HIV or HIV-therapy? Causal attributions of symptoms and their impact on treatment decisions among women and men with HIV

Association between HIV status and psychological symptoms in perimenopausal women

OBJECTIVE

HIV-infected women are burdened by depression and anxiety, which may impact adherence to antiretroviral therapy and overall quality of life. Yet, little is known about the scope of psychological symptoms in the growing number of HIV-infected women reaching menopause, when affective symptoms are more prevalent in the general population. We conducted a longitudinal study to compare affective symptoms between perimenopausal HIV-infected and non-HIV-infected women.

METHODS

The Center for Epidemiologic Studies Depression Scale (CES-D), and the Generalized Anxiety Disorder scale (GAD-7) were completed at baseline and 12 months among 33 HIV-infected and 33 non-HIV-infected perimenopausal women matched by race, age, menstrual patterns, and BMI. Linear regression models estimated the relationship of baseline GAD-7 and CES-D scores with clinical factors.

RESULTS

All women were perimenopausal at baseline, and the vast majority remained perimenopausal throughout follow-up. HIV status was associated with higher baseline CES-D scores (median [interquartile range] 21 [12, 29] vs 10 [5, 14]; P = 0.03) and GAD-7 scores (7 [5, 15] vs 2 [1, 7]; P = 0.01), controlling for smoking, substance use, and antidepressant use. Depressive symptoms and anxiety remained significantly higher in the HIV-infected women at 12 months (P ≤ 0.01). Significant relationships of depressive symptoms (P = 0.048) and anxiety (P = 0.02) with hot flash severity were also observed.

CONCLUSIONS

Perimenopausal HIV-infected women experienced a disproportionately high level of affective symptom burden over a 12-month observation period. Given the potential for these factors to influence adherence to HIV clinical care and quality of life, careful assessment and referral for treatment of these symptoms is essential.

Protein Phosphatase-1 -targeted Small Molecules, Iron Chelators and Curcumin Analogs as HIV-1 Antivirals

BACKGROUND

Despite efficient suppression of HIV-1 replication, current antiviral drugs are not able to eradicate HIV-1 infection. Permanent HIV-1 suppression or complete eradication requires novel biological approaches and therapeutic strategies. Our previous studies showed that HIV-1 transcription is regulated by host cell protein phosphatase-1. We also showed that HIV-1 transcription is sensitive to the reduction of intracellular iron that affects cell cycle-dependent kinase 2. We developed protein phosphatase 1-targeting small molecules that inhibited HIV-1 transcription. We also found an additional class of protein phosphatase-1-targeting molecules that activated HIV-1 transcription and reported HIV-1 inhibitory iron chelators and novel curcumin analogs that inhibit HIV-1. Here, we review HIV-1 transcription and replication with focus on its regulation by protein phosphatase 1 and cell cycle dependent kinase 2 and describe novel small molecules that can serve as future leads for anti-HIV drug development.

RESULTS

Our review describes in a non-exhaustive manner studies in which HIV-1 transcription and replication are targeted with small molecules. Previously, published studies show that HIV-1 can be inhibited with protein phosphatase-1-targeting and iron chelating compounds and curcumin analogs. These results are significant in light of the current efforts to eradicate HIV-1 through permanent inhibition. Also, HIV-1 activating compounds can be useful for "kick and kill" therapy in which the virus is reactivated prior to its inhibition by the combination antiretroviral therapy.

CONCLUSION

The studies described in our review point to protein phosphatase-1 as a new drug target, intracellular iron as subject for iron chelation and novel curcumin analogs that can be developed for novel HIV-1 transcription- targeting therapeutics.

The relationship between gastrointestinal symptom attribution, bothersomeness, and antiretroviral adherence among adults with HIV

Patients who attribute their symptoms to HIV medications, rather than disease, may be prone to switching antiretrovirals (ARVs) and experience poor retention/adherence to care. Gastrointestinal (GI) symptoms (e.g., nausea/vomiting) are often experienced as a side effect of ARVs, but little is known about the relationship of symptom attribution and bothersomeness to adherence. We hypothesized that attribution of a GI symptom to ARVs is associated with a reduction in adherence, and that this relationship is moderated by the bothersomeness of the symptom. Data for our analysis come from the pre-randomization enrollment period of a larger study testing an adherence improvement intervention. Analyses revealed that patients with diarrhea who attributed the symptom to ARVs (compared to those who did not) had significantly worse adherence. We did not find a significant moderating effect of bothersomeness on this relationship. Incorporating patient beliefs about causes of symptoms into clinical care may contribute to improved symptom and medication management, and better adherence.

Reactivation of latent HIV-1 provirus via targeting protein phosphatase-1

Background

HIV-1 escapes antiretroviral drugs by integrating into the host DNA and forming a latent transcriptionally silent HIV-1 provirus. This provirus presents the major hurdle in HIV-1 eradication and cure. Transcriptional activation, which is prerequisite for reactivation and the eradication of latent proviruses, is impaired in latently infected T cells due to the lack of host transcription factors, primarily NF-κB and P-TEFb (CDK9/cyclin T1). We and others previously showed that protein phosphatase-1 (PP1) regulates HIV-1 transcription by modulating CDK9 phosphorylation. Recently we have developed a panel of small molecular compounds targeting a non-catalytic site of PP1.

Results

Here we generated a new class of sulfonamide-containing compounds that activated HIV-1 in acute and latently infected cells. Among the tested molecules, a small molecule activator of PP1 (SMAPP1) induced both HIV-1 replication and reactivation of latent HIV-1 in chronically infected cultured and primary cells. In vitro, SMAPP1 interacted with PP1 and increased PP1 activity toward a recombinant substrate. Treatment with SMAPP1 increased phosphorylation of CDK9’s Ser90 and Thr186 residues, but not Ser175. Proteomic analysis showed upregulation of P-TEFb and PP1 related proteins, including PP1 regulatory subunit Sds22 in SMAPP1-treated T cells. Docking analysis identified a PP1 binding site for SMAPP1 located within the C-terminal binding pocket of PP1.

Conclusion

We identified a novel class of PP1-targeting compounds that reactivate latent HIV-1 provirus by targeting PP1, increasing CDK9 phosphorylation and enhancing HIV transcription. This compound represents a novel candidate for anti-HIV-1 therapeutics aiming at eradication of latent HIV-1 reservoirs.

'Not Until I'm Absolutely Half-Dead and Have To:' Accounting for Non-Use of Antiretroviral Therapy in Semi-Structured Interviews with People Living with HIV in Australia

Current debates regarding the use of antiretroviral therapy (ART) to promote both individual- and population-level health benefits underscore the importance of understanding why a subpopulation of people with diagnosed HIV and access to treatment choose not to use it. Semi-structured interviews were conducted between 2012 and 2014 with 27 people living with HIV in Australia who were not using ART at the time of interview. Analytic triangulation permitted an appreciation of not only the varied personal reasons for non-use of treatment, but also underlying views on HIV treatment, and the ideal conditions imagined necessary for treatment initiation. Policy goals to increase the number of people with HIV using ART must recognize the diverse explanations for non-use of ART, which include concerns about the various impacts of committing to lifelong pharmaceutical treatment use. Our research identified distinctive subgroups among people who are not using antiretroviral therapy, with a range of individual and social needs that may affect treatment decisions. These findings challenge assumptions about treatment non-use in resource-rich settings, revealing persistent consumer fears about the potent and unknown effects of HIV medications that deserve greater recognition in policy debate on treatment uptake.

Stress and coping in women living with HIV: a meta-analytic review

To examine effects between stressors and coping mechanisms on behavioral health outcomes a meta-analysis was conducted using forty empirical articles which sampled 7,602 adult women living with HIV/AIDS in the U.S. (M = 36.3 years). Three independent reviewers conducted searches in abstract databases from 1997 to present day. Articles reporting effect sizes amongst psychosocial stressors and coping mechanisms with indices of behavioral/mental health were selected. The meta-analyses revealed that in a time frame characterized by the widespread availability of anti-retroviral medication, poor mental health outcomes were predicted, in a similar manner, by psychosocial stress and HIV/AIDS symptomology. Significant effects were also observed with functional impairment, though to a lesser degree. Coping by avoidance and social isolation predicted more severe mental health outcomes. Spirituality and positive reappraisal predicted greater psychological adaptation than did social support seeking. Despite advancements in anti-retroviral treatment for women, HIV/AIDS symptoms and acute and/or chronic psychosocial stress pose the same threat to behavioral and mental health. In the face of these stressors, positive reframing appears to promote psychological adaptation in a way which may lead to positive health outcomes in women living with HIV/AIDS.

Strategies adopted by late middle-age and older adults with HIV/AIDS to explain their physical symptoms

Although the attributions individuals make about what causes their physical symptoms are known to influence their care seeking and self-care behaviours, much less is known about the strategies they use to arrive at these attributions. The strategies employed to understand the causes of their symptoms were investigated using in-depth interviews with 100 late middle-age and older adults with HIV/AIDS in New York City. The data revealed that most participants actively sought to explain their symptoms. The explanatory strategies identified included: relying upon illness or medication representations, lay beliefs about the body and ageing, invoking pre-existing vulnerabilities, engaging in lay experimentation, social comparison processes, considering temporal ordering and consulting authoritative sources. While most of them offered a single cause for their symptoms, some offered more complex multi-causal explanations. These findings provide understanding into the reasons why some older adults with HIV/AIDS misattribute symptoms resulting in delay in care or care over-utilisation, suggesting the need for patient education.

Comparison of polysomnographic data in age-, sex- and Axis I psychiatric diagnosis matched HIV-seropositive and HIV-seronegative insomnia patients

OBJECTIVE

There is a high prevalence of insomnia in HIV-seropositive patients. Insomnia is associated with poorer disease outcomes, cognitive impairment and HIV-associated dementia. However there is limited data characterizing the type of sleep disturbances, and the cause. Previous studies report conflicting results, and observed changes in the distribution of REM and SWS were hypothesized to result from co-morbid mood disorders, although this is not established. We carried out this study to determine if there are differences in polysomnographic (PSG) sleep data in age-, sex- and Axis I diagnoses- matched HIV-seropositive and HIV-seronegative patients.

METHODS

Eighteen HIV-seropositive insomniacs were matched to HIV-seronegative insomniacs based on age, sex and Axis I diagnoses. Participants spent 2 consecutive nights in a sleep lab recording of PSG data.

RESULTS

Multivariate analysis revealed an overall significant match-by-variable interaction (p=0.0126). Follow-up analysis show that compared to HIV-seronegative insomnia controls, HIV-seropositive insomniacs have significantly longer SOL, 8% decreased sleep efficiency, and 8-10% decreased time spent in REM sleep (p's<0.05).

CONCLUSION

This study provides preliminary evidence that even after accounting for differences in age, sex and psychiatric diagnoses, HIV-seropositive patients with insomnia have significantly worse sleep than HIV-seronegative patients with insomnia.

SIGNIFICANCE

Unlike what previous authors have proposed, our results do not support the view that comorbid psychiatric disorders like depression are responsible for the observed differences in PSG findings and the greater incidence of insomnia, in HIV-seropositive patients when compared with other groups of insomnia patients. This suggests the presence of other etiologies including neuronal damage, psychosocial stressors, or comorbid medical conditions. Further studies are needed to determine the extent to which these play a role in insomnia in the HIV-seropositive population.

Association between missed early visits and mortality among patients of china national free antiretroviral treatment cohort

BACKGROUND

China's National Free Antiretroviral Treatment program has scaled-up rapidly since 2002, leading to a significant reduction of mortality among its participants. However, few studies have evaluated indicators for patient access to medical care and their association with mortality.

METHODS

Patients enrolled into this national program between June 2002 and June 2009 for at least 7.5 months were retrospectively analyzed.

RESULTS

Twenty-seven thousand five hundred four patients were included into the analysis, among whom 10,034 (37%) had at least 1 missed visit during the first 6 months of treatment. In Cox proportional hazard regression analysis, controlled for baseline demographic and clinical factors, patients with more missed visits had a higher risk of mortality, with an adjusted hazard ratio of 1.3 (95% confidence interval: 1.1 to 1.5) for 1-2 missed visits and 1.7 (95% confidence interval 1.4 to 2.2) for ≥3 missed visits compared with patients with no missed visits. In multivariate logistic regression models, factors independently associated with a higher likelihood of early missed visits included female gender, age >60, HIV transmission via injection drug use or via plasma donation compared with sexual transmission, baseline alanine aminotransferase >100 IU/L, having more symptoms at antiretroviral therapy initiation and receiving a didanosine-based regimen compared with lamivudine-based regimen. Lower baseline CD4 count was protective against missed visits.

CONCLUSIONS

Missing early visits occurred in a sizable number of patients in this cohort and was associated with a higher mortality rate. Early missed visits may serve as an early warning indicator to trigger additional outreach effort.

Position of the American Dietetic Association: Nutrition Intervention and Human Immunodeficiency Virus Infection

It is the position of the American Dietetic Association that efforts to optimize nutritional status through individualized medical nutrition therapy, assurance of food and nutrition security, and nutrition education are essential to the total system of health care available to people with human immunodeficiency virus (HIV) infection throughout the continuum of care. Broad-based efforts to improve health care access and treatment have stabilized HIV prevalence levels in many parts of the world and led to longer survival for people living with HIV infection. Confounding clinical and social issues, such as medication interactions, comorbidities, wasting, lipodystrophy, food insecurity, aging, and other related conditions further complicate disease management. With greater understanding of the mechanisms of HIV disease and its impact on body function, development of new treatments, and wider ranges of populations affected, the management of chronic HIV infection continues to become more complex and demanding. Achievement of food and nutrition security and management of nutrition-related complications of HIV infection remain significant challenges for clients with HIV infection and health care professionals. Registered dietitians and dietetic technicians, registered, should integrate their efforts into the overall health care strategies to optimize their clinical and social influence for people living with HIV infection.

Depression in women living with HIV: clinical and psychosocial correlates

The number of Brazilian women living with HIV has increased significantly in past years, rendering studies of their particular care demands including psychiatric issues. This study measures the prevalence of major depression, using the Structured Clinical Interview for DSM-IV Axis I Disorders, in a sample of 120 women living with HIV in treatment at a reference centre in São Paulo. Socio-demographic variables, HIV-related clinical and laboratory data, including CD4+ cell counts and HIV plasma viral loads, as well as psychosocial features (intimate relationships, disclosure of HIV serostatus, partner's serostatus and patient's emotional and financial support) were investigated as factors potentially associated with depression. The prevalence of major depression at the time of evaluation was 25.8% (95% CI 18.2-33.4%). Clinical status (p = 0.002), lack of emotional support (p = 0.02), use of antidepressants (p = 0.028) and length of time since HIV diagnosis (p = 0.05) were associated with major depression in univariate analysis. In multivariate multiple-regression model, HIV clinical status, lack of emotional support and higher plasma viral loads were associated with depression. Sixty per cent of the women have a major depression diagnosis during lifetime. We conclude that major depression is highly prevalent among women living with HIV, but it is still underdiagnosed and undertreated.