Understanding and optimizing brain health in HIV now: protocol for a longitudinal cohort study with multiple randomized controlled trials

In Support of Multidimensional Frailty: A Structural Equation Model from the Canadian Positive Brain Health Now Cohort

The objective of this study was to estimate the structure and relationships between four h ypothesized frailty dimensions (physical, emotional, cognitive, and social) and the extent to which personal and HIV-related factors and comorbidity associate with these frailty dimensions. This is a secondary analysis of an existing dataset arising from Positive Brain Health Now study (n = 856) in people aging with HIV (mean age: 52.3 ± 8.1 years). Structural equation modeling (SEM) models were applied to two cross-sections of the data: one at study entry and one at second visit, 9-month apart. Multidimensional frailty was modeled based on the combined Wilson-Cleary and International Classification of Functioning, Disability and Health framework. Four dimensions were operationalized with patient-reported and self-report measures from standardized questionnaires. The SEM model from the first visit was replicated using data from the second visit, testing measurement invariance. The proposed model showed acceptable fit at both visits (including no violation of measurement invariance). The final model for the first visit showed that sex, body mass index, HIV diagnosis pre-1997, current or nadir CD4 counts, and comorbidity did not associate with any frailty dimension; however, age (β range: 0.12-0.25), symptoms (β range: -0.35 to -0.58), and measured cognition (β range: 0.10-0.24) directly associated with all frailty dimensions. The model remained stable across the two visits. This study contributes evidence for operationalizing multidimensional frailty. Evidence-based interventions are available for many of the measures considered here, offering opportunities to improve the lives of people with frailty in the context of HIV.

The association between anticholinergic/sedative burden and physical frailty in people aging with HIV

OBJECTIVE

This study aimed to estimate the strength of the association between anticholinergic/sedative burden and concurrent physical frailty in people aging with HIV.

DESIGN

This cross-sectional analysis examined baseline data from 824 adults with a mean age of 53 enrolled in the Positive Brain Health Now study.

METHODS

Anticholinergic medications were identified using four methods: Anticholinergic Cognitive Burden (ACB) Scale, Anticholinergic Risk Scale (ARS), Anticholinergic Drug Scale (ADS), and the anticholinergic list of the Anticholinergic and Sedative Burden Catalog (ACSBC). Sedatives were identified using the Sedative Load Model (SLM) and the sedative list of the ACSBC. Physical frailty was assessed using a modified Fried Frailty Phenotype (FFP) based on self-report items. Multivariable logistic regression models, adjusted for sociodemographic factors, lifestyle considerations, HIV-related variables, comorbidities, and co-medication use, were used to estimate odds ratios (ORs).

RESULTS

Anticholinergic burden demonstrated associations with frailty across various methods: total anticholinergic burden (OR range: 1.22-1.32; 95% confidence interval (CI) range: 1.03-1.66), sedative burden (OR range: 1.18-1.24; 95% CI range: 1.02-1.45), high anticholinergic burden (OR range: 2.12-2.74; 95% CI range: 1.03-6.19), and high sedative burden (OR range: 1.94-2.18; 95% CI: 1.01-4.34).

CONCLUSION

The anticholinergic and sedative burdens may represent modifiable risk factors for frailty in people aging with HIV. Future studies should evaluate the effects of reducing anticholinergic and sedative burdens on frailty outcomes and explore the prognostic value of diverse scoring methods.

Randomised trials conducted using cohorts: a scoping review

INTRODUCTION

Cohort studies generate and collect longitudinal data for a variety of research purposes. Randomised controlled trials (RCTs) increasingly use cohort studies as data infrastructures to help identify and recruit trial participants and assess outcomes.

OBJECTIVE

To examine the extent, range and nature of research using cohorts for RCTs and describe the varied definitions and conceptual boundaries for RCTs using cohorts.

DESIGN

Scoping review.

DATA SOURCES

Searches were undertaken in January 2021 in MEDLINE (Ovid) and EBM Reviews-Cochrane Methodology Registry (Final issue, third Quarter 2012).

ELIGIBILITY CRITERIA

Reports published between January 2007 and December 2021 of (a) cohorts used or planned to be used, to conduct RCTs, or (b) RCTs which use cohorts to recruit participants and/or collect trial outcomes, or (c) methodological studies discussing the use of cohorts for RCTs.

DATA EXTRACTION AND SYNTHESIS

Data were extracted on the condition being studied, age group, setting, country/continent, intervention(s) and comparators planned or received, unit of randomisation, timing of randomisation, approach to informed consent, study design and terminology.

RESULTS

A total of 175 full-text articles were assessed for eligibility. We identified 61 protocols, 9 descriptions of stand-alone cohorts intended to be used for future RCTs, 39 RCTs using cohorts and 34 methodological papers.The use and scope of this approach is growing. The thematics of study are far-ranging, including population health, oncology, mental and behavioural disorders, and musculoskeletal conditions.Authors reported that this approach can lead to more efficient recruitment, more representative samples, and lessen disappointment bias and crossovers.

CONCLUSION

This review outlines the development of cohorts to conduct RCTs including the range of use and innovative changes and adaptations. Inconsistencies in the use of terminology and concepts are highlighted. Guidance now needs to be developed to support the design and reporting of RCTs conducted using cohorts.

The Patient Generated Index (PGI) as an early-warning system for predicting brain health challenges: a prospective cohort study for people living with Human Immunodeficiency Virus (HIV)

PURPOSE

In research people are often asked to fill out questionnaires about their health and functioning and some of the questions refer to serious health concerns. Typically, these concerns are not identified until the statistician analyses the data. An alternative is to use an individualized measure, the Patient Generated Index (PGI) where people are asked to self-nominate areas of concern which can then be dealt with in real-time. This study estimates the extent to which self-nominated areas of concern related to mood, anxiety and cognition predict the presence or occurrence of brain health outcomes such as depression, anxiety, psychological distress, or cognitive impairment among people aging with HIV at study entry and for successive assessments over 27 months.

METHODS

The data comes from participants enrolled in the Positive Brain Health Now (+ BHN) cohort (n = 856). We analyzed the self-nominated areas that participants wrote on the PGI and classified them into seven sentiment groups according to the type of sentiment expressed: emotional, interpersonal, anxiety, depressogenic, somatic, cognitive and positive sentiments. Tokenization was used to convert qualitative data into quantifiable tokens. A longitudinal design was used to link these sentiment groups to the presence or emergence of brain health outcomes as assessed using standardized measures of these constructs: the Hospital Anxiety and Depression Scale (HADS), the Mental Health Index (MHI) of the RAND-36, the Communicating Cognitive Concerns Questionnaire (C3Q) and the Brief Cognitive Ability Measure (B-CAM). Logistic regressions were used to estimate the goodness of fit of each model using the c-statistic.

RESULTS

Emotional sentiments predicted all of the brain health outcomes at all visits with adjusted odds ratios (OR) ranging from 1.61 to 2.00 and c-statistics > 0.73 (good to excellent prediction). Nominating an anxiety sentiment was specific to predicting anxiety and psychological distress (OR 1.65 & 1.52); nominating a cognitive concern was specific to predicting self-reported cognitive ability (OR 4.78). Positive sentiments were predictive of good cognitive function (OR 0.36) and protective of depressive symptoms (OR 0.55).

CONCLUSIONS

This study indicates the value of using this semi-qualitative approach as an early-warning system in predicting brain health outcomes.

Translocation of bacterial LPS is associated with self-reported cognitive abilities in men living with HIV receiving antiretroviral therapy

BACKGROUND

Gut damage allows translocation of bacterial lipopolysaccharide (LPS) and fungal β-D-glucan (BDG) into the blood. This microbial translocation contributes to systemic inflammation and risk of non-AIDS comorbidities in people living with HIV, including those receiving antiretroviral therapy (ART). We assessed whether markers of gut damage and microbial translocation were associated with cognition in ART-treated PLWH.

METHODS

Eighty ART-treated men living with HIV from the Positive Brain Health Now Canadian cohort were included. Brief cognitive ability measure (B-CAM) and 20-item patient deficit questionnaire (PDQ) were administered to all participants. Three groups were selected based on their B-CAM levels. We excluded participants who received proton pump inhibitors or antiacids in the past 3 months. Cannabis users were also excluded. Plasma levels of intestinal fatty acid binding protein (I-FABP), regenerating islet-derived protein 3 α (REG3α), and lipopolysaccharides (LPS = were quantified by ELISA, while 1-3-β-D-glucan BDG) levels were assessed using the Fungitell assay. Univariable, multivariable, and splines analyses were performed.

RESULTS

Plasma levels of I-FABP, REG3α, LPS and BDG were not different between groups of low, intermediate and high B-CAM levels. However, LPS and REG3α levels were higher in participants with PDQ higher than the median. Multivariable analyses showed that LPS association with PDQ, but not B-CAM, was independent of age and level of education. I-FABP, REG3α, and BDG levels were not associated with B-CAM nor PDQ levels in multivariable analyses.

CONCLUSION

In this well characterized cohort of ART-treated men living with HIV, bacterial but not fungal translocation was associated with presence of cognitive difficulties. These results need replication in larger samples.

Development of a self-report measure of cognitive change: assessment of interpretability in two samples, people with HIV and people without HIV

AIM

The overall aim of this study was to develop a method of measuring change in cognitive ability from the person's perspective.

METHODS

Cognitive change items came from an item pool that was used to develop the Communicating Cognitive Concerns Questionnaire (C3Q). The change items were administered to a test sample of 211 people with HIV + and a sample of 484 people drawn from the general population (HIV- sample). Rasch analysis was used to identify items that formed a linear continuum and correlations with measures of related constructs were used to support the interpretability of the new measure.

RESULTS

Eleven of the original 12 change items fit the unidimensional Rasch model in both samples with a near similar ordering of the items. The average value for cognitive change of the HIV + sample was greater than that of the HIV- sample. Values on C3Q-Change correlated most highly (> 0.7) with current self-reported cognitive status and measures of depression and anxiety (> 0.6). The lowest correlation was with performance-based cognitive ability (r = 0.2).

CONCLUSION

The items of C3Q-Change fit a strong measurement model and related to converging constructs in an expected way. Further work needs to be done to assess the meaning of self-reported cognitive change in relationship to measured change and to examine sources of differential item functioning.

Effectiveness of a personalized health profile on specificity of self-management goals among people living with HIV in Canada: findings from a blinded pragmatic randomized controlled trial

PURPOSE

To estimate among people living with chronic HIV, to what extent providing feedback on their health outcomes will affect the number and specificity of patient-formulated self-management goals.

METHODS

A personalized feedback profile was produced for individuals enrolled in a Canadian HIV Brain Health Now study. Goal specificity was measured by total number of specific words (matched to a domain-specific developed lexicon) per person-words using text mining techniques.

RESULTS

Of 176 participants enrolled and randomly assigned to feedback and control groups, 110 responses were received. The average number of goals was similar for both groups (3.7 vs 3.9). The number of specific words used in the goals formulated by the feedback and control group were 642 and 739, respectively. Specific nouns and actionable verbs were present to some extent and "measurable" and "time-bound" words were mainly missing. Negative binomial regression showed no difference in goal specificity among groups (RR = 0.93, 95% CI 0.78-1.10). Goals set by both groups overlapped in 8 areas and had little difference in rank.

CONCLUSION

Personalized feedback profile did not help with formulation of high-quality goals. Text mining has the potential to help with difficulties of goal evaluation outside of the face-to-face setting. With more data and use of learning models automated answers could be generated to provide a more dynamic platform.

Development of a Prototype for a Bilingual Patient-Reported Outcome Measure of the Important Health Aspects of Quality of Life in People Living with HIV: The Preference Based HIV Index (PB-HIV)

(1) Background: The aim of this project was to develop a short, HIV-specific, health-related quality of life measure with a scoring system based on patient preferences for the different dimensions of the Preference-Based HIV Index (PB-HIV). (2) Methods: This study is a cross-sectional analysis of data from the Canadian Positive Brain Health Now cohort (n = 854; mean age 53 years). Items from the standardized measures were mapped to the areas from the Patient-Generated Index and formed the domains. A Rasch analysis was used to identify the best performing item to represent each dimension. Each item was then regressed on self-rated health (scored 0 to 100) and the regression parameters were used as scaling weights to form an index score for the prototype measure. (3) Results: Seven independent dimensions with three declarative statements ordered as response options formed the PB-HIV Index (pain, fatigue, memory/concentration, sleep, physical appearance/body image, depression, motivation). Regression parameters from a multivariable model yielded a measure with a scoring range from 0 (worst health) to 100 (perfect health). (4) Conclusions: Preference-based measures are optimal, as the total score reflects gains in some dimensions balanced against losses in others. The PB-HIV Index is the first HIV-specific preference-based measure.

Efficacy potential of Goal Management Training to improve cognitive function in older people living with HIV

Goal Management Training® (GMT) teaches strategies to reduce cognitive load and improve focus in everyday tasks. The aim of this study was to ascertain feasibility, acceptability, and efficacy potential of GMT for people (≥50 years) with stable HIV infection scoring low on tests of cognitive ability. A two-sample, parallel, controlled trial was carried out. Feasibility was demonstrated, as 21/30 participants in the GMT group attended ≥8 of the 9 sessions and completed at least half of the homework. There was no change on the primary performance-based cognitive outcomes in the GMT group or in the control group (n = 23). There was a meaningful improvement in self-reported cognition in those adherent to the intervention. GMT is a promising intervention for people aging with HIV who are dealing with cognitive difficulties affecting their everyday life and should be further investigated.

Relationship between reward-related evoked potentials and real-world motivation in older people living with human immunodeficiency virus

Apathy, a clinical disorder characterized by low motivation, is prevalent in people living with Human Immunodeficiency Virus (HIV). It affects mental and physical health-related quality-of-life, medication adherence, and is associated with cognitive decline. However, the causes of apathy and the underlying brain mechanisms in HIV are unknown. Brain responses to reward may be relevant to understanding apathy and might serve as biomarkers for diagnosis or treatment response. Electroencephalogram (EEG) responses to gain and loss feedback in simple guessing tasks have been related to apathy in neurodegenerative conditions and healthy individuals. The primary aim of this study is to contribute evidence regarding the relationship between two EEG correlates of reward processing, the Reward Positivity, and the Feedback-P300, and real-world motivated behavior indicated by self-reported hours engaged in goal-directed leisure activities per week, in older individuals with well-controlled HIV infection. High-density EEG was collected from 75 participants while they performed a guessing task with gain or loss feedback. We found that a later component of reward processing, the Feedback-P300, was related to real-world engagement, while the earlier Reward Positivity was not. The Feedback-P300 measured with EEG holds promise as a biomarker for motivated behavior in older people living with HIV. These findings lay the groundwork for a better understanding of the neurobiology of apathy in this condition.

Factors Influencing Psychological Distress During the COVID-19 Pandemic in People Aging with HIV

Older adults living with HIV may be at increased risk of experiencing distress during the coronavirus disease 2019 (COVID-19) pandemic. We took advantage of a cohort study in older adults living with HIV in Canada (The Positive Brain Health Now [+BHN]) to study the psychological impact of the first wave of the COVID-19 pandemic. A longitudinal study was conducted in which participants in the +BHN study who had access to the internet and agreed to be contacted were queried on symptoms of psychological distress and its predictors each week between mid-April and the end of June 2020. Evolution of distress, measured with the Hospital Anxiety and Depression Scale (HADS), was modeled using Group Based Trajectory Analysis and logistic regression was used to identify factors predictive of psychological distress in the clinical range. The study was approved by the Research Ethics Board of the McGill University Health Center and all participants provided informed consent. The 77 +BHN participants who took part in this study were mostly men (92%) and on average 57.3 years of age. Over the study period, 32.5% experienced psychological distress in the clinical range at one or more weekly surveys. In the transition between the pre-COVID-19 and the COVID-19 periods, the HADS scores followed five distinct trajectories: (1) 39.5 % of the sample, with normal HADS scores in the several months preceding the pandemic, experienced an increase in HADS scores; (2) 30.6% of the sample had normal prepandemic HADS scores, remained stable; and (3) 29.9%, with prepandemic presence of distress, had a decrease in HADS scores. During the first wave of COVID-19, some attenuation in distress was seen over time. Feeling lonely and financial insecurity were associated with distress. Presence of psychological distress during the first wave of the COVID-19 pandemic was not universal among older adults with HIV, with as many as one third of the participants reporting an improvement in mental health. Distress was predicted by loneliness and financial insecurity.

Does effort-cost decision-making relate to real-world motivation in people living with HIV?

INTRODUCTION

Low motivation is frequent in older people with HIV, yet poorly understood. Effort-cost decision-making (ECDM) tasks inspired by behavioral economics have shown promise as indicators of motivation or apathy. These tasks assess the willingness to exert effort to earn a monetary reward, providing an estimate of the subjective "cost" of effort for each participant. Here we sought evidence for a relationship between ECDM task performance and self-reported motivation in a cross-sectional study involving 80 middle-aged and older people with well-controlled HIV infection, a chronic health condition with a high burden of mental and cognitive health challenges.

METHODS

Participants attending a regular follow-up visit for a Canadian longitudinal study of brain health in HIV completed a computerized ECDM task and a self-report measure of motivation. Other brain health measures were available, collected for the parent study (cognition, depression, anxiety, and vitality, as well as self-reported time spent on real-world leisure activities).

RESULTS

Contrary to our hypothesis, we found no relationship between ECDM performance and self-reported motivation. However, those willing to accept higher effort in the ECDM task also reported more time engaged in real-world activities. This association had a small-to-moderate effect size.

CONCLUSIONS

The behavioral economics construct of subjective cost of effort, measured with a laboratory ECDM task, does not relate to motivation in people living with chronic HIV. However, the task shows some relationship with real-world goal-directed behavior, suggesting this construct has potential clinical relevance. More work is needed to understand how the subjective cost of effort plays out in clinical symptoms and everyday activities.

Development and Validation of a Cognitive Reserve Index in HIV

OBJECTIVES

In the neuroHIV literature, cognitive reserve has most often been operationalized using education, occupation, and IQ. The effects of other cognitively stimulating activities that might be more amenable to interventions have been little studied. The purpose of this study was to develop an index of cognitive reserve in people with HIV, combining multiple indicators of cognitively stimulating lifetime experiences into a single value.

METHODS

The data set was obtained from a Canadian longitudinal study (N = 856). Potential indicators of cognitive reserve captured at the study entry included education, occupation, engagement in six cognitively stimulating activities, number of languages spoken, and social resources. Cognitive performance was measured using a computerized test battery. A cognitive reserve index was formulated using logistic regression weights. For the evidence on concurrent and predictive validity of the index, the measures of cognition and self-reported everyday functioning were each regressed on the index scores at study entry and at the last follow-up [mean duration: 25.9 months (SD 7.2)], respectively. Corresponding regression coefficients and 95% confidence intervals (CIs) were computed.

RESULTS

Professional sports [odds ratio (OR): 2.9; 95% CI 0.59-14.7], visual and performance arts (any level of engagement), professional/amateur music, complex video gaming and competitive games, and travel outside North America were associated with higher cognitive functioning. The effects of cognitive reserve on the outcomes at the last follow-up visit were closely similar to those at study entry.

CONCLUSION

This work contributes evidence toward the relative benefit of engaging in specific cognitively stimulating life experiences in HIV.

Factors partitioning physical frailty in people aging with HIV: A classification and regression tree approach

OBJECTIVE

To estimate the extent to which comorbidity and lifestyle factors were associated with physical frailty in middle-aged and older Canadians living with HIV.

DESIGN

Cross-sectional analysis of 856 participants from the Canadian Positive Brain Health Now cohort.

METHODS

The frailty indicator phenotype was adapted from Fried's criteria using self-report items. Univariate logistic regression and classification and regression tree (CaRT) models were used to identify the most relevant independent contributors to frailty.

RESULTS

In all, 100 men (14.0%) and 26 women (19.7%) were identified as frail (≥ 3/5 criteria) for an overall prevalence of 15.2%. Nine comorbidities showed an influential association with frailty. The most influential comorbidities were hypothyroidism [odds ratio (OR) = 2.55, 95% confidence interval (CI): 1.29-50.3] and arthritis (OR = 2.54, 95% CI: 1.58-4.09). Additionally, tobacco (OR = 1.79, 95% CI: 1.05-3.04) showed an association. Any level of alcohol consumption showed a protective effect for frailty. The CaRT model showed nine pathways that led to frailty. Arthritis was the most discriminatory variable followed by alcohol, hypothyroidism, tobacco, cancer, cannabis, liver disease, kidney disease, osteoporosis, lung disease and peripheral vascular disease. The prevalence of physical frailty for people with arthritis was 27.4%; with additional cancer or tobacco and alcohol the prevalence rates were 47.1% and 46.1%, respectively. The protective effect of alcohol consumption evident in the univariate model appeared again in the CaRT model, but this effect varied. Cognitive frailty (19.5% overall) and emotional frailty (37.9% overall) were higher than the prevalence of physical frailty.

CONCLUSIONS

Specific comorbidities and tobacco use were implicated in frailty, suggesting that it is comorbidities causing frailty. However, some frailty still appears to be HIV-related. The higher prevalence of cognitive and emotional frailty highlights the fact that physical frailty should not be the only focus in HIV.

Feasibility and potential benefits of a structured exercise program on cognitive performance in HIV

Although exercise has been shown to improve cardiorespiratory and metabolic outcomes in people with HIV, its effect on cognitive ability remains understudied. Our study aimed to estimate the feasibility and efficacy potential of a 12-week aerobic and resistance training program on cognitive and physical performance outcomes. This is an externally controlled, two time-point, feasibility study within a larger study using a cohort multiple randomized controlled design yielding 3 groups: intervention group; comparison group and refusers. The intervention consisted of high-intensity interval training and resistance exercises 3 days/week. Specific feasibility and brain health outcomes were evaluated. Cognitive ability was ascertained by the Brief Cognitive Ability Measure (B-CAM) in all three groups. Standardized tests of physical performance were performed in the intervention group. Effect size, 95% confidence intervals, responder status analyses and reliable change indices were computed. Adherence to the intervention schedule and acceptability outcomes were good. There was no reliable change on B-CAM in the exercise group. Most physical performance measures benefited from the exercise training (effect sizes: 0.2 - 1.5). Although the 12-week exercise program improved physical capacity, it did not yield gains in cognitive ability in HIV. Further research is required to determine the exercise parameters that could benefit cognition.

A Short-term Psychological Intervention for People Living with HIV During the First Wave of COVID-19

Research on the psychosocial impact of COVID-19 has found significant levels of distress among the general population, and among those especially vulnerable due to chronic social or health challenges. Among these are individuals aging with HIV infection, who are encountering COVID-19 as a new infectious threat to their health and wellbeing. In a longitudinal observational study of the psychosocial impact of COVID-19 in middle-aged and older people living with HIV, we identified a subset of participants who expressed heightened levels of distress and were referred for clinical intervention. This paper describes the supportive and contemporary cognitive-behavioral interventions that were provided and presents data on changes in distress in this case series. This work provides a model for identifying people in at-risk groups in acute need of psychological intervention and for implementing an individualized clinical response that can be safely delivered in the context of COVID-19 and future crisis situations.

Predicting occupational outcomes from neuropsychological test performance in older people with HIV

OBJECTIVE

The ability to work is amongst the top concerns of people living with well treated HIV. Cognitive impairment has been reported in many otherwise asymptomatic persons living with HIV and even mild impairment is associated with higher rates of occupational difficulties. There are several classification algorithms for HIV-associated neurocognitive disorder (HAND) as well as overall scoring methods available to summarize neuropsychological performance. We asked which method best explained work status and productivity.

DESIGN

Participants (N = 263) drawn from a longitudinal Canadian cohort underwent neuropsychological testing.

METHODS

: Several classification algorithms were applied to establish a HAND diagnosis and two summary measures (NPZ and Global Deficit Score) were computed. Self-reported work status and productivity was assessed at each study visit (four visits, 9 months apart). The association of work status with each diagnostic classification and summary measure was estimated using logistic regression. For those working, the value on the productivity scale was regressed within individuals over time, and the slopes were regressed on each neuropsychological outcome.

RESULTS

The application of different classification algorithms to the neuropsychological data resulted in rates of impairment that ranged from 28.5 to 78.7%. Being classified as impaired by any method was associated with a higher rate of unemployment. None of the diagnostic classifications or summary methods predicted productivity, at time of testing or over the following 36 months.

CONCLUSION

Neuropsychological diagnostic classifications and summary scores identified participants who were more likely to be unemployed, but none explained productivity. New methods of assessing cognition are required to inform optimal workforce engagement.

Action for better brain health among people living with HIV: protocol for a randomized controlled trial

BACKGROUND

Lifestyle changes can protect or improve brain health in older adults. However, sustained lifestyle change is difficult for everyone and may be more difficult for those with executive dysfunction, including some people living with HIV. Thus, the key question is how we can improve adherence to the most promising interventions among people living with HIV experiencing cognitive difficulties. Goal management training is a cognitive rehabilitation program that targets executive dysfunction by teaching goal-directed behaviour and self-management. It is a promising means to improve adherence to lifestyle interventions.

OBJECTIVE

To estimate the extent to which goal management training before a healthy lifestyle program is associated with greater adherence to health recommendations, achievement of health-related goals, and better brain health and health outcomes compared to the healthy lifestyle program alone among people living with HIV.

METHODS

Brain Health Now cohort participants with cognitive difficulties or are not aging successfully are eligible. All participants will be given health resources, a health coach, a goal-setting digital application, and access to an online goal-setting workshop. The intervention group will participate in nine 2-h goal management training sessions and then will enter the healthy lifestyle program. Control participants will enter the healthy lifestyle program directly. A total sample of 100 participants will participate for 12 months. The main outcome is adherence to the healthy lifestyle program, defined as the number of weeks where physical activity adherence targets were met (150 min per week, measured with an activity monitor). Weekly social activities will be captured via self-report with confidential photo validation. We will send weekly health state reports to the participants. Downstream outcomes include cognitive ability, health-related quality of life, mobility, vascular risk profile, and social network size. We will analyze the data using a linear regression model.

DISCUSSION

This project is the first to test whether goal management training can augment adherence to health recommendations among individuals with cognitive difficulties. If successful, behavioural interventions such as goal management training could be implemented as an adjunct to lifestyle interventions in other clinical populations.

TRIAL REGISTRATION

This trial was registered on clinicaltrials.gov (NCT04345484) on April 14, 2020, https://clinicaltrials.gov/ct2/show/NCT04345484?term=NCT04345484&draw=2&rank=1 .

Multimodal neuroimaging markers of variation in cognitive ability in older HIV+ men

OBJECTIVE

This study used converging methods to examine the neural substrates of cognitive ability in middle-aged and older men with well-controlled HIV infection.

METHODS

Seventy-six HIV+ men on antiretroviral treatment completed an auditory oddball task and an inhibitory control (Simon) task while time-locked high-density EEG was acquired; 66 had usable EEG data from one or both tasks; structural MRI was available for 43. We investigated relationships between task-evoked EEG responses, cognitive ability and immunocompromise. We also explored the structural correlates of these EEG markers in the sub-sample with complete EEG and MRI data (N = 27).

RESULTS

EEG activity was associated with cognitive ability at later (P300) but not earlier stages of both tasks. Only the oddball task P300 was reliably associated with HIV severity (nadir CD4). Source localization confirmed that the tasks engaged partially distinct circuits. Thalamus volume correlated with oddball task P300 amplitude, while globus pallidus volume was related to the P300 in both tasks.

INTERPRETATION

This is the first study to use task-evoked EEG to identify neural correlates of individual differences in cognition in men living with well-controlled HIV infection, and to explore the structural basis of the EEG markers. We found that EEG responses evoked by the oddball task are more reliably related to cognitive performance than those evoked by the Simon task. We also provide preliminary evidence for a subcortical contribution to the effects of HIV infection severity on P300 amplitudes. These results suggest brain mechanisms and candidate biomarkers for individual differences in cognition in HIV.

Impact of Loneliness on Brain Health and Quality of Life Among Adults Living With HIV in Canada

BACKGROUND

People aging with HIV are at risk for loneliness, with stigmatization and economic marginalization added to the health challenges arising from chronic infection. This study provides evidence for the extent, contributors, and consequences of loneliness in people living with HIV, focusing on brain health and quality of life.

SETTING

Cross-sectional data from 856 middle-aged and older adults living with HIV recruited from 5 urban specialty clinics in Canada were drawn from the inaugural visit of the Positive Brain Health Now cohort study.

METHODS

Participants completed an extensive assessment of biopsychosocial variables. The prevalence, severity, and quality of life impact of self-reported loneliness were described. Clinical and environmental factors hypothesized as contributing to loneliness, and the consequences of loneliness on health and function were identified using logistic, ordinal, and linear regression.

RESULTS

Eighteen percent reported being "quite often" and 46% "sometimes" lonely. Those with more loneliness were younger, less mobile, suffered more financial hardship, and were more likely to use opioids. HIV symptoms, pain, fatigue, low motivation, stigma, and unemployment were related to loneliness. Loneliness increased the odds of cognitive impairment, low mood, stress, and poor physical health. Those who were "quite often" lonely were over 4 times more likely to report poor or very poor quality of life than those who were "almost never" lonely.

CONCLUSION

Loneliness is common in middle-aged and older people living with HIV in Canada. Many of the associated factors are modifiable, offering novel targets for improving brain health, general health, and quality of life in HIV.

Development and validation of a voice-of-the-patient measure of cognitive concerns experienced by people living with HIV

PURPOSE

People living with HIV may experience some degree of mild cognitive impairment. They are best placed to report on their cognitive symptoms, but no HIV-specific questionnaire exists to elicit these concerns. This study aimed to validate a set of items to form a measure METHODS: 48 items were tested on an initial sample of 204 people with HIV. Rasch analysis was used to identify those that fit a hierarchical continuum. The hierarchy was validated on a new sample of 703 people with HIV and a sample of 484 people without HIV.

RESULTS

18 items fit the model and formed the Communicating Cognitive Concerns Questionnaire (C3Q). The items spanned the full range of cognitive ability, distinguished between people working and not working, and correlated with other self-report outcomes such as mental health (0.56) and work productivity (0.60), although showed a low correlation with cognitive test performance.

CONCLUSION

The C3Q is the first questionnaire specifically developed for use among people with HIV. While not strongly associated with cognitive test performance, it reflects real-life concerns of people and is associated with mood, work, and work productivity. It is a needed step in assessing cognition in this population.

Development and usability of a feedback tool, "My Personal Brain Health Dashboard", to improve setting of self-management goals among people living with HIV in Canada

OBJECTIVE

(1) To develop a personalized health outcome profile as a feedback tool to improve self-management in people living with chronic conditions such as HIV and (2) to evaluate the interpretability and usefulness of the feedback tool for setting specific goals.

METHODS

The development of "My Personal Brain Health Dashboard" was inspired by the knowledge-to-action framework. A health outcome profile was computer generated in SAS from the outcome measures, at first and last recorded visits, of each person enrolled in the +BHN cohort from five sites in Canada. The Wilson-Cleary model framed the outcome measurement strategy. Single actionable items with evidence of life impact were chosen. The response option from the original item was the person's value and the optimal level was provided to help persons compare their results to an optimal target. Cognitive interviews were conducted with members of HIV community. Appropriateness of the Dashboard for goal-setting was tested by asking participants to write specific goals according to the Dashboard they were given.

RESULTS

Fifteen respondents were recruited from Montreal and Vancouver. Items most endorsed to be changed were cognition, pain, and body mass index. 80% found the Dashboard useful for setting health-related goals. A total of 85 goals were set, the text of which was mined to create a lexicon for scoring goal quality in future endeavours.

CONCLUSION

This study was the preparatory phase for a future trial on a method to stimulate setting specific goals. The future trial would provide a thorough understanding of the quality of person-defined goals.

Feasibility and Impact of a Yoga Intervention on Cognition, Physical Function, Physical Activity, and Affective Outcomes among People Living with HIV: A Randomized Controlled Pilot Trial

The purpose of this pilot randomized controlled trial is to assess the feasibility and impact of a triweekly 12-week yoga intervention among people living with HIV (PLWH). Additional objectives included evaluating cognition, physical function, medication adherence, health-related quality of life (HRQoL), and mental health among yoga participants versus controls using blinded assessors. We recruited 22 medically stable PLWH aged ≥35 years. A priori feasibility criteria were ≥70% yoga session attendance and ≥70% of participants satisfied with the intervention using a postparticipation questionnaire. Two participants withdrew from the yoga group. Mean yoga class attendance was 82%, with 100% satisfaction. Intention-to-treat analyses (yoga n = 11, control n = 11) showed no within- or between-group differences in cognitive and physical function. The yoga group improved over time in HRQoL cognition (P = .047) with trends toward improvements in HRQoL health transition (P =.063) and depression (P = .055). This pilot study provides preliminary evidence of feasibility and benefits of yoga for PLWH.

Relationships between cognition, function, and quality of life among HIV+ Canadian men

OBJECTIVE

To estimate the extent to which HIV-related variables, cognition, and other brain health factors interrelate with other HIV-associated symptoms to influence function, health perception, and QOL in older HIV+ men in Canada.

DESIGN

Cross-sectional structural equation modelling (SEM) of data from the inaugural visit to the Positive Brain Health Now Cohort.

SETTING

HIV clinics at 5 Canadian sites.

SUBJECTS

707 men, age ≥ 35 years, HIV+ for at least one year, without clinically diagnosed dementia.

MAIN OUTCOME MEASURES

Five latent and 21 observed variables from the World Health Organization's biopsychosocial model for functioning and disability and the Wilson-Cleary Model were analysed. SEM was used to link disease factors to symptoms, impairments, function, health perception, and QOL with a focus on cognition.

RESULTS

QOL was explained directly by depression, social role, health perception, social support, and quality of the environment. Measured cognitive performance had direct effects on activity/function and indirect effects on participation, HP and QOL, acting through self-reported cognitive difficulties and meaningful activities.

CONCLUSION

The biopsychosocial model showed good fit, with RMSEA < 0.05. This is the first time the full model has been tested in HIV. All of the domains included in the model are theoretically amenable to intervention and many have evidence-based interventions that could be harnessed to improve QOL.

Evaluating the Feasibility and Impact of a Yoga Intervention on Cognition, Physical Function, Physical Activity, and Affective Outcomes in People Living With HIV: Protocol for a Randomized Pilot Trial

Background

Despite lower mortality rates due to combination antiretroviral therapy, people living with HIV (PLWH) are grappling with increasingly complex health issues, including cognitive impairments in areas such as memory, attention, processing speed, and motor function. Yoga has been shown to be an effective form of exercise and mindfulness-based stress reduction for many clinical populations. However, no randomized trials have evaluated the impact of yoga on cognitive and physical function among PLWH.

Objective

The aim of this pilot randomized trial was to determine the feasibility of a yoga intervention to lay the groundwork for a full-scale, multisite, community-based trial for PLWH. Specific objectives are to (1) assess the feasibility of study protocol and procedures, (2) compare cognition in the yoga group with the usual care control group after 12 weeks of the intervention in PLWH, and (3) compare the effects of the 12-week yoga intervention versus control on balance, walking speed, physical activity, mental health, medication adherence, and quality of life among PLWH.

Methods

We propose a pilot randomized trial with 2 parallel groups (yoga versus control). We will recruit 25 PLWH (>35 years) from community and health organizations in Halifax, Canada. After baseline assessment with blinded assessors, participants will be randomly assigned to the yoga or control group, using a random computer generator. Participants in the yoga group will engage in supervised 60-min group-based yoga sessions 3 times a week for 12 weeks at a yoga studio. Participants in the control group will maintain their current physical activity levels throughout the study.

Results

As per the Consolidated Standards of Reporting Trials extension for pilot studies, means of all outcomes, mean change, and 95% CIs will be calculated for each group separately. Two-tailed independent t tests and Fisher exact tests will be used to compare groups at baseline. We will analyze quantitative postintervention questionnaire responses using Chi-square tests, and open-ended responses will be analyzed thematically. Intention-to-treat and per-protocol analyses will be used to analyze secondary variables. Changes in outcome variables will be examined between groups and within groups. Effect sizes will be reported for each outcome. A priori adherence and satisfaction criteria will be met if participants attend >70% of the yoga sessions and if >70% of the participants are satisfied with the intervention as determined by a postparticipation questionnaire. Study enrollment began in January 2018, with results expected for October 2019.

Conclusions

This pilot randomized trial will be the first to investigate the feasibility and effect of a yoga intervention on cognitive and physical outcomes among PLWH. This work will inform the feasibility of further investigations in terms of capacity building, participant recruitment and retention, and assessment and intervention protocols.

Trial Registration

ClinicalTrials.gov NCT03071562; https://clinicaltrials.gov/ct2/show/NCT03071562 (Archived by WebCite at http://www.webcitation.org/785sfhWkw)

International Registered Report Identifier (IRRID)

DERR1-10.2196/13818

Properties of a brief assessment tool for longitudinal measurement of cognition in people living with HIV

Background

Mild cognitive impairment is common in chronic HIV infection and there is concern that it may worsen with age. Distinguishing static impairment from on-going decline is clinically important, but the field lacks well-validated cognitive measures sensitive to decline and feasible for routine clinical use. Measures capable of detecting improvement are also needed to assess interventions. The objective of this study is to estimate the extent of change on repeat administration of three different forms of a brief computerized cognitive assessment battery (B-CAM) developed for assessing cognitive ability in the mildly-impaired to normal range in people living with HIV. We hypothesized no change over a six-month period in people on effective antiretroviral therapy.

Methods

102 HIV+ individuals completed a set of computerized cognitive tasks on three occasions over a six-month period. Rasch analysis was used to determine if change over time (i.e. improvement due to practice) was uniform across tasks and to refine scoring in order to produce three forms of the B-CAM of equivalent level of difficulty. Group-based trajectory analysis (GBTA) was then applied to determine if performance at baseline influenced the magnitude of practice-related improvement on the battery as a whole over the course of follow-up.

Results

Two cognitive tasks (fluency and word recall) had different levels of difficulty across test sessions, related to the different forms of the tasks. These two items were split by testing session. For all other items, the level of difficulty remained constant across all three time points. GBTA showed that the sample was composed of three distinct groups of people with unique trajectories, defined mainly by level of cognitive ability at baseline. Only the highest group showed an apparent improvement over time, but this change fell within measurement error.

Conclusions

Rasch analysis provides mathematical confirmation that these three forms of the B-CAM are of equivalent difficulty. GBTA demonstrates that no adjustment of the total score is required to correct for practice effects. Application of these modern statistical methods paves the way towards rapid and robust quantification of change in cognition.

The cohort multiple randomized controlled trial design was found to be highly susceptible to low statistical power and internal validity biases

Objectives

The “cohort multiple randomized controlled trial” (cmRCT) is a recent innovation by which novel interventions are trialed within large longitudinal cohorts of patients to gain efficiencies and align trials more closely to standard clinical practice. The use of cmRCTs is outpacing its methodological understanding, and more appropriate methods for designing and analyzing such trials are urgently needed.

Study Design and Setting

We established the UK Comprehensive Longitudinal Assessment of Salford Integrated Care cohort of 4,377 patients with long-term conditions within which we are conducting a cmRCT (“Proactive Telephone Coaching and Tailored Support”) of telephone-based health coaching.

Results

We identify some key methodological challenges to the use of the cmRCT in actual practice. Principal are issues around statistical power, sample size, and treatment effect estimation, for which we provide appropriate methods. Sampling procedures commonly applied in conventional RCTs can result in unintentional selection bias. The fixed data collection points that feature in cmRCTs can also threaten validity.

Conclusion

The cmRCT may offer advantages over conventional trial designs. However, a cmRCT requires appropriate power calculation, sampling, and analysis procedures; else, studies may be underpowered or subject to validity biases. We offer solutions to some of the key issues, but further methodological investigations are needed. Cohort multiple RCT–specific Consolidated Standards of Reporting Trials guidance may be indicated.

Ethics and practice of Trials within Cohorts: An emerging pragmatic trial design

BACKGROUND

With increasing emphasis on pragmatic trials, new randomized clinical trial designs are being proposed to enhance the "real world" nature of the data generated. We describe one such design, appropriate for unmasked pragmatic clinical trials in which the control arm receives usual care, called "Trials within Cohorts" that is increasingly used in various countries because of its efficiency in recruitment, advantages in reducing subject burden, and ability to better mimic real-world consent processes.

METHODS

Descriptive, ethical, and US regulatory analysis of the Trials within Cohorts design.

RESULTS

Trials within Cohorts design involves, after recruitment into a cohort, randomization of eligible subjects, followed by an asymmetric treatment of the two arms: those selected for the experimental arm provide informed consent for the intervention trial, while the data from the control arm are used based on prior broad permission. Thus, unlike the traditional Zelen post-randomization consent design, the cohort participants are informed about future research within the cohort; however, the extent of this disclosure currently varies among studies. Thus, ethical analysis is provided for two types of situations: when the pre-randomization disclosure and consent regarding the embedded trials are fairly explicit and detailed versus when they consist of only general statements about future data use. These differing ethical situations could have implications for how ethics review committees apply US research rules regarding waivers and alterations of informed consent.

CONCLUSION

Trials within Cohorts is a promising new pragmatic randomized controlled trial design that is being increasingly used in various countries. Although the asymmetric consent procedures for the experimental versus control arm subjects can initially raise ethical concerns, it is ethically superior to previous post-randomization consent designs and can have important advantages over traditional trial designs.

Monitoring HIV-Associated Neurocognitive Disorder Using Screenings: a Critical Review Including Guidelines for Clinical and Research Use

Screening tools to identify HIV-associated neurocognitive disorder (HAND) are primarily devised to detect cognitive impairment on a single occasion. With the chronicity of HIV infection and the risk of HAND developing or progressing despite viral control, it may be pertinent to repeat HAND screening at more than one time point. Despite this, there are limited data on longitudinal use of such screening tools, particularly with regard to the role of practice effects. Additionally, no guidelines currently exist on the timeframe between testing intervals, or recommendation of the magnitude of baseline impairment that warrants follow-up testing. The aim of the current paper was to review existing evidence for longitudinal validity of HAND screening tools. Only those HAND screening tools previously found to have high cross-sectional criterion validity were included. Preliminary recommendations for clinical use and future research are proposed including in international settings.

Measuring and managing cognitive impairment in HIV

: Cognitive impairment remains a frequently reported complaint in HIV-positive patients despite virologically suppressive antiretroviral therapy. Rates of cognitive impairment in antiretroviral treated HIV-positive cohorts vary and strongly depend on definitions utilized.The underlying pathogenesis is likely to be multifactorial and includes immune activation, neuroinflammation, antiretroviral neurotoxicity, the presence of noninfectious comorbidities such as vascular disease and depression and patient lifestyle factors such as recreational drug use.Contributing factors to cognitive impairment may change over time with ageing HIV-positive populations. Cerebrovascular disease and neurodegenerative causes of cognitive impairment may become more common with advancing age; how these factors interact with HIV-associated cognitive impairment is not yet known.Cerebrospinal fluid HIV RNA escape may occur in up to 10% of patients undergoing lumbar puncture clinically and can be associated with compartmentalized and resistant virus.Changes in antiretroviral therapy in patients with cognitive impairment should be based on current and historic resistance profiles of cerebrospinal fluid and plasma virus, or on potential antiretroviral drug neurotoxicity. Whether and how antiretroviral therapy should be changed in the absence of these factors is not known and requires study in adequately powered randomized trials in carefully selected clinical cohorts.

The electrophysiology of neuroHIV: A systematic review of EEG and MEG studies in people with HIV infection since the advent of highly-active antiretroviral therapy

OBJECTIVE

The Human Immunodeficiency Virus (HIV) has an impact on the brain, even when the infection is well-controlled with modern highly-active antiretroviral therapy (HAART). While dementia is rare in those on HAART, milder cognitive impairment is common. The causes, patterns, and evolution of brain dysfunction in people living with HIV remain uncertain. We evaluate whether electrophysiological methods provide informative measures of brain dysfunction in this population.

METHODS

A systematic literature search identified studies that used EEG or MEG to evaluate persons living with HIV published between 1996 (when HAART became available) and 2016.

RESULTS

Twenty-eight studies were identified. Most involved small samples, and all but four were cross-sectional. Reduced amplitude of Event Related Potentials and decreased power in the alpha band at rest were the most frequent differences between people with and without HIV infection. Of the 16 studies that also assessed cognitive ability, 13 found a significant relationship between cognition and electrophysiological changes in the HIV+ groups. Five of those studies also reported a significant relationship with current immunosuppression, suggesting a direct effect of HIV on the brain. There were few longitudinal studies; whether these electrophysiological changes progress over time, or respond to treatment, remains unclear.

CONCLUSIONS

EEG and MEG can provide useful information about brain dysfunction in people with HIV infection, but more consistent assessments of both cognition and EEG patterns, as well as longitudinal studies with larger, better characterized samples are needed.

SIGNIFICANCE

This is the first systematic review of electrophysiological findings in HIV since the availability of HAART. EEG and MEG measures are sensitive to brain dysfunction in this population, and could complement other approaches in improving the assessment, understanding and treatment of neurocognitive disorders in HIV.