Psychiatric symptom burden in older people living with HIV with and without cognitive impairment: the UCSF HIV over 60 cohort study

Patient reported experiences in older adults living with HIV - a scoping review

Effective antiretroviral therapy has extended the life expectancy of people living with HIV and in Western countries, with 50% of individuals in Western countries now aged 50 or older. The aim was to review empirical research on adults who are 60 years or older on their experiences of living with HIV and their healthcare needs. A scoping review with a systematic literature search in Cinahl, Psycinfo and PubMed was performed in February and March 2022. A total of 4757 references, published 2012-2022, were screened and 20 studies were included. The findings indicate that the experiences and needs of older adults living with HIV vary depending on whether they are in the younger or the eldest part of the cohort. Overall, the group lives with multiple chronic conditions, is at a higher risk of cognitive limitations and reports more loneliness than people with no HIV. Limited qualitative research was available. Thus, future research should describe the subjective experiences of older adults to understand psychosocial aspects that impact successful ageing. This knowledge can inform interventions and services to support the well-being of older adults living with HIV, not only in Western countries but globally as the ageing population living with HIV continues to grow.

United Voices Group-Singing Intervention to Address Loneliness and Social Isolation Among Older People With HIV During the COVID-19 Pandemic: Intervention Adaption Study

BACKGROUND

People living with HIV experience HIV stigma alongside a spectrum of aging-related health conditions that accelerate their vulnerability to the ill effects of loneliness and social isolation. Group-singing interventions are efficacious in improving psychosocial well-being among older people in the general population; however, the social curative effects of group singing have not been explored in relation to HIV stigma. By promoting group identification, bonding, and pride, group singing may reduce loneliness, social isolation, and other negative impacts of HIV stigma among older people living with HIV. Access to group-singing programs may be enhanced by technology.

OBJECTIVE

While group singing has been extensively studied in older adults, group-singing interventions have not been adapted for older people living with HIV to target loneliness and social isolation in the context of HIV stigma. The objective of this study was to describe the systematic development of a group-singing intervention to reduce loneliness and social isolation among older people living with HIV.

METHODS

In the San Francisco Bay Area between February 2019 and October 2019, we engaged older people living with HIV in a rigorous, 8-stage, community-engaged intervention adaptation process using the Assessment, Decision, Adaptation, Production, Topical Experts, Integration, Training, and Testing (ADAPT-ITT) framework. On the basis of a formative assessment of the needs and preferences of older people living with HIV, we selected an evidence-based group-singing intervention for older adults and systematically adapted the intervention components by administering them to a community advisory council (n=13).

RESULTS

The result was United Voices, a 12-week hybrid (web-based and in-person) group-singing intervention for older people living with HIV. United Voices comprises 12 web-based (ie, via Zoom [Zoom Video Communications]) rehearsals, web-based and in-person drop-in helpdesk sessions, and a professionally produced final concert recording.

CONCLUSIONS

Through an iterative process and in consultation with stakeholders and topic experts, we refined and manualized United Voices and finalized the design of a pilot randomized controlled trial to evaluate the feasibility and acceptability of the intervention protocol and procedures. The findings provide insights into the barriers and facilitators involved in culturally tailoring interventions for older people living with HIV, implementing intervention adaptations within web-based environments, and the promise of developing hybrid music-based interventions for older adults with HIV.

Patient experiences with value-based healthcare interventions at the HIV outpatient clinic of the Erasmus Medical Centre

BACKGROUND

One of the aims of value-based healthcare (VBHC) is to deliver more patient-centred care. However, little is known about the effect of VBHC interventions on patient experiences. We aim to explore how patients experience VBHC as implemented in an HIV outpatient clinic in an academic hospital in the Netherlands.

METHODS

The HIV outpatient clinic of the Erasmus MC, Rotterdam, the Netherlands, an academic tertiary hospital, implemented a VBHC intervention consisting of 1) implementation of a generic quality of life questionnaire, administered before each visit, 2) a change in consultation schedule; from twice a year face-to-face to one face-to-face double consultation and one remote consultation per year, and 3) a change in consultation structure; from a single face-to-face consultation with the infectious diseases (ID) specialist to a double consultation in which the patient visits both the nurse and the ID specialist. Semi-structured interviews were held with Dutch or English-speaking adult patients, that had been a patient within Erasmus MC for more than 5 years, on their experiences with the implemented changes.

RESULTS

Thirty patients were interviewed. Patients had no objections towards completing the questionnaires especially if it could provide the professionals with additional information. Patients were primarily positive about the change in consultation schedule. For the yearly remote consultation they preferred a telephone-consultation above a video-consultation. The change in consultation structure ensured that more topics, including psychosocial and medical aspects could be discussed. Some patients did not see the added value of talking to two professionals on the same day or completing the quality of life questionnaire before their consultation.

CONCLUSION

Patients are generally positive towards the VBHC interventions implemented at the HIV outpatient clinic. Our findings may inform further optimization of VBHC interventions and improve patient-centred care in outpatient HIV clinics.

Mindfulness-Based Stress Reduction for Symptom Management in Older Individuals with HIV-Associated Neurocognitive Disorder

The growing number of people aging with HIV represents a group vulnerable to the symptom burdens of HIV-associated neurocognitive disorder (HAND). Among younger groups, Mindfulness-Based Stress Reduction (MBSR) has been shown to help people living with HIV manage HIV-related and other life stress, and although there is some theoretical and empirical evidence that it may be effective among those with cognitive deficits, the approach has not been studied in older populations with HAND. Participants (n = 180) 55 years or older with HIV and cognitive impairment were randomly assigned to either an 8-week MBSR arm or a waitlist control. We assessed the impact of MBSR compared to a waitlist control on psychological outcomes [stress, anxiety, depression, and quality of life (QOL)] and cognitive metrics (e.g., speed of information processing, working memory, attention, impulsivity) measured at baseline, immediately post intervention (8 weeks) and one month later (16 weeks). Intent to treat analyses showed significant improvement in the MBSR group compared to control on symptoms of depression from baseline to 8 weeks, however, the difference was not sustained at 16 weeks. The MBSR group also showed improvement in perceived QOL from baseline to 16 weeks compared to the waitlist control group. Cognitive performance did not differ between the two treatment arms. MBSR shows promise as a tool to help alleviate the symptom burden of depression and low QOL in older individuals living with HAND and future work should address methods to better sustain the beneficial impact on depression and QOL.

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.

Waitlist-controlled trial of an online intervention to address mental health among older people living with HIV

Background: Older people living with HIV (PLWH) often experience elevated levels of depression, anxiety, and loneliness.Methods: This waitlist-controlled trial examined the effectiveness of online audio mindfulness lessons in impacting these feelings among older PLWH.Results: Among 214 participants, the mean (SD) age was 60.4 (5.9) years, 89% were male, and 69% were white. After 25 days, the intervention group showed significant improvements versus the waitlist control group in symptoms of depression (20.3% improvement, p < .01) and symptoms of anxiety (22.4% improvement, p = .03), but not in loneliness as measured by a Daily Diary (12.9% improvement, p = .07) or the 3-Item Loneliness Scale (4.8% improvement, p = .27). Secondary analyses among participants with elevated baseline symptoms of depression showed a 26.3% improvement (p < .01), with a moderate effect size (Hedge's g = 0.69). Similarly, those with elevated baseline symptoms of anxiety showed a 25.6% improvement (p < .01), a moderate effect size (g = 0.54), while those with moderate or severely elevated loneliness showed an 18.9% improvement in daily loneliness (p < .01), a moderate effect size (g = 0.55).Conclusion: This waitlist-controlled trial is the first to show that a series of brief, online audio mindfulness lessons improves mental health outcomes among older PLWH. For many patients, this intervention may offer relief that is both accessible and affordable.

Frailty and Aging in HIV- Status Post 13 Years of National Awareness

The People aged 50 years and above comprise over 50% of people living with HIV (PLWH) in the US. Despite the advances made with anti-retroviral therapy in increasing their life span, PLWH are plagued with non-AIDS associated conditions which increase their risk for morbidity and mortality. Frailty, a decline in physical and functional reserve, is one of the manifestations of aging, has a prevalence of 5-30%, and occurs up to 2 decades earlier in people aging with HIV (PAWH). The majority of providers for PAWH have minimal experience with the concept of gerontology, frailty, and aging. Hence, there is a gap in clinicians' knowledge on how to address frailty and aging in PAWH. This review will focus on the clinical interventions that mitigate frailty and aging in PAWH as well as highlight areas of investigation towards achieving these mediations. Beyond the identification of the roles of exercise and nutrition, more studies are needed on the pragmatic approach to apply these resources to routine care. There should be continued reinforcement of the proven strategy of combination antiretroviral therapy as well as treatment of co-infections and age-appropriate health and cancer screening in PAWH.

The impact of depression and post-traumatic stress symptoms on physical health perceptions and functional impairment among sexual minority men living with HIV with histories of trauma

Mental health symptoms may compromise health-related quality of life (HRQOL), including among men who have sex with men (MSM) living with HIV, who experience high rates of trauma and other stressors. This study sought to examine the relative contributions of post-traumatic stress disorder (PTSD) symptoms, depression symptoms, and biological indices of HIV disease status on HRQOL in this population. Participants were 79 MSM with HIV (49% White; 35% Black; 8% Hispanic/Latinx) with trauma histories (52% met current PTSD diagnostic criteria). HRQOL outcomes were general perceptions of health (0-100 visual analog scale) and functional disability (WHODAS 2.0). Dominance analysis was applied to examine the relative share of variance in these outcomes accounted for by PTSD symptom severity, depression symptom severity, viral suppression status, and CD4 count. Depression symptom severity accounted for 70% and 92% of variance in perceived health, respectively, across models (p's < 0.05). Both PTSD symptom severity (45%) and depression symptom severity (43%) scores also accounted for significant variance in functional disability (p's < 0.05). Medical indices of HIV disease progression did not explain significant variance in HRQOL in any model. A trauma-informed approach may aid clinicians in interpreting reports of health and physical functioning in MSM with HIV.

Emerging directions of cognitive aging with HIV: practice and policy implications for social work

Cognitive impairments have been endemic to the HIV epidemic since its beginning and persist to this day. These impairments are attributed to HIV-induced neuroinflammation, the long-term effects of combination antiretroviral therapy, lifestyle factors (e.g., sedentary behavior, substance use), neuro-comorbidities (e.g., depression), age-associated comorbidities (e.g., heart disease, hypertension), and others causes. Normal aging and lifestyle also contribute to the development of cognitive impairment. Regardless of the etiology, such cognitive impairments interfere with HIV care (e.g., medication adherence) and everyday functioning (e.g., driving safely, financial management). With more than half of people with HIV (PWH) 50 years and older, and ~45% of all PWH meeting the criteria for HIV-Associated Neurocognitive Disorder (HAND), those aging PWH are more vulnerable for developing cognitive impairment. This article provides an update to a social work model to identify and monitor PWH for cognitive impairment. Within this update, the state of the science on protecting brain health and cognitive reserve within the context of neuroHIV is also presented. From this, implications for practice and policy to promote successful cognitive functioning in older PWH are provided.

Deprenyl reduces inflammation during acute SIV infection

In the era of antiretroviral therapy, inflammation is a central factor in numerous HIV-associated comorbidities, such as cardiovascular disease, cognitive impairment, and neuropsychiatric disorders. This highlights the value of developing therapeutics that both reduce HIV-associated inflammation and treat associated comorbidities. Previous research on monoamine oxidase inhibitors (MAOIs) suggests this class of drugs has anti-inflammatory properties in addition to neuropsychiatric effects. Therefore, we examined the impact of deprenyl, an MAOI, on SIV-associated inflammation during acute SIV infection using the rhesus macaque model of HIV infection. Our results show deprenyl decreased both peripheral and CNS inflammation but had no effect on viral load in either the periphery or CNS. These data show that the MAOI deprenyl may have broad anti-inflammatory effects when given during the acute stage of SIV infection, suggesting more research into the anti-inflammatory effects of this drug could result in a beneficial adjuvant for antiretroviral therapy.

A Heavy Burden: Preexisting Physical and Psychiatric Comorbidities and Differential Increases Among Male and Female Participants After Initiating Antiretroviral Therapy in the HIV Outpatient Study, 2008-2018

Attention to non-AIDS comorbidities is increasingly important in the HIV care and management in the United States. We sought to assess comorbidities before and after antiretroviral therapy (ART) initiation among persons with HIV (PWH). Using the 2008-2018 HIV Outpatient Study (HOPS) data, we assessed changes in prevalence of physical and psychiatric comorbidities, by sex, among participants initiating ART. Cox proportional hazards models were fit to investigate factors associated with the first documented occurrence of key comorbidities, adjusting for demographics and other covariates, including insurance type, CD4⁺ cell count, ART regimen, and smoking status. Among 1,236 participants who initiated ART (median age 36 years, CD4 cell count 375 cells/mm³), 79% were male, 66% non-white, 44% publicly insured, 53% ever smoked, 33% had substance use history, and 22% had body mass index ≥30 kg/m². Among females, the percentages with at least one condition were: at ART start, 72% had a physical and 42% a psychiatric comorbidity, and after a median of 6.1 years of follow-up, these were 87% and 63%, respectively. Among males, the percentages with at least one condition were: at ART start, 61% had a physical and 32% a psychiatric comorbidity, and after a median of 4.6 years of follow-up, these were 82% and 53%, respectively. In multivariable Cox proportional hazards analyses, increasing age and higher viral loads (VL) were associated with most physical comorbidities, and being a current/former smoker and higher VL were associated with all psychiatric comorbidities analyzed. HOPS participants already had a substantial burden of physical and psychiatric comorbidities at the time of ART initiation. With advancing age, PWH who initiate ART experience a clinically significant increase in the burden of chronic non-HIV comorbidities that warrants continued surveillance, prevention, and treatment.

Exploring the Psychosocial Impact of Living With HIV on Minority Older Women

BACKGROUND: Among older adults, minority older women will account for 60% of the new HIV diagnoses. The psychosocial impact of living with HIV among this vulnerable population narrated by their own voices has been understudied. AIMS: The purpose of this study was to explore the psychosocial impact of living with HIV on minority older women. METHODS: In-depth interviews were conducted with 28 minority older women living with HIV at an Ambulatory Care Center HIV Clinic in South Florida. All interviews were audio-recorded and transcribed verbatim. Conventional content analysis was used to identify and define the major themes that emerged from the interviews. Questions included those concerning description of life after the HIV diagnosis, most challenging aspects of life after the diagnosis, and daily activities since the diagnosis. RESULTS: The analysis of the interview data led to five main themes: (I) Social Impact of HIV, (II) Threats to Health and Well-Being, (III) HIV as a Death Sentence, (IV) Spirituality, and (V) HIV Treatment Adherence. In their narratives, women described a myriad of psychosocial issues such as depressed mood, isolation, economic challenges, stigma, anhedonia of interest, fear of death, among others. CONCLUSIONS: There is a compelling empirical need for rapid implementation of a culturally tailored, holistic, low-cost, multistrategy intervention to early screen and reduce the psychosocial impact of HIV among minority older women.

Evaluation of Computerized Cognitive Training and Cognitive and Daily Function in Patients Living With HIV: A Meta-analysis

IMPORTANCE

In the era of antiretroviral therapy (ART), the incidence of HIV-associated neurocognitive disorder (HAND) has not yet been controlled. With the exception of ART, there is no beneficial pharmacologic treatment. However, some studies have reported that computerized cognitive training (CCT) programs may improve cognitive function among people living with HIV.

OBJECTIVE

To examine the association between CCT programs and 8 domains measuring cognitive function (7 domains) and daily function (1 domain) among people living with HIV.

DATA SOURCES

Records from the Cochrane Library, PsycINFO, PubMed, and Web of Science were searched from database inception to December 15, 2020. Supplementary searches to identify missing studies were conducted in Google Scholar using updated search terms from database inception to November 18, 2021.

STUDY SELECTION

Studies that compared changes before and after a CCT intervention among people living with HIV were included. Search terms were a combination of words associated with HIV (eg, people living with HIV, HIV, and/or AIDS) and cognitive training (eg, cognitive intervention, nonpharmacology intervention, computer game, video game, computerized training, cognitive exercise, cognitive stimulation, and/or cognitive enhancement). Studies were included if they (1) used CCT as the primary intervention or combined CCT with other types of interventions; (2) used placebo, passive control conditions, traditional cognitive training, or single training tasks as control conditions; (3) reported changes between baseline and posttraining; (4) included participants 18 years or older; and (5) were randomized clinical trials (RCTs). Studies were excluded if they (1) were not associated with HIV, (2) were research protocols or feedback reports, (3) were case reports, or (4) did not report findings for domains of interest.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Random-effects models were used to quantitatively synthesize the existing data.

MAIN OUTCOMES AND MEASURES

Primary outcomes were the meta-synthesized changes in each domain after CCT.

RESULTS

Among 1245 records identified, 1043 were screened after removal of duplicates. Of those, 1019 records were excluded based on titles and abstracts, and 24 full-text articles were assessed for eligibility. After exclusions, 12 eligible RCTs were selected for inclusion in the meta-analysis. These RCTs involved 596 total participants, with 320 individuals in the CCT group (mean age, 47.5-59.7 years; 0%-94% female; 8.3-14.2 years of education) and 276 individuals in the control group (mean age, 44.2-60.0 years; 19%-90% female; 9.0-14.9 years of education). The average HIV inhibition ratio (the proportion of participants who achieved virological suppression) ranged from 30% to 100%, and the CD4+ T-cell count ranged from 471 to 833 cells/μL. The time since training ranged from 3 to 24 weeks. After receipt of CCT, function significantly improved in 6 of the 8 domains: abstraction and executive function (standardized mean difference [SMD], 0.58; 95% CI, 0.26-0.91; P < .001), attention and working memory (SMD, 0.62; 95% CI, 0.33-0.91; P < .001), memory (SMD, 0.59; 95% CI, 0.20-0.97; P = .003), motor skills (SMD, 0.50; 95% CI, 0.24-0.77; P < .001), speed of information processing (SMD, 0.65; 95% CI, 0.37-0.94; P < .001), and daily function (SMD, 0.44; 95% CI, 0.02-0.86; P = .04). Sensory and perceptual skills (SMD, 0.06; 95% CI, -0.36 to 0.48; P = .78) and verbal and language skills (SMD, 0.46; 95% CI, -0.07 to 0.99; P = .09) did not significantly improve after CCT.

CONCLUSIONS AND RELEVANCE

This meta-analysis of RCTs found that CCT programs were associated with improvements in cognitive and daily function among people living with HIV. Future studies are needed to design optimal specific training programs and use implementation science to enable the transformation of CCT from a scientific research tool to a real-world clinical intervention.

The High-Intensity Exercise Study to Attenuate Limitations and Train Habits in Older Adults With HIV (HEALTH): A Research Protocol

ABSTRACT

The High-Intensity Exercise Study to Attenuate Limitations and Train Habits in Older Adults With HIV (HEALTH), which incorporates an exercise and biobehavioral coaching intervention, has the following overall goals: (a) to determine whether high-intensity interval training (HIIT) mitigates physical function impairments, fatigue, and impairments in mitochondrial bioenergetics of older people living with HIV (PLWH) to a greater extent than continuous moderate exercise (CME); and (b) to determine whether a biobehavioral coaching and mobile health text messaging intervention after HIIT or CME can promote long-term adherence to physical activity. The HEALTH study is a randomized trial of 100 older PLWH (≥50 years of age) who self-report fatigue and have a sedentary lifestyle. Enrolled participants will be randomized to 16 weeks of supervised HIIT or CME training, followed by a 12-week maintenance phase, involving a mobile health coaching intervention. Outcomes of the HEALTH study will inform the development of scalable, effective exercise recommendations tailored to the unique needs of aging PLWH.

Targeting neurotransmitter-mediated inflammatory mechanisms of psychiatric drugs to mitigate the double burden of multimorbidity and polypharmacy

The increased incidence of multimorbidities and polypharmacy is a major concern, particularly in the growing aging population. While polypharmacy can be beneficial, in many cases it can be more harmful than no treatment, especially in individuals suffering from psychiatric disorders, who have elevated risks of multimorbidity and polypharmacy. Age-related chronic inflammation and immunopathologies might contribute to these increased risks in this population, but the optimal clinical management of drug-drug interactions and the neuro-immune mechanisms that are involved warrants further investigation. Given that neurotransmitter systems, which psychiatric medications predominantly act on, can influence the development of inflammation and the regulation of immune function, it is important to better understand these interactions to develop more successful strategies to manage these comorbidities and complicated polypharmacy. I propose that expanding upon research in translationally relevant human in vitro models, in tandem with other preclinical models, is critical to defining the neurotransmitter-mediated mechanisms by which psychiatric drugs alter immune function. This will define more precisely the interactions of psychiatric drugs and other immunomodulatory drugs, used in combination, enabling identification of novel targets to be translated into more efficacious diagnostic, preventive, and therapeutic interventions. This interdisciplinary approach will aid in better precision polypharmacy for combating adverse events associated with multimorbidity and polypharmacy in the future.

Exploring Intimate Partner Relationships before and after HIV Diagnosis among Minority Older Women

OBJECTIVES

Literature shows that sexual activity remains important at older age and is a valued part of life. However, little is known about the intimate partner relationships (IPR) among minority older women living with Human Immunodeficiency Virus (HIV). The purpose of this study is to explore the effect HIV diagnosis had on the intimate partner relationships (IPR) among minority older women living with HIV (MOWH).

METHODS

Qualitative descriptive study. A total of 28 MOWH (Black and Latinas) aged 50 years and older participated in face to face semi-structured in-depth interviews. Interviews were analyzed using content analysis.

RESULTS

Three themes emerged from the analysis: (a)"Intimate partner relationships before HIV diagnosis" that revealed sexual practices increasing the risk for HIV in their intimate relationships; (b)"Facing relationship consequences of HIV disclosure after diagnosis" explored the consequences of HIV disclosure, and how disclosure determined the future of their intimate relationships; and (c) "Intimate partner relationships after HIV diagnosis" described the quality of intimate partner relationships and changes after HIV diagnosis.

CONCLUSIONS

Results from this study contribute to understanding and increasing awareness of the effect of HIV on the intimacy of MOWH.

CLINICAL IMPLICATIONS

Education provided by health care workers and interventions targeting MOWH should address the effect of HIV in IPR, address MOWH's concerns about it, and help them to improve their overall health.

Considering the Impact of Aging When Caring For and Treating Adults With HIV

The current study investigates how age impacts factors associated with successfully managing HIV. One hundred thirty adults with HIV were recruited for the study. Participants were divided into two groups, those age ≥50 and those age <50. Cognitive impairment and depressive symptoms were seen at higher rates in older adults, and the severity of depressive symptoms was also higher in older adults. Depressive symptoms impacted cognitive function to a higher degree in older adults compared to younger adults (r = -0.293, p = 0.018 vs. r = -0.109, p = 0.387). Polypharmacy was a greater concern in older adults, with 88% having polypharmacy compared with 60% of younger adults. Similarly, the prevalence of comorbidities was more than double in older adults compared to younger adults. Factors associated with aging complicate management of HIV. Gaining insight into the challenges of caring for this population will furnish nurses with information necessary to provide the best possible care for this growing population. [Journal of Gerontological Nursing, 46(4), 31-40.].

Prevalence and 1-year incidence of HIV-associated neurocognitive disorder (HAND) in adults aged ≥50 years attending standard HIV clinical care in Kilimanjaro, Tanzania

OBJECTIVES

HIV-associated neurocognitive disorders (HANDs) are prevalent in older people living with HIV (PLWH) worldwide. HAND prevalence and incidence studies of the newly emergent population of combination antiretroviral therapy (cART)-treated older PLWH in sub-Saharan Africa are currently lacking. We aimed to estimate HAND prevalence and incidence using robust measures in stable, cART-treated older adults under long-term follow-up in Tanzania and report cognitive comorbidities.

DESIGN

Longitudinal study.

PARTICIPANTS

A systematic sample of consenting HIV-positive adults aged ≥50 years attending routine clinical care at an HIV Care and Treatment Centre during March-May 2016 and followed up March-May 2017.

MEASUREMENTS

HAND by consensus panel Frascati criteria based on detailed locally normed low-literacy neuropsychological battery, structured neuropsychiatric clinical assessment, and collateral history. Demographic and etiological factors by self-report and clinical records.

RESULTS

In this cohort (n = 253, 72.3% female, median age 57), HAND prevalence was 47.0% (95% CI 40.9-53.2, n = 119) despite well-managed HIV disease (Mn CD4 516 (98-1719), 95.5% on cART). Of these, 64 (25.3%) were asymptomatic neurocognitive impairment, 46 (18.2%) mild neurocognitive disorder, and 9 (3.6%) HIV-associated dementia. One-year incidence was high (37.2%, 95% CI 25.9 to 51.8), but some reversibility (17.6%, 95% CI 10.0-28.6 n = 16) was observed.

CONCLUSIONS

HAND appear highly prevalent in older PLWH in this setting, where demographic profile differs markedly to high-income cohorts, and comorbidities are frequent. Incidence and reversibility also appear high. Future studies should focus on etiologies and potentially reversible factors in this setting.

Cognitive ageing is premature among a community sample of optimally treated people living with HIV

OBJECTIVES

Evidence of premature cognitive ageing amongst people living with HIV (PLHIV) remains controversial due to previous research limitations including underpowered studies, samples with suboptimal antiretroviral access, varying rate of virological control, high rate of AIDS, over-representation of non-community samples, and inclusion of inappropriate controls. The current study addresses these limitations, while also considering mental health and non-HIV comorbidity burden to determine whether PLHIV showed premature cognitive ageing compared with closely comparable HIV-negative controls.

METHODS

This study enrolled 254 PLHIV [92% on antiretroviral therapy; 84% with HIV RNA < 50 copies/mL; 15% with AIDS) and 72 HIV-negative gay and bisexual men [mean (SD) age = 49 (10.2) years] from a single primary care clinic in Sydney, Australia. Neurocognitive function was evaluated with the Cogstate Computerized Battery (CCB) at baseline and 6 months after. Linear mixed-effects (LME) models examined main and interaction effects of HIV status and chronological age on the CCB demographically uncorrected global neurocognitive z-score (GZS), adjusting for repeated testing, and then adjusting sequentially for HIV disease markers, mental health and comorbidities.

RESULTS

HIV status and age interacted with a lower GZS (β = -0.43, P < 0.05). Higher level of anxiety symptoms (β = -0.11, P < 0.01), historical AIDS (β = -0.12, P < 0.05) and historical HIV brain involvement (β = -0.12, P < 0.05) were associated with lower GZS.

CONCLUSIONS

We found a robust medium-sized premature ageing effect on cognition in a community sample with optimal HIV care. Our study supports routine screening of cognitive and mental health among PLHIV aged ≥ 50 years.

HIV-1 Tat promotes age-related cognitive, anxiety-like, and antinociceptive impairments in female mice that are moderated by aging and endocrine status

Hypogonadism is a common comorbidity associated with HIV-1 that is more prevalent among infected individuals over the age of 45. The underlying mechanisms are unknown, but both combined antiretroviral therapeutics and HIV-1 proteins, such as trans-activator of transcription protein (Tat), dysregulate steroid-synthetic mechanisms including lipid storage/synthesis and mitochondrial function. Thus, Tat expression may accelerate age-related comorbidities partly by impairing endocrine function. Few studies exist of Tat-mediated behavioral deficits in aged animals and effects of endocrine status have not been investigated. Accordingly, we tested whether conditional Tat expression in aged (~ 1.5 years old), female, Tat-transgenic [Tat(+)] mice increases anxiety-like behavior, impairs cognition, and augments mechanical allodynia, when compared to age-matched controls that do not express Tat protein [Tat(-)]. We further tested whether aged mice that maintained their endocrine status (pre-estropausal) were more resilient to Tat/age-related comorbidities than peri- or post-estropausal mice. Tat and endocrine aging status exerted separate and interacting effects that influenced anxiety-like and cognitive behaviors. Peri- and post-estropausal mice exhibited greater anxiety-like behavior in the elevated plus-maze and impaired learning in the radial arm water maze compared to pre-estropausal mice. Irrespective of estropause status, Tat(+) mice demonstrated impaired learning, reduced grip strength, and mechanical allodynia compared to Tat(-) mice. Tat exposure reduced circulating estradiol in post-estropausal mice and increased the estradiol-to-testosterone ratio in pre-estropausal mice. Changes in circulating estradiol, testosterone, and progesterone correlated with grip strength. Thus, endocrine status is an important factor in age-related anxiety, cognition, neuromuscular function, and allodynia that can be accelerated by HIV-1 Tat protein.

Sex Differences in the Patterns and Predictors of Cognitive Function in HIV

Despite advancements in antiretroviral therapy, mild cognitive deficits persist in nearly half of people with HIV (PWH). The profile of impairment in HIV is highly variable with deficits observed in a range of cognitive domains. Despite evidence of greater cognitive impairment among women with HIV (WWH) vs. men with HIV (MWH), it is unclear how MWH and WWH differ in the type of cognitive impairment and in risk factors associated with cognitive impairment profiles. In a large and well-characterized sample of PWH, we used machine learning to identify profiles of cognitive functioning and their associated factors overall and within sex. Participants included 1,666 PWH (201 WWH; 1,465 MMH) from the HIV Neurobehavioral Research Program who completed a neuropsychological test battery at their baseline visits. Using demographically-adjusted T-scores from 13 test outcomes assessing motor skills, executive functioning, attention/working memory, episodic learning and memory, verbal fluency, and processing speed, we used Kohonen self-organizing maps to identify patterns of high-dimensional data by mapping participants to similar nodes based on T-scores (MCLUST R package). Random forest models were used to determine how sociodemographic (e.g., age, education), clinical (e.g., depressive symptoms, substance use disorder), and biological (e.g., HIV disease characteristics) factors differentially related to membership within a cognitive profile. All analyses were repeated within sex. Three cognitive profiles were identified overall and within each sex. Overall and within MWH, there were unimpaired and global weakness profiles. The third profile in the total sample demonstrated relatively weak auditory attention whereas in MWH showed relative strengths in attention and processing speed. Conversely, there was no unimpaired profile among WWH. Rather, WWH demonstrated separate profiles reflecting weakness in motor skills, a relative weakness in learning and delayed recall, and global weaknesses with spared recognition memory. Despite different cognitive profiles by sex, the most discriminative factors were similar between men and women and included reading level (cognitive reserve), current and nadir CD4 count, plasma HIV viral load, duration of HIV disease, age, depressive symptoms, and race/ethnicity. Findings fill a knowledge gap concerning sex differences in cognitive impairment in PWH and inform personalized risk reduction and therapeutic strategies.

Mindfulness-based stress reduction for HIV-associated neurocognitive disorder: Rationale and protocol for a randomized controlled trial in older adults

The symptom burden of HIV-associated neurocognitive disorder (HAND) is high among older individuals, and treatment options are limited. Mindfulness-based stress reduction (MBSR) has potential to improve neurocognitive performance, psychosocial wellbeing, and quality of life, but empirical studies in this growing vulnerable population are lacking. In this trial, participants (N = 180) age 55 and older who are living with HIV infection, are on combination antiretroviral therapy with suppressed viral loads, and yet continue to experience behavioral and cognitive symptoms of HAND, are randomized to MBSR or to a waitlist control arm that receives MBSR following a 16-week period of standard care. Primary outcomes (attention, executive function, stress, anxiety, depression, everyday functioning, quality of life) and potential mediators (affect, mindfulness) and moderators (social support, loneliness) are assessed at baseline and weeks 8, 16, and 48 in both groups, with an additional assessment at week 24 (post-MBSR) in the crossover control group. Assessments include self-report and objective measures (e.g., neuropsychological assessment, neurological exam, clinical labs). In addition, a subset of participants (n = 30 per group) are randomly selected to undergo fMRI to evaluate changes in functional connectivity networks and their relationship to changes in neuropsychological outcomes. Forthcoming findings from this randomized controlled trial have the potential to contribute to a growing public health need as the number of older adults with HAND is expected to rise.

Association Between Informant-Reported Sleep Disturbance and Incident Dementia: An Analysis of the National Alzheimer's Coordinating Center Uniform Data Set

Informants' reports can be useful in screening patients for future risk of dementia. We aimed to determine whether informant-reported sleep disturbance is associated with incident dementia, whether this association varies by baseline cognitive level and whether the severity of informant-reported sleep disturbance is associated with incident dementia among those with sleep disturbance. A longitudinal retrospective cohort study was conducted using the uniform data set collected by the National Alzheimer's Coordinating Center. Older adults without dementia at baseline living with informants were included in analysis. Cox proportional hazards models showed that participants with an informant-reported sleep disturbance were more likely to develop dementia, although this association may be specific for older adults with normal cognition. In addition, older adults with more severe sleep disturbance had a higher risk of incident dementia than those with mild sleep disturbance. Informant-reported information on sleep quality may be useful for prompting cognitive screening.

A tai chi/qigong intervention for older adults living with HIV: a study protocol of an exploratory clinical trial

Background

Almost half of people living with HIV (PLWH) in the USA are over 50 years of age; this is expected to increase to 70% by 2020. Yet, few interventions exist for older PLWH that address psychological and physical symptoms combined, both prevalent in this population. There is a need to find innovative and accessible interventions that can help older PLWH to manage their symptoms. Mind-body interventions, like tai chi/qigong (TCQ), improve both physical and psychological health. TCQ is a series of slow, low-impact meditative movements that integrates breathwork, meditation, and stances.

Methods

The present study is an exploratory clinical trial that will evaluate the acceptability and feasibility of a 12-week, small group TCQ intervention (n = 24), a sham qigong control condition (n = 24), and a standard of care control condition (n = 24) for older people living with HIV/AIDS. It will also explore any preliminary associations between the TCQ intervention and symptom alleviation. Participants will be recruited from community-based health and social services organizations in Miami, FL, and randomized to one of the 3 conditions.

Discussion

We will assess feasibility and acceptability through questionnaires and adherence to TCQ. We will assess preliminary associations with symptoms such as depression, anxiety, social support, chronic HIV-related fatigue, and clinical outcomes. These will be described through proportions, means, and changes over time through graphing techniques. Outcomes will be assessed at baseline, at post-intervention, and at 3 months follow-up. These preliminary analyses also will provide information necessary to estimate effect size and power needed for a larger clinical trial.

Trial registration

ClinicalTrials.gov NCT03840525. Registered on 16 July 2018.

Plasma inflammatory biomarkers link to diffusion tensor imaging metrics in virally suppressed HIV-infected individuals

OBJECTIVE

Inflammation may contribute to brain white matter health in people living with HIV who report cognitive symptoms despite adherence to combination antiretroviral therapy and viral suppression. We explored relationships between diffusion tensor imaging (DTI) metrics of white matter, plasma biomarkers of immune activation, and cognitive function in the HIV-infected population.

DESIGN

Retrospective study of older adults living with HIV who are combination antiretroviral therapy adherent, virally suppressed, and self-report cognitive symptoms.

METHODS

MRI, blood draws, and standardized neuropsychological test scores were collected from HIV-infected individuals. DTI metrics (fractional anisotropy, mean diffusivity, radial diffusivity, axial diffusivity) and plasma biomarkers (soluble CD163, soluble CD14, neopterin, IFN γ-induced protein 10, monocyte chemoattractant protein 1) were quantified. Statistical analysis explored associations between biomarker levels or neuropsychological test scores and DTI metrics using region of interest analyses and a voxelwise approach.

RESULTS

A total of 43 participants with median (interquartile range) age of 64 (62-66 years), CD4 cell count of 600 (400-760 cell/μl) who were all virally suppressed (<100 copies/ml) were selected. Higher levels of monocyte chemoattractant protein 1 associated with lower fractional anisotropy and higher mean diffusivity (P < 0.05) across white matter tracts including corpus callosum, corona radiata, and superior longitudinal fasciculus. Higher neopterin associated with higher mean diffusivity in the genu of corpus callosum, and higher soluble CD14 associated with lower fractional anisotropy in the bilateral superior corona radiata (P < 0.05). Worse global performance and speed domain scores associated with higher mean diffusivity and lower fractional anisotropy, and worse executive domain scores associated with lower fractional anisotropy (P < 0.05).

CONCLUSION

Elevated inflammatory plasma biomarkers link to white matter abnormalities among virally suppressed individuals. DTI abnormalities associate to cognitive performance. We conclude that inflammatory processes impact clinically relevant brain health indices despite viral suppression.

Cytomegalovirus-Specific CD4+ T-cell Responses and CMV-IgG Levels Are Associated With Neurocognitive Impairment in People Living With HIV

BACKGROUND

Mechanisms leading to neurocognitive impairment (NCI) in people living with HIV (PLWHIV) on stable combination antiretroviral therapy (cART) remain unknown. We investigated the association between immunity against cytomegalovirus (CMV), HIV-specific variables, and NCI in PLWHIV on stable cART and with low comorbidity.

METHODS

Fifty-two PLWHIV on stable cART and 31 HIV-uninfected controls matched on age, sex, education, and comorbidity were tested with a neurocognitive test battery, and CMV-immunoglobulin G (CMV-IgG) levels were measured. In PLWHIV, CMV-specific (CMV-pp65 and CMV-gB) CD4 and CD8 T-cell responses were measured using intracellular cytokine staining and flow cytometry. NCI was defined as a global deficit scale score (GDS score) ≥0.5. GDS scores and domain-specific scores defined severity of NCI. Logistic and linear multivariable regression analyses were used.

RESULTS

NCI was detected in 30.8% of PLWHIV, and HIV was associated with an adjusted odds ratio (aOR) of 5.18 [95% confidence interval (CI): 1.15 to 23.41, P = 0.033] for NCI. In PLWHIV, higher CMV-specific CD4 T-cell responses increased the probability of NCI with an aOR of 1.68 (95% CI: 1.10 to 2.57) for CMV-pp65 or an aOR of 3.73 (95% CI: 1.61 to 16.98) for CMV-gB, respectively. Similar associations were not found with CMV-IgG or CMV-specific CD8 T cells, but when assessing severity of NCI, higher CMV-IgG (per 100 U/mL) was associated with worse GDS scores (β = 0.08) (0.01-0.16), P = 0.044), specifically in the domain of speed of information processing (β = 0.20 (0.04-0.36, P = 0.019).

CONCLUSIONS

PLWHIV had increased risk of NCI. Excess risk may be associated with CMV-specific CD4 T-cell responses and CMV-IgG. Larger longitudinal studies investigating the impact of immunity against CMV on risk of NCI are warranted.

Longitudinal brain atrophy patterns and neuropsychological performance in older adults with HIV-associated neurocognitive disorder compared with early Alzheimer's disease

Older HIV-infected patients are at risk for both HIV-associated neurocognitive disorder (HAND) and Alzheimer's disease. We investigated neuroimaging and neuropsychological performance of 61 virally suppressed older adults with HAND (mean (SD) age 64.3 (3.9) years), 53 demographically matched individuals with mild cognitive impairment of the Alzheimer's type (MCI-AD; 65.0 [4.8]), and 89 healthy controls (65.0 [4.3]) cross-sectionally and over 20 months. At the baseline, both disease groups exhibited lower volumes in multiple cortical and subcortical regions compared with controls. Hippocampal volume differentiated MCI-AD from HAND. Cognitively, MCI-AD performed worse on memory and language compared with HAND. Adjusted longitudinal models revealed greater diffuse brain atrophy in MCI-AD compared with controls, whereas HAND showed greater atrophy in frontal gray matter and cerebellum compared with controls. Comparing HAND with MCI-AD showed similar atrophy rates in all brain regions explored, with no significant findings. MCI-AD exhibited more pronounced language decline compared with HAND. These findings reveal the need for further work on unique cognitive phenotypes and neuroimaging signatures of HAND compared with early AD, providing preliminary clinical insight for differential diagnosis of age-related brain dysfunction in geriatric neuroHIV.

Dopaminergic impact of cART and anti-depressants on HIV neuropathogenesis in older adults

The success of combination antiretroviral therapy (cART) has transformed HIV infection into a chronic condition, resulting in an increase in the number of older, cART-treated adults living with HIV. This has increased the incidence of age-related, non-AIDS comorbidities in this population. One of the most common comorbidities is depression, which is also associated with cognitive impairment and a number of neuropathologies. In older people living with HIV, treating these overlapping disorders is complex, often creating pill burden or adverse drug-drug interactions that can exacerbate these neurologic disorders. Depression, NeuroHIV and many of the neuropsychiatric therapeutics used to treat them impact the dopaminergic system, suggesting that dopaminergic dysfunction may be a common factor in the development of these disorders. Further, changes in dopamine can influence the development of inflammation and the regulation of immune function, which are also implicated in the progression of NeuroHIV and depression. Little is known about the optimal clinical management of drug-drug interactions between cART drugs and antidepressants, particularly in regard to dopamine in older people living with HIV. This review will discuss those interactions, first examining the etiology of NeuroHIV and depression in older adults, then discussing the interrelated effects of dopamine and inflammation on these disorders, and finally reviewing the activity and interactions of cART drugs and antidepressants on each of these factors. Developing better strategies to manage these comorbidities is critical to the health of the aging, HIV-infected population, as the older population may be particularly vulnerable to drug-drug interactions affecting dopamine.

Depression and aging with HIV: Associations with health-related quality of life and positive psychological factors

BACKGROUND

Depression is prevalent among persons living with HIV (PLWH). This study investigated the relationships between depressive symptomatology, health-related quality of life (HRQoL), and positive psychological factors in PLWH and age-matched HIV-individuals.

METHODS

One hundred twenty-two PLWH and 94 HIV- individuals, recruited in three age cohorts (36-45, 46-55, 56-65 years old), completed self-report questionnaires on depressive symptoms (CES-D), HRQoL, and positive psychological factors (resilience, grit, and self-rated successful aging [SRSA]). Participants were classified based on HIV status (H+ vs H-) and elevated depressive symptoms (D+ vs D-) into four groups (H+/D+; H-/D+; H+/D-; H-/D-).

RESULTS

Fifty-eight percent of PLWH had elevated depressive scores, compared to 33% of HIV- individuals (p < 0.001). The proportion of individuals reporting elevated depressive symptoms only differed among individuals 36-45 years old (H+: 61.5%; H-: 17.9%; p < 0.001). Individuals in the H+/D+ group reported the lowest HRQoL, resilience, grit, and SRSA across age cohorts. However, there were no differences on HRQoL or positive psychological factors between H+/D- and H-/D- groups; in fact, individuals 56-65 years in the H+/D- group endorsed aging the most successfully.

LIMITATIONS

Small sample size within the groups and the cross-sectional nature of the analysis limit the ability to address onset of depressive symptoms in relation to HRQoL or positive psychological factors.

CONCLUSIONS

Among PLWH depressive symptoms show a strong association with HRQoL and positive psychological factors compared to HIV- individuals. In the absence of elevated depressive symptoms, however, PLWH report similar HRQoL and positive psychological factors to HIV- individuals.

The effect of increased physical activity on symptom burden in older persons living with HIV

Advancements in antiretroviral therapy have extended the longevity of people living with HIV (PLWH). However, they often experience symptoms that negatively impact their quality of life, including fatigue, weight change, depression, pain, and memory loss. Although there is a dearth of data on the effect of physical activity (PA) for HIV-associated symptom management, increased PA has generally been associated with improvements in strength and overall quality of life. In this study, we enrolled 40 participants (mean age = 51.5; 40% female; 17.4 mean years living with HIV) and used Omron pedometers to measure daily step counts over 12 weeks. The 20-item HIV Symptom Index was administered at baseline and week 12. Increased PA was not associated with improvement in overall HIV symptom burden. However, bothersome symptoms were reduced, and total symptom burden was highly correlated with PA level at week 12 (r = -.48, p = .01), such that participants with  higher step counts reported lower symptom burden. Significant gender differences in symptom burden were noted: males on average reported lower symptom burden. Further research is needed to examine associations between PA and HIV symptom burden and to further explore gender differences in HIV symptom burden to improve overall quality of life for all older PLWH.

The current understanding of overlap between characteristics of HIV-associated neurocognitive disorders and Alzheimer's disease

The advent of effective antiretroviral medications (ARVs) has led to an aging of the HIV population with approximately 50% of people with HIV (PWH) being over the age of 50 years. Neurocognitive complications, typically known as HIV-associated neurocognitive disorders (HAND), persist in the era of ARVs and, in addition to risk of HAND, older PWH are also at risk for age-associated, neurodegenerative disorders including Alzheimer's disease (AD). It has been postulated that risk for AD may be greater among PWH due to potential compounding effects of HIV and aging on mechanisms of neural insult. We are now faced with the challenge of disentangling AD from HAND, which has important prognostic and treatment implications given the more rapidly debilitating trajectory of AD. Herein, we review the evidence to date demonstrating both parallels and differences in the profiles of HAND and AD. We specifically address similarities and difference of AD and HAND as it relates to (1) neuropsychological profiles (cross-sectional/longitudinal), (2) AD-associated neuropathological features as evidenced from neuropathological, cerebrospinal fluid and neuroimaging assessments, (3) biological mechanisms underlying cortical amyloid deposition, (4) parallels in mechanisms of neural insult, and (5) common risk factors. Our current understanding of the similarities and dissimilarities of AD and HAND should be further delineated and leveraged in the development of differential diagnostic methods that will allow for the early identification of AD and more suitable and effective treatment interventions among graying PWH.

Costs associated with hospitalization in HIV-positive patients in France

OBJECTIVES

To estimate the number of patients hospitalized for HIV-related reasons in France, to describe their characteristics and to estimate hospitalization-associated costs.

DESIGN

A retrospective analysis of the French hospital medical information database (Programme de médicalisation des systèmes d'information en médecine, chirurgie, obstétrique et odontologie database).

METHODS

Patients hospitalized with HIV in France in 2013 and 2014 were identified in the database through International Classification of Diseases, 10th revision diagnostic codes as well as comorbidities and opportunistic infections. Hospital stays for each patient were extracted over a 12-month period following the initial index hospitalization. Costing was performed from the perspective of national health insurance. Direct costs were attributed from national tariffs for medical acts and expressed in 2016 Euros.

RESULTS

During the study period, 70 180 stays, including day (80%) and overnight (20%) hospitalization, of patients with HIV were identified, of which 37 477 stays (by 20 126 patients) were directly related to HIV. In patients with overnight hospitalization, an opportunistic infection was documented in 50% of patients and at least one comorbidity were identified in 85% of patients. The overall estimated total annual cost of hospital stays was &OV0556; 64 126 616 (median annual cost per patient: &OV0556; 545). The median annual per capita cost was &OV0556; 541 for day hospitalization, &OV0556; 7664 for overnight stay with comorbidities and &OV0556; 9059 for overnight stay with opportunistic infections.

CONCLUSION

Most patients hospitalized with HIV in France presented an opportunistic infection or at least one comorbidity that contributed to costs of hospitalization. The organization of interfaces between different healthcare providers in hospital and community practice needs to be organized so that comorbidities are identified and managed optimally.

Positive Psychological Factors are Linked to Successful Cognitive Aging Among Older Persons Living with HIV/AIDS

We aimed to characterize successful cognitive aging (SCA) among older HIV-infected (HIV+) and HIV-uninfected (HIV-) adults, and to determine associations with positive psychological factors and health-related quality of life (HRQoL). Ninety-nine HIV+ and 46 HIV- older adults (≥ 50 years) completed measures of neurocognition, positive psychological factors, and HRQoL. Using study-defined SCA criteria (i.e., no cognitive or everyday impairment or major depressive disorder), we compared positive psychological factors and HRQoL across four groups: HIV+/SCA+, HIV+/SCA-, HIV-/SCA+, HIV-/SCA-. SCA was identified in 29% of the HIV+ sample compared to 61% of the HIV- sample (p < 0.01). HIV+/SCA+ participants had higher scores on 8 of 10 measures of positive psychological factors as well as better HRQoL (ps < 0.05) as compared to the HIV+/SCA- group. Furthermore, the HIV+/SCA+ participants had comparable scores on these factors as HIV- adults. Fewer HIV+ than HIV- participants met SCA criteria; however, the level of positive psychological factors among the HIV+/SCA+ group was comparable to the HIV- sample. Our findings present opportunities for interventions to optimize positive psychological factors and potentially improve SCA among older HIV+ adults.

Differentiating HIV-Associated Neurocognitive Disorders From Alzheimer's Disease: an Emerging Issue in Geriatric NeuroHIV

PURPOSE OF REVIEW

The purpose of this review was to examine characteristics that may distinguish HIV-associated neurocognitive disorder (HAND) from early Alzheimer's disease (AD).

RECENT FINDINGS

Cerebrospinal fluid (CSF) AD biomarkers are perturbed in HIV, yet these alterations may be limited to settings of advanced dementia or unsuppressed plasma HIV RNA. Neuropsychological testing will require extensive batteries to maximize utility. Structural imaging is limited for early AD detection in the setting of HIV, but proper studies are absent. While positron-emission tomography (PET) amyloid imaging has altered the landscape of differential diagnosis for age-associated neurodegenerative disorders, costs are prohibitive. Risk for delayed AD diagnosis in the aging HIV-infected population is now among the most pressing issues in geriatric neuroHIV. While clinical, imaging, and biomarker characterizations of AD are extensively defined, fewer data define characteristics of HIV-associated neurocognitive disorder in the setting of suppressed plasma HIV RNA. Data needed to inform the phenotype of AD in the setting of HIV are equally few.

Redefining Aging in HIV Infection Using Phenotypes

Purpose of review

This article critically reviews the utility of “phenotypes” as behavioral descriptors in aging/HIV research that inform biological underpinnings and treatment development. We adopt a phenotypic redefinition of aging conceptualized within a broader context of HIV infection and of aging. Phenotypes are defined as dimensions of behavior, closely related to fundamental mechanisms, and, thus, may be more informative than chronological age. Primary emphasis in this review is given to comorbid aging and cognitive aging, though other phenotypes (i.e., disability, frailty, accelerated aging, successful aging) are also discussed in relation to comorbid aging and cognitive aging.

Recent findings

The main findings that emerged from this review are as follows: (1) the phenotypes, comorbid aging and cognitive aging, are distinct from each other, yet overlapping; (2) associative relationships are the rule in HIV for comorbid and cognitive aging phenotypes; and (3) HIV behavioral interventions for both comorbid aging and cognitive aging have been limited.

Summary

Three paths for research progress are identified for phenotype-defined aging/HIV research (i.e., clinical and behavioral specification, biological mechanisms, intervention targets), and some important research questions are suggested within each of these research paths.

Mechanisms of Cognitive Aging in the HIV-Positive Adult

PURPOSE OF REVIEW

As of the year 2016, an estimated 50% of the United States' HIV-Positive population is aged 50 years or older. Due to a combination of increased rates of infection in older adults, and successful anti-retroviral (ART) regimens allowing HIV-positive adults to survive for decades with the disease, we are now faced with a steadily graying HIV-positive population, with only limited knowledge of how the cognitive and physiological effects of aging intersect with those of chronic HIV-infection.

RECENT FINDINGS

Age-related changes to mood, cognition, and neurological health may be experienced differently in those living with HIV, and research concerning quality of life, mental health, and cognitive aging needs to account for and explore these factors more carefully in the coming years.

SUMMARY

This review will explore the topic of cognitive aging with HIV: 1. Central nervous system (CNS) infection of HIV and how the virus affects brain integrity and function; 2. Cognitive and behavioral symptoms of HIV-Associated Neurocognitive Disorders (HAND); 3. Neurobiological theories of Cognitive Aging and how these processes may be exacerbated by HIV-infection; 4: Clinical implications and complications of aging with HIV and factors that may result in poorer cognitive outcomes.

Longitudinal Modeling of Depressive Trajectories Among HIV-Infected Men Using Cocaine

Cocaine use is prevalent among HIV-infected individuals. While cross-sectional studies suggest that cocaine users may be at increased risk for depression, long-term effects of cocaine on depressive symptoms remain unclear. This is a longitudinal study of 341 HIV-infected and uninfected men (135 cocaine users and 206 controls) ages 30-60 enrolled in the Multicenter AIDS Cohort Study during 1996-2009. The median baseline age was 41; 73% were African-American. In mixed-effects models over a median of 4.8 years of observation, cocaine use was associated with higher depressive symptoms independent of age, education level, and smoking (n = 288; p = 0.02); HIV infection modified this association (p = 0.03). Latent class mixed models were used to empirically identify distinct depressive trajectories (n = 160). In adjusted models, cocaine use was associated with threefold increased odds of membership in the class with persistent high depressive symptoms (95% confidence interval (CI) 1.38-6.69) and eightfold increased odds (95% CI (2.73-25.83) when tested among HIV-infected subjects only. Cocaine use is a risk factor for chronic depressive symptoms, particularly among HIV-infected men, highlighting the importance of integrating mental health and substance use treatments to address barriers to well-being and successful HIV-care.