Association of age and time of disease with HIV-associated neurocognitive disorders: a Japanese nationwide multicenter study

Prevalence and associated factors of low vigor in patients living with HIV and hemophilia in Japan: A cross-sectional observational study

People living with human immunodeficiency virus (HIV) are at high risk of mental health problems. However, little is known about this risk in HIV-infected patients with hemophilia (HPH) who contracted the virus through blood products. This cross-sectional, observational study assessed patients' mood states and the factors associated with them among Japanese HPH to evaluate the need for psychosocial support. HPH completed self-administered questionnaires (Profile of Mood States [POMS] and General Health Questionnaire-28), neuropsychological tests, and brain magnetic resonance imaging (MRI) and fluorodeoxyglucose positron emission tomography/computerized tomography scans. HIV-infected patients with no hemophilia (HPnH) completed POMS and neuropsychological tests. Socio-demographic characteristics and HIV- and hemophilia-related data were obtained from participants' medical records and interviews. A Mann-Whitney U test and chi-squared analyses were conducted. Fifty-six HPH and 388 HPnH completed the questionnaires and neuropsychological tests. HPH had a significantly lower prevalence of tension-anxiety (HPH, 7%; HPnH, 18%; p = 0.049) and a significantly higher prevalence of low vigor (HPH, 63%; HPnH, 32%; p < 0.001). Low vigor in HPH was significantly associated with impaired executive function (low vigor, 66%; high vigor, 33%; p = 0.019) and a social dysfunction score ≥ 3 (moderate; low vigor, 26%; high vigor, 5%; p = 0.047). Our results highlight the high prevalence of low vigor among HPH, leading to impairments in executive and social functions. Therefore, healthcare workers need to pay attention to the vigor, executive function, and social function of HPH.

Lack of Association of Vascular Risk Factors with HIV-Associated Neurocognitive Disorders in cART-Treated Adults Aged ≥ 50 Years in Tanzania

HIV-associated neurocognitive disorders (HAND) are highly prevalent in those ageing with HIV. High-income country data suggest that vascular risk factors (VRFs) may be stronger predictors of HAND than HIV-disease severity, but data from sub-Saharan Africa are lacking. We evaluated relationships of VRFs, vascular end-organ damage and HAND in individuals aged ≥ 50 in Tanzania. c-ART-treated individuals were assessed for HAND using consensus criteria. The prevalence of VRFs and end organ damage markers were measured. The independent associations of VRFs, end organ damage and HAND were examined using multivariable logistic regression. Data were available for 153 individuals (median age 56, 67.3% female). HAND was highly prevalent (66.7%, 25.5% symptomatic) despite well-managed HIV (70.5% virally suppressed). Vascular risk factors included hypertension (34%), obesity (10.5%), hypercholesterolemia (33.3%), diabetes (5.3%) and current smoking (4.6%). End organ damage prevalence ranged from 1.3% (prior myocardial infarction) to 12.5% (left ventricular hypertrophy). Measured VRFs and end organ damage were not independently associated with HAND. The only significant association was lower diastolic BP (p 0.030, OR 0.969 (0.943-0.997). Our results suggest that vascular risk factors are not major drivers of HAND in this setting. Further studies should explore alternative aetiologies such as chronic inflammation.

HIV associated neurocognitive disorder screening and diagnosis pathways in Australia: a scoping review and international implications

Symptomatic HIV-associated neurocognitive disorder (HAND) is a complication of HIV (cognitive impairment, difficulties with everyday functioning). If detected early, interventions assist with optimizing care, avoiding rapid decline and enhancing coping. There remains inconsistency surrounding screening/diagnosis information within Australian healthcare professionals and community settings. A scoping review of academic literature, government policies and non-government organisations (NGOs) was conducted to map existing screening/diagnosis information using the guidelines of Joanna Briggs Institute. A literature search of EBSCOhost and Medline (dates: 2015-2021), the Australian government NGO web domains, Google and unpublished academic works was conducted (July 2021) and updated (December 2022) to identify Australian items (past 5 years). Seventeen items met the inclusion criteria. No government guidelines were identified. Various HIV-related organisations proposed different diagnostic guidelines. Most HAND research originated in Sydney. The most accessible information was from Dementia Australia, with some inaccuracies noted. There is scant Australian research/information on HAND screening/diagnosis. HAND translational research and screening/diagnosis standards are urgently needed to inform best practices. The Australian context is used to discuss international implications regarding higher-income countries with similar patterns/healthcare.

A reappraisal on amyloid cascade hypothesis: the role of chronic infection in Alzheimer's disease

Alzheimer disease (AD) is a progressive neurological disorder that accounted for the most common cause of dementia in the elderly population. Lately, 'infection hypothesis' has been proposed where the infection of microbes can lead to the pathogenesis of AD. Among different types of microbes, human immunodeficiency virus-1 (HIV-1), herpes simplex virus-1 (HSV-1), Chlamydia pneumonia, Spirochetes and Candida albicans are frequently detected in the brain of AD patients. Amyloid-beta protein has demonstrated to exhibit antimicrobial properties upon encountering these pathogens. It can bind to microglial cells and astrocytes to activate immune response and neuroinflammation. Nevertheless, HIV-1 and HSV-1 can develop into latency whereas Chlamydia pneumonia, Spirochetes and Candida albicans can cause chronic infections. At this stage, the DNA of microbes remains undetectable yet active. This can act as the prolonged pathogenic stimulus that over-triggers the expression of Aβ-related genes, which subsequently lead to overproduction and deposition of Aβ plaque. This review will highlight the pathogenesis of each of the stated microbial infection, their association in AD pathogenesis as well as the effect of chronic infection in AD progression. Potential therapies for AD by modulating the microbiome have also been suggested. This review will aid in understanding the infectious manifestations of AD.

The cognitive remediation of attention in HIV-associated neurocognitive disorders (HAND): A meta-analysis and systematic review

Background: Despite medical advances in Highly Active Antiretroviral Therapy (HAART), patients living with HIV continue to be at risk for developing HIV-associated neurocognitive disorders (HAND). The optimization of non-HAART interventions, including cognitive rehabilitation therapy (CRT), shows promise in reversing the impact of HAND. No data exist indicating the efficacy of CRT in remediating attention skills following neuroHIV. This paper presents a meta-analysis of randomised and non-randomised controlled trials (RCTs) to remediate attention skills following HIV CRT. Methods: The database search included literature from Google Scholar, ERIC, Cochrane Library, ISI Web of Knowledge, PubMed, PsycINFO, and grey literature published between 2013 and 2022. Inclusion criteria included studies with participants living with HIV who had undergone CRT intervention to remediate attention skills following neuroHIV. Exclusion criteria included case studies, non-human studies, and literature reviews. To assess study quality, including, randomisation, allocation concealment, participant and personnel blinding, the Cochrane Collaboration ratings system was applied. Results: A total of 14 studies met the inclusion criteria (n = 532). There were significant pre- to post-intervention between-group benefits due to CRT in the experimental group relative to control conditions for the remediation of attention skills following HIV acquisition (Hedges g = 0.251, 95% CI = 0.005 to 0.497; p < 0.05). No significant effects (p > 0.05) were demonstrated for subgroup analysis. Conclusions: To the author's knowledge, this is the first meta-analysis that exclusively analyses the remediation of attention skills in the era of HAART and neuroHIV, where all studies included participants diagnosed with HIV. The overall meta-analysis effect indicates the efficacy of CRT in remediating attention skills in HIV and HAND. It is recommended that future cognitive rehabilitation protocols to remediate attention skills should be context and population-specific and that they be supplemented by objective biomarkers indicating the efficacy of the CRT. Registration: Protocols.io (01/03/2023).

Predictors of an Active Lifestyle in Middle-Aged and Older Adults with HIV in the United States Deep South

Background and Purpose

An active lifestyle is important for health maintenance and disease prevention. This study was to examine what factors predict an active lifestyle in HIV+ and HIV- adults from the United States Deep South.

Methods

The sample included 279 participants (174 HIV+ and 105 HIV-) who completed a comprehensive assessment. An active lifestyle composite was created using variables of employment status, level of social support, level of physical activity, and diet. Correlations and regression analyses were conducted between the active lifestyle composite and possible predictors for all (HIV+ and HIV-), HIV+, and HIV- participants, respectively.

Results

Lower levels of depression, higher socioeconomic status (SES), and younger age were significant predictors of a more active lifestyle for the full sample, HIV+, and HIV- participants, respectively.

Conclusion

SES and depression represent important factors influencing engagement in an active lifestyle in PLWH. Such factors should be considered when developing and implementing lifestyle interventions.

Health-Related Quality of Life in People Living With HIV With Cognitive Symptoms: Assessing Relevant Domains and Associations

This study aimed to validate and assess a comprehensive set of illness-specific health-related quality of life (HRQL) domains in people living with HIV (PLWH) with cognitive symptoms. One hundred and three HIV patients with cognitive symptoms (n = 93 male, 90.3%) were identified from two UK HIV clinics and complete a series of validated scales measuring seven HRQL domains identified as important to HRQL by PLWH with cognitive impairment. These included: physical functioning, cognition, social connectedness, self-concept, HIV stigma, acceptance of and perceived control over cognitive health, and physical and mental health and wellbeing. Exploratory factor analysis confirmed that domain total scores loaded onto one main factor, representing HRQL. Scale cut-off scores revealed a significant proportion of patients scored outside the normal range on single domains (between 26.2% and 79.6%), and many patients on multiple domains (40.8% on 4 or more domains). We found evidence of poor HRQL across domains in the majority of PLWH with cognitive symptoms and identified domains driving these experiences. This provides targets for intervention development and clinical action to maintain or improve HRQL in PLWH with cognitive symptoms or impairment.

Cognitive Differences between Men and Women with HIV: A Systematic Review and Meta-Analysis

OBJECTIVE

Although many studies report that women with HIV (WWH) are more vulnerable to cognitive impairment than men with HIV (MWH), this trend is not described consistently in the literature. In this systematic review and meta-analysis, we investigated whether the weight of evidence supports the existence of a significant sex difference in cognitive functioning among people with HIV and, if so, whether specific domains are affected.

METHOD

A systematic literature search retrieved 4,062 unique articles published between January 2000 and June 2019. Eligibility criteria were that studies directly compared adult WWH and MWH using a neuropsychological test battery. After extensive screening, we included 11 studies in the systematic review (N = 3,333) and 6 in the meta-analysis (N = 2,852).

RESULTS

Six studies included in the systematic review found WWH performed significantly more poorly on measures of cognitive performance than MWH; the other five found no sex differences. Meta-analytic results indicated that WWH performed significantly more poorly than MWH in three cognitive domains (psychomotor coordination, visuospatial learning, and memory), but magnitudes of effect sizes were small (d = -.16, -.43, and - .30, respectively). Analyses detected no sex differences in global cognitive functioning and in the other cognitive domains.

CONCLUSIONS

Sex differences in cognitive performance are small, and sociodemographic and psychiatric characteristics of WWH and MWH differ between studies. Cognitive differences between WWH and MWH may be explained by sex-based variation in these characteristics, the impact of which seems to outweigh that of HIV-related clinical variables (e.g., CD4 count and viral load).

MRI imaging features of HIV-related central nervous system diseases: diagnosis by pattern recognition in daily practice

With the advent of antiretroviral therapy (ART), the prognosis of people infected with human immunodeficiency virus (HIV) has improved, and the frequency of HIV-related central nervous system (CNS) diseases has decreased. Nevertheless, mortality from HIV-related CNS diseases, including those associated with ART (e.g., immune reconstitution inflammatory syndrome) remains significant. Magnetic resonance imaging (MRI) can improve the outlook for people with HIV through early diagnosis and prompt treatment. For example, HIV encephalopathy shows a diffuse bilateral pattern, whereas progressive multifocal leukoencephalopathy, HIV-related primary CNS lymphoma, and CNS toxoplasmosis show focal patterns on MRI. Among the other diseases caused by opportunistic infections, CNS cryptococcosis and CNS tuberculosis have extremely poor prognoses unless diagnosed early. Immune reconstitution inflammatory syndrome shows distinct MRI findings from the offending opportunistic infections. Although distinguishing between HIV-related CNS diseases based on imaging alone is difficult, in this review, we discuss how pattern recognition approaches can contribute to their early differentiation.

Is There Any Evidence of Premature, Accentuated and Accelerated Aging Effects on Neurocognition in People Living with HIV? A Systematic Review

Despite evidence of premature, accentuated and accelerated aging for some age-related conditions such as cardiovascular diseases in people living with HIV (PLHIV), the evidence for these abnormal patterns of aging on neurocognition remains unclear. Further, no systematic review has been dedicated to this issue. Using PRISMA guidelines, we searched standard databases (PubMed, EMBASE, CINAHL and PsycINFO). Articles were included if they analyzed and reported the effect of age on neurocognition among PLHIV as one of their major findings, if they were conducted in the combination anti-retroviral therapy era (after 1996) and published in a peer-reviewed journal in English. Quality appraisal was conducted using the Joanna Briggs Institute (JBI) appraisal tools. To systematically target the abnormal patterns of neurocognitive aging, we define premature cognitive aging as significant interaction effect of HIV status and age on cross-sectional neurocognitive test performance covering both the normal and abnormal performance range; accentuated cognitive aging as significant interaction effect of HIV status and age on cross-sectional neurocognitive impairment (NCI) rate, thus covering the abnormal performance range only; accelerated cognitive aging as significant interaction effect of HIV status and age on longitudinal neurocognitive test performance or incidence of NCI. Because these definitions require an age-comparable HIV-negative (HIV-) control group, when no controls were included, we determined the range of the age effect on neurocognitive test performance or NCI among PLHIV. A total of 37 studies originating from the US (26), UK (2), Italy (2), Poland (2), China (2), Japan (1), Australia (1), and Brazil (1) were included. Six studies were longitudinal and 14 included HIV- controls. The quality appraisal showed that 12/37 studies neither used an age-matched HIV- controls nor used demographically corrected cognitive scores. A meta-analysis was not possible because study methods and choice of neurocognitive measurement methods and outcomes were heterogeneous imposing a narrative synthesis. In studies with an HIV- control sample, premature neurocognitive aging was found in 45% of the cross-sectional analyses (9/20), while accelerated neurocognitive aging was found in 75% of the longitudinal analyses (3/4). There was no evidence for accentuated aging, but this was tested only in two studies. In studies without an HIV- control sample, the age effect was always present but wide (NCI OR = 1.18-4.8). While large sample size (> 500) was associated with abnormal patterns of cognitive aging, most of the studies were under powered. Other study characteristics such as longitudinal study design and higher proportion of older participants were also associated with the findings of abnormal cognitive aging. There is some support for premature and accelerated cognitive aging among PLHIV in the existing literature especially among large and longitudinal studies and those with higher proportion of older samples. Future HIV and cognitive aging studies need to harmonize neuropsychological measurement methods and outcomes and use a large sample from collaborative multi-sites to generate more robust evidences.

Association between education level and HIV-associated neurocognitive disorder: a systematic review and meta-analysis

In the era of antiretroviral treatment, human immunodeficiency virus (HIV)-associated neurocognitive disorder (HAND) is common in HIV-positive (HIV+) patients, with an incidence of 30-50%. The relationship between education level and HAND has been evaluated in some studies, however, the results were inconsistent. The aim of this meta-analysis was to provide compelling evidence on the association between education level and the risk of HAND. Reports were searched for in the databases of Medline, Embase and PsyclNFO. Studies evaluating the relationship between education level and HAND in adult HIV+ patients were included. The pooled odds ratio/risk ratio was analysed by using the random-effects model. Two subgroup analyses were performed according to the adjustment of educational level in the neurocognitive impairment assessment and the income level. In total, 18 studies were included. Six studies and 12 studies reported education level as the continuous variable and categorical variable, respectively. The methods used for the assessment of neurocognitive impairment in included studies were neuropsychological battery tests (n = 10), HIV Dementia Scale (n = 1), the International HIV Dementia Scale (n = 6) and the Chinese version of the Montreal Cognitive Assessment (n = 1). The result showed that the risk of HAND in HIV+ patients who have lower education attainment was significantly higher than that in HIV+ patients who have higher education attainment. In conclusion, this meta-analysis demonstrated that HIV+ patients who have low education attainment carry higher risk of developing HAND compared with HIV+ patients who have high education attainment. This study highlighted the importance of early neurological screening for HIV+ patients who have low education level.

The Prevalence of Frascati-Criteria-Based HIV-Associated Neurocognitive Disorder (HAND) in HIV-Infected Adults: A Systematic Review and Meta-Analysis

Background: The HIV associated mortality is decreasing in most countries due to the widespread use of antiretroviral therapy. However, HIV-associated neurocognitive disorder (HAND) remains a problematic issue that lowers the quality of life and increases the public health burden among people living with HIV. The prevalence of HAND varies across studies and selected samples. Therefore, we aimed to quantitatively summarize the pooled prevalence of Frascati-criteria-based HAND and to explore the potential demographic, clinical, and immunological factors. Methods: A comprehensive literature search in PubMed/Medline, Web of Science, Embase, and PsycINFO was performed. A random-effects meta-analysis was conducted using the event rate (ER) for the estimation of the incidence of HAND. Subgroup meta-analyses were used to evaluate between-group differences in categorical variables. Meta-regression with the unrestricted maximum likelihood (ML) method was used to evaluate associations of continuous variables. Results: Eighteen studies whose sample sizes ranged from 206 to 1555 were included in the final analyses. The estimated prevalence of HAND, ANI, MND and HAD were 44.9% (95% CI 37.4-52.7%), 26.2% (95% CI 20.7-32.7%), 8.5% (95% CI 5.6-12.7%), 2.1% (95% CI 1.2-3.7%), respectively. Factors associated with HAND were percent female, current CD4 count, education level and country development level (all ps < 0.05). Conclusion: Longitudinal cohort and multimodal neuroimaging studies are needed to verify the clinical prognosis and the underlying neurocognitive mechanism of HAND. In addition, it is urgently necessary to establish a standardized HAND diagnostic process.

Prevalence and Predictors of Neurocognitive Impairment in Ethiopian Population Living with HIV

BACKGROUND

Modern antiretroviral therapy has extended the life expectancies of people living with HIV; however, the prevention and treatment of their associated neurocognitive decline have remained a challenge. Consequently, it is desirable to investigate the prevalence and predictors of neurocognitive impairment to help in targeted screening and disease prevention.

MATERIALS AND METHODS

Two hundred and forty-four people living with HIV were interviewed in a study using a cross-sectional design and the International HIV Dementia Scale (IHDS). Additionally, the sociodemographic, clinical, and psychosocial characteristics of the patients were recorded. Chi-square and binary logistic regression analysis were used to determine the level of significance among the independent risk factors and probable neurocognitive impairment.

RESULTS

The point prevalence of neurocognitive impairment was found to be 39.3%. Participants' characteristics of being older than 40 years (AOR= 2.81 (95% CI; 1.11-7.15)), having a history of recreational drug use (AOR= 13.67 (95% CI; 6.42-29.13)), and being non-compliant with prescribed medications (AOR= 2.99 (95% CI; 1.01-8.87)) were independent risk factors for neurocognitive impairment.

CONCLUSION

The identification of predictors, in the Ethiopian people living with HIV, may help in the targeted screening of vulnerable groups during cART follow-up visits. This may greatly help in strategizing and implementation of the prevention program, more so, because (i) HIV-associated neurocognitive impairment is an asymptomatic condition for considerable durations, and (ii) clinical trials on neurocognitive impairment therapies have been unsuccessful.

Risk factors for symptomatic HIV-associated neurocognitive disorder in adults aged 50 and over attending a HIV clinic in Tanzania

OBJECTIVES

HIV-associated neurocognitive disorder (HAND), although prevalent, remains a poorly researched cause of morbidity particularly in sub-Saharan Africa (SSA). We aimed to explore the risk factors for HAND in people aged 50 and over under regular follow-up at a government HIV clinic in Tanzania.

METHODS

HIV-positive adults aged 50 years and over were approached for recruitment at a routine HIV clinic appointment over a 4-month period. A diagnostic assessment for HAND was implemented, including a full medical/neurological assessment and a collateral history from a relative. We investigated potential risk factors using a structured questionnaire and by examination of clinic records.

RESULTS

Of the cohort (n = 253), 183 (72.3%) were female and the median age was 57 years. Fifty-five individuals (21.7%) met the criteria for symptomatic HAND. Participants were at a greater risk of having symptomatic HAND if they lived alone [odds ratio (OR) = 2.566, P = .015], were illiterate (OR 3.171, P = .003) or older at the time of HIV diagnosis (OR = 1.057, P = .015). Age was correlated with symptomatic HAND in univariate, but not multivariate analysis.

CONCLUSIONS

In this setting, HIV-specific factors, such as nadir CD4 count, were not related to symptomatic HAND. The "legacy theory" of early central nervous system damage prior to initiation of anti-retroviral therapy initiation may contribute, only in part, to a multifactorial aetiology of HAND in older people. Social isolation and illiteracy were associated with symptomatic HAND, suggesting greater cognitive reserve might be protective.

Cognitive Reserve Over the Lifespan: Neurocognitive Implications for Aging With HIV

Approximately 59% of adults living with HIV experience HIV-associated neurocognitive disorder, a collection of symptoms and cognitive deficits in various cognitive domains. As the HIV population ages, the prevalence and severity of such cognitive deficits are expected to grow. Understanding how these cognitive deficits manifest is important for nurses and health care providers. This article provides an overview of cognitive reserve and evidence of how it is compromised by HIV, aging, and individual characteristics. Within this context of cognitive reserve, the role of neuroinflammation, neurotoxicity, substance use, comorbidities, depression and anxiety, social isolation, and sedentary lifestyle is reviewed. From this, strategies used to address cognitive deficits are provided, including topics such as psychostimulants, cognitive training, multimodal lifestyle interventions, and compensation strategies. Scenarios of successful and unsuccessful cognitive aging are presented to provide a lifespan perspective of cognitive reserve. Implications for clinical practice and research are provided, as it relates to aging.

Potential pharmacological approaches for the treatment of HIV-1 associated neurocognitive disorders

HIV associated neurocognitive disorders (HAND) are the spectrum of cognitive impairments present in patients infected with human immunodeficiency virus type 1 (HIV-1). The number of patients affected with HAND ranges from 30 to 50% of HIV infected individuals and although the development of combinational antiretroviral therapy (cART) has improved longevity, HAND continues to pose a significant clinical problem as the current standard of care does not alleviate or prevent HAND symptoms. At present, the pathological mechanisms contributing to HAND remain unclear, but evidence suggests that it stems from neuronal injury due to chronic release of neurotoxins, chemokines, viral proteins, and proinflammatory cytokines secreted by HIV-1 activated microglia, macrophages and astrocytes in the central nervous system (CNS). Furthermore, the blood-brain barrier (BBB) not only serves as a route for HIV-1 entry into the brain but also prevents cART therapy from reaching HIV-1 brain reservoirs, and therefore could play an important role in HAND. The goal of this review is to discuss the current data on the epidemiology, pathology and research models of HAND as well as address the potential pharmacological treatment approaches that are being investigated.

Neurocognitive dysfunction and brain FDG-PET/CT findings in HIV-infected hemophilia patients and HIV-infected non-hemophilia patients

This single-institution cross-sectional study aimed to grasp the prevalence and features of neurocognitive dysfunction in HIV-infected hemophilia patients in Japan. We conducted neuropsychological tests and medical examinations in 56 HIV-infected hemophilia patients who received outpatient treatment at the AIDS Clinical Center, National Center for Global Health and Medicine. A total of 388 HIV-infected non-hemophilia patients who received outpatient treatment at the same institution were included as a control group. To investigate sites responsible for neurocognitive dysfunction in HIV-infected hemophilia patients using brain FDG-PET/CT scans, the accumulation of FDG in each brain region was compared. Approximately 50% of HIV-infected hemophilia patients had neurocognitive dysfunction. The prevalence of asymptomatic neurocognitive impairment was high (34%). Neurocognitive dysfunction was associated with educational level in HIV-infected hemophilia patients. In the symptomatic group, hemophilic arthropathy and history of cerebrovascular disorders were associated with neurocognitive dysfunction. Left temporal lobe function was reduced in the symptomatic group.

Pathogenesis, clinical course, and recent issues in HIV-1-infected Japanese hemophiliacs: a three-decade follow-up

Nearly 30% of Japanese hemophiliacs were infected with HIV-1 in the early 1980s. They have unique characteristics compared to HIV-1-infected individuals through other routes, including date of infection of 1986 or earlier, mean age of nearly 50 years, and common co-infection with hepatitis C, but rarely with other sexually transmitted diseases. Antiretroviral therapy (ART) was introduced in Japan in 1997. The clinical courses before and after 1997 were quite different. Careful analysis of the pre-1997 clinical data allowed expansion of our knowledge about the natural course and pathogenesis of the disease. Switching to the second receptor agents proved critical in subsequent disease progression. HIV-1 continued to escape immune pressure, pushing disease progression faster. In contrast, ART was effective enough to overcome the natural course. Prognosis improved dramatically and cause of death changed from AIDS-related opportunistic infections and malignancies before 1997, to hepatitis C virus-related cirrhosis and hepatocellular carcinoma (HCC) around 2010, and again to non-AIDS defining malignancies recently. In most cases, hepatitis C was cured with direct acting antiviral therapy. However, HCV progressed to cirrhosis in some cases and risk of HCC is still high among these patients. Together with improvement in anticoagulants and aging of the patients, risk of myocardial infarction has increased recently. In addition, the numbers of patients with life-style related co-morbidities, such as diabetes mellitus, hypertension, and chronic kidney disease have been also increasing. Finally, stigma is still an important barrier to a better life in HIV-1-positive individuals.

Cognitive function and drivers of cognitive impairment in a European and a Korean cohort of people living with HIV

Although cognitive impairments are still prevalent in the current antiretroviral therapy era, limited investigations have compared the prevalence of cognitive disorder in people living with HIV (PLWH) and its determinants in different regions and ethnicities. We compared cognitive performance across six domains using comparable batteries in 134 PLWH aged ≥45 years from the COBRA study (Netherlands, UK), and 194 PLWH aged ≥18 years from the NeuroAIDS Project (South Korea). Cognitive scores were standardized and averaged to obtain domain and global T-scores. Associations with global T-scores were evaluated using multivariable regression and the ability of individual tests to detect cognitive impairment (global T-score ≤45) was assessed using the area-under-the-receiver-operating-characteristic curve (AUROC). The median (interquartile range) age of participants was 56 (51, 62) years in COBRA (88% white ethnicity, 93% male) and 45 (37, 52) years in NeuroAIDS (100% Korean ethnicity, 94% male). The rate of cognitive impairment was 18.8% and 18.0%, respectively ( p = 0.86). In COBRA, Black-African ethnicity was the factor most strongly associated with cognitive function (11.1 [7.7, 14.5] lower scores vs. white ethnicity, p < 0.01), whereas in NeuroAIDS, age (0.6 [0.1, 1.3] per 10-year, p<0.01) and education (0.7 [0.5, 0.9] per year, p<0.01) were significantly associated with cognitive function with anemia showing only a weak association (−1.2 [−2.6, 0.3], p=0.12). Cognitive domains most associated with cognitive impairment were attention (AUROC = 0.86) and executive function (AUROC = 0.87) in COBRA and processing speed (AUROC = 0.80), motor function (AUROC = 0.78) and language (AUROC = 0.78) in NeuroAIDS. Two cohorts of PLWH from different geographical regions report similar rates of cognitive impairment but different risk factors and cognitive profiles of impairment.

Non-AIDS-defining malignancies in Japanese hemophiliacs with HIV-1 infection

Along improvement of prognosis of HIV-1-infected patients due to successful anti-retroviral therapy, main causes of death in the patients have been changing from AIDS to non-AIDS defining malignancies (NADM) recently. However, little is known about the prevalence and incidence of NADM in patients, and especially in HIV-1-infected hemophiliacs. We prospectively conducted NADM screening with FDG-PET, chest CT, upper gastrointestinal endoscopy, tumor markers, and stool occult blood in hemophiliacs with a mean age of 48.9 years. Screening was done twice from December 2016 through March 2019; the first screening was used to calculate prevalence in 69 patients and the second was used to calculate incidence in 56 patients. The first screening revealed 4 cases of malignancies; three were cases of thyroid cancer and one was a case of a neuroendocrine tumor in the pancreas; prevalence was 5.8% (95% CI: 0.2-11.4%). During a mean follow-up of 1.2 years with 68.2 person-years (PYs), cancer was diagnosed in 2 cases (pancreatic and liver cancer) during the second screening. Incidence was 2.99/100 PY. It can be speculated that there might be around 40 cases of undiagnosed NADM currently and 20 cases of new NADM annually in this population, because 718 HIV-1-infected hemophiliacs are surviving in Japan according to the 2018 Nationwide Survey on Coagulation Disorders. Screening for NADM in HIV-1-infected hemophiliacs at other hospitals is strongly recommended.

Prevalence and Correlates of Neurocognitive Disorders among HIV Patients on Antiretroviral Therapy at a Kenyan Hospital

Background

HIV-associated neurocognitive disorders (HAND) represent a spectrum of cognitive abnormalities affecting attention, concentration, learning, memory, executive function, psychomotor speed, and/or dexterity. Our objectives in this analysis are to determine the prevalence of HAND and the covariates in a Kenyan population.

Methods

We conducted a cross-sectional study in a convenient sample of people living with HIV on antiretroviral therapy (ART) attending routine care visits at the Kenyatta National Hospital HIV clinic between July and August 2015. Baseline demographics were obtained using interviewer-administered questionnaires; clinical data were abstracted from patient records. Trained research clinicians determined the neurocognitive status by administration of the International HIV Dementia Scale (IHDS), the Montreal Cognitive Assessment (MOCA) scale, and the Lawton Instrumental Activities of Daily Living (IADL) scale. Cognitive impairment was defined as a score of ≤26 on the MOCA and ≤10 on the IHDS. Descriptive analysis and logistic regression to determine predictors of screening positive for HAND were done with the significance value set at <0.05.

Results

We enrolled 345 participants (202 men; 143 women). The mean age of the study population was 42 years (±standard deviation (SD) 9.5). Mean duration since HIV diagnosis and mean duration on ART were 6.3 (±SD 3.7) and 5.6 years (±SD 3.4), respectively. Median CD4 count at interview was 446 cells/mm³ (interquartile range (IQR) 278–596). Eighty-eight percent of participants screened positive for HAND, of whom 87% had asymptomatic neurocognitive impairment (ANI) and minor neurocognitive disorders (MND) grouped together while 1% had HIV-associated dementia (HAD). Patients on AZT/3TC/EFV were 3.7 times more likely to have HAND (OR = 3.7, p=0.03) compared to other HAART regimens. In the adjusted analysis, women were more likely to suffer any form of HAND than men (aOR = 2.17, 95% CI: 1.02, 4.71; p=0.045), whereas more years in school and a higher CD4 count (aOR = 0.58, 95% CI: 0.38, 0.88; p=0.012), (aOR = 0.998, 95% CI 0.997, 0.999; p=0.013) conferred a lowered risk.

Conclusion

Asymptomatic and mild neurocognitive impairment is prevalent among people living with HIV on treatment. Clinical care for HIV-positive patients should involve regular screening for neurocognitive disorders while prioritizing women and those with low education and/or low CD4 counts.

The Iowa Gambling Task on HIV-infected subjects

HIV-associated neurocognitive disorders (HAND) are characterized by cognitive, behavioral, and motor dysfunctions, which impact daily functioning and are predictive of poor survival among patients. The diagnosis of HAND is marked by clinically significant declines in multiple domains of neurocognitive functioning. Some patients diagnosed with HAND have social problem; however, higher brain dysfunction is not detected in general neuropsychological assessments and the intelligence quotient may remain unchanged. Impaired decision-making may reduce social and occupational qualities of life. The Iowa Gambling Task (IGT) has been developed as a task to evaluate risk predictions at the time of decision-making. In the present study, 38 HIV-infected patients enrolled in our hospital performed IGT and we investigated whether the results obtained are associated with HAND. The median net IGT score of all HIV-infected subjects was significantly lower than that of healthy controls. Patients diagnosed with HAND accounted for 43.8% of the negative net score group. We elucidated the relationship between the net IGT score and HAND for the first time. We think that IGT is a good tool to detect decision-making impairment for ANI and MND. Careful follow-ups of the progression of HAND and increased awareness among HIV-infected patients and medical care workers of the risk of social behavioral disorders, which negatively impact daily life before they are detected, are needed in order to prevent deteriorations in the quality of life of these patients.

Effect of HIV Subtype and Antiretroviral Therapy on HIV-Associated Neurocognitive Disorder Stage in Rakai, Uganda

BACKGROUND

Combination antiretroviral therapy (ART) improves HIV-associated neurocognitive disorder (HAND) stage in the United States where subtype B predominates, but the effect of ART and subtype on HAND stage in individuals in Uganda with subtypes D and A is largely unknown.

SETTING

A community-based cohort of participants residing in Rakai, Uganda.

METHODS

Three hundred ninety-nine initially ART-naive HIV-seropositive (HIV+) individuals were followed up over 2 years. Neurological and neuropsychological tests and functional assessments were used to determine HAND stage. Frequency and predictors of HAND and HIV-associated dementia (HAD) were assessed at baseline and at follow-up after ART initiation in 312 HIV+ individuals. HIV subtype was determined from gag and env sequences.

RESULTS

At 2-year follow-up, HAD frequency among HIV+ individuals on ART (n = 312) decreased from 13% to 5% (P < 0.001), but the overall frequency of HAND remained unchanged (56%-51%). Subtype D was associated with higher rates of impaired cognition (global deficit score ≥ 0.5) compared with HIV+ individuals with subtype A (55% vs. 24%) (P = 0.008). Factors associated with HAD at baseline were older age, depression, and plasma HIV viral load >100,000 copies/mL. At follow-up, age and depression remained significantly associated with HAD.

CONCLUSIONS

HIV+ individuals on ART in rural Uganda had a significant decrease in the frequency of HAD, but HAND persists after 2 years on ART. The current guideline of immediate ART initiation after HIV diagnosis is likely to greatly reduce HAD in sub-Saharan Africa. Further studies of the effect of HIV subtype and neurocognitive performance are warranted.

Various associations of aging and long-term HIV infection with different neurocognitive functions: detailed analysis of a Japanese nationwide multicenter study

Detailed information of the effects of age and long-term HIV infection on various neurocognitive function have not been fully evaluated yet. In a prospective Japanese nationwide multicenter study of 17 facilities (J-HAND study), 728 HIV-infected individuals completed 14 neuropsychological (NP) tests; Verbal Fluency (VF; category and letter), Digit Span (DS; forward and backward), Trail Making Test (TMT) A-B, Rey-Osterrieth Complex Figure Test (ROCFT; copy, immediate and delayed recall), Story Memory Test (SMT; immediate and delayed recall), Digit Symbol Subset (DSS), and the Grooved Pegboard (GP; dominant and non-dominant). Multivariate analysis identified older age (≥ 50 years) to be associated with lower scores in all three ROCFT and GP dominant [odds ratio (OR) [95% confidence interval (CI)] 1.801 (1.217-2.664), 2402 (1.366-3.055), 2.691 (1.720-4.211), and 2.302 (1.145-4.628), respectively], whereas longer time since diagnosis was associated with a lower score in ROCFT (delayed recall) (OR 1.224, 95%CI 1.045-1.434). In VF letter, older age and longer time since diagnosis were associated with a better score [OR (95%CI) 0.449 (0.234-0.861) and 0.831 (0.692-0.997)]. In DSS and TMT-A, longer time since diagnosis was associated with a better score [OR (95%CI): 0.808 (0.670-0.973) and 0.795 (0.665-0.949), respectively]. Older patients in later years since diagnosis are at higher risk of visuospatial and motor impairments despite ART, whereas they are less likely to develop verbal impairment, suggesting that verbal function is relatively resistant to aging and long history of HIV infection under ART. These findings suggest that customtailored supports should be established based on the individual background.

No Association Between Human Immunodeficiency Virus Infections And Dementia: A Nationwide Cohort Study In Taiwan

BACKGROUND

The associations between the human immunodeficiency virus (HIV) and dementias are as yet to be studied in Taiwan. The aim of this study is to clarify as to whether HIV infections are associated with the risk of dementia.

METHODS

A total of 1,261 HIV-infected patients and 3,783 controls (1:3) matched for age and sex were selected between January 1 and December 31, 2000 from Taiwan's National Health Insurance Research Database (NHIRD). Fine and Gray's survival analysis (competing with mortality) analyzed the risk of dementias during the 15-year follow up. The association between the highly active antiretroviral therapy (HAART) and dementia was analyzed by stratifying the HAART status among the HIV subjects.

RESULTS

During the follow-up period, 25 in the HIV group (N= 1,261) and 227 in the control group (N= 3,783) developed dementia (656.25 vs 913.15 per 100,000 person-years). Fine and Gray's survival analysis revealed that the HIV patients were not associated with an increased risk of dementia, with the adjusted hazard ratio (HR) as 0.852 (95% confidence interval [CI]: 0.189-2.886, p=0.415) after adjusting for sex, age, comorbidities, geographical region, and the urbanization level of residence. There was no significant difference between the two groups of HIV-infected patients with or without HAART in the risk of dementia.

CONCLUSION

This study found that HIV infections, either with or without HAART, were not associated with increased diagnoses of neurodegenerative dementias in patients older than 50 in Taiwan.

Targeting HIV-Related Neurocognitive Impairments with Cognitive Training Strategies: Insights from the Cognitive Aging Literature

Approximately 50% of older adults with HIV meet the Frascati diagnostic criteria of HIV-associated neurocognitive disorders (HAND) which can interfere with everyday function such as medication adherence, employment, and driving ability, thus reducing quality of life. As the number of older adults with HIV continues to grow, many will become vulnerable to cognitive frailty, especially as they experience multimorbidities, polypharmacy, and geriatric syndromes. Healthcare professionals need strategies to prevent, remediate, and compensate for cognitive losses observed in memory, language, executive functioning, and speed of processing. Sadly, there are no standard protocols or accepted treatment/intervention guidelines to address HAND at this time. Fortunately, evidence from the cognitive aging literature indicates that cognitive training can protect and improve cognition in normal older adults and may even reduce the incidence of dementia/MCI. This article provides the scientific context in which computerized cognitive training approaches have been successfully used in older adults and provides examples of how these approaches have been translated to adults with HIV. Evidence from ongoing clinical trials are also presented that suggest that reversing a diagnosis of HAND may be possible. Recommendations for clinical practice and research are provided.

Computerized Cognitive Training for the Neurocognitive Complications of HIV Infection: A Systematic Review

The synergistic effects of HIV and aging on the brain may compromise cognitive reserve, resulting in HIV-associated neurocognitive disorder. The neuroscience literature suggests that computerized cognitive training programs represent a practical strategy to protect or remediate cognitive functioning in older adults. Such cognitive training programs may hold similar therapeutic benefits for adults living with HIV. This systematic review evaluated the effects of cognitive training interventions in adults living with HIV. This systematic review includes 13 studies that have been conducted or are being conducted. Results suggest that cognitive training may improve the cognitive domain that is the target of training. One case study even demonstrated a reversal of HIV-associated neurocognitive disorder after cognitive training. Although greater evidence is needed to establish treatment guidelines, current evidence suggests that cognitive training improves cognitive function, which translates to more optimal everyday functioning (i.e., driving), improved mood, greater locus of control, and enhanced quality of life.

Comparison of two screening tests for HIV-Associated Neurocognitive Disorder suspected Japanese patients with respect to cART usage

In this study, we demonstrated the pervasiveness of HIV-associated neurocognitive disorders (HAND) among a selection of Japanese patients as well as evaluated and compared the Mini Mental State Examination (MMSE) and the International HIV Dementia Scale (IHDS) for use as a screening tool among combination anti-retroviral therapy (cART)-naïve and cART experienced patients. The MMSE and the IHDS have both been used as HAND screening tests around the world with variable success. It has been reported the increased usage of cART the utility of these screening tests may have been diminished due to the decreased severity of impairment and the altered pattern of neurocognitive impairments in cART era HAND patients. It is therefore possible the MMSE and the IHDS may still be useful among cART-naïve patients even in the cART era. However, only one study has investigated and compared the screening results of the IHDS among cART-naïve and cART experienced patients. All HIV positive patients who visited, or were admitted, to the Ryukyu University Hospital between January 2009 and March 2014 were evaluated for inclusion. Selected patients (n = 49) had data without omission for all tests. The overall prevalence of HAND in our cohort was 44%. The area under the curve (AUC), for all subjects using the MMSE and the IHDS, were 0.60 and 0.69, respectively. However, the AUC among cART-naïve patients were 0.58 and 0.76 for the MMSE and the IHDS, respectively. Whereas, cART experienced patients had an AUC of 0.60 and 0.61, respectively. Overall, the MMSE demonstrated a poor screening ability for HAND, regardless of cART usage (the cut-off value of 27 had a Youden's J-Index of 0.1, in all groups). Alternatively, the IHDS was moderately useful for HAND screening among cART-naïve patients (the cut-off value of 11 had a Youden's J-Index of 0.4), but performed poorly as a screening test among cART experienced patients (the cut-off value of 11 had a Youden's J-Index of 0.1).