance) MR scanner. FreeSurfer software was used to perform cortical reconstruction and volumetric segmentation of subcortical gray matter structures.

RESULTS

HIV-positive patients with executive functions deficits had smaller volumes in the right and left caudate compared with the HIV-positive patients without executive functions deficits and control groups. In addition, HIV-positive patients with executive functions deficits had smaller volumes in their left accumbens, right putamen, and globus pallidum compared with the control group. No significant differences in cortical thickness were observed between the groups.

CONCLUSION

HIV-positive patients with executive functions deficits have reduced volumes of several subcortical structures, primarily in the caudate nucleus.

Persons Living With HIV/AIDS: Employment as a Social Determinant of Health

Purpose: For persons living with HIV/AIDS (PLWHA), the advent of highly active antiretroviral therapy has increased their longevity and quality of life. As HIV progresses, many PLWHA present declined domains of functioning that impede their ability to work. The authors explore employment as a social determinant of health to identify issues impacting employment outcomes for PLWHA.

Methods: The authors reviewed the literature addressing HIV across the domains of mental health functioning, neurocognitive functioning, and physical function and employment.

Results: When providing employment services to PLWHA, considerations for rehabilitation practitioners and educators include HIV/AIDS education, functional assessment, social support, considerations for women with HIV, highly active antiretroviral therapy (HAART), HIV/AIDS stigma, and employment resources for PLWHA.

Conclusion: With more than 1.2 million PLWHA in the United States, and most of new infections among persons 25–44 years of age, the prevalence of PLWHA seeking employment and inclusive of the U.S. workforce will continue to increase. Proving employment services for PLWHA is a complex process that is best served by an integrative service approach.

Neurocognitive impairment is associated with lower health literacy among persons living with HIV infection

This study sought to determine the effects of HIV-associated neurocognitive disorders (HAND) on health literacy, which encompasses the ability to access, understand, appraise, and apply health-related information. Participants included 56 HIV seropositive individuals, 24 of whom met Frascati criteria for HAND, and 24 seronegative subjects who were comparable on age, education, ethnicity, and oral word reading. Each participant was administered a brief battery of well-validated measures of health literacy, including the Expanded Numeracy Scale (ENS), Newest Vital Sign (NVS), Rapid Estimate of Adult Literacy in Medicine (REALM), and Brief Health Literacy Screen (BHLS). Results revealed significant omnibus differences on the ENS and NVS, which were driven by poorer performance in the HAND group. There were no significant differences on the REALM or the BHLS by HAND status. Among individuals with HAND, lower scores on the NVS were associated with greater severity of neurocognitive dysfunction (e.g., working memory and verbal fluency) and self-reported dependence in activities of daily living. These preliminary findings suggest that HAND hinders both fundamental (i.e., basic knowledge, such as numeracy) and critical (i.e., comprehension and application of healthcare information) health literacy capacities, and therefore may be an important factor in the prevalence of health illiteracy. Health literacy-focused intervention may play an important role in the treatment and health trajectories among persons living with HIV infection.

The role of decision-making ability in HIV/AIDS: impact on prospective memory

BACKGROUND

Prospective memory (ProM), a form of episodic memory related to execution of future intentions, is important for everyday functioning. Among persons living with HIV (PLWH), executive dysfunction is implicated in ProM impairments. However, specific subcomponents of executive functioning involved in ProM deficits remain poorly understood. Unlike more "traditional" neurocognitive (NC) measures of executive functioning associated with dorsolateral prefrontal cortex (i.e., conceptual reasoning, abstraction), those associated with medial orbitofrontal/ventromedial prefrontal (mOF/vmP) cortex (i.e., decision making, inhibitory control, goal-oriented behavior) have yet to be examined in ProM.

METHOD

This study characterized ProM ability in a sample of 89 HIV-seropositive adults and examined the unique role of decision-making ability in ProM. Participants completed a standard NC battery, the Iowa Gambling Task (IGT; a decision-making measure), and the Memory for Intentions Screening Test (MIST; a ProM measure).

RESULTS

Correlational analyses revealed that both traditional executive functioning measures and the IGT were associated with ProM. Regression analyses revealed that the IGT significantly predicted ProM, even after accounting for NC measures. Among all NC measures, only executive functioning significantly contributed to ProM.

DISCUSSION

Further examination of mOF/vmP-sensitive executive dysfunction within this population is needed as PLWH may require more tailored treatment recommendations due to specific decision-making difficulties that can impact medication management.

Task importance affects event-based prospective memory performance in adults with HIV-associated neurocognitive disorders and HIV-infected young adults with problematic substance use

Two experiments were conducted to examine the effects of task importance on event-based prospective memory (PM) in separate samples of adults with HIV-associated neurocognitive disorders (HAND) and HIV-infected young adults with substance use disorders (SUD). All participants completed three conditions of an ongoing lexical decision task: (1) without PM task requirements; (2) with PM task requirements that emphasized the importance of the ongoing task; and (3) with PM task requirements that emphasized the importance of the PM task. In both experiments, all HIV+ groups showed the expected increase in response costs to the ongoing task when the PM task's importance was emphasized. In Experiment 1, individuals with HAND showed significantly lower PM accuracy as compared to HIV+ subjects without HAND when the importance of the ongoing task was emphasized, but improved significantly and no longer differed from HIV+ subjects without HAND when the PM task was emphasized. A similar pattern of findings emerged in Experiment 2, whereby HIV+ young adults with SUD (especially cannabis) showed significant improvements in PM accuracy when the PM task was emphasized. Findings suggest that both HAND and SUD may increase the amount of cognitive attentional resources that need to be allocated to support PM performance in persons living with HIV infection.

Perinatally acquired HIV infection: long-term neuropsychological consequences and challenges ahead

Over the past three decades, perinatal HIV infection in the United States has evolved from a fatal disease to a manageable chronic illness. As the majority of youth with perinatal HIV infection age into adolescence and adulthood, management of this stigmatizing, transmittable disease in the backdrop of a cadre of environmental stressors presents challenges beyond those of other chronic illnesses. The neurologic and neuropsychological consequences of this neurotropic virus have important implications for the successful navigation of responsibilities related to increasingly independent living of this aging population. This article will review the neurologic and neuropsychological consequences of perinatal HIV infection and concomitant factors in the era of highly active antiretroviral therapy and will provide an overview of the neuropathology, pathogenesis, neuroimaging findings, and treatment of perinatal HIV infection, as well as recommendations for service provision and future research.

Reproductive health decision-making in perinatally HIV-infected adolescents and young adults

With widespread access to antiretroviral therapy in the United States, many perinatally HIV-infected (PHIV+) children are surviving into adolescence and adulthood, becoming sexually active and making decisions about their reproductive health. The literature focusing on the reproductive decisions of individuals behaviorally infected with HIV can serve as a springboard for understanding the decision-making process of PHIV+ youth. Yet, there are many differences that critically distinguish reproductive health and related decision-making of PHIV+ youth. Given the potential public health implications of their reproductive decisions, better understanding of factors influencing the decision-making process is needed to help inform the development of salient treatment and prevention interventions. To begin addressing this understudied area, a "think tank" session, comprised of clinicians, medical providers, and researchers with expertise in the area of adolescent HIV, was held in Bethesda, MD, on September 21, 2011. The focus was to explore what is known about factors that influence the reproductive decision-making of PHIV+ adolescents and young adults, determine what important data are needed in order to develop appropriate intervention for PHIV+ youth having children, and to recommend future directions for the field in terms of designing and carrying out collaborative studies. In this report, we summarize the findings from this meeting. The paper is organized around the key themes that emerged, including utilizing a developmental perspective to create an operational definition of reproductive decision-making, integration of psychosocial services with medical management, and how to design future research studies. Case examples are presented and model program components proposed.