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Ayoub SM, Holloway BM, Miranda AH, Roberts BZ, Young JW, Minassian A, Ellis RJ. The Impact of Cannabis Use on Cognition in People with HIV: Evidence of Function-Dependent Effects and Mechanisms from Clinical and Preclinical Studies. Curr HIV/AIDS Rep 2024; 21:87-115. [PMID: 38602558 PMCID: PMC11129923 DOI: 10.1007/s11904-024-00698-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 04/12/2024]
Abstract
PURPOSE OF REVIEW Cannabis may have beneficial anti-inflammatory effects in people with HIV (PWH); however, given this population's high burden of persisting neurocognitive impairment (NCI), clinicians are concerned they may be particularly vulnerable to the deleterious effects of cannabis on cognition. Here, we present a systematic scoping review of clinical and preclinical studies evaluating the effects of cannabinoid exposure on cognition in HIV. RECENT FINDINGS Results revealed little evidence to support a harmful impact of cannabis use on cognition in HIV, with few eligible preclinical data existing. Furthermore, the beneficial/harmful effects of cannabis use observed on cognition were function-dependent and confounded by several factors (e.g., age, frequency of use). Results are discussed alongside potential mechanisms of cannabis effects on cognition in HIV (e.g., anti-inflammatory), and considerations are outlined for screening PWH that may benefit from cannabis interventions. We further highlight the value of accelerating research discoveries in this area by utilizing translatable cross-species tasks to facilitate comparisons across human and animal work.
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Affiliation(s)
- Samantha M Ayoub
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive MC 0804, La Jolla, CA, 92093-0804, USA.
| | - Breanna M Holloway
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive MC 0804, La Jolla, CA, 92093-0804, USA
| | - Alannah H Miranda
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive MC 0804, La Jolla, CA, 92093-0804, USA
| | - Benjamin Z Roberts
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive MC 0804, La Jolla, CA, 92093-0804, USA
| | - Jared W Young
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive MC 0804, La Jolla, CA, 92093-0804, USA
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA
| | - Arpi Minassian
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive MC 0804, La Jolla, CA, 92093-0804, USA
- VA Center of Excellence for Stress and Mental Health, Veterans Administration San Diego HealthCare System, 3350 La Jolla Village Drive, San Diego, CA, USA
| | - Ronald J Ellis
- Department of Neuroscience, University of California San Diego, La Jolla, CA, USA
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Akay-Espinoza C, Newton SEB, Dombroski BA, Kallianpur A, Bharti A, Franklin DR, Schellenberg GD, Heaton RK, Grant I, Ellis RJ, Letendre SL, Jordan-Sciutto KL. Genetic Variations in EIF2AK3 are Associated with Neurocognitive Impairment in People Living with HIV. J Neuroimmune Pharmacol 2024; 19:25. [PMID: 38789639 PMCID: PMC11126443 DOI: 10.1007/s11481-024-10125-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
Based on emerging evidence on the role for specific single-nucleotide variants (SNVs) in EIF2AK3 encoding the integrated stress response kinase PERK, in neurodegeneration, we assessed the association of EIF2AK3 SNVs with neurocognitive performance in people with HIV (PWH) using a candidate gene approach. This retrospective study included the CHARTER cohort participants, excluding those with severe neuropsychiatric comorbidities. Genome-wide data previously obtained for 1047 participants and targeted sequencing of 992 participants with available genomic DNA were utilized to interrogate the association of three noncoding and three coding EIF2AK3 SNVs with the continuous global deficit score (GDS) and global neurocognitive impairment (NCI; GDS ≥ 0.5) using univariable and multivariable methods, with demographic, disease-associated, and treatment characteristics as covariates. The cohort characteristics were as follows: median age, 43.1 years; females, 22.8%; European ancestry, 41%; median CD4 + T cell counts, 175/µL (nadir) and 428/µL (current). At first assessment, 70.5% used ART and 68.3% of these had plasma HIV RNA levels ≤ 200 copies/mL. All three noncoding EIF2AK3 SNVs were associated with GDS and NCI (all p < 0.05). Additionally, 30.9%, 30.9%, and 41.2% of participants had at least one risk allele for the coding SNVs rs1805165 (G), rs867529 (G), and rs13045 (A), respectively. Homozygosity for all three coding SNVs was associated with significantly worse GDS (p < 0.001) and more NCI (p < 0.001). By multivariable analysis, the rs13045 A risk allele, current ART use, and Beck Depression Inventory-II value > 13 were independently associated with GDS and NCI (p < 0.001) whereas the other two coding SNVs did not significantly correlate with GDS or NCI after including rs13045 in the model. The coding EIF2AK3 SNVs were associated with worse performance in executive functioning, motor functioning, learning, and verbal fluency. Coding and non-coding SNVs of EIF2AK3 were associated with global NC and domain-specific performance. The effects were small-to-medium in size but present in multivariable analyses, raising the possibility of specific SNVs in EIF2AK3 as an important component of genetic vulnerability to neurocognitive complications in PWH.
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Affiliation(s)
- Cagla Akay-Espinoza
- Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, 240 S. 40th St, Rm 312 Levy, Philadelphia, PA, 19104, USA
| | - Sarah E B Newton
- Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, 240 S. 40th St, Rm 312 Levy, Philadelphia, PA, 19104, USA
| | - Beth A Dombroski
- Department of Pathology and Laboratory Medicine, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Asha Kallianpur
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Ajay Bharti
- Departments of Medicine, University of California, San Diego, CA, USA
| | - Donald R Franklin
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Gerard D Schellenberg
- Department of Pathology and Laboratory Medicine, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert K Heaton
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Igor Grant
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Ronald J Ellis
- Department of Psychiatry, University of California, San Diego, CA, USA
- Department of Neurosciences, University of California, San Diego, CA, USA
| | - Scott L Letendre
- Department of Psychiatry, University of California, San Diego, CA, USA
- Department of Neurosciences, University of California, San Diego, CA, USA
| | - Kelly L Jordan-Sciutto
- Department of Oral Medicine, School of Dental Medicine, University of Pennsylvania, 240 S. 40th St, Rm 312 Levy, Philadelphia, PA, 19104, USA.
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Mitchell MM, Tseng TY, Rubin LH, Cruz-Oliver D, Catanzarite Z, Clair CA, Moore DJ, Knowlton AR. Social support network factors associated with verbal fluency among vulnerable persons living with HIV. AIDS Care 2024; 36:358-367. [PMID: 37345842 PMCID: PMC10739652 DOI: 10.1080/09540121.2023.2216925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/16/2023] [Indexed: 06/23/2023]
Abstract
Vulnerable persons living with HIV (PLWH) are at high risk of cognitive impairment and challenges accessing quality social support in later life. Impaired verbal fluency (VF), a cognitive domain linked to HIV, could impede social support associated with health and well-being for already vulnerable PLWH. We examined the structure of social support, using latent class analysis, and the associations among quantity, specific forms and quality of social support and VF among PLWH. Participants enrolled in the BEACON study (n = 383) completed the Controlled Oral Word Association test (COWAT) and a social support network inventory. Latent class analysis with count variables was used to determine the number of classes of PLWH based on their social network characteristics. The majority of PLWH were male (61.4%) and African American (85.9%). Two distinct latent classes, with a major distinction in the number of network members who were female, knew participants' HIV status and HIV medication usage. Fewer support network members (β = -.13, p < 0.01), greater negative interactions (β = -.16, p < 0.01), and less positive interactions with network members (β = .15, p < 0.05) were significantly associated with lower COWAT scores. Comprehensive screening of high-risk PLWH and early intervention with those with cognitive impairment are important for addressing social support needs.
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Affiliation(s)
- Mary M. Mitchell
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, Baltimore, MD, USA
| | - Tuo-Yen Tseng
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, Baltimore, MD, USA
| | - Leah H. Rubin
- Departments of Neurology and Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA
| | - Dulce Cruz-Oliver
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Zachary Catanzarite
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, Baltimore, MD, USA
| | - Catherine A. Clair
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, Baltimore, MD, USA
| | - David J. Moore
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
| | - Amy R. Knowlton
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, Baltimore, MD, USA
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McIntosh RC, Clark US, Cherner M, Cysique LA, Heaton RK, Levin J, Remien RH, Thames A, Moore DJ, Rubin LH. The Evolution of Assessing Central Nervous System Complications in Human Immunodeficiency Virus: Where Do We Go From Here? J Infect Dis 2023; 227:S30-S37. [PMID: 36930636 PMCID: PMC10022716 DOI: 10.1093/infdis/jiac316] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
In this fifth decade of the human immunodeficiency virus (HIV) epidemic, central nervous system (CNS) complications including cognitive impairment and mental health remain a burden for people with HIV (PWH) on antiretroviral therapy. Despite the persistence of these complications, which often co-occur, the underlying pathophysiology remains elusive and consequently treatments remain limited. To continue to grow our understanding of the underlying mechanisms of CNS complications among PWH, there is a need to reexamine our current approaches, which are now more than 2 decades old. At the 2021 National Institutes of Health-sponsored meeting on Biotypes of CNS Complications in PWH, the Neurobehavioral Working Group addressed the following: (1) challenges inherent to determining CNS complications; (2) heterogeneity in CNS complications; and (3) problems and solutions for examining integrated biotypes. The review below provides a summary of the main points presented and discussed by the Neurobehavioral Working Group at the meeting.
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Affiliation(s)
- Roger C McIntosh
- Department of Psychology, University of Miami, Miami, Florida, USA
| | - Uraina S Clark
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mariana Cherner
- Department of Psychiatry, University of California, San Diego, California, USA
| | - Lucette A Cysique
- Department of Psychology, University of New South Wales, Sydney, Australia
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Robert K Heaton
- Department of Psychiatry, University of California, San Diego, California, USA
| | - Jules Levin
- National AIDS Treatment Advocacy Project, New York, New York, USA
| | - Robert H Remien
- Department of Psychiatry, Columbia University, New York, New York, USA
| | - April Thames
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, California, USA
| | - David J Moore
- Department of Psychiatry, University of California, San Diego, California, USA
| | - Leah H Rubin
- Departments of Neurology, Psychiatry and Behavioral Sciences, Epidemiology, and Molecular and Comparative Pathology, Johns Hopkins University, Baltimore, Maryland, USA
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Paul RH, Cho K, Belden A, Carrico AW, Martin E, Bolzenius J, Luckett P, Cooley SA, Mannarino J, Gilman JM, Miano M, Ances BM. Cognitive Phenotypes of HIV Defined Using a Novel Data-driven Approach. J Neuroimmune Pharmacol 2022; 17:515-525. [PMID: 34981318 PMCID: PMC10364465 DOI: 10.1007/s11481-021-10045-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/13/2021] [Indexed: 01/13/2023]
Abstract
The current study applied data-driven methods to identify and explain novel cognitive phenotypes of HIV. Methods: 388 people with HIV (PWH) with an average age of 46 (15.8) and median plasma CD4+ T-cell count of 555 copies/mL (79% virally suppressed) underwent cognitive testing and 3T neuroimaging. Demographics, HIV disease variables, and health comorbidities were recorded within three months of cognitive testing/neuroimaging. Hierarchical clustering was employed to identify cognitive phenotypes followed by ensemble machine learning to delineate the features that determined membership in the cognitive phenotypes. Hierarchical clustering identified five cognitive phenotypes. Cluster 1 (n=97) was comprised of individuals with normative performance on all cognitive tests. The remaining clusters were defined by impairment on action fluency (Cluster 2; n=46); verbal learning/memory (Cluster 3; n=73); action fluency and verbal learning/memory (Cluster 4; n=56); and action fluency, verbal learning/memory, and tests of executive function (Cluster 5; n=114). HIV detectability was most common in Cluster 5. Machine learning revealed that polysubstance use, race, educational attainment, and volumes of the precuneus, cingulate, nucleus accumbens, and thalamus differentiated membership in the normal vs. impaired clusters. The determinants of persistent cognitive impairment among PWH receiving suppressive treatment are multifactorial nature. Viral replication after ART plays a role in the causal pathway, but psychosocial factors (race inequities, substance use) merit increased attention as critical determinants of cognitive impairment in the context of ART. Results underscore the need for comprehensive person-centered interventions that go beyond adherence to patient care to achieve optimal cognitive health among PWH.
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Affiliation(s)
- Robert H Paul
- Department of Psychological Sciences, University of Missouri Saint Louis, Missouri, Saint Louis, US. .,Missouri Institute of Mental Health, University of Missouri Saint Louis, Missouri, Saint Louis, US.
| | - Kyu Cho
- Missouri Institute of Mental Health, University of Missouri Saint Louis, Missouri, Saint Louis, US
| | - Andrew Belden
- Missouri Institute of Mental Health, University of Missouri Saint Louis, Missouri, Saint Louis, US
| | - Adam W Carrico
- Department of Public Health, University of Miami School of Medicine, Coral Gables, Florida, US
| | - Eileen Martin
- Department of Psychiatry, Rush University School of Medicine, Chicago, Illinois, US
| | - Jacob Bolzenius
- Missouri Institute of Mental Health, University of Missouri Saint Louis, Missouri, Saint Louis, US
| | - Patrick Luckett
- Department of Neurology, Washington University, Saint Louis, Missouri, US
| | - Sarah A Cooley
- Department of Neurology, Washington University, Saint Louis, Missouri, US
| | - Julie Mannarino
- Missouri Institute of Mental Health, University of Missouri Saint Louis, Missouri, Saint Louis, US
| | - Jodi M Gilman
- Center for Addiction Medicine, Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts, US
| | - Mariah Miano
- Department of Communication Sciences and Disorders, Northern Arizona University, Flagstaff, Arizona, US
| | - Beau M Ances
- Department of Neurology, Washington University, Saint Louis, Missouri, US
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Unraveling the mechanisms of HIV-induced hearing loss. AIDS 2022; 36:1737-1740. [PMID: 36052541 DOI: 10.1097/qad.0000000000003320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Spence AB, Liu C, Rubin L, Aouizerat B, Vance DE, Bolivar H, Lahiri CD, Adimora AA, Weber K, Gustafson D, Sosanya O, Turner RS, Kassaye S. Class-Based Antiretroviral Exposure and Cognition Among Women Living with HIV. AIDS Res Hum Retroviruses 2022; 38:561-570. [PMID: 35109713 PMCID: PMC9297324 DOI: 10.1089/aid.2021.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Neurologic complications of the human immunodeficiency virus (HIV) are common in treated individuals, and toxicity of certain antiretroviral therapies (ART) may contribute to cognitive impairment. We investigated exposures to specific ART and cognition among women living with HIV (WLWH). Virologically suppressed (viral load <200 copies/mL during at least two semi-annual visits) WLWH and age/race matched HIV-seronegative controls enrolled in the Women's Interagency HIV Study who completed at least two biennial cognitive assessments were included. Analysis of WLWH was restricted to those with exposure to the drug class of interest and a nucleoside reverse transcriptase inhibitor (NRTI) backbone. Generalized estimating equations were used to evaluate repeated measures of cognition over time in association with ART class exposure. Among 1,242 eligible WLWH, 20% (n = 247) had isolated drug exposure to non-nucleoside reverse transcriptase inhibitors (NNRTI), 18% (n = 219) to protease inhibitors (PIs), and 6% (n = 79) to integrase inhibitors with a NRTI backbone. Cognitive assessments were performed at a median of 3 biennial visits {IQR 2-4 visits}. At the index assessment, 21% of WLWH demonstrated global cognitive impairment versus 29% at their last cognitive assessment. In multivariable analyses adjusted for hypertension, depression, diabetes mellitus, history of AIDS-defining illness, alcohol use, number of medications, and time on ART, WLWH exposed to NNRTIs demonstrated verbal learning improvements (mean T-score change 1.3, p = .020) compared to other treated women. Compared to HIV-seronegative women, WLWH exposed to PIs had worse verbal learning (mean T-score difference -2.62, p = .002) and verbal memory performance (mean T-score difference -1.74, p = .032) at baseline. Compared to HIV-seronegative women, WLWH exposed to PIs had improvements in verbal learning (mean T-score slope difference 0.36, p = .025) and verbal memory (mean T-score slope difference 0.32, p = .042). The index T-score and slope of change in the T-score were similar among other treated groups and the HIV-seronegative group. We noted emerging trends in cognition in WLWH exposed to specific drug classes. Ongoing study of this relatively young group is important to characterize long-term cognitive outcomes and effect of antiretrovirals as treatment guidelines evolve.
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Affiliation(s)
- Amanda Blair Spence
- Division of Infectious Diseases, Georgetown University Medical Center, Washington, District of Columbia, USA.,Address correspondence to: Amanda Blair Spence, Division of Infectious Diseases, Georgetown University Medical Center, 3800 Reservoir Road NW, 5th Floor PHC, Washington, DC 20007, USA
| | - Chenglong Liu
- Division of Infectious Diseases, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Leah Rubin
- Department of Neurology and John Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, and John Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Psychiatry, John Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bradley Aouizerat
- Department of Oral and Maxillofacial Surgery, College of Dentistry, New York University, New York, New York, USA.,Bluestone Center for Clinical Research, College of Dentistry, New York University, New York, New York, USA
| | - David Eugene Vance
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Hector Bolivar
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Cecile Delille Lahiri
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine and Grady Healthcare System, Atlanta, Georgia, USA
| | - Adaora A. Adimora
- School of Medicine and UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kathleen Weber
- Cook County Health/Hektoen Institute of Medicine, Chicago, Illinois, USA
| | - Deborah Gustafson
- Department of Neurology, State University of New York-Downstate Health Sciences University, Brooklyn, New York, USA
| | - Oluwakemi Sosanya
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Raymond Scott Turner
- Department of Neurology, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Seble Kassaye
- Division of Infectious Diseases, Georgetown University Medical Center, Washington, District of Columbia, USA
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Saloner R, Lobo JD, Paolillo EW, Campbell LM, Letendre SL, Cherner M, Grant I, Heaton RK, Ellis RJ, Roesch SC, Moore DJ, Grant I, Letendre SL, Ellis RJ, Marcotte TD, Franklin D, McCutchan JA, Smith DM, Heaton RK, Atkinson JH, Dawson M, Fennema-Notestine C, Taylor MJ, Theilmann R, Gamst AC, Cushman C, Abramson I, Vaida F, Sacktor N, Rogalski V, Morgello S, Simpson D, Mintz L, McCutchan JA, Collier A, Marra C, Storey S, Gelman B, Head E, Clifford D, Al-Lozi M, Teshome M. Identification of Youthful Neurocognitive Trajectories in Adults Aging with HIV: A Latent Growth Mixture Model. AIDS Behav 2022; 26:1966-1979. [PMID: 34878634 PMCID: PMC9046348 DOI: 10.1007/s10461-021-03546-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 11/12/2022]
Abstract
Despite the neurocognitive risks of aging with HIV, initial cross-sectional data suggest a subpopulation of older people with HIV (PWH) possess youthful neurocognition (NC) characteristic of SuperAgers (SA). Here we characterize longitudinal NC trajectories of older PWH and their convergent validity with baseline SA status, per established SuperAging criteria in PWH, and baseline biopsychosocial factors. Growth mixture modeling (GMM) identified longitudinal NC classes in 184 older (age ≥ 50-years) PWH with 1–5 years of follow-up. Classes were defined using ‘peak-age’ global T-scores, which compare performance to a normative sample of 25-year-olds. 3-classes were identified: Class 1Stable Elite (n = 31 [16.8%], high baseline peak-age T-scores with flat trajectory); Class 2Quadratic Average (n = 100 [54.3%], intermediate baseline peak-age T-scores with u-shaped trajectory); Class 3Quadratic Low (n = 53 [28.8%], low baseline peak-age T-scores with u-shaped trajectory). Baseline predictors of Class 1Stable Elite included SA status, younger age, higher cognitive and physiologic reserve, and fewer subjective cognitive difficulties. This GMM analysis supports the construct validity of SuperAging in older PWH through identification of a subgroup with longitudinally-stable, youthful neurocognition and robust biopsychosocial health.
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Recent Advances in the Molecular and Cellular Mechanisms of gp120-Mediated Neurotoxicity. Cells 2022; 11:cells11101599. [PMID: 35626635 PMCID: PMC9139548 DOI: 10.3390/cells11101599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/05/2022] [Accepted: 05/07/2022] [Indexed: 02/01/2023] Open
Abstract
Axonal degeneration and loss of synapses are often seen in different brain areas of people living with human immunodeficiency virus (HIV). Nevertheless, the underlying causes of the pathological alterations observed in these individuals are poorly comprehended, considering that HIV does not infect neurons. Experimental data have shown that viral proteins, including the envelope protein gp120, cause synaptic pathology followed by neuronal cell death. These neurotoxic effects on synapses could be the result of a variety of mechanisms that decrease synaptic plasticity. In this paper, we will briefly present new emerging concepts connected with the ability of gp120 to promote the degeneration of synapses by either directly damaging the axonal cytoskeleton and/or the indirect activation of the p75 neurotrophin receptor death domain in dendrites.
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Rubin LH, Severson J, Marcotte TD, Savin MJ, Best A, Johnson S, Cosman J, Merickel M, Buchholz A, Del Bene VA, Eldred L, Sacktor NC, Fuchs JB, Althoff KN, Moore RD. Tablet-Based Cognitive Impairment Screening for Adults With HIV Seeking Clinical Care: Observational Study. JMIR Ment Health 2021; 8:e25660. [PMID: 34499048 PMCID: PMC8461534 DOI: 10.2196/25660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 05/15/2021] [Accepted: 05/25/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Neurological complications including cognitive impairment persist among people with HIV on antiretrovirals; however, cognitive screening is not routinely conducted in HIV clinics. OBJECTIVE Our objective for this study was 3-fold: (1) to determine the feasibility of implementing an iPad-based cognitive impairment screener among adults seeking HIV care, (2) to examine the psychometric properties of the tool, and (3) to examine predictors of cognitive impairment using the tool. METHODS A convenience sample of participants completed Brain Baseline Assessment of Cognition and Everyday Functioning (BRACE), which included (1) Trail Making Test Part A, measuring psychomotor speed; (2) Trail Making Test Part B, measuring set-shifting; (3) Stroop Color, measuring processing speed; and (4) the Visual-Spatial Learning Test. Global neuropsychological function was estimated as mean T score performance on the 4 outcomes. Impairment on each test or for the global mean was defined as a T score ≤40. Subgroups of participants repeated the tests 4 weeks or >6 months after completing the first test to evaluate intraperson test-retest reliability and practice effects (improvements in performance due to repeated test exposure). An additional subgroup completed a lengthier cognitive battery concurrently to assess validity. Relevant factors were abstracted from electronic medical records to examine predictors of global neuropsychological function. RESULTS The study population consisted of 404 people with HIV (age: mean 53.6 years; race: 332/404, 82% Black; 34/404, 8% White, 10/404, 2% American Indian/Alaskan Native; 28/404, 7% other and 230/404, 58% male; 174/404, 42% female) of whom 99% (402/404) were on antiretroviral therapy. Participants completed BRACE in a mean of 12 minutes (SD 3.2), and impairment was demonstrated by 34% (136/404) on Trail Making Test A, 44% (177/404) on Trail Making Test B, 40% (161/404) on Stroop Color, and 17% (67/404) on Visual-Spatial Learning Test. Global impairment was demonstrated by 103 out of 404 (25%). Test-retest reliability for the subset of participants (n=26) repeating the measure at 4 weeks was 0.81 and for the subset of participants (n=67) repeating the measure almost 1 year later (days: median 294, IQR 50) was 0.63. There were no significant practice effects at either time point (P=.20 and P=.68, respectively). With respect for validity, the correlation between global impairment on the lengthier cognitive battery and BRACE was 0.63 (n=61; P<.001), with 84% sensitivity and 94% specificity to impairment on the lengthier cognitive battery. CONCLUSIONS We were able to successfully implement BRACE and estimate cognitive impairment burden in the context of routine clinic care. BRACE was also shown to have good psychometric properties. This easy-to-use tool in clinical settings may facilitate the care needs of people with HIV as cognitive impairment continues to remain a concern in people with HIV.
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Affiliation(s)
- Leah H Rubin
- Johns Hopkins University, Baltimore, MD, United States
| | | | | | | | - Allen Best
- Digital Artefacts LLC, Iowa City, IA, United States
| | | | | | | | | | | | - Lois Eldred
- Johns Hopkins University, Baltimore, MD, United States
| | - Ned C Sacktor
- Johns Hopkins University, Baltimore, MD, United States
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Cornell J, Salinas S, Huang HY, Zhou M. Microglia regulation of synaptic plasticity and learning and memory. Neural Regen Res 2021; 17:705-716. [PMID: 34472455 PMCID: PMC8530121 DOI: 10.4103/1673-5374.322423] [Citation(s) in RCA: 142] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Microglia are the resident macrophages of the central nervous system. Microglia possess varied morphologies and functions. Under normal physiological conditions, microglia mainly exist in a resting state and constantly monitor their microenvironment and survey neuronal and synaptic activity. Through the C1q, C3 and CR3 “Eat Me” and CD47 and SIRPα “Don’t Eat Me” complement pathways, as well as other pathways such as CX3CR1 signaling, resting microglia regulate synaptic pruning, a process crucial for the promotion of synapse formation and the regulation of neuronal activity and synaptic plasticity. By mediating synaptic pruning, resting microglia play an important role in the regulation of experience-dependent plasticity in the barrel cortex and visual cortex after whisker removal or monocular deprivation, and also in the regulation of learning and memory, including the modulation of memory strength, forgetfulness, and memory quality. As a response to brain injury, infection or neuroinflammation, microglia become activated and increase in number. Activated microglia change to an amoeboid shape, migrate to sites of inflammation and secrete proteins such as cytokines, chemokines and reactive oxygen species. These molecules released by microglia can lead to synaptic plasticity and learning and memory deficits associated with aging, Alzheimer’s disease, traumatic brain injury, HIV-associated neurocognitive disorder, and other neurological or mental disorders such as autism, depression and post-traumatic stress disorder. With a focus mainly on recently published literature, here we reviewed the studies investigating the role of resting microglia in synaptic plasticity and learning and memory, as well as how activated microglia modulate disease-related plasticity and learning and memory deficits. By summarizing the function of microglia in these processes, we aim to provide an overview of microglia regulation of synaptic plasticity and learning and memory, and to discuss the possibility of microglia manipulation as a therapeutic to ameliorate cognitive deficits associated with aging, Alzheimer’s disease, traumatic brain injury, HIV-associated neurocognitive disorder, and mental disorders.
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Affiliation(s)
- Jessica Cornell
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Pomona, CA, USA
| | - Shelbi Salinas
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Pomona, CA, USA
| | - Hou-Yuan Huang
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Pomona, CA, USA
| | - Miou Zhou
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Pomona, CA, USA
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12
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The Influence of Virus Infection on Microglia and Accelerated Brain Aging. Cells 2021; 10:cells10071836. [PMID: 34360004 PMCID: PMC8303900 DOI: 10.3390/cells10071836] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/15/2021] [Accepted: 07/16/2021] [Indexed: 12/12/2022] Open
Abstract
Microglia are the resident immune cells of the central nervous system contributing substantially to health and disease. There is increasing evidence that inflammatory microglia may induce or accelerate brain aging, by interfering with physiological repair and remodeling processes. Many viral infections affect the brain and interfere with microglia functions, including human immune deficiency virus, flaviviruses, SARS-CoV-2, influenza, and human herpes viruses. Especially chronic viral infections causing low-grade neuroinflammation may contribute to brain aging. This review elucidates the potential role of various neurotropic viruses in microglia-driven neurocognitive deficiencies and possibly accelerated brain aging.
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Dash PK, Akay-Espinoza C. FDG PET/computed tomography can detect region-specific neuronal changes following antiretroviral therapy in HIV-infected patients. AIDS 2021; 35:1309-1310. [PMID: 34076617 DOI: 10.1097/qad.0000000000002925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Prasanta K Dash
- Department of Pharmacology and Experimental Neuroscience, College of Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Cagla Akay-Espinoza
- Department of Basic and Translational Sciences, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Rubin LH, Li Y, Fitzgerald KC, Dastgheyb R, Spence AB, Maki PM, Sharma A, Gustafson DR, Milam J, Weber KM, Adimora AA, Haughey NJ, Ofotokun I, Fischl MA, Konkle-Parker D, Xu Y, Williams DW. Associations between Antiretrovirals and Cognitive Function in Women with HIV. J Neuroimmune Pharmacol 2021; 16:195-206. [PMID: 32212091 PMCID: PMC7511435 DOI: 10.1007/s11481-020-09910-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 02/14/2020] [Indexed: 02/01/2023]
Abstract
Cognitive complications persist in antiretroviral therapy(ART)-treated people with HIV. However, the pattern and severity of domain-specific cognitive performance is variable and may be exacerbated by ART-mediated neurotoxicity. 929 women with HIV(WWH) from the Women's Interagency HIV Study who were classified into subgroups based on sociodemographic and longitudinal behavioral and clinical data using semi-parametric latent class trajectory modelling. Five subgroups were comprised of: 1) well-controlled HIV with vascular comorbidities(n = 116); 2) profound HIV legacy effects(CD4 nadir <250 cells/μL; n = 275); 3) primarily <45 year olds with hepatitis C(n = 165); 4) primarily 35-55 year olds(n = 244), and 5) poorly-controlled HIV/substance use(n = 129). Within each subgroup, we fitted a constrained continuation ratio model via penalized maximum likelihood to examine adjusted associations between recent ART agents and cognition. Most drugs were not associated with cognition. However, among the few drugs, non-nucleoside reverse transcriptase inhibitor (NNRTIs) and protease inhibitors(PIs) were most commonly associated with cognition, followed by nucleoside reverse transcriptase inhibitors(NRTIs) and integrase inhibitors(IIs). Directionality of ART-cognition associations varied by subgroup. Better psychomotor speed and fluency were associated with ART for women with well-controlled HIV with vascular comorbidities. This pattern contrasts women with profound HIV legacy effects for whom poorer executive function and fluency were associated with ART. Motor function was associated with ART for younger WWH and primarily 35-55 year olds. Memory was associated with ART only for women with poorly-controlled HIV/substance abuse. Findings demonstrate interindividual variability in ART-cognition associations among WWH and highlight the importance of considering sociodemographic, clinical, and behavioral factors as an underlying contributors to cognition. Are antiretroviral agents a risk factor for cognitive complications in women with HIV? We examind associations between ART-agents and cognitive function among similar subgroups of women with HIV from the Women's Interagency HIV study. The patterns of associations depended on sociodemographic, clinical, and behavioral characteristics of women.
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Affiliation(s)
- Leah H Rubin
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street/ Meyer 6-113, Baltimore, MD, 21287-7613, USA.
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Yuliang Li
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, MD, USA
| | - Kathryn C Fitzgerald
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street/ Meyer 6-113, Baltimore, MD, 21287-7613, USA
| | - Raha Dastgheyb
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street/ Meyer 6-113, Baltimore, MD, 21287-7613, USA
| | - Amanda B Spence
- Department of Medicine, Division of Infectious Disease and Travel Medicine, Georgetown University, Washington, DC, USA
| | - Pauline M Maki
- Departments of Psychiatry and Psychology, University of Illinois at Chicago, Chicago, IL, USA
| | - Anjali Sharma
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Deborah R Gustafson
- Department of Neurology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Joel Milam
- Institute for Health Promotion & Disease Prevention Research, University of Southern California, Los Angeles, CA, USA
| | - Kathleen M Weber
- CORE Center, Cook County Health and Hektoen Institute of Medicine, Chicago, IL, USA
| | - Adaora A Adimora
- Division of Infectious Diseases, Department of Medicine,, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Norman J Haughey
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street/ Meyer 6-113, Baltimore, MD, 21287-7613, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Igho Ofotokun
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, GA, USA
| | | | - Deborah Konkle-Parker
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS, USA
| | - Yanxun Xu
- Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, MD, USA
- Division of Biostatistics and Bioinformatics at The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dionna W Williams
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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15
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Saloner R, Fields JA, Marcondes MCG, Iudicello JE, von Känel S, Cherner M, Letendre SL, Kaul M, Grant I. Methamphetamine and Cannabis: A Tale of Two Drugs and their Effects on HIV, Brain, and Behavior. J Neuroimmune Pharmacol 2020; 15:743-764. [PMID: 32929575 DOI: 10.1007/s11481-020-09957-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/10/2020] [Indexed: 12/12/2022]
Abstract
HIV infection and drug use intersect epidemiologically, and their combination can result in complex effects on brain and behavior. The extent to which drugs affect the health of persons with HIV (PWH) depends on many factors including drug characteristics, use patterns, stage of HIV disease and its treatment, comorbid factors, and age. To consider the range of drug effects, we have selected two that are in common use by PWH: methamphetamine and cannabis. We compare the effects of methamphetamine with those of cannabis, to illustrate how substances may potentiate, worsen, or even buffer the effects of HIV on the CNS. Data from human, animal, and ex vivo studies provide insights into how these drugs have differing effects on the persistent inflammatory state that characterizes HIV infection, including effects on viral replication, immune activation, mitochondrial function, gut permeability, blood brain barrier integrity, glia and neuronal signaling. Moving forward, we consider how these mechanistic insights may inform interventions to improve brain outcomes in PWH. This review summarizes literature from clinical and preclinical studies demonstrating the adverse effects of METH, as well as the potentially beneficial effects of cannabis, on the interacting systemic (e.g., gut barrier leakage/microbial translocation, immune activation, inflammation) and CNS-specific (e.g., glial activation/neuroinflammation, neural injury, mitochondrial toxicity/oxidative stress) mechanisms underlying HIV-associated neurocognitive disorders.
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Affiliation(s)
- Rowan Saloner
- Department of Psychiatry, HIV Neurobehavioral Research Program, University of California, San Diego, San Diego, CA, USA. .,Joint Doctoral Program in Clinical Psychology, San Diego State University/University of California, San Diego , San Diego, CA, USA.
| | - Jerel Adam Fields
- Department of Psychiatry, HIV Neurobehavioral Research Program, University of California, San Diego, San Diego, CA, USA
| | | | - Jennifer E Iudicello
- Department of Psychiatry, HIV Neurobehavioral Research Program, University of California, San Diego, San Diego, CA, USA
| | - Sofie von Känel
- Department of Psychiatry, HIV Neurobehavioral Research Program, University of California, San Diego, San Diego, CA, USA
| | - Mariana Cherner
- Department of Psychiatry, HIV Neurobehavioral Research Program, University of California, San Diego, San Diego, CA, USA
| | - Scott L Letendre
- Department of Psychiatry, HIV Neurobehavioral Research Program, University of California, San Diego, San Diego, CA, USA
| | - Marcus Kaul
- Department of Psychiatry, HIV Neurobehavioral Research Program, University of California, San Diego, San Diego, CA, USA.,Division of Biomedical Sciences, University of California, Riverside, Riverside, CA, USA
| | - Igor Grant
- Department of Psychiatry, HIV Neurobehavioral Research Program, University of California, San Diego, San Diego, CA, USA
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16
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Abstract
OBJECTIVE People living with HIV (PLWH) may be at an increased risk for dementia as they age. Surprisingly, it remains unclear whether PLWH have a higher risk of developing dementia in late life than those without. We explored whether HIV-infection is associated with incident dementia diagnosis in older U.S. veterans accounting for potential confounders and competing risk of death. METHODS We included 1114 veterans diagnosed with HIV, ages at least 55 years (mean = 62 years, SD = 6), followed in the Veterans Health Administration healthcare system from 2004 to 2015, and a propensity-matched comparison group (n = 1114) without HIV. HIV and dementia diagnoses were determined using electronic medical records. Using Fine-Gray proportional hazards models, we examined whether HIV status was associated with a greater risk of incident dementia. RESULTS During follow-up (mean = 7 years, SD = 4 from date of HIV diagnosis), 5% of veteran PLWH developed dementia compared with 3% without (P = 0.01). Accounting for the competing risk of death and adjusted for demographics, substance use, education and income, PLWH remained 50% more likely to receive a dementia diagnosis [adjusted hazard ratio (aHR) = 1.50, 95% confidence interval 0.96-2.35]. Although combination antiretroviral therapy (cART) exposure was associated with an increased risk of incident dementia, this was driven by differences in illness severity as captured by CD4 cell count. There was no evidence of a differential effect by cART class. CONCLUSION In a cohort of older USA veterans, HIV infection increased risk of dementia by 50%, while exposure to cART did not offset this risk. It is critical to understand the mechanisms by which HIV increases risk for developing dementia in later life.
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17
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Kanmogne GD, Fonsah JY, Umlauf A, Moul J, Doh RF, Kengne AM, Tang B, Tagny CT, Nchindap E, Kenmogne L, Franklin D, Njamnshi DM, Kuate CT, Mbanya D, Njamnshi AK, Heaton RK. Effects of HIV infection, antiretroviral therapy, and immune status on the speed of information processing and complex motor functions in adult Cameroonians. Sci Rep 2020; 10:14016. [PMID: 32820234 PMCID: PMC7441321 DOI: 10.1038/s41598-020-70981-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 07/28/2020] [Indexed: 12/12/2022] Open
Abstract
HIV-associated neurocognitive deficits include impaired speed-of-information processing (SIP) and motor functions. There is lack of Cameroonian adult norms for assessing SIP or motor functions. This study of 683 Cameroonians (320 HIV+, 363 HIV-) establishes demographically-adjusted norms for six SIP [Wechsler-Adult-Intelligence-Scale (WAIS)-III Digit Symbol (WAIS-IIIDS) and Symbol Search (WAIS-IIISS), Stroop Color-Naming, Stroop Word-Reading, Trail-Making Test-A (TMT-A), Color Trails-1 (CTT1)], and two motor function [Grooved Pegboard-dominant (GP-DH) and non-dominant (GP-NDH) hands] tests. We assessed viral effects on SIP and motor functions. HIV-infected persons had significantly lower (worse) T scores on GP-DH, WAIS-IIIDS, Stroop Word-Reading, TMT-A; lower motor and SIP summary T scores. Significantly higher proportion of cases (20.7%) than controls (10.3%) had impaired SIP. Male cases had better T scores than female cases on GP-NDH, WAIS-IIIDS, WAIS-IIISS, TMT-A, CTT1; better SIP summary T scores. Antiretroviral therapy (ART) was associated with significantly better T scores on GP-NDH, WAIS-IIIDS, Stroop Color-Naming; better motor and SIP summary T scores. Cases with higher CD4 had better T scores on WAIS-IIIDS, TMT-A, CTT1; better SIP summary T scores. Overall, we demonstrate that HIV infection in Cameroon is associated with deficits in SIP and motor functions; ART and higher CD4 are associated with better cognitive performance. We provide SIP and psychomotor functions normative standards, which will be useful for neurobehavioral studies in Cameroon of diseases affecting the brain.
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Affiliation(s)
- Georgette D Kanmogne
- Vice-Chair for Resource Allocation and Faculty Development, Department of Pharmacology and Experimental Neuroscience, College of Medicine, University of Nebraska Medical Center, Omaha, NE, 68198-5800, USA.
| | - Julius Y Fonsah
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Department of Neurology, Yaoundé Central Hospital/Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
| | - Anya Umlauf
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Jacob Moul
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Roland F Doh
- Department of Neurology, Yaoundé Central Hospital/Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
| | - Anne M Kengne
- Department of Neurology, Yaoundé Central Hospital/Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
| | - Bin Tang
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Claude T Tagny
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Yaoundé University Teaching Hospital, Yaoundé, Cameroon
| | | | | | - Donald Franklin
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Dora M Njamnshi
- HIV-Day Care Service, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Callixte T Kuate
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Department of Neurology, Laquintinie Hospital, Douala, Cameroon
| | - Dora Mbanya
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Yaoundé University Teaching Hospital, Yaoundé, Cameroon
| | - Alfred K Njamnshi
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Department of Neurology, Yaoundé Central Hospital/Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
| | - Robert K Heaton
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
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