Neuropsychiatric outcomes before and after switching to dolutegravir-based therapy in an acute HIV cohort

Cognitive performance, neuropsychiatric symptoms, and cerebrospinal fluid viral control following programmatic switch from efavirenz-based to dolutegravir-based antiretroviral therapy in South Africa (CONNECT): a prospective cohort study

BACKGROUND

Both efavirenz and dolutegravir have been associated with neuropsychiatric side-effects and cognitive impairment. Furthermore, cerebrospinal fluid (CSF) HIV RNA escape has not been comprehensively studied in African populations. We aimed to examine changes in cognition, neuropsychiatric symptoms, and CSF viral control associated with the widespread switch from efavirenz-based to dolutegravir-based antiretroviral therapy (ART).

METHODS

This prospective cohort study of people with HIV and people without HIV recruited adults with HIV (aged 18-55 years) from the Gugulethu Community Health Centre in a low-income periurban area of Cape Town, South Africa. Eligible participants had been receiving efavirenz-based ART for at least 1 year and were identified by the clinic to switch to dolutegravir-based ART as part of the national programmatic switch. Participants were studied at baseline and followed up at 1 year after switch to dolutegravir. People without HIV were recruited from the same area, matched for age and gender, and followed up at the same time interval. People with HIV and people without HIV underwent comprehensive cognitive testing over seven domains and measures of functioning, mood, anxiety, and sleep. People with HIV had CSF sampling for HIV RNA quantification.

FINDINGS

Between Aug 12, 2019, and Sept 16, 2022, we recruited 178 people with HIV and 95 people without HIV. 145 (81%) of 178 people with HIV and 40 (66%) of 60 people without HIV who were offered underwent follow-up. Global cognitive performance was 2·57 T score points lower in people with HIV than in people without HIV at baseline (p=0·0008). At follow-up, cognition in people with HIV improved more than practice effects observed in people without HIV (coefficient 1·40, 95% CI 0·48-2·32, p=0·0028) and no significant difference in cognitive performance between groups was apparent (51·43 vs 52·73; p=0·22). Sleep quality improved following the switch (risk ratio 0·90, 95% CI 0·84-0·95; p=0·0002), driven mainly by indicators of disturbed sleep. There were nine incident cases of depression, although baseline differences were present. There was one case (1%) of CSF escape at baseline and three cases (4%) at follow-up; all were at low levels or resolved with repeated sampling.

INTERPRETATION

Improvements in cognition and sleep are probably related to switching from efavirenz. However, the possible increase in depression warrants further examination. Cognitive performance in virally supressed African people with HIV receiving dolutegravir-based therapy is similar to people without HIV. CSF escape is uncommon on both efavirenz-based and dolutegravir-based therapy.

FUNDING

South African Medical Research Council and UK Medical Research Council, Newton Fund.

Food insecurity and the risk of sleep disorders in people living with HIV/AIDS as a neglected health concern: A national survey in Iran

Food insecurity (FI) and sleep problems are major modifiable health issues among people living with HIV/AIDS (PLWH), and there is limited knowledge about their prevalence among this underrepresented population. Our study aimed to assess the relationship between FI and sleep problems as important environmental factors affecting PLWH in Iran. The national survey was conducted on 1185 confirmed HIV-positive patients who attended consulting centers in 15 geographically diverse provinces in Iran, during 2021-2022. Standard questionnaires were used to measure FI and sleep problems (Insomnia, Obstructive Sleep apnea (OSA), Excessive Daytime Sleepiness (EDS), and Poor sleep quality), and a logistic regression model was used to assess the association between FI and the odds of experiencing sleep problems. About 764 (The prevalence of FI = 64.47 %) of the participants had insecure status, with a mean score of 11.73 (SE = 0.34). Those with FI had a higher prevalence of insomnia, EDS, and poor sleep quality (54.84 %, 31.79 %, and 55.17 %, respectively) compared to those without FI (30.69 %, 17.03 %, and 40.42 %, respectively). FI increased the odds of being at risk for Insomnia (OR = 2.39, 95 % CI: 1.81-3.15), EDS (OR = 1.44, 95 % CI: 1.04-2.01), and poor sleep quality (OR = 1.79, 95 % CI: 1.29-2.48) in the multiple regression model. The results highlight the strong association between FI and a broad range of sleep problems in PLWH. Considering the impact of FI and impaired sleep health on PLWH, more attention is needed for at-risk groups for screening and intervention purposes.

Prevalence of and factors associated with chronic kidney disease among patients infected with human immunodeficiency virus attending care and treatment centers at tertiary hospitals in dodoma, Tanzania

Background

The burden and risk of developing chronic kidney disease (CKD) among patients with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) is higher than in the general population. This study aimed to determine prevalence of and associated factors with CKD among adults infected with human immunodeficiency virus at tertiary hospitals in Dodoma, Tanzania.

Method

ology: A cross-sectional study was carried out between November 2022 to April 2023. Patients' demographic data, and clinical measurements were obtained on the day of the visit. Laboratory investigations were performed as standard of care. Descriptive and inferential analyses were performed, and variables associated with CKD were identified by multivariable logistic regression.

Results

A total of 223 patients were enrolled, with a median age of 47 (IQR 38-56) years, and 72.2 % were female. The CKD prevalence was 23.3 % whereby 18.4 % had CKD stage 3a, 4.5 % had CKD stage 3 b, and 0.4 % had CKD stage 4. CKD was observed largely among patients with obesity (34.15 %), anemia (29.41 %), hypertension (45.00 %), and diabetes mellitus (50.00 %). Variables with higher odds for CKD after adjusted analysis were hypertension (OR 3.03, 95 %% CI 1.29-7.11, P = 0.0109), diabetes mellitus (OR 4.50, 95 % CI 1.35-15.03, P = 0.0144), obesity (OR 3.07, 95 % CI 1.11-8.47, P = 0.0301), anaemia (OR 2.42, 95 % CI 1.12-5.26, P = 0.0252) and for each one-unit increase in age (years), there was statistically significant increase in the odds of having CKD by 1.084 folds (OR = 1.084, 95 % CI 1.039-1.131, p = 0.0002).

Conclusion

The prevalence of CKD among patients with HIV/AIDS is high. Age, obesity, anaemia, hypertension, and diabetes mellitus were strongly associated with CKD suggesting a need for integrating initiatives for non-communicable disease control in this population.

Stigma and mental health among people living with HIV across the COVID-19 pandemic: a cross-sectional study

BACKGROUND

Mental health (MH) is extremely relevant when referring to people living with a chronic disease, such as people living with HIV (PLWH). In fact - although life expectancy and quality have increased since the advent of antiretroviral therapy (ART) - PLWH carry a high incidence of mental disorders, and this burden has been exacerbated during the COVID-19 pandemic. In this scenario, UNAIDS has set new objectives for 2025, such as the linkage of at least 90% of PLWH to people-centered, context-specific MH services. Aim of this study was to determine the prevalence of MD in PLWH followed at the Clinic of Infectious Diseases of the University of Bari, Italy.

METHODS

From January 10th to September 10th, 2022, all PLWH patients accessing our outpatient clinic were offered the following standardized tools: HAM-A for anxiety, BDI-II for depression, PC-PTSD-5 for post-traumatic stress disorder, CAGE-AID for alcohol-drug abuse. Factors associated with testing positive to the four MD were explored with a multivariable logistic regression model.

RESULTS

578 out of 1110 HIV-patients agreed to receive MH screening, with 141 (24.4%) people resulting positive to at least one MH disorder. HAM-A was positive in 15.8% (n = 91), BDI-II in 18% (n = 104), PC-PTSD-5 in 5% (n = 29) and CAGE in 6.1% (n = 35). The multivariable logistic regression showed a higher probability of being diagnosed with anxiety, depression and post-traumatic stress disorder for PLWH who reported severe stigma, social isolation, psychological deterioration during the COVID-19 pandemic and for those receiving a dolutegravir (DTG)-based regimen. Moreover, history of drug use (OR 1.13; [95% CE 1.06-4.35]), family stigma (2.42 [1.65-3.94]) and social isolation (2.72 [1.55;4.84]) were found to be associated to higher risk for substance use disorder.

CONCLUSIONS

In this study, stigma was a strong predictor for being diagnosed of a MH disorder among PLWH. Also, the possible role of dolutegravir as a risk factor for the onset of MH disorders should be considered in clinical practice, and MH of patients receiving DTG-containing regimens should be constantly monitored.

Recent advances in HIV-associated neurocognitive disorders: a focus on older adults and sub-Saharan Africa

PURPOSE OF REVIEW

We reviewed recent literature on prevalence and interventional approaches for cognitive impairment in the context of HIV infection alongside current controversies and challenges around its nomenclature, screening, and diagnosis.

RECENT FINDINGS

Prevalence estimates for HIV-associated neurocognitive disorder (HAND) indicate that HAND remains highly prevalent despite combination antiretroviral treatment (cART) widely used. The available data are heterogeneous, particularly in sub-Saharan Africa (SSA) where recent reviews indicate substantial heterogeneity, wide prevalence estimates and lack of data from the majority SSA countries, despite them currently experiencing the greatest burden worldwide of both HIV and HAND.Several alternative approaches to diagnosis and classification of cognitive impairment in HIV have been published, taking into account changing clinical phenotypes.

SUMMARY

Cognitive impairment remains a significant challenge in the care of people living with HIV despite advances in treatment. Ongoing controversies exist around nomenclature and classification, screening measures, and the phenotype and aetiology of observed impairments. Two current areas of research priority and focus include understanding current phenotypes of individuals living and ageing with treated HIV and differing levels of risk for HAND in these phenotypes, alongside the effects of commonly occurring comorbidities.The current evidence base for interventional approaches is limited, but growing. The most promising avenues appear to be multidisciplinary. These are currently focussed on high income settings rather than SSA where the majority of people living with HIV, and affected by cognitive impairment in the context of HIV, currently reside.

Common antiretroviral combinations are associated with somatic depressive symptoms in women with HIV

OBJECTIVE

While modern antiretroviral therapy (ART) is highly effective and safe, depressive symptoms have been associated with certain ART drugs. We examined the association between common ART regimens and depressive symptoms in women with HIV (WWH) with a focus on somatic vs. nonsomatic symptoms.

DESIGN

Analysis of longitudinal data from the Women's Interagency HIV Study.

METHODS

Participants were classified into three groups based on the frequency of positive depression screening (CES-D ≥16): chronic depression (≥50% of visits since study enrollment), infrequent depression (<50% of visits), and never depressed (no visits). Novel Bayesian machine learning methods building upon a subset-tree kernel approach were developed to estimate the combined effects of ART regimens on depressive symptoms in each group after covariate adjustment.

RESULTS

The analysis included 1538 WWH who participated in 12 924 (mean = 8.4) visits. The mean age was 49.9 years, 72% were Black, and 14% Hispanic. In the chronic depression group, combinations including tenofovir alafenamide and cobicistat-boosted elvitegravir and/or darunavir were associated with greater somatic symptoms of depression, whereas those combinations containing tenofovir disoproxil fumarate and efavirenz or rilpivirine were associated with less somatic depressive symptoms. ART was not associated with somatic symptoms in the infrequent depression or never depressed groups. ART regimens were not associated with nonsomatic symptoms in any group.

CONCLUSIONS

Specific ART combinations are associated with somatic depressive symptoms in WWH with chronic depression. Future studies should consider specific depressive symptoms domains as well as complete drug combinations when assessing the relationship between ART and depression.

Impact of Integrase Strand Transfer Inhibitors on Cognition in the HAILO Cohort

BACKGROUND

Integrase inhibitors (INSTIs) have been associated with poorer cognition in people with HIV (PWH). We examined the impact of switching to INSTIs on neuropsychological (NP) outcomes in PWH 40 years of age and older.

METHODS

From the AIDS Clinical Trials Group observational cohort study, HAILO, we identified PWH who switched to INSTIs, had ≥2 NP assessments before and at least 1 after switch, and maintained viral suppression while on INSTIs. NP performance was assessed with a composite score (NPZ4) including Hopkins Verbal Learning Test (HVLT-R), Digit Symbol test (DSY), Trail Making A, and Trail Making B, while adjusting for covariates and learning effects. Outcomes changes from preswitch and postswitch periods were estimated using piecewise linear mixed models.

RESULTS

Among 395 PWH (mean age 54 years, 81% male, 20% Hispanic, and 29% Black) NPZ4 increased preswitch and postswitch. There was no difference in slopes between periods for NPZ4 [preswitch 0.036/year (95% CI: 0.03 to 0.043); postswitch 0.022/year (95% CI: 0.006 to 0.005); P = 0.147]. All tests scores improved preswitch (P < 0.01). Postswitch, Trail Making A and DSY increased (all P < 0.01) without differences in rate of change (all P > 0.05). HVLT-R had a nonsignificant decrease postswitch (P = 0.22), resulting in a significant preswitch vs postswitch difference in slopes (P = 0.03).

CONCLUSIONS

NP performance improved regardless of INSTI use. There was an attenuation of improvement in verbal memory in the postswitch vs preswitch period. The clinical significance of these changes is unclear but, overall, INSTIs did not have a consistent detrimental effect on NP outcomes.

Lived experience of people living with HIV in Blantyre, Malawi: an exploratory qualitative study

Background

People living with the Human Immunodeficiency Virus (HIV) encounter a range of complex challenges that impact their physical, psychological, and social well-being. The combined effects of these challenges significantly impact their daily functioning. Despite the relatively high prevalence of HIV in Malawi, there is limited knowledge on how the challenges experienced by people living with HIV correlate with their societal participation and performance of activities.

Objectives

This study aimed to explore the lived experience of people living with HIV and how the challenges experienced impact societal participation and activity performance.

Method

A qualitative exploratory study design was used. Fourteen participants were purposefully selected for the study, with an equal number of males and females. The data was gathered through semi-structured interviews and manually analyzed using thematic analysis.

Results

It was found that participants faced discrimination, stigma, depression, anxiety, and worries. The study participants associated their taking of antiretroviral therapy with physical impairments such as dizziness, leg pain, yellow eyes, and fatigue. The physical impairments hampered participants' ability to walk, work, conduct business, perform household chores, and care for children.

Conclusion

This study identified the difficulties that people living with HIV faced in their communities and how these challenges impact societal participation and performance in activities. There is a need for a holistic approach to managing these challenges and making referrals to specialized professionals.

An Integrative Approach to the Current Treatment of HIV-Associated Neurocognitive Disorders and the Implementation of Leukemia Inhibitor Factor as a Mediator of Neurocognitive Preservation

HIV-associated neurocognitive disorders (HANDs) continue to impact patients despite antiretroviral therapy. A combination of antiretroviral therapies can diminish the HIV viral load to near undetectable levels, but fails to preserve neurocognitive integrity. The cytokine leukemia inhibitory factor (LIF) has shown neuroprotective properties that could mitigate neurodegeneration in HANDs. The LIF promotes neurogenesis, neural cell differentiation, and survival. Combination antiretroviral therapy reduces severe forms of HANDs, but neurocognitive impairment persists; additionally, some antiretrovirals have additional adverse neurotoxic effects. The LIF counteracts neurotoxic viral proteins and limits neural cell damage in models of neuroinflammation. Adding the LIF as an adjuvant therapy to enhance neuroprotection merits further research for managing HANDs. The successful implementation of the LIF to current therapies would contribute to achieving a better quality of life for the affected population.

Central nervous system disorders after use of dolutegravir: evidence from preclinical and clinical studies

The evaluation of dolutegravir based on available preclinical and clinical studies reveals a risk of central nervous system (CNS) disorders associated with long-term use of the drug. The available literature on the pharmacokinetics of the drug, including its penetration of the blood-brain barrier, was reviewed, as well as clinical trials assessing the incidence of adverse effects in the CNS and the frequency of its discontinuation. This paper also summarizes the impact of factors affecting the occurrence of CNS disorders and indicates the key role of pharmacovigilance in the process of supplementing knowledge on the safety of drugs, especially those that are newly registered.

Neurocognitive improvement in HIV-positive patients treated with dolutegravir-based regimens

Background

Neurocognitive disorders due to human immunodeficiency virus (HIV) remain highly prevalent, specifically mild forms despite effective antiretroviral therapy (ART). Dolutegravir-based regimens are the first line of treatment for adult HIV-positive patients. Controversies exist regarding the neurocognitive effects of dolutegravir. Evidence regarding the neurocognitive effects of dolutegravir is important, in support of its use in patients with HIV-associated neurocognitive disorders (HAND).

Aim

This study aimed to describe the change in cognitive function using the International HIV Dementia Scale (IHDS) and Brief Neuropsychological Cognitive Examination (BNCE) in HIV positive, treatment naïve patients before and 3 months after initiation of ART using a dolutegravir-based regimen.

Setting

The HIV initiation clinic of Hillbrow Community Health Centre in Johannesburg.

Methods

This prospective, quantitative cohort study assessed adult HIV-positive patients who were ART naïve being initiated on a dolutegravir-based regimen, using the BNCE and IHDS at baseline and after 3 months of treatment.

Results

Neurocognitive test results of 26 participants showed significant improvements for IHDS (Z = 1.84, p = 0.033) and time to complete BNCE (Z = 2.47, p = 0.007). BNCE total results showed improvements that were not significant (Z = 1.44, p = 0.075); however, Part 2 of the BNCE reflecting that of executive function showed significant improvements (Z = 66.5, p = 0.043).

Conclusion

The trend of neurocognitive function is towards improvement in HIV-positive treatment naïve patients who receive 3 months of dolutegravir-based ART.

Contribution

The findings support the use of dolutegravir-based regimens in the treatment of patients with HIV-associated neurocognitive disorders.

Keywords

HIV-associated neurocognitive disorders; BNCE; IHDS; dolutegravir; neurocognitive screening; neurocognitive impairment; South Africa.

Antiretroviral Therapy Intensification for Neurocognitive Impairment in Human Immunodeficiency Virus

BACKGROUND

Neurocognitive impairment (NCI) in people with HIV (PWH) on antiretroviral therapy (ART) is common and may result from persistent HIV replication in the central nervous system.

METHODS

A5324 was a randomized, double-blind, placebo-controlled, 96-week trial of ART intensification with dolutegravir (DTG) + MVC, DTG + Placebo, or Dual - Placebo in PWH with plasma HIV RNA <50 copies/mL on ART and NCI. The primary outcome was the change on the normalized total z score (ie, the mean of individual NC test z scores) at week 48.

RESULTS

Of 357 screened, 191 enrolled: 71% male, 51% Black race, 22% Hispanic ethnicity; mean age 52 years; mean CD4+ T-cells 681 cells/µL. Most (65%) had symptomatic HIV-associated NC disorder. Study drug was discontinued due to an adverse event in 15 (8%) and did not differ between arms (P = .17). Total z score, depressive symptoms, and daily functioning improved over time in all arms with no significant differences between them at week 48 or later. Adjusting for age, sex, race, study site, efavirenz use, or baseline z score did not alter the results. Body mass index modestly increased over 96 weeks (mean increase 0.32 kg/m2, P = .006) and did not differ between arms (P > .10).

CONCLUSIONS

This is the largest, randomized, placebo-controlled trial of ART intensification for NCI in PWH. The findings do not support empiric ART intensification as a treatment for NCI in PWH on suppressive ART. They also do not support that DTG adversely affects cognition, mood, or weight.

Neuropsychiatric Adverse Events Following Antiretroviral Therapy in People Living with HIV: A Real-World Study of Dynamic Trends and Risk Factors in Hangzhou, China

Purpose

Neuropsychiatric adverse events (NPAEs) occur frequently in people living with human immunodeficiency virus (PLWH) receiving antiretroviral therapy (ART). This study aimed to assess the dynamic trends and risk factors of NPAEs among PLWH in Hangzhou taking efavirenz (EFV)- or dolutegravir (DTG)- or elvitegravir (EVG)-based regimens.

Patients and Methods

A total of 287 ART-naive PLWH were included in this study, EFV (400mg)- (n = 122), EFV (600mg)- (n = 37), DTG- (n = 73), EVG-based (n = 47) and other ART regimens (n = 8) as the initial ART regimen were administered for 12 months. All data were collected at five time points within a 12-month follow-up. The Pittsburgh Sleep Quality Index and Hospital Anxiety and Depression Scale were used to evaluate sleep disorders and anxiety and depression symptoms, respectively. The dynamic trends and potential risk factors of NPAEs were investigated using a generalized linear mixed model.

Results

Mean age was 29.4 (SD: 7.5) years with 97.2% males. After 12 months of ART, the prevalence of sleep disorders and anxiety decreased significantly, although only a slight improvement was observed for depression. In addition, there was a significant positive correlation between sleep disorders, anxiety, and depression. The risk factors for NPAEs differed slightly depending on the choice of ART regimen, but the seven factors most commonly associated with NPAEs were age, sex, marital status, education level, smoking status, body mass index, and WHO clinical stage. Treatment-induced changes in CD4-positive T-cell count and virological suppression did not depend on the particular choice of ART regimen.

Conclusion

The prevalence of sleep disorders and anxiety changed significantly over time on ART and the risks of these disorders were associated with seven common clinical and demographic factors.

Cost-effectiveness of dolutegravir vs. efavirenz-based combined antiretroviral therapies in HIV-infected treatment-naive patients in a Nigerian treatment centre

BACKGROUND

Dolutegravir (DTG) based antiretroviral therapy (ART) has largely replaced Efavirenz (EFV) based therapy as the preferred first-line regimen in the treatment of adults with HIV. This study was carried out to evaluate the comparative cost-effectiveness of DTG and EFV-based ART in HIV-infected treatment-naïve patients in a treatment centre in Nigeria.

METHODS

This was a retrospective case-control study of patients initiated on DTG vs. EFV-based regimens from January 2018 to December 2019 at the APIN/HAVARD clinic of Nigeria's Jos University Teaching Hospital. The current viral load result was used to determine treatment effectiveness using a benchmark of ≤200 copies/mL. Sensitivity analysis was carried out to ensure the robustness of the benchmark. The total cost of treatment was obtained by summing up the relevant cost components. Appropriate descriptive and inferential statistics were employed in data analysis using Statistical Product and Services Solutions (SPSS) V.25. The incremental cost-effectiveness ratio of DTG compared to EFV was presented as cost/effectiveness.

RESULTS

Treatment was effective in 42(51.9%) and 58(71.6%) patients initiated on DTG and EFV-based regimen, respectively. The incremental cost-effective ratio (ICER) of patients on DTG compared to those on EFV was $10.5076 per effectiveness, which was less than 1% of the Nigerian 2019 per capita Gross Domestic Product. Sensitivity analysis showed the robustness of the result.

CONCLUSION

Efavirenz based regimen had higher treatment effectiveness than DTG-based regimen in treatment-naive patients after initiating treatment in a short term. Compared to EFV, DTG-based regimen is cost-effective in the management of treatment naïve HIV patients.

Immunological, Cognitive, and Psychiatric Outcomes After Initiating Efavirenz- and Dolutegravir-based Antiretroviral Therapy During Acute Human Immunodeficiency Virus Infection

BACKGROUND

Efavirenz (EFV)- and dolutegravir (DTG)-based antiretroviral therapy (ART) is the former and current recommended regimen for treatment-naive individuals with human immunodeficiency virus type 1 (HIV-1). Whether they impact the immunological and neuropsychiatric profile differentially remains unclear.

METHODS

This retrospective analysis included 258 participants enrolled during acute HIV-1 infection (AHI). Participants initiated 1 of 3 ART regimens during AHI: EFV-based (n = 131), DTG-based (n = 92), or DTG intensified with maraviroc (DTG/MVC, n = 35). All regimens included 2 nucleoside reverse-transcriptase inhibitors and were maintained for 96 weeks. CD4+ and CD8+ T-cell counts, mood symptoms, and composite score on a 4-test neuropsychological battery (NPZ-4) were compared.

RESULTS

At baseline, the median age was 26 years, 99% were male, and 36% were enrolled during Fiebig stage I-II. Plasma viral suppression at weeks 24 and 96 was similar between the groups. Compared with the EFV group, the DTG group showed greater increments of CD4+ (P < .001) and CD8+ (P = .015) T-cell counts but a similar increment of CD4/CD8 ratio at week 96. NPZ-4 improvement was similar between the 2 groups at week 24 but greater in the DTG group at week 96 (P = .005). Depressive mood and distress symptoms based on the Patient Health Questionnaire and distress thermometer were similar between the 2 groups at follow-up. Findings for the DTG/MVC group were comparable to those for the DTG group vs the EFV group.

CONCLUSIONS

Among individuals with AHI, 96 weeks of DTG-based ART was associated with greater increments of CD4+ and CD8+ T-cell counts and improvement in cognitive performance.

Dolutegravir in real life: Self-reported mental and physical health outcomes after transitioning from efavirenz- to dolutegravir-based antiretroviral therapy in a prospective cohort study in Lesotho

INTRODUCTION

HIV programmes across many countries in Africa have recently transitioned people living with HIV from efavirenz (EFV)- to dolutegravir (DTG)-containing antiretroviral therapy (ART). As both drugs are associated with neuropsychiatric adverse effects, this study assessed the mental health and HIV/ART-associated symptoms of people living with HIV before and after transition to DTG.

METHODS

The prospective DO-REAL cohort enrolled people starting DTG-based ART in Lesotho from February to December 2020. For this analysis within DO-REAL, we included adults changing from tenofovir disoproxil fumarate (TDF)/lamivudine (3TC)/EFV to TDF/3TC/DTG within first-line therapy. At transition and 16 weeks thereafter, participants completed the Patient Health Questionnaire-9 (PHQ-9; depression screening), the 12-item Short-Form Health Survey (SF-12; mental and physical health), and a modified HIV Symptom Index (mHSI; HIV/ART-related symptoms). We also assessed weight change. We used McNemar tests with Bonferroni corrections to assess binary outcomes.

CLINICALTRIALS

gov: NCT04238767.

RESULTS

Among 1228 participants, 1131 completed follow-up. Of these, 60.0% were female, the median age was 46 years (interquartile range [IQR] 38-55), and the median time taking ART was 5.7 years (IQR 3.5-8.9). No change was observed for weight or overall PHQ-9 or SF-12 outcomes. However, three mHSI items decreased at follow-up: 'feeling sad/down/depressed' (bothered 6.0% vs. 3.3% of participants at least 'a little' before vs. after transition; adjusted p = 0.048); 'feeling nervous/anxious' (7.4% vs. 3.4%; adjusted p = 0.0009); and 'nightmares, strange/vivid dreams' (6.3% vs. 3.5%; adjusted p = 0.027). Individual PHQ-9 or SF-12 items also improved. Being symptom free across all measures increased from 5.1% to 11.4% (p < 0.0001).

CONCLUSIONS

We observed no negative impacts and potential moderate improvements with DTG, providing further support for the rollout of DTG.

Course and characteristics of depression over a 12-month period among Ghanaians living with HIV: the EVERLAST study

Individuals with HIV are predisposed to depression but there is limited data on its dynamics and correlates. We aimed to assess course and characteristics of depression among Ghanaian HIV patients over a 12-month period. We interrogated a longitudinal study dataset of patients at a tertiary hospital and assessed depression at month 0 and 12 using the Patient Health Questionnaire-9 (PHQ-9). Association between clinical, sociodemographic factors and changes in PHQ-9 scores were evaluated. Among 320 study participants, 171 (53.4%) and 55 (17.2%) had depression at month 0 and 12 respectively. Persistent depression was detected in 41 (24.0%) of the 171 patients with depression at month 0, whilst 135 (42.2%) of them never experienced depression. Patients' CD4 count was associated with depression at month 0 and 12 (p<0.05). Predictors of change in depression scores were urban dwelling [-1.98, 95%CI: -3.86 to -0.06, p=0.039], not knowing one's monthly income [2.10, 95%CI: 0.58 to 3.61, p=0.007], participant being single [-1.62 95%CI: -2.45 to -0.78, p<0.001] and being on antiretroviral therapy at recruitment [-1.5, 95%CI: -2.55 to -0.45, p<0.001]. There was a significant decrease in depression scores over a 12-month period and persistent depression is rife among this cohort of Ghanaians with HIV.

Pharmacokinetic and pharmacogenetic associations with dolutegravir neuropsychiatric adverse events in an African population

BACKGROUND

Dolutegravir has been associated with neuropsychiatric adverse events (NPAEs), but relationships between dolutegravir concentrations and NPAEs are unclear.

OBJECTIVES

To determine in an African population whether a concentration-response relationship exists between dolutegravir and treatment-emergent NPAEs, and whether selected loss-of-function polymorphisms in genes encoding UDP-glucuronosyltransferase-1A1 (the major metabolizing enzyme for dolutegravir) and organic cation transporter-2 (involved in neurotransmitter transport and inhibited by dolutegravir) are associated with NPAEs.

METHODS

Antiretroviral therapy-naive participants randomized to dolutegravir-based therapy in the ADVANCE study were enrolled into a pharmacokinetic sub-study. Primary outcome was change in mental health screening [modified mini screen (MMS)] and sleep quality from baseline to weeks 4, 12 and 24. Dolutegravir exposure was estimated using a population pharmacokinetic model. Polymorphisms analysed were UGT1A1 rs887829 and SLC22A2 rs316019.

RESULTS

Data from 464 participants were available for pharmacokinetic analyses and 301 for genetic analyses. By multivariable linear regression, higher dolutegravir exposure was associated with worsening sleep quality only at week 12 [coefficient  = -0.854 (95% CI -1.703 to -0.005), P = 0.049], but with improved MMS score at weeks 12 and 24 [coefficient = -1.255 (95% CI -2.250 to -0.261), P = 0.013 and coefficient = -1.199 (95% CI -2.030 to -0.368), P = 0.005, respectively]. The UGT1A1 and SLC22A2 polymorphisms were not associated with change in MMS score or sleep quality.

CONCLUSIONS

Only at week 12 did we find evidence of a relationship between dolutegravir exposure and worsening sleep quality. However, higher dolutegravir exposure was associated with improved MMS scores, suggesting a possible beneficial effect.

Developments in Neuroprotection for HIV-Associated Neurocognitive Disorders (HAND)

PURPOSE OF REVIEW

Reducing the risk of HIV-associated neurocognitive disorders (HAND) is an elusive treatment goal for people living with HIV. Combination antiretroviral therapy (cART) has reduced the prevalence of HIV-associated dementia, but milder, disabling HAND is an unmet challenge. As newer cART regimens that more consistently suppress central nervous system (CNS) HIV replication are developed, the testing of adjunctive neuroprotective therapies must accelerate.

RECENT FINDINGS

Successes in modifying cART regimens for CNS efficacy (penetrance, chemokine receptor targeting) and delivery (nanoformulations) in pilot studies suggest that improving cART neuroprotection and reducing HAND risk is achievable. Additionally, drugs currently used in neuroinflammatory, neuropsychiatric, and metabolic disorders show promise as adjuncts to cART, likely by broadly targeting neuroinflammation, oxidative stress, aerobic metabolism, and/or neurotransmitter metabolism. Adjunctive cognitive brain therapy and aerobic exercise may provide additional efficacy. Adjunctive neuroprotective therapies, including available FDA-approved drugs, cognitive therapy, and aerobic exercise combined with improved cART offer plausible strategies for optimizing the prevention and treatment of HAND.

Individual Differences in CD4/CD8 T-Cell Ratio Trajectories and Associated Risk Profiles Modeled From Acute HIV Infection

OBJECTIVE

We examined individual differences in CD4/CD8 T-cell ratio trajectories and associated risk profiles from acute HIV infection (AHI) through 144 weeks of antiretroviral therapy (ART) using a data-driven approach.

METHODS

A total of 483 AHI participants began ART during Fiebig I-V and completed follow-up evaluations for 144 weeks. CD4+, CD8+, and CD4/CD8 T-cell ratio trajectories were defined followed by analyses to identify associated risk variables.

RESULTS

Participants had a median viral load (VL) of 5.88 copies/ml and CD4/CD8 T-cell ratio of 0.71 at enrollment. After 144 weeks of ART, the median CD4/CD8 T-cell ratio was 1.3. Longitudinal models revealed five CD4/CD8 T-cell ratio subgroups: group 1 (3%) exhibited a ratio >1.0 at all visits; groups 2 (18%) and 3 (29%) exhibited inversion at enrollment, with normalization 4 and 12 weeks after ART, respectively; and groups 4 (31%) and 5 (18%) experienced CD4/CD8 T-cell ratio inversion due to slow CD4+ T-cell recovery (group 4) or high CD8+ T-cell count (group 5). Persistent inversion corresponded to ART onset after Fiebig II, higher VL, soluble CD27 and TIM-3, and lower eosinophil count. Individuals with slow CD4+ T-cell recovery exhibited higher VL, lower white blood cell count, lower basophil percent, and treatment with standard ART, as well as worse mental health and cognition, compared with individuals with high CD8+ T-cell count.

CONCLUSIONS

Early HIV disease dynamics predict unfavorable CD4/CD8 T-cell ratio outcomes after ART. CD4+ and CD8+ T-cell trajectories contribute to inversion risk and correspond to specific viral, immune, and psychological profiles during AHI. Adjunctive strategies to achieve immune normalization merit consideration.

Comprehensive knowledge about HIV/AIDS and associated factors among women of reproductive age in sub-Saharan Africa: a multilevel analysis using the most recent demographic and health survey of each country

Background

Women of reproductive age in sub-Saharan African (SSA) share the greatest burden of the HIV/AIDS epidemic. Comprehensive knowledge about HIV is seen as pivotal in combating the epidemic. Therefore, this study aimed to assess comprehensive knowledge about HIV/AIDS and associated factors among women of reproductive age in sub-Saharan Africa.

Objective

To examine comprehensive knowledge about HIV/AIDS and associated factors among women of reproductive age in sub-Saharan Africa.

Methods

We used the most recent SSA countries Demographic and Health Surveys (DHS) data. To assess comprehensive knowledge, a composite score of six separate questions (can get HIV by witchcraft or supernatural means, can reduce risk of getting HIV by using condoms during sex, reduce the risk of getting HIV by having one sex partner only, can get HIV from mosquito bites, can get HIV by sharing food with a person who has HIV/AIDS, and a healthy-looking person can have HIV) was used. Those who answered all six questions correctly were considered to have comprehensive knowledge. To assess the factors associated with comprehensive knowledge of HIV/AIDS, we used a multilevel binary logistic regression model since the data had hierarchical nature.

Results

In this study, the comprehensive knowledge about HIV/AIDS was 38.56% (95% CI: 38.32, 38.75). Both individual and community-level factors were associated with comprehensive knowledge about HIV/AIDS. Among individual-level factors, older age, having primary and above educational level, being from wealthy households, contraceptive use, listening to the radio, and reading newspaper were associated with higher odds of comprehensive knowledge about HIV/AIDS. Being from urban areas and the Eastern African region were the community-level factors that were associated with higher odds of comprehensive knowledge about HIV/AIDS.

Conclusion

The study found that comprehensive knowledge of HIV/AIDS is low. Individual and community-level factors were associated with comprehensive knowledge of HIV/AIDS. Therefore, giving special attention to those young women, women who had no formal education, those from poor socioeconomic status, and those who are from remote areas could decrease the epidemics of HIV/AIDS by increasing the comprehensive knowledge about HIV/AIDS. Besides, it is better to strengthen media campaigns regarding HIV/AIDS to increase comprehensive knowledge about HIV/AIDS.

CNS Considerations in ART Simplification Strategies

PURPOSE OF THE REVIEW

This review summarizes current knowledge on central nervous system (CNS) considerations in ART simplification strategies.

RECENT FINDINGS

Antiretroviral therapies (ART) showing efficacy in plasma will usually show efficacy in the cerebrospinal fluid (CSF). ART simplification may virologically fail if the new regimen has less than two active drugs, the genetic barrier of drugs is not high, and the patient may harbour archived resistance. Dual therapies including a boosted protease inhibitor (PI) or dolutegravir (DTG) are generally effective from the CNS perspective. In cases of related neurotoxicity, switching from either efavirenz (EFV) or DTG to another equally effective drug with better CNS tolerability usually leads to complete resolution of CNS symptoms. However, improvement may be incomplete when factors other than ART that cannot be easily modified are involved.

An update on neuropsychiatric adverse effects with second-generation integrase inhibitors and nonnucleoside reverse transcriptase inhibitors

PURPOSE OF REVIEW

Neuropsychiatric adverse effects (NPAE) associated with integrase strand transfer inhibitors (INSTIs) and nonnucleoside reverse transcriptase inhibitors (NNRTIs) are a growing concern, with higher rates in the real-world compared to phase III trials. This paper reviews the incidence, risk factors, and management of NPAE with second-generation INSTIs, INSTI/rilpivirine dual therapy, and doravirine.

RECENT FINDINGS

Recent cohort data confirm up to 8% NPAE-associated discontinuations for dolutegravir; NPAE with dolutegravir/rilpivirine therapy are higher than with dolutegravir alone, whereas bictegravir appears similar to dolutegravir. In contrast, NPAE with cabotegravir alone or with rilpivirine appears to be low. Doravirine has NPAE rates similar to rilpivirine and lower than efavirenz. Risk factors for NPAE include female gender, concurrent abacavir use, Sub-Saharan African descent, and age, whereas underlying psychiatric conditions do not appear to increase risk. Strategies to manage NPAE include changing administration time, therapeutic drug monitoring, or regimen modification including within-class INSTI changes. People experiencing NPAE with dolutegravir may tolerate bictegravir.

SUMMARY

Overall, mild to moderate NPAE are associated with INSTIs and newer NNRTIs. Rarely, more severe symptoms may occur and lead to treatment discontinuation. Clinicians should be aware of NPAE to identify and manage drug-related adverse effects.

Cognitive trajectories after treatment in acute HIV infection

OBJECTIVE

People with HIV continue to exhibit cognitive symptoms after suppressive antiretroviral therapy (ART). It remains unclear if initiating ART during acute HIV-1 infection (AHI) uniformly improves cognitive outcomes.

METHODS

Sixty-seven individuals (96% men, median age 28 years) initiated ART immediately after AHI diagnosis and maintained viral suppression for 6 years. They underwent a four-test neuropsychological battery that measured fine motor speed and dexterity, psychomotor speed, and executive functioning at baseline (pre-ART AHI), weeks 12, 24 and 96, and annually thereafter through week 288. Performances were standardized to calculate an overall (NPZ-4) score and frequencies of impaired cognitive performance (≤-1 SD on at least two tests, or ≤-2 SD on at least one test). Group-based trajectory analysis (GBTA) was applied to identify distinct neuropsychological trajectories modelled from baseline to week 288. Posthoc analyses examined HIV-1 and demographic factors that differed between trajectory subgroups.

RESULTS

NPZ-4 scores improved from baseline to week 96 (P < 0.001) and from weeks 96 to 288 (P < 0.001), with frequencies of impaired performance of 30, 6 and 2% at the respective time-points. The amplitude of NPZ-4 improvement throughout the period was more than 0.5 SD and beyond practice effects. GBTA identified three NPZ-4 trajectory subgroups that all showed improvement over-time. The subgroup with lowest baseline performance exhibited worse depressive symptoms at baseline (P = 0.04) and the largest improvement among the three. HIV-1 indices did not differ between the subgroups.

CONCLUSION

Cognitive performance improved in a sustained and stable manner after initiating ART during AHI. Largest improvements were seen in participants with worst baseline cognitive performance.

Integrase Strand Transfer Inhibitor Start or Switch Impacts Learning in Women With HIV

BACKGROUND

Integrase strand transfer inhibitors (INSTIs) are first-line regimens for HIV treatment. We aimed to examine their impact on cognitive performance and depressive symptoms in women with HIV (WWH).

SETTING

Women's Interagency HIV Study, a multisite, prospective, cohort study.

METHODS

WWH who started or switched to INSTI-based antiretroviral therapy (ART) and completed neuropsychological testing and the Center for Epidemiological Studies-Depression (CES-D) scale before and after INSTI start/switch were included in the analyses. Primary outcomes were demographically corrected cognitive domain T-scores. Linear mixed-effects models adjusted for relevant covariates were used to examine effects of start/switch of any INSTI and individual INSTI drugs on cognition and CES-D scores.

RESULTS

Six hundred thirty-nine WWH, median age 49 (interquartile range 12) years, 66% Black non-Hispanic, had neuropsychological and CES-D scale data before and after INSTI start/switch. Although 14% started INSTI-based ART, the remainder switched to INSTI-based ART from another regimen. Overall, any INSTI use was associated with poorer learning post-INSTI. Specifically, use of dolutegravir and elvitegravir, but not raltegravir, was associated with poorer learning. In analyses restricted to INSTI switch, any INSTI use, and dolutegravir use, was associated with poorer learning. Among those switching from a PI-based regimen, INSTIs overall and dolutegravir remained associated with poorer learning; switching from a nonnucleoside reverse transcriptase inhibitor to dolutegravir was also associated with poorer learning. INSTI start/switch was not related to depressive symptom changes.

CONCLUSIONS

INSTI use was associated with poorer learning among WWH. These changes were mainly observed in elvitegravir and dolutegravir users, indicating that the impact of INSTI on cognition in WWH may not be a class effect.

Antiretroviral Drugs Impact Autophagy with Toxic Outcomes

Antiretroviral drugs have dramatically improved the morbidity and mortality of people living with HIV (PLWH). While current antiretroviral therapy (ART) regimens are generally well-tolerated, risks for side effects and toxicity remain as PLWH must take life-long medications. Antiretroviral drugs impact autophagy, an intracellular proteolytic process that eliminates debris and foreign material, provides nutrients for metabolism, and performs quality control to maintain cell homeostasis. Toxicity and adverse events associated with antiretrovirals may be due, in part, to their impacts on autophagy. A more complete understanding of the effects on autophagy is essential for developing antiretroviral drugs with decreased off target effects, meaning those unrelated to viral suppression, to minimize toxicity for PLWH. This review summarizes the findings and highlights the gaps in our knowledge of the impacts of antiretroviral drugs on autophagy.

The clinical utility of the Distress Thermometer in non-oncological contexts: A scoping review

AIMS

To assess the clinical utility of the Distress Thermometer (DT) in non-cancer populations.

METHODS

The search was performed between the 6th and the 18th of April 2020, on the following databases: Web of Science (all databases included), Scopus and Science Direct. One last update was performed on 5 June 2020. The findings were reported using the PRISMA-ScR.

RESULTS

Fifty-three studies were included. Overall results indicated that this tool has been used in several contexts and populations (clinical and non-clinical). The DT is highly accessible, suitable and relevant for health professionals and/or researchers who aim to use it as a distress screening tool, particularly in patients with chronic physical conditions. Assumptions about its practicality and acceptability in non-oncology care should be made with caution since few studies have explored the psychometric qualities of this instrument, the completers' perceptions about completing the DT and the perceptions of health professionals who administer the tool.

CONCLUSIONS

This lack of information undermines conclusions about the overall clinical utility of the DT as a screening tool for distress in individuals who do not have cancer.

IMPLICATIONS FOR PRACTICE

Future research should aim to fill this gap and investigate the psychometric qualities of the DT through validation studies and, thus, increase the rigour of its application and clinical utility in non-oncological contexts.