Psychosocial influences on HIV-1 disease progression: neural, endocrine, and virologic mechanisms

A pilot cross-sectional investigation of chronic shame as a mediator of the relationship between subjective social status and self-rated health among middle-aged adults

Subjective social status (SSS) is an important independent predictor of health outcomes, however, the pathways through which it affects health are poorly understood. Chronic shame has previously been suggested as a potential mechanism but this has never been investigated and the relationship between chronic shame and health is under-researched. The purpose of this pilot study was to explore whether chronic shame explains a significant portion of the association between SSS and self rated health (SRH). Two-hundred American adults aged 30-55 years were recruited via a crowd-sourcing platform and were asked to provide information on their SSS, level of chronic shame, and SRH. Chronic shame significantly mediated the relationship between SSS and SRH. This pilot study provides initial evidence that shame explains a significant portion of the relationship between subjective social status and self-rated health. These findings support the initiation of larger, longitudinal investigations into chronic shame as a mediator of the subjective social status and self-rated health relationship.

The Endocannabinoid System as a Potential Therapeutic Target for HIV-1-Associated Neurocognitive Disorder

Background: Despite the successful introduction of combined antiretroviral therapy, the prevalence of mild to moderate forms of HIV-associated neurocognitive disorders (HAND) remains high. It has been demonstrated that neuronal injury caused by HIV is excitotoxic and inflammatory, and it correlates with neurocognitive decline in HAND. Endocannabinoid system (ECS) protects the body from excitotoxicity and neuroinflammation on demand and presents a promising therapeutic target for treating HAND. Here, we firstly discuss the potential pathogenesis of HAND. We secondly discuss the structural and functional changes in the ECS that are currently known among HAND patients. We thirdly discuss current clinical and preclinical findings concerning the neuroprotective and anti-inflammatory properties of the ECS among HAND patients. Fourth, we will discuss the interactions between the ECS and neuroendocrine systems, including the hypothalamic-pituitary-adrenocortical (HPA) and hypothalamic-pituitary-gonadal (HPG) axes under the HAND conditions. Materials and Methods: We have carried out a review of the literature using PubMed to summarize the current state of knowledge on the association between ECS and HAND. Results: The ECS may be ideally suited for modulation of HAND pathophysiology. Direct activation of presynaptic cannabinoid receptor 1 or reduction of cannabinoid metabolism attenuates HAND excitotoxicity. Chronic neuroinflammation associated with HAND can be reduced by activating cannabinoid receptor 2 on immune cells. The sensitivity of the ECS to HIV may be enhanced by increased cannabinoid receptor expression in HAND. In addition, indirect regulation of the ECS through modulation of hormone-related receptors may be a potential strategy to influence the ECS and also alleviate the progression of HAND due to the reciprocal inhibition of the ECS by the HPA and HPG axes. Conclusions: Taken together, targeting the ECS may be a promising strategy to alleviate the inflammation and neurodegeneration caused by HIV-1 infection. Further studies are required to clarify the role of endocannabinoid signaling in HIV neurotoxicity. Strategies promoting endocannabinoid signaling may slow down cognitive decline of HAND are proposed.

Hair levels of steroid, endocannabinoid, and the ratio biomarkers predict viral suppression among people living with HIV/AIDS in China

BACKGROUND

Predicting viral suppression early is crucial to improving treatment outcomes among people living with HIV/AIDS (PLWH) in clinics. Viral suppression is affected by stress, making stress indicators a potential predictive factor. Most of previous studies used the self-report questionnaire as stress indicators, but there were great drawbacks due to its subjective. In contrast, end products of neuroendocrine systems such as hypothalamic-pituitaryadrenal (HPA) and hypothalamic-pituitary-gonadal (HPG) axes and endogenous cannabinoid system (ECS) that involved in regulating stress as objective stress indicators are urgently needed to predict viral suppression. Therefore, this study aimed to investigate whether neuroendocrine indictors can strongly predict viral suppression among PLWH in China.

METHODS

This cross-sectional study recruited 1198 PLWH on antiretroviral therapy (ART) in Guangxi, China. The concentrations of steroids (i.e., cortisol, cortisone, dehydroepiandrosterone, testosterone and progesterone) and endocannabinoids (i.e., N-arachidonoyl-ethanolamine and 1-arachidonyl glycerol) in hair were quantitated using the LC-APCI+-MS/MS method. To screen biomarkers that were used to predict viral suppression, association between hair biomarkers and viral suppression was examined by Mann-Whitney U test and partial correlation analyses. Receiver operating characteristic (ROC) curves and binary logistic regression based on the optimal classification threshold determined with ROC curves were used to estimate the prediction effects of the screened biomarkers on viral suppression (HIV-1 RNA < 200 copies/mL).

RESULTS

Hair levels of dehydroepiandrosterone (DHEA), and N-arachidonoyl-ethanolamine (AEA), and the cortisol to DHEA ratio exhibited significant intergroup differences (ps < 0.05) and were correlated with HIV viral load (ps < 0.05). Hair DHEA concentrations strongly predicted viral suppression, showing good classification performance (area under the ROC curve = 0.651, p < 0.01) and strong predictive utility (adjusted odd ratio = 2.324, 95 % confidence interval = 1.211-4.899, p < 0.05) with an optimal threshold of 10.5 pg/mg. A hair AEA concentration of 2.4 pg/mg was the optimal threshold for predicting viral suppression based on good classification performance (area under the ROC curve = 0.598, p < 0.05) and predictive power (adjusted odd ratio = 2.124, 95 % confidence interval = 1.045-4.244, p < 0.05). In hair levels of cortisol to DHEA, viral suppression was observed to be highly predictive, with a threshold of 10.5 pg/mg being optimal for classification (area under the ROC curve = 0.624, p < 0.05) and prediction (adjusted odd ratio = 0.421, 95 % confidence interval = 0.201-0.785, p < 0.05).

CONCLUSION

Hair levels of DHEA, and AEA and the cortisol to DHEA ratio were screened and verified to have significant predictive power with optimal thresholds for predicting viral suppression in a large-scale cohort. The data may provide new insights into predictors of successful virological outcomes and inform public health intervention and clinical practice to assist PLWH in achieving and sustaining viral suppression.

Sexual Minority Stress and Cellular Aging in Methamphetamine-Using Sexual Minority Men With Treated HIV

OBJECTIVE

Sexual minority men (e.g., gay, bisexual, and other men who have sex with men) experience stigma and sexual minority stress, which are theorized to drive negative health outcomes. Sexual minority men with treated HIV display persistent immune dysregulation, which could be amplified by sexual minority stress responses to potentiate cellular aging.

METHODS

This cross-sectional study included 52 sexual minority men living with HIV who had undetectable viral load (<40 copies/mL) and biologically confirmed recent methamphetamine use. Participants completed measures assessing sexual minority stress and openness about sexual minority status (i.e., outness). DNA methylation-derived outcomes included the following: the extrinsic epigenetic age acceleration clock, telomere length, naive CD4+ T-helper cells, and naive CD8+ T-cytotoxic/suppressor cells.

RESULTS

After adjusting for negative affect and recent stimulant use, higher sexual minority stress was associated with a faster extrinsic epigenetic age acceleration clock ( β = 0.29, p = .030), shorter telomere length ( β = -0.43, p = .002), and fewer naive CD4+ (β = -0.57, p < .001) and naive CD8+ T cells ( β = -0.57, p < .001). Greater outness was associated with higher naive CD4+ ( β = 0.32, p = .030) and naive CD8+ T cells ( β = 0.38, p = .008) as well as lower plasma interleukin 6 ( β = -0.33, p = .027).

CONCLUSIONS

Sexual minority stress processes are associated with markers of cellular aging and inflammation in methamphetamine-using sexual minority men living with HIV. Longitudinal research should elucidate biobehavioral mechanisms linking sexual minority stress processes with accelerated cellular aging in those with and without HIV.

Social Genomics of Methamphetamine Use, HIV Viral Load, and Social Adversity

Background

Social genomics has demonstrated altered inflammatory and type I interferon (IFN) gene expression among people experiencing chronic social adversity. Adverse social experiences such as discrimination and violence are linked to stimulant misuse and HIV, conditions that dysregulate inflammatory and innate antiviral responses, leading to increased HIV viral replication and risk of chronic diseases.

Purpose

We aimed to determine whether methamphetamine (MA) use, unsuppressed HIV viral load (VL) (≥200 c/mL), and experienced intimate partner violence (IPV) (past 12 months) predicted inflammatory and type I IFN gene expression in HIV-positive Black and Latinx men who have sex with men (MSM).

Methods

Participants were 147 HIV-positive Black and Latinx MSM recruited from the mSTUDY, a cohort of 561 MSM aged 18–45 in Los Angeles, CA, of whom half are HIV-positive and substance-using. Transcriptomic measures of inflammatory and type I IFN activity were derived from RNA sequencing of peripheral blood mononuclear cells and matched to urine drug tests, VL, and survey data across two time points 12 months apart. Analysis used linear random intercept modeling of MA use, unsuppressed VL, and experienced IPV on inflammatory and type I IFN expression.

Results

In adjusted models, MA use predicted 27% upregulated inflammatory and 31% upregulated type I IFN expression; unsuppressed VL predicted 84% upregulated type I IFN but not inflammatory expression; and experienced IPV predicted 31% upregulated inflammatory and 26% upregulated type I IFN expression.

Conclusions

In Black and Latinx MSM with HIV, MA use, unsuppressed VL, and experienced IPV predicted upregulated social genomic markers of immune functioning.

Psychoneuroimmunology in the time of COVID-19: Why neuro-immune interactions matter for mental and physical health

The brain and immune system are intricately connected, and perturbations in one system have direct effects on the other. This review focuses on these dynamic psychoneuroimmune interactions and their implications for mental and physical health in the context of the COVID-19 pandemic. In particular, we describe how psychological states influence antiviral immunity and the vaccine response, and how immune changes triggered by COVID (either via infection with SARS-CoV-2 or associated stressors) can influence the brain with effects on cognition, emotion, and behavior. We consider negative psychological states, which have been the primary focus of psychological research in the context of COVID-19 (and psychoneuroimmunology more generally). We also consider positive psychological states, including positive affect and eudaimonic well-being, given increasing evidence for their importance as modulators of immunity. We finish with a discussion of interventions that may be effective in improving immune function, the neuro-immune axis, and ultimately, mental and physical health.

The acute effect of a laboratory shame induction protocol on endothelial function in young, healthy adults

NEW FINDINGS

What is the central question of this study? Shame is a form of social stress which involves internalizing social devaluations imposed by others. The aim of this study was to determine, for the first time, how acutely experiencing shame impacts endothelial function. What is the main finding and its importance? Brachial artery flow-mediated dilation, an index of endothelial function, was impaired following an intervention that acutely increased self reported shame. This occurred without increases in cortisol or tumor necrosis factor alpha receptor binding. Frequent or prolonged shame induced endothelial dysfunction could have important cardiovascular consequences.

ABSTRACT

Objective The objective of this study was to examine the impact of a shame induction protocol on endothelial function. Methods Fifteen participants (n = 7 men, n = 8 women) completed both a written shame induction and control protocol on two different experimental days. Pre- and post-protocol we assessed: 1) Endothelial function and arterial shear rate via a standard brachial artery reactive hyperemia flow-mediated dilation (FMD) test across two post-intervention time points (15 and 35-min post); 2) Perceived shame via the Experiential Shame Scale (ESS), and; 3) Cortisol and sTNFαRII (soluble tumor necrosis factor alpha receptor) through oral fluid analysis. Results Shame increased after the shame induction protocol (pre: 2.9±.6 vs. post: 3.7±.5, p<.001) but not the control protocol (pre: 3.0±.5 vs. post: 2.8±.5, p = .15) (protocol by time interaction: p<.001). When all three time points were included in the analysis, %FMD did not change over time. Considering only the lowest point, %FMD significantly decreased in response to the shame protocol (pre: 4.8±1.9 vs. post: 3.2±1.6, p<.001) but not the control protocol (4.2±1.8 vs. post: 3.8±1.5, p = .45) (protocol by time interaction: p = .035). Covariation of the shear rate stimulus for FMD did not alter the FMD results. When including both the control and shame protocol, but not the shame protocol alone, increased shame was significantly associated with decreased FMD (r = -.37, p<.046). There were no significant time by protocol interaction effects for cortisol or sTNFαRII. Conclusions Temporary increases in shame may cause transient endothelial dysfunction which, if chronically repeated, could manifest as reduced vasoprotection against atherosclerosis. This article is protected by copyright. All rights reserved.

The relationship of hair glucocorticoid levels to immunological and virological outcomes in a large cohort of combination antiretroviral therapy treated people living with HIV

Background

Existing literature mostly investigated the relationship of acute or short-term glucocorticoid exposure to HIV disease progression using cortisol levels in serum, saliva, or urine. Data are limited on the relationship of long-term glucocorticoid exposure to HIV disease progression. This study examined whether hair glucocorticoid levels, novel retrospective indicators of long-term glucocorticoid exposure, are associated with two common indicators of HIV disease progression (CD4 count and HIV viral load) among a large cohort of combination antiretroviral therapy treated Chinese people living with HIV (PLHIV).

Methods

A total of 1198 treated PLHIV provided hair samples for glucocorticoid (cortisol and cortisone) assay and completed a survey assessing sociodemographic, lifestyle, and HIV-related characteristics. Meanwhile, CD4 count and HIV viral load were retrieved from their medical records. Spearman correlation was used to examine the associations of hair cortisol and cortisone levels to continuous CD4 count and HIV viral load. Multivariate logistic regression was used to predict CD4 count < 500 cells/mm³.

Results

Both hair cortisol and cortisone levels were negatively associated with CD4 count but not with HIV viral load. The odds ratio for CD4 count < 500 cells/mm³ was 1.41 [95% CI 0.99–2.00] and 2.15 [95% CI 1.51–3.05] for those with hair cortisol and cortisone levels in the highest quartile compared to the lowest when controlling for sociodemographic, lifestyle, HIV-related covariates, and HIV viral load.

Conclusion

Hair glucocorticoid levels were associated with CD4 count but not viral load in treated Chinese PLHIV. Our data furtherly supported the hypothesis that elevated glucocorticoid levels are associated with the lower CD4 count.

Sympathetic Nerves and Innate Immune System in the Spleen: Implications of Impairment in HIV-1 and Relevant Models

The immune and sympathetic nervous systems are major targets of human, murine and simian immunodeficiency viruses (HIV-1, MAIDS, and SIV, respectively). The spleen is a major reservoir for these retroviruses, providing a sanctuary for persistent infection of myeloid cells in the white and red pulps. This is despite the fact that circulating HIV-1 levels remain undetectable in infected patients receiving combined antiretroviral therapy. These viruses sequester in immune organs, preventing effective cures. The spleen remains understudied in its role in HIV-1 pathogenesis, despite it hosting a quarter of the body’s lymphocytes and diverse macrophage populations targeted by HIV-1. HIV-1 infection reduces the white pulp, and induces perivascular hyalinization, vascular dysfunction, tissue infarction, and chronic inflammation characterized by activated epithelial-like macrophages. LP-BM5, the retrovirus that induces MAIDS, is a well-established model of AIDS. Immune pathology in MAIDs is similar to SIV and HIV-1 infection. As in SIV and HIV, MAIDS markedly changes splenic architecture, and causes sympathetic dysfunction, contributing to inflammation and immune dysfunction. In MAIDs, SIV, and HIV, the viruses commandeer splenic macrophages for their replication, and shift macrophages to an M2 phenotype. Additionally, in plasmacytoid dendritic cells, HIV-1 blocks sympathetic augmentation of interferon-β (IFN-β) transcription, which promotes viral replication. Here, we review viral–sympathetic interactions in innate immunity and pathophysiology in the spleen in HIV-1 and relevant models. The situation remains that research in this area is still sparse and original hypotheses proposed largely remain unanswered.

Positive Psychological Factors and Life Themes in Relation to Health Outcomes in Women Living with HIV

BACKGROUND

This mixed methods study identified positive psychological factors and life themes expressed in autobiographical narratives of predominantly Black women living with HIV (WLWH) and investigated these in relation to depressive symptoms, antiretroviral therapy (ART) adherence (≥ 95% of time), and undetectable HIV viral load (VL) (< 80 copies/ml).

METHOD

Ninety-eight WLWH from the Women's Interagency HIV Study Chicago site (M age = 45.3; 91% Black) narrated three autobiographical life turning points, reliably coded for positive factors and life themes. ART adherence, VL and depressive symptoms, assessed with Center for Epidemiologic Studies Depression Scale total score (TOT) including its four factors (negative affect (NA), positive affect (PA), somatic symptoms (SS), and interpersonal problems (IP)), were collected over two time points: concurrently with narratives and 6 months later. Composite scores across the two time points were used in all analyses.

RESULTS

Ten positive psychological factors (gratitude, insight, compassion, meaning-making, acceptance, mindfulness, generativity, optimism, self-reliance, and benevolent God beliefs) and three positive life themes (health improvements, positive relationships, and accomplishments) were identified in narratives. Higher accomplishments, overall positive factors, insight, mindfulness, self-reliance, optimism, meaning-making, and acceptance related to lower depressive symptoms (TOT, NA, SS, or IP). Positive factors and life themes did not significantly relate to PA. Higher compassion related to higher ART adherence. Higher accomplishments related to undetectable VL independent of ART adherence.

CONCLUSION

Findings that positive psychological factors and life accomplishments may relate to better health, especially to lower depression, potentially contribute to developing positive psychology interventions for Black WLWH.

A biopsychosocial framework for understanding sexual and gender minority health: A call for action

The number of US adults identifying as lesbian, gay, bisexual, transgender, or a different sexual identity has doubled since 2008, and about 40 % of the sexual and gender minority population identify as people of color. Minority stress theory posits that sexual and gender minorities are at particular risk for stress via stigma and discrimination at the structural, interpersonal, and individual levels. This stress, in turn, elevates the risk of adverse health outcomes across several domains. However, there remains a conspicuously limited amount of research on the psychoneuroimmunology of stress among sexual and gender minorities. We developed the Biopsychosocial Minority Stress Framework which posits that sexual minority status leads to unique experiences of minority stress which results in adverse health behavioral factors, elevated psychological distress and sleep disturbance, and immune dysregulation. Moderators in the model include both individual differences and intersectional identities. There is a crucial need to understand the biological-psychological axis of stress among the increasingly visible sexual and gender minority population to increase their health, longevity, and quality of life.

The impact of trauma on South African women with HIV: The role of anxiety and physical symptomology

Rates of trauma and HIV are high in South Africa, and those who experience more trauma have higher levels of psychological distress. This cross-sectional study examined trauma, physical, and mental health among black South African women living with HIV (WLH). We hypothesised that WLH would have higher rates of trauma than women not living with HIV (WNLH). We also hypothesised that there would be a relationship between trauma, anxiety, and physical symptoms, such that anxiety would mediate the relationship between trauma and physical symptoms for WLH. This study enrolled 242 women, 99 WLH. Women were individually interviewed, completing the Life Stressor Checklist (trauma history), the Physical Symptom Inventory, and the IPAT Anxiety Scale. WLH reported significantly more traumatic life events (M = 3.69, SD = 2.32) than WNLH (M = 3.06, SD = 2.42), t = -2.07, p = 0.04. Additionally, traumatic life events were positively associated with physical symptoms. Further, there was an indirect effect of trauma history on physical symptoms through anxiety, b = 0.97, 95% BC CI [0.29, 1.89], such that the direct effect of trauma on physical symptoms was no longer significant, b = 0.87, 95% BC CI [-0.83, 2.56] when anxiety was added to the model. This pattern of findings suggests that anxiety is a key mechanism through which trauma history is associated with more physical symptoms in WLH. Future research should focus on the effect of interventions alleviating the impact that trauma may have on the mental and physical health of WLH.

Depression and Psychosocial Stress Are Associated With Subclinical Carotid Atherosclerosis Among Women Living With HIV

Background To identify reasons for increased atherosclerotic risk among women living with HIV (WLWH), we evaluated the associations between psychosocial risk factors (depressive symptoms, perceived stress, and posttraumatic stress disorder symptoms) and subclinical atherosclerosis among WLWH and HIV-negative women. Methods and Results Carotid artery focal plaque (localized intima-media thickness >1.5 mm) was measured using B-mode ultrasound imaging in 2004-2005 and 2010-2012 in the Women's Interagency HIV Study. We created psychosocial risk groups using latent class analysis and defined prevalent plaque at the final measurement. We also examined repeated semiannual depression measures with respect to focal plaque formation throughout follow-up. The associations between latent class and prevalent plaque, and between depressive symptom persistence and plaque formation, were assessed separately by HIV status using multivariable logistic regression. Among 700 women (median age 47 years), 2 latent classes were identified: high (n=163) and low (n=537) psychosocial risk, with corresponding prevalence of depression (65%/13%), high stress (96%/12%), and probable posttraumatic stress disorder (46%/2%). Among WLWH, plaque prevalence was 23% and 11% in high versus low psychosocial risk classes (adjusted odds ratio [aOR], 2.12; 95% CI, 1.11-4.05) compared with 9% and 9% among HIV-negative women (aOR, 1.07; 95% CI, 0.24-4.84), respectively. New plaque formation occurred among 17% and 9% of WLWH who reported high depressive symptoms at ≥45% versus <45% of visits (aOR, 1.96; 95% CI, 1.06-3.64), compared with 9% and 7% among HIV-negative women (aOR, 0.82; 95% CI, 0.16-4.16), respectively. Conclusions Psychosocial factors were independent atherosclerotic risk factors among WLWH. Research is needed to determine whether interventions for depression and psychosocial stress can mitigate the increased risk of atherosclerosis for WLWH.

Serious infection may systemically increase noradrenergic signaling and produce psychological effects

Serious infection elicits inflammatory processes that act through a range of molecular pathways, including cytokine signaling. It is not established however that noradrenaline (NA), a widely distributed neurotransmitter in the brain that is also a principal output molecule of the sympathetic nervous system, can produce psychological effects associated with infection. This paper puts forth the hypothesis that through neural-immune crosstalk, serious infection increases noradrenergic signaling, both in the central nervous system and in peripheral organs. In this manner, elevated noradrenergic transmission may help produce basic symptoms of infection such as fever, fatigue, aches and pains (including headache), nausea, and loss of appetite. NA may also promote cognitive impairment, major depression, unipolar mania, and even epileptic seizures in some cases. The paper focuses on three major types of infection: influenza (viral), tuberculosis (bacterial), malaria (parasitic), while also summarizing the potential relationship between NA and human immunodeficiency virus (HIV) infection. Four lines of evidence are used to test association between NA and influenza, tuberculosis, and malaria: direct measures of NA and its metabolites; and incidence of hypertension, bipolar mania, and epileptic seizures, since the latter three conditions may be associated with elevated NA. In addition, heart rate variability data are examined with respect to a number of infectious diseases, since those data provide information on sympathetic nervous system activity. While the data do not unequivocally support elevated noradrenergic signaling promoting psychological symptomatology with infection, many studies are consistent with this view.

Depression and HIV Disease Progression: A Mini-Review

Background

Depression is the most common mental disorder and a leading cause of disability, which commonly presents unexplained psychological and physical symptoms. Depression and HIV/AIDS are commonly comorbid. This review provides an insight into the effect of depression on disease progression among people living with HIV.

Methods

A search for relevant articles was conducted using a database like MEDLINE, Scopus, PsycINFO and CINAHL. Peer-reviewed English journals published between 2015 and 2019 were included in the review.

Results

A total of eight studies conducted in different settings were included in the review. This review has found that psychosocial, neurohormonal and virologic factors associated with depression affect HIV disease progression. Yet, the chronicity of depression, absence of the hormones that have a buffer effect on depression and lack of examination if depression is a predictor, or an outcome of disease progression, were some of the gaps that require further investigation.

Conclusion

Considerably, more research is needed to better understand the effect of mental disorder, especially depression, on HIV disease progression to AIDS and future interventions should, therefore, concentrate on the integration of mental health screening in HIV clinical setup.

Experienced discrimination and racial differences in leukocyte gene expression

Racial disparities in health outcomes between African Americans and European Americans have been well-documented, but not fully understood. Chronic inflammation contributes to several of the diseases showing racial disparities (e.g., Human Immunodeficiency Virus [HIV]), and racial differences in stress exposure (e.g., experiences of racial discrimination) that stimulate pro-inflammatory processes that may contribute to differential health outcomes. We performed a cross-sectional bioinformatic analyses relating perceived discrimination (as measured by the Perceived Ethnic Discrimination Questionnaire [PED-Q]) to the activity of pro-inflammatory, neuroendocrine, and antiviral transcription control pathways relevant to the conserved transcriptional response to adversity (CTRA) in peripheral blood leukocytes. Subjects were 71 individuals (37 HIV-seropositive (HIV+); 34 HIV-seronegative (HIV-)) (mean age = 53 years, range 27-63), who self-identified either as African American/Black (n = 48) or European American/White (n = 23). This provided the opportunity to examine the independent effects of race and HIV, as well as the modifying role of perceived discrimination on pathways involved in CTRA. Exploratory analysis examined the interactive effects of HIV and race on pathways involved in CTRA. Relative to European Americans, African Americans showed increased activity of two key pro-inflammatory transcription control pathways (NF- кB and AP-1) and two stress-responsive signaling pathways (CREB and glucocorticoid receptor); these effects did not differ significantly as a function of HIV infection (HIV x Race interaction, all p > .10). Results suggested that differences in experiences of racial discrimination could potentially account for more than 50% of the total race-related difference in pro-inflammatory transcription factor activity. In sum, differential exposure to racial discrimination may contribute to racial disparities in health outcomes in part by activating threat-related molecular programs that stimulate inflammation and contribute to increased risk of chronic illnesses.

Psychological Stress and Mitochondria: A Conceptual Framework

BACKGROUND

The integration of biological, psychological, and social factors in medicine has benefited from increasingly precise stress response biomarkers. Mitochondria, a subcellular organelle with its own genome, produce the energy required for life and generate signals that enable stress adaptation. An emerging concept proposes that mitochondria sense, integrate, and transduce psychosocial and behavioral factors into cellular and molecular modifications. Mitochondrial signaling might in turn contribute to the biological embedding of psychological states.

METHODS

A narrative literature review was conducted to evaluate evidence supporting this model implicating mitochondria in the stress response, and its implementation in behavioral and psychosomatic medicine.

RESULTS

Chronically, psychological stress induces metabolic and neuroendocrine mediators that cause structural and functional recalibrations of mitochondria, which constitutes mitochondrial allostatic load. Clinically, primary mitochondrial defects affect the brain, the endocrine system, and the immune systems that play a role in psychosomatic processes, suggesting a shared underlying mechanistic basis. Mitochondrial function and dysfunction also contribute to systemic physiological regulation through the release of mitokines and other metabolites. At the cellular level, mitochondrial signaling influences gene expression and epigenetic modifications, and modulates the rate of cellular aging.

CONCLUSIONS

This evidence suggests that mitochondrial allostatic load represents a potential subcellular mechanism for transducing psychosocial experiences and the resulting emotional responses-both adverse and positive-into clinically meaningful biological and physiological changes. The associated article in this issue of Psychosomatic Medicine presents a systematic review of the effects of psychological stress on mitochondria. Integrating mitochondria into biobehavioral and psychosomatic research opens new possibilities to investigate how psychosocial factors influence human health and well-being across the life-span.

Psychosocial risk and management of physical diseases

During the 40 years since the Yale conference on Behavioral Medicine and the founding of the Journal of Behavioral Medicine considerable progress has been made in understanding the role of psychosocial risk and management of physical diseases. We here describe the development of these fundamental concepts from early research on stress through studies of the Type A behavior pattern to more contemporary approaches to the relationship between psychosocial risks and benefits in relation to disease processes. This includes the relationship of psychosocial risk to cancers, cardiovascular diseases (CVD), cardiometabolic disorders, Human Immunodeficiency Virus (HIV)/Acquired Human Immune Deficiency Syndrome. During the past 40 years the effects of prolonged distress responses in the pathogenesis of some cancers and CVD have been well-established and modifiable behavioral, cognitive and social factors have been shown to produce favorable outcome components in the management of such diseases as breast cancer, coronary heart disease and HIV.

The effects of repetitive stress on tat protein-induced pro-inflammatory cytokine release and steroid receptor expression in the hippocampus of rats

Human immunodeficiency virus type 1 (HIV-1) affects the central nervous system (CNS) that may lead to the development of HIV-associated neuropathologies. Tat protein is one of the viral proteins that have been linked to the neurotoxic effects of HIV. Since many individuals living with HIV often experience significant adverse circumstances, the present study investigated whether exposure to stressful conditions would exacerbate harmful effects of tat protein on brain function. Tat protein (10 μg/10 μl) was injected bilaterally into the dorsal hippocampus of the animal using stereotaxic techniques. The control group received an injection of saline (10 μl). Some control and tat protein-treated animals were subjected to restrain stress for 6 h per day for 28 days and compared to a non-stress group. All animals underwent two behavioural tests, the open field test (OFT) and the novel object recognition test (NORT) to assess their mood state and cognitive function respectively. The release of pro-inflammatory cytokines (TNF-α and IL-1β) and the expression of mineralocorticoid (MR) and glucocorticoid (GR) receptors were also measured to see whether the impact of the repetitive stress on Tat protein-induced behavioural effects was mediated by elements of the immune system and the HPA axis. Rats treated with tat protein showed the following behavioural changes when compared to control animals: there was a significant decrease in time spent in the center of the open field during the OFT, a significant reduction in time spent with the novel object during the NORT, but no change in locomotor activity. Real-time PCR data showed that the expression levels of GR and MR mRNA were significantly reduced, while Western blot analysis showed that the protein expression levels of TNF-α and IL-1β were significantly increased. The present findings indicated that injection of tat protein into the hippocampus of rats not subjected to stress may lead to anxiety-like behaviour and deficits in learning and memory. Tat-treated animals subjected to stress evoked only a modest effect on their behaviour and neurochemistry, while stress alone led to behavioural and neurochemical changes similar to tat protein.

Resting-state connectivity and spontaneous activity of ventromedial prefrontal cortex predict depressive symptomology and peripheral inflammation in HIV

Depression and chronic inflammation are common in persons infected with the human immunodeficiency virus (HIV+). Although depression and response to inflammatory challenge are shown to reflect activity in common neural networks, little is known regarding sub-clinical presentation in persons chronically infected with HIV. The relationship of resting-state functional connectivity (rsFC) between the subgenual anterior cingulate cortex (sgACC) and bilateral amygdala to Beck Depression Inventory-1 (BDI) scores were compared within a group of 23 HIV+ and 23 HIV-negative comparison adults. An interaction was found wherein lower rsFC between the sgACC and both right and left amygdala was associated with higher BDI scores in HIV+ individuals. Total BDI scores and plasma levels of IL-6, IL-8, TNF-α, and IL-10 made available from 10 of the HIV+ patients were regressed upon an index of spontaneous whole-brain activity at rest; i.e., the amplitude of low-frequency fluctuations (ALFFs). Elevated levels of depression and IL-6 were associated with increased ALFF in a cluster of voxels on the medial portion of the ventral surface of the frontal lobe (Brodmann Area 11). Within this sample of HIV+ individuals lower rsFC of the sgACC with subcortical limbic regions predicts greater burden of depressive symptomology whereas elevated activity in the adjacent BA 11 may reflect sickness, indexed by elevated IL-6, and associated depressive behaviors.

The role of catecholamines in HIV neuropathogenesis

The success of anti-retroviral therapy has improved the quality of life and lifespan of HIV + individuals, transforming HIV infection into a chronic condition. These improvements have come with a cost, as chronic HIV infection and long-term therapy have resulted in the emergence of a number of new pathologies. This includes a variety of the neuropathological and neurocognitive effects collectively known as HIVassociated neurocognitive disorders (HAND) or NeuroHIV. These effects persist even in the absence of viral replication, suggesting that they are mediated the long-term changes in the CNS induced by HIV infection rather than by active replication. Among these effects are significant changes in catecholaminergic neurotransmission, especially in dopaminergic brain regions. In HIV-infected individuals not treated with ARV show prominent neuropathology is common in dopamine-rich brain regions and altered autonomic nervous system activity. Even infected individuals on therapy, there is significant dopaminergic neuropathology, and elevated stress and norepinephrine levels correlate with a decreased effectiveness of antiretroviral drugs. As catecholamines function as immunomodulatory factors, the resultant dysregulation of catecholaminergic tone could substantially alter the development of HIVassociated neuroinflammation and neuropathology. In this review, we discuss the role of catecholamines in the etiology of HIV neuropathogenesis. Providing a comprehensive examination of what is known about these molecules in the context of HIV-associated disease demonstrates the importance of further studies in this area, and may open the door to new therapeutic strategies that specifically ameliorate the effects of catecholaminergic dysregulation on NeuroHIV.

Psychological Distress Mediates the Effect of Alexithymia on 2-Year Change in HIV Viral Load

PURPOSE

Individuals with trait alexithymia (AL) display poor cognitive assimilation of thoughts, feelings, and emotions. This may result in the persistence of stress, anxiety, and depressive disorders. The cumulative effect of this psychological distress is also linked clinical markers of human immunodeficiency virus (HIV) disease progression. This study examines the indirect effect of AL on HIV viral load as a function of baseline levels and change in psychological distress.

METHODS

N = 123 HIV positive adults aged 37.9 ± 9.2 years provided blood samples for HIV-1 viral RNA and CD4 T lymphocytes along with self-reported stress, anxiety, and depression every 6 months for 2 years. A second-order conditional latent growth model was used to represent baseline and 2-year change in cumulative levels of psychological distress and to test the indirect effect of baseline levels of trait AL on change in HIV-1 viral load through this latent measure.

RESULTS

AL was associated with baseline and latent change in psychological distress. Furthermore, baseline psychological distress predicted 2-year change in HIV-1 viral RNA after controlling for viral load at baseline. Altogether, trait AL had a significant indirect effect on change in viral load (β = 0.16, p = 0.03) as a function of baseline levels of distress.

CONCLUSION

Identification and communication of thoughts, feelings, and emotions are important for long-term psychological adaptation in HIV. Greater psychological distress, in turn, allows for persistence of peripheral viral replication.

Childhood maltreatment and HIV-associated neurocognitive disorders share similar pathophysiology: a potential sensitisation mechanism?

HIV-associated neurocognitive disorders (HAND) are increasingly prevalent despite the use of antiretroviral therapies. Previous research suggests that individual host factors play an important role in determining susceptibility to HAND. In this review, we propose that childhood trauma (CT) and HAND share several common aetiological mechanisms, namely hypothalamic-pituitary-adrenal axis dysregulation, neuroinflammation and oxidative stress. These convergent and consequent mechanisms may translate into an increased risk of developing HAND in individuals who have experienced early life stress. We provide an overview of basic and clinical research relating to these pathophysiological mechanisms and suggest that further research examine brain-derived neurotrophic factor and telomere length as common mediating factors and potential therapeutic targets for HAND and CT. Graphical abstract Both childhood trauma and HIV-associated neurocognitive disorders are associated with HPA axis dysregulation, inflammation and oxidative stress.

Depression and Survival in a 17-Year Longitudinal Study of People With HIV: Moderating Effects of Race and Education

OBJECTIVE

The prevalence of clinically significant depressive symptoms is three times higher in people living with HIV than in the general population. Although studies have shown that depression predicts worse course with HIV, few have investigated its relationship with mortality, and none have had a 17-year follow-up period and been conducted entirely during the time since the advent of protease inhibitors.

METHODS

We followed a diverse sample of HIV-positive people (N = 177) in the mid-range of illness for a study on stress and coping. Participants were assessed every 6 months (for 12 years) via blood draw, questionnaires, and interview. Depression was measured using the Beck Depression Inventory. The study began in March 1997 and mortality was assessed in April 2014.

RESULTS

In the primary analysis depression, analyzed as a continuous variable, significantly predicted all-cause mortality (hazard ratio = 1.038, 95% confidence interval = 1.008-1.068). With Beck Depression Inventory scores dichotomized, the hazard ratio was 2.044 (95% confidence interval = 1.176-3.550). Furthermore, this result was moderated by race and educational attainment such that depression only predicted worse survival for non-African Americans and those with a college education or higher.

CONCLUSION

Depression is associated with worse long-term survival in people with HIV during 17 years of follow-up. Interventions targeting depression may improve well-being and potentially survival in individuals with HIV. However, since depression did not predict survival in African Americans or those with low education, more research is needed to identify risk factors for long term outcomes in these groups.

Chronic distress and the vulnerable host: a new target for HIV treatment and prevention?

Pathologic stress (distress) disturbs immune, cardiovascular, metabolic, and behavioral homeostasis. Individuals living with HIV and those at risk are vulnerable to stress disorders. Corticotropin-releasing hormone (CRH) is critical in neuroendocrine immune regulation. CRH, a neuropeptide, is distributed in the central and peripheral nervous systems and acts principally on CRH receptor type 1 (CRHR1). CRH in the brain modulates neuropsychiatric disorders. CRH and stress modulation of immunity is two-pronged; there is a direct action on hypothalamic-pituitary-adrenal secretion of glucocorticoids and through immune organ sympathetic innervation. CRH is a central and systemic proinflammatory cytokine. Glucocorticoids and their receptors have gene regulatory actions on viral replication and cause central and systemic immune suppression. CRH and stress activation contributes to central nervous system (CNS) viral entry important in HIV-associated neurocognitive disorders and HIV-associated dementia. CNS CRH overproduction short-circuits reward, executive, and emotional control, leading to addiction, cognitive impairment, and psychiatric comorbidity. CRHR1 is an important therapeutic target for medication development. CRHR1 antagonist clinical trials have focused on psychiatric disorders with little attention paid to neuroendocrine immune disorders. Studies of those with HIV and those at risk show that concurrent stress-related disorders contribute to higher morbidity and mortality; stress-related conditions, addiction, immune dysfunction, and comorbid psychiatric illness all increase HIV transmission. Neuropsychiatric disease, chronic inflammation, and substance abuse are endemic, and chronic distress is a pathologic factor. It is being understood that stress and CRH are fundamental to neuroendocrine immunity; therapeutic interventions with existing and novel agents hold promise for restoring homeostasis, reducing morbidity and mortality for those with HIV and possibly reducing future disease transmission.

A meta-analysis of HIV and heart rate variability in the era of antiretroviral therapy

BACKGROUND

Heart rate variability (HRV) has been used to assess autonomic dysfunction since the beginning of the HIV epidemic. Although autonomic failure was commonly detected in HIV and AIDS patients prior to the advent of antiretroviral therapy (ART), the effect of HIV on HRV in the current era of widespread ART availability is more ambiguous.

METHODS

A systematic search and review was conducted on cross-sectional observational and case-control studies published in the era of ART (1996-2015) that compared HRV between HIV + individuals treated with ART and HIV - controls. Eight out of the 20 studies identified, enrolling a total of 292 HIV + adults (mean age 38.7 years) and 201 HIV seronegative controls (mean age 35.1 years), were included in a meta-analysis based on stringent methodological criteria.

RESULTS

At rest, individuals with HIV showed lower HRV in the time (g) = -0.72, 95 % CI (-1.03 to -0.42) and low-frequency (LF) domain (g) = -0.51, (-0.81 to -0.21); markers of lower parasympathetic tone in the time (g) = -0.55, (-0.85 to -0.25) and high-frequency (HF) domain (g) = -0.42, (-0.71 to -0.12); and higher LF:HF ratio (g) = 0.46, (0.12-0.86) in the frequency domain, suggestive of parasympathetic withdrawal.

CONCLUSION

This meta-analysis confirmed, within a relatively young cohort of HIV + adults on ART, a general reduction in autonomic function with a shift toward sympathetic dominance. This shift may predispose HIV patients to early and elevated risk of arrhythmias, cardiac events, and accelerated HIV disease progression.

Interhemispheric Asymmetries and Theta Activity in the Rostral Anterior Cingulate Cortex as EEG Signature of HIV-Related Depression: Gender Matters

Resting EEGs of 40 people living with HIV (PLWH) on long-term antiretroviral treatment were examined for z-scored deviations from a healthy control (normative database) to examine the main and interaction effects of depression and gender. Regions of interest were frontal (alpha) and central (all bands) for interhemispheric asymmetries in quantitative EEGs and theta in the rostral anterior cingulate cortex (rACC) in low-resolution electromagnetic tomography (LORETA). Z-scored normed deviations of depressed PLWH, compared with nondepressed, showed right-dominant interhemispheric asymmetries in all regions. However, after adjusting for multiple testing, significance remained only central for theta, alpha, and beta. Reversed (left-dominant) frontal alpha asymmetry is a potential EEG marker of depression in the HIV negative population that was not reversed in depressive PLWH; however, corresponding with extant literature, gender had an effect on the size of frontal alpha asymmetry. The LORETA analysis revealed a trending interactional effect of depression and gender on theta activity in the rACC in Brodmann area 32. We found that compared to men, women had greater right-dominant frontal alpha-asymmetry and elevated theta activity in voxels of the rACC, which may indicate less likelihood of depression and a higher likelihood of response to antidepressants. In conclusion, subtle EEG deviations, such as right-dominant central theta, alpha, and beta asymmetries and theta activity in the rACC may mark HIV-related depressive symptoms and may predict the likelihood of response to antidepressants but gender effects need to be taken into account. Although this study introduced the use of LORETA to examine the neurophysiological correlates of negative affect in PLWH, further research is needed to assess the utility of this tool in diagnostics and treatment monitoring of depression in PLWH.

Psychosocial and Neurohormonal Predictors of HIV Disease Progression (CD4 Cells and Viral Load): A 4 Year Prospective Study

Most studies of psychosocial predictors of disease progression in HIV have not considered norepinephrine (NE), a neurohormone related to emotion and stress, even though NE has been related to accelerated viral replication in vitro and impaired response to antiretroviral therapy (ART). We therefore examined NE, cortisol, depression, hopelessness, coping, and life event stress as predictors of HIV progression in a diverse sample. Participants (n = 177) completed psychological assessment, blood draws [CD4, viral load (VL)], and a 15 h urine sample (NE, cortisol) every 6 months over 4 years. Hierarchical linear modeling (HLM) was used to model slope in CD4 and VL controlling for ART at every time point, gender, age, race, SES, and initial disease status. NE (as well as depression, hopelessness, and avoidant coping) significantly predicted a greater rate of decrease in CD4 and increase in VL. Cortisol was not significantly related to CD4, but predicted VL increase. To our knowledge, this is the first study relating NE, in vivo, to accelerated disease progression over an extended time. It also extends our previous 2 year study by relating depressed mood and coping to accelerated disease progression over 4 years.

Illness perceptions and coping strategies among individuals diagnosed with HIV

Illness perceptions can influence the coping strategies used in response to HIV-related stressors, and ultimately patients' clinical status. With this work, we aimed to: (1) identify illness perception-related profiles of HIV-positive patients; (2) evaluate the association between the profiles, illness-related coping strategies, HIV-progression biomarkers (CD4+ cell counts and viral load) and antiretroviral therapy use. Data about illness perceptions, HIV-related coping strategies and HIV-progression biomarkers (CD4+ and viral load) were collected from 248 Italian HIV-positive patients. Three latent classes ("high," "moderate" and "low" influence perception) that differed on consequences, emotional representation, personal control and identity were identified. A greater perception of illness influence was associated with dysfunctional coping strategies (e.g., passive coping and alcohol use), and greater viral load was observed among patients with high and moderate influence perception. In conclusion, patients with detectable or high viral load may show a greater perception of illness influence (i.e., consequences), which is associated with dysfunctional coping strategies in response to HIV-related stressors.

Integration of the interaction model of client health behavior and transactional model of stress and coping as a tool for understanding retention in HIV care across the lifespan

Retaining people living with HIV (PLWH) in care over the lifespan is critical to quality and longevity of life. Individual health behavior decisions that affect care retention are complicated and multifactorial. Current health behavior theories are inadequate in isolation to guide retention in care research. Two existing models, Cox's Interaction Model of Client Health Behavior, and Lazarus and Folkman's Transactional Model of Stress and Coping have both guided research with PLWH, although not related to retention in care. Integration of these models may more comprehensively inform care retention research and practice across the lifespan as it incorporates not only intra- and inter-personal characteristics and relationships but also the stress and coping experiences inevitable when living with a chronic illness such as HIV.

Antiretroviral treatment adherence as a mediating factor between psychosocial variables and HIV viral load

Psychosocial factors may directly impact HIV health measures such as viral load (VL) whether or not patients are taking antiretroviral treatment (ART) consistently. Structural equation modeling plus Baron and Kenny's (1986) four-step approach were used to test a mediated model predicting VL among 246 HIV-infected adults who were on ART. Exogenous variables were social support, barriers to adherence, and stress. Moderators were alcohol use, marijuana use, and neurocognitive impairment. A small positive association between marijuana use and ART adherence approached significance. Only barriers to adherence predicted a decrease in adherence rates and an increase in VL. No other factors were significantly associated with either VL or adherence, and no interaction effects between exogenous variables and moderators were identified. The association between barriers to adherence and VL was partially mediated by ART adherence. Findings provide modest support for a direct link between psychosocial variables and a virologic response to ART.

Critical consciousness, racial and gender discrimination, and HIV disease markers in African American women with HIV

Critical consciousness, the awareness of social oppression, is important to investigate as a buffer against HIV disease progression in HIV-infected African American women in the context of experiences with discrimination. Critical consciousness comprises several dimensions, including social group identification, discontent with distribution of social power, rejection of social system legitimacy, and a collective action orientation. The current study investigated self-reported critical consciousness as a moderator of perceived gender and racial discrimination on HIV viral load and CD4+ cell count in 67 African American HIV-infected women. Higher critical consciousness was found to be related to higher likelihood of having CD4+ counts over 350 and lower likelihood of detectable viral load when perceived racial discrimination was high, as revealed by multiple logistic regressions that controlled for highly active antiretroviral therapy (HAART) adherence. Multiple linear regressions showed that at higher levels of perceived gender and racial discrimination, women endorsing high critical consciousness had a larger positive difference between nadir CD4+ (lowest pre-HAART) and current CD4+ count than women endorsing low critical consciousness. These findings suggest that raising awareness of social oppression to promote joining with others to enact social change may be an important intervention strategy to improve HIV outcomes in African American HIV-infected women who report experiencing high levels of gender and racial discrimination.

Alexithymia is linked to neurocognitive, psychological, neuroendocrine, and immune dysfunction in persons living with HIV

The neuropathological changes resulting from Human Immunodeficiency Virus (HIV) infection may manifest in alexithymia (AL), a multidimensional trait characterized by impairments in the cognitive assimilation of feelings and emotions. A sample of 93 HIV survivors scoring high, i.e., ⩾74 on the 26-item Toronto Alexithymia Scale (TAS-26), were compared to 79 low AL (TAS-26⩽54) survivors on measures of neurocognitive, psychological, neuroendocrine and immune function. Neurocognitive function was evinced by a standardized test of psychomotor speed, cognitive flexibility and task switching ability, HIV Dementia and general cognitive status. Patients were also screened for levels of depression, anxiety and psychological stress. A 24-h urinary norepinephrine (NE) and cortisol (CORT) collection was taken; blood was drawn for T lymphocyte subset counts (CD4+CD3+) and HIV-1 viral load. Alexithymic patients exhibited higher levels of executive dysfunction, psychological distress, norepinephrine-to-cortisol (NE/CORT) ratio and viral load. Linear regression models accounting for sociodemographic and disease-related variables revealed two AL subscales, difficulties identifying and describing feelings, predicted and explained a significant proportion of variance in the outcome measures. Specifically, poorer executive task-switching/cognitive flexibility was associated with greater difficulty describing feelings; dysregulated autonomic response (high NE/CORT ratio) and depressive symptoms were predicted by difficulty identifying feelings; higher levels of anxiety and psychological stress were both predicted by greater difficulty describing and identifying feelings. Overall, the psychoneuroimmunological profile of alexithymia in HIV positive persons at mid-stage of infection suggests a greater vulnerability for disease progression.

The relationship between sexual trauma, peritraumatic dissociation, posttraumatic stress disorder, and HIV-related health in HIV-positive men

This study tested a novel extension of P. P. Schnurr and B. L. Green's (2004) model of the relationships between trauma symptoms and health outcomes with specific application to HIV-positive men. A diverse sample of 167 HIV-positive men recruited from San Francisco Bay Area HIV clinics completed demographic, medical, trauma history, and symptom questionnaires. Mediation analyses were conducted using the method proposed by R. Baron and D. Kenny (1986). Regression analyses found that sexual revictimization (SR) significantly mediated the relationship between child sexual abuse and peritraumatic dissociation (PD), and PD mediated the relationship between SR and current posttraumatic stress (PTS) symptom severity. PTS symptoms partially mediated the relationship between SR and current HIV symptom severity. The findings indicate that among HIV-positive men, sexually revictimized men constitute a vulnerable group that is prone to PD, which places them at risk for posttraumatic stress disorder (PTSD) and worsened HIV-related health. Furthermore, traumatic stress symptoms were associated with worse HIV-related symptoms, suggesting that PTS symptoms mediate the link between trauma and health outcomes. This study highlights the need for future research to identify the biobehavioral mediators of the PTSD-health relationship in HIV-positive individuals.

Cortisol patterns are associated with T cell activation in HIV

Objective

The level of T cell activation in untreated HIV disease is strongly and independently associated with risk of immunologic and clinical progression. The factors that influence the level of activation, however, are not fully defined. Since endogenous glucocorticoids are important in regulating inflammation, we sought to determine whether less optimal diurnal cortisol patterns are associated with greater T cell activation.

Methods

We studied 128 HIV-infected adults who were not on treatment and had a CD4⁺ T cell count above 250 cells/µl. We assessed T cell activation by CD38 expression using flow cytometry, and diurnal cortisol was assessed with salivary measurements.

Results

Lower waking cortisol levels correlated with greater T cell immune activation, measured by CD38 mean fluorescent intensity, on CD4⁺ T cells (r = −0.26, p = 0.006). Participants with lower waking cortisol also showed a trend toward greater activation on CD8⁺ T cells (r = −0.17, p = 0.08). A greater diurnal decline in cortisol, usually considered a healthy pattern, correlated with less CD4⁺ (r = 0.24, p = 0.018) and CD8⁺ (r = 0.24, p = 0.017) activation.

Conclusions

These data suggest that the hypothalamic-pituitary-adrenal (HPA) axis contributes to the regulation of T cell activation in HIV. This may represent an important pathway through which psychological states and the HPA axis influence progression of HIV.

Randomized controlled trial of mindfulness-based stress reduction delivered to human immunodeficiency virus-positive patients in Iran: effects on CD4⁺ T lymphocyte count and medical and psychological symptoms

OBJECTIVE

To evaluate the immediate and long-term effectiveness of mindfulness-based stress reduction (MBSR) on biological and symptomatological markers of health among human immunodeficiency virus-positive (HIV+) patients in Tehran, Iran.

METHODS

Using a randomized controlled trial design, data from 173 HIV+ patients (CD4 count > 250) not yet receiving antiretroviral therapy, who participated in either an 8-week MBSR (n = 87) or a brief education and support condition (n = 86) at the Imam Khomeini Hospital, were analyzed. Assessments included CD4 count, Symptom Checklist-90-Revised (SCL-90R), and Medical Symptom Checklist (MSCL) at baseline, immediate post-treatment, and at the 3-, 6-, 9-, and 12-month follow-up periods.

RESULTS

The treatment-adherent sample had a mean (standard deviation) age of 35.1 (6.5) years and 69% were male. Linear mixed-model estimates indicated that, in the MBSR condition, the mean CD4 count increased from baseline up to 9 months after treatment and then returned to baseline level at 12 months. Improvements in mean SCL-90R (up to 6 months) and MSCL (up to 12 months) scores were observed for the MBSR condition, whereas education and support condition scores remained the same over time; however, only MSCL improvements significantly differed between groups and these changes lasted up to the final assessment.

CONCLUSIONS

Findings suggest that among treatment-adherent Iranian HIV+ patients not yet receiving antiretroviral drug treatment, MBSR seems to have the strongest potential to improve self-reported medical symptoms.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials: IRCT201106084076N2.

Translational implications of inflammatory biomarkers and cytokine networks in psychoneuroimmunology

Developments in psychoneuroimmunology (PNI) need to be translated into personalized medicine to achieve better clinical outcomes. One of the most critical steps in this translational process is to identify systemic biomarkers for better diagnosis and treatment. Applications of systems biology approaches in PNI would enable the insights into the correlations among various systems and different levels for the identification of the basic elements of the psychophysiological framework. Among the potential PNI biomarkers, inflammatory markers deserve special attention as they play a pivotal role linking various health conditions and disorders. The elucidation of inflammatory markers, cytokine networks, and immune-brain-behavior interactions may help establish PNI profiles for the identification of potential targets for personalized interventions in at risk populations. The understanding of the general systemic pathways among different disorders may contribute to the transition from the disease-centered medicine to patient-centered medicine. Integrative strategies targeting these factors and pathways would be useful for the prevention and treatment of a spectrum of diseases that share the common links. Examples of the translational implications of potential PNI biomarkers and networks in diseases including depression, Alzheimer's disease, obesity, cardiovascular disease, stroke, and HIV are discussed in details.

The influence of depression on the progression of HIV: direct and indirect effects

The authors suggest a theoretical model of pathways of HIV progression, with a focus on the contributions of depression-as well as secondary, behavioral and emotional variables. Literature was reviewed regarding (a) comorbid depression and the direct physiological effects on HIV progression and (b) intermediary factors between HIV and disease progression. Intermediary factors included (a) substance use, (b) social support, (c) hopelessness, (d) medication nonadherence, and (e) risky sexual behavior and the contraction of secondary infections. The authors suggest direct physiological pathways from depression to HIV progression and indirect pathways (e.g., behavioral, social, and psychological). In addition to depression, substance use, poor social support, hopelessness, medication nonadherence, and risky sexual behavior seem to be integral in HIV progression. Based on the individual relationships of these variables to depression and HIV progression, a comprehensive multipath model, incorporating all factors, serves to explain how severe emotional distress may lead to accelerated progression to AIDS.

Stress buffering effects of oxytocin on HIV status in low-income ethnic minority women

BACKGROUND

Elevated perceptions of psychosocial stress and stressful life events are linked to faster disease progression in individuals living with HIV and these associations may be stronger for women from ethnic minority populations. Levels of neurohormones such as oxytocin (OT), cortisol, and norepinephrine (NE) have been shown to influence the effects of psychosocial stress in different populations. Understanding how intrinsic neuroendocrine substances moderate the effects of stressors in minority women living with HIV (WLWH) may pave the way for interventions to improve disease management.

METHODS

We examined circulating levels of plasma OT as a moderator of the effects of stress on disease status (viral load, CD4+ cell count) in 71 low-income ethnic minority WLWH.

RESULTS

At low levels of OT, there was an inverse association between stress and CD4+ cell counts. Counter-intuitively, at high levels of OT there was a positive association between stress and CD4+ cell counts. This pattern was unrelated to women's viral load. Other neuroendocrine hormones known to down-regulate the immune system (cortisol, norepinephrine) did not mediate the effects of OT and stress on immune status.

CONCLUSIONS

OT may have stress buffering effects on some immune parameters and possibly health status in low income ethnic minority WLWH reporting elevated stress.

Substance use and HIV disease progression in the HAART era: implications for the primary prevention of HIV

Prior to the era of highly active anti-retroviral therapy (HAART), cohort studies provided equivocal evidence to support the hypothesis that substance use predicts more rapid HIV disease progression. The present review examined the effects of substance use on HIV disease progression in cohort studies with follow-up that continued into the HAART era. Of the 20 studies included in this review, 16 observed that substance use predicted at least one indicator of HIV disease progression. Ten of the 11 studies that followed participants exclusively in the HAART era observed an effect of substance use on HIV disease progression. Findings across studies indicate that stimulant use promotes more rapid HIV disease progression and the effects of substance use on HIV disease progression can persist after controlling for self-reported HAART non-adherence. Future investigations that examine the bio-behavioral pathways whereby substance use promotes HIV disease progression should include: measures of HIV genotypic and phenotypic resistance, multi-method assessment of adherence, and assessment of co-morbid infections that are more prevalent among substance users. Although further mechanistic research is needed, findings from existing cohort studies have clear clinical implications. Implementing screening, brief intervention and referral to substance abuse treatment in HIV medical care could optimize health outcomes and decrease HIV transmission rates by boosting the effectiveness of "Test and Treat" approaches to HIV prevention.

Mental health pathways from interpersonal violence to health-related outcomes in HIV-positive sexual minority men

OBJECTIVE

We examined mental health pathways between interpersonal violence (IPV) and health-related outcomes in HIV-positive sexual minority men engaged with medical care.

METHOD

HIV-positive gay and bisexual men (N = 178) were recruited for this cross-sectional study from 2 public HIV primary care clinics that treated outpatients in an urban setting. Participants (M age = 44.1 years, 36% non-White) filled out a computer-assisted survey and had health-related data extracted from their electronic medical records. We used structural equation modeling to test associations among the latent factors of adult abuse and partner violence (each comprising indicators of physical, sexual, and psychological abuse) and the measured variables: viral load, health-related quality of life (HRQOL), HIV medication adherence, and emergency room (ER) visits. Mediation was tested for the latent construct mental health problems, comprising depression, anxiety, symptomatology of posttraumatic stress disorder, and suicidal ideation.

RESULTS

The final model demonstrated acceptable fit, chi(2)(123) = 157.05, p = .02, CFI = .95, TLI = .94, RMSEA = .04, SRMR = .06, accounting for significant portions of the variance in viral load (13%), HRQOL (41%), adherence (7%), and ER visits (9%), as well as the latent variable mental health problems (24%). Only 1 direct link emerged: a positive association between adult abuse and ER visits.

CONCLUSIONS

Findings indicate a significant role of IPV and mental health problems in the health of people living with HIV/AIDS. HIV care providers should assess for IPV history and mental health problems in all patients and refer for evidence-based psychosocial treatments that include a focus on health behaviors.

Improving access to mental health services via a clinic-wide mental health intervention in a Southeastern US infectious disease clinic

Stepleman, Hann, Santos, and House (2006) described a brief psychological consultation model, which aims to improve integration of mental health services into HIV primary care. This retrospective chart review sought to examine which patients in our adult Infectious Disease clinic were served by this model in a one-year period. Furthermore, we examined whether the patients who subsequently engage in mental health care differ demographically from the consult population. Results indicated that 26.1% (n=252) of the patients at our Infectious Disease clinic (n=963; 36% female, 75% racial minority) received a mental health consultation. We observed no statistically significant differences between the consult and clinic populations with respect to gender, age, or race. Moreover, 43.3% (n=109) of those patients served by the consult model received specialized psychiatric care. There were statistically significant racial differences between those patients who engaged specialty psychiatric care and those who did not after receiving a consultation (chi(2)(1)=16.65, p<0.001; 70% racial minority in consult vs. 47.7% racial minority in psychiatric care). While our in-clinic consultation service reached a representative population, we had less success recruiting this diverse patient population into traditional psychiatric care. Future efforts will need to examine how mental health consultation and traditional psychiatric services can best reduce barriers to engagement and retention in care.

Stress biomarkers as outcomes for HIV+ prevention: participation, feasibility and findings among HIV+ Latina and African American mothers

Mothers living with HIV (MLH) are at high risk for acute and chronic stress, given challenges related to their HIV status, ethnicity, economic and urban living conditions. Biomarkers combined into a composite index show promise in quantifying psychosocial stress in healthy people, but have not yet been examined among MLH. According, we examined potential biomarker correlates of stress [cortisol and catecholamines from home-collected urine and basic health indicators (blood pressure, height and weight, waist-to-hip ratio) measured during an interview] among 100 poor African American and Latina mothers MLH and demographic-matched control mothers without HIV (n = 50). Participants had been enrolled in a randomized controlled trial about 18 months earlier and had either received (MLH-I) or were awaiting (MLH-W) the psychosocial intervention. Participation was high, biomarkers were correctly collected for 93% of cases, and a complete composite biomarker index (CBI) calculated for 133 mothers (mean age = 42). As predicted, MLH had a significantly higher CBI than controls, but there was no CBI difference across ethnicity or intervention group. CBI predicted CD4 counts independently after controlling for age, years since diagnosis, prior CD4 counts, medication adherence, and depression symptoms. The study demonstrates acceptability, feasibility and potential utility of community-based biomarker collections in evaluating individual differences in psychosocial stress.

Human immunodeficiency virus and highly active antiretroviral therapy-associated metabolic disorders and risk factors for cardiovascular disease

The successful introduction of highly active antiretroviral therapy (HAART), a combination of potent antiretroviral agents, including protease inhibitors, nucleoside reverse transcriptase inhibitors, and nonnucleoside reverse transcriptase inhibitors, has impacted positively on morbidity and mortality among human immunodeficiency virus (HIV)-positive patients. Over time, HAART has been associated with a number of metabolic and anthropometric abnormalities, including dyslipidemia and insulin resistance as well as subcutaneous fat loss and abdominal obesity, potentially contributing to cardiovascular risk. Recent studies have more firmly established that both HIV infection and HAART might increase the risk of clinical cardiovascular events. Furthermore, whereas HIV/HAART is associated with multiple aspects of endocrine dysfunction, there has been less focus on bone disease, although some studies indicate a higher prevalence of osteoporosis among HIV-positive subjects compared to HIV-negative controls. The relationship between bone and fat metabolism under HIV-positive conditions deserves further attention, and available data suggest the possibility of an intriguing connection. In the future, an increasing population of aging HIV-positive patients with a spectrum of antiretroviral therapies and accumulation of endocrine abnormalities and conventional cardiovascular risk factors will present preventive and therapeutic challenges to our health-care system.

Routine screening for depression: identifying a challenge for successful HIV care

Individuals with HIV experience fluctuating levels of distress throughout the course of HIV infection. This study was conducted to examine the associations of depressive symptomatology with HIV disease in a cohort of individuals who are engaged in routine medical care. This cross-sectional study examined the prevalence of depressive symptoms that were measured as part of a standard of care behavioral assessment among individuals at an urban HIV clinic in the Midwest. Demographic characteristics, depressive symptoms, and behavioral risk factors were collected. A total of 514 individuals participated in the study, the majority of whom was male and African American. One quarter of the sample endorsed symptoms of other depressive disorder, while 18% (n = 91) endorsed symptoms of major depressive disorder as measured by the Patient Health Questionnaire-9 (PHQ-9). Among those on highly active antiretroviral therapy (HAART), individuals who were unemployed (adjusted odds ratio [AOR] = 2.47, 95% confidence interval [CI] = 1.54, 3.97), had a minor dependent (AOR = 2.17, 95% CI = 1.25, 3.77), or between the ages of 18 and 34 years (AOR = 1.37, CI = 1.03, 1.94) and detectable HIV viral load (AOR = 2.52, 95% CI = 1.22, 5.23) were more likely to report depressive disorder symptoms when controlling for age, gender, race, and education. Nearly 15% of the sample endorsed having suicidal thoughts at least once in the past two weeks. Regardless of HAART prescription, individuals who were unemployed had a higher likelihood of expressing suicidal ideation (AOR = 3.43, 95% CI = 1.66, 7.06). Given the association between depressive symptomatology and poor rates of HIV viral suppression, screening and appropriate interventions for depressive symptoms are warranted in the HIV outpatient setting to improve outcomes.