HIV infection, antiretroviral therapy initiation and longitudinal changes in biomarkers of organ function

The association between benzodiazepine use and greater risk of neurocognitive impairment is moderated by medical burden in people with HIV

Benzodiazepine use is linked to neurocognitive impairment (NCI) in the general population and people with HIV (PWH); however, this relationship may depend on age-related factors such as medical comorbidities, which occur at an elevated rate and manifest earlier in PWH. We retrospectively examined whether chronological age or medical burden, a clinical marker for aging, moderated the relationship between benzodiazepine use and NCI in PWH. Participants were 435 PWH on antiretroviral therapy who underwent neurocognitive and medical evaluations, including self-reported current benzodiazepine use. A medical burden index score (proportion of accumulated multisystem deficits) was calculated from 28 medical deficits. Demographically corrected cognitive deficit scores from 15 neuropsychological tests were used to calculate global and domain-specific NCI based on established cut-offs. Logistic regressions separately modeled global and domain-specific NCI as a function of benzodiazepine x age and benzodiazepine x medical burden interactions, adjusting for current affective symptoms and HIV disease characteristics. A statistically significant benzodiazepine x medical burden interaction (p = .006) revealed that current benzodiazepine use increased odds of global NCI only among those who had a high medical burden (index score > 0.3 as indicated by the Johnson–Neyman analysis), which was driven by the domains of processing speed, motor, and verbal fluency. No age x benzodiazepine interactive effects on NCI were present. Findings suggest that the relationship between BZD use and NCI among PWH is specific to those with greater medical burden, which may be a greater risk factor for BZD-related NCI than chronological age.

Examining the Acceptability of a Resilience Building Intervention Among Adults Aging With HIV

ABSTRACT

Few interventions have targeted resilience resources in people living with HIV (PLWH). We tested the acceptability of an existing resilience intervention in middle-age and older PLWH. Fourteen PLWH attended one 3-hr group session, which included videos, quizzes, and written activities. Participants provided quantitative and qualitative feedback. The mean acceptability rating was 8.71 (1.27) on a 10-point scale. A majority of participants reported that the intervention was an appropriate length; that it improved their resilience, mood, and ability to manage HIV; and that they would likely continue using the tools. Average content retention accuracy was 75% (12.66). Qualitative feedback suggested addressing HIV-specific stressors, including disclosure concerns, stigma, health concerns, and treatment adherence. The resilience intervention was deemed highly acceptable among older PLWH. Uptake may increase by addressing HIV-specific stressors and improving comprehensibility. Future research should further refine and test the efficacy of a modified version of the intervention.

An Exploratory Study of Correlates of Allostatic Load in Older People Living With HIV

BACKGROUND

Older people living with HIV (PLWH) experience poorer outcomes than seronegative counterparts. Allostatic load (AL) markers have shown utility as indicators of cumulative wear-and-tear of stress on biological systems. However, little is known about correlates of AL in PLWH.

METHODS

Ninety-six PLWH aged 50+ completed a comprehensive neurobehavioral assessment and blood draw. Select AL markers (ie, 10 blood markers) were available for a subset (n = 75) of seronegative controls. AL was operationalized as a sum of markers in the highest risk quartile for: cortisol, DHEA, IL-6, TNF-alpha, C-reactive protein, glucose, total cholesterol, high-density lipoprotein cholesterol, triglycerides, albumin, systolic and diastolic blood pressure, and body mass index.

RESULTS

PLWH had higher risk levels than seronegatives with small-medium effect sizes for several biomarkers. Among HIV+ African Americans (84% of PLWH), higher AL was associated with lower psychological resilience (rho = -0.27, P = 0.02), less physical activity (rho = -0.29, P < 0.01), poorer neurocognitive functioning (rho = -0.26, P = 0.02), greater basic activity of daily living complaints (P < 0.01), and diabetes (P < 0.01). Multivariable regressions within African American PLWH for significant AL-outcome associations (ie, neurocognitive function, basic activity of daily living complaints, diabetes) showed that associations with AL remained significant when adjusting for relevant covariates. Mediation analysis suggested that the association between socioeconomic status and neurocognitive function was mediated by AL.

CONCLUSIONS

These exploratory findings are consistent with the larger aging literature, suggesting that lower AL may serve as a pathway to better health and functional outcomes, particularly in African American PLWH. Furthermore, resilience and physical activity may reduce AL in this population.

Successful Functional Aging in Middle-Aged and Older Adults with HIV

People living with HIV (PLWH) experience greater everyday functioning impairment. We examined frequency and correlates of successful functional aging (SFA) in PLWH. Using gold-standard questionnaires, SFA was defined in 174 HIV+ and 71 HIV- adults as absence of significant everyday cognitive symptoms and declines in instrumental activities of daily living. More HIV- (45%) than HIV+ (18%) adults met SFA criteria (p < 0.01). Depression, cognitive functioning, socioeconomic status, and HIV status were independent correlates of SFA (p values < 0.05). Motor ability, learning, and verbal fluency were associated with SFA. SFA was associated with health-related quality of life (HRQoL). PLWH are three times less likely to achieve SFA than HIV- adults, a phenotype that translates to HRQoL. While SFA is multifactorial, driven by clinico-demographic factors, HIV may pose additional risk to achieving SFA. Further work should examine other mechanisms whereby HIV hinders SFA (e.g., biomarkers, stress, mental health) and ultimately inform interventions to facilitate SFA.

Biomarkers of Inflammation Correlate With Clinical Scoring Indices in Human Immunodeficiency Virus-Infected Kenyans

Background

In high-income countries, inflammation has been associated with increased morbidity and mortality in human immunodeficiency virus (HIV)-infected individuals despite treatment with antiretroviral therapy (ART). However, these findings may not be generalizable to low-income settings.

Methods

In this cross-sectional study, multivariable linear regression was used to compare 28 inflammatory biomarker levels in HIV-infected and -uninfected participants. Correlations between biomarkers and Veterans Aging Cohort Study (VACS) index, Fibrosis-4 (FIB-4) score, and Framingham risk score were assessed.

Results

Plasma samples from 304 Kenyans were analyzed. Compared to HIV-uninfected controls, virologically suppressed HIV-infected participants had higher levels of CCL5, CXCL10, fatty acid binding protein (FABP) 2, fas ligand (FASLG), matrix metalloproteinase (MMP) 1, MMP7, soluble CD14 (sCD14), and soluble CD163 (sCD163) and lower MMP9 (P < .01). CD4+/HLA-DR+CD38+ (ρ = 0.32; P < .001), sCD14 (ρ = 0.25; P = .004), and sCD163 (ρ = 0.24; P = .006) were correlated with the VACS index. FABP2 was positively correlated (ρ = 0.29; P = .002), whereas MMP1 (ρ = -.32; P < .001) and MMP2 (ρ = -0.28; P = .002) were inversely correlated with the FIB-4 score.

Conclusions

Differences in biomarker levels exist between well-controlled HIV-infected participants on ART and uninfected controls. Some biomarkers are correlated to scoring indices predictive of morbidity and mortality. These biomarkers could serve as prognostic indicators and inform therapeutic development.

Cerebrospinal fluid (CSF) biomarkers of iron status are associated with CSF viral load, antiretroviral therapy, and demographic factors in HIV-infected adults

Background

HIV-associated neurocognitive disorder (HAND) remains common, despite antiretroviral therapy (ART). HIV dysregulates iron metabolism, but cerebrospinal fluid (CSF) levels of iron and iron-transport proteins in HIV-infected (HIV+) persons are largely unknown. The objectives of this study were to characterize CSF iron-related biomarkers in HIV+ adults and explore their relationships to known predictors of HAND.

Methods

We quantified total iron, transferrin and heavy-chain (H)-ferritin by immunoassay in CSF sampled by lumbar puncture in 403 HIV+ participants in a multi-center, observational study and evaluated biomarker associations with demographic and HIV-related correlates of HAND [e.g., age, sex, self-reported race/ethnicity, ART, and detectable plasma virus and CSF viral load (VL)] by multivariable regression. In a subset (N = 110) with existing CSF: serum albumin (Q_Alb) measurements, Q_Alb and comorbidity severity were also included as covariates to account for variability in the blood–CSF-barrier.

Results

Among 403 individuals (median age 43 years, 19% women, 56% non-Whites, median nadir CD4+ T cell count 180 cells/µL, 46% with undetectable plasma virus), men had 25% higher CSF transferrin (median 18.1 vs. 14.5 µg/mL), and 71% higher H-ferritin (median 2.9 vs. 1.7 ng/mL) than women (both p-values ≤0.01). CSF iron was 41% higher in self-reported Hispanics and 27% higher in (non-Hispanic) Whites than in (non-Hispanic) Blacks (median 5.2 and 4.7 µg/dL in Hispanics and Whites, respectively, vs. 3.7 µg/dL in Blacks, both p ≤ 0.01); these findings persisted after adjustment for age, sex, and HIV-specific factors. Median H-ferritin was 25% higher (p < 0.05), and transferrin 14% higher (p = 0.06), in Whites than Blacks. Transferrin and H-ferritin were 33 and 50% higher, respectively, in older (age > 50 years) than in younger persons (age ≤ 35 years; both p < 0.01), but these findings lost statistical significance in subset analyses that adjusted for Q_Alb and comorbidity. After these additional adjustments, associations were observed for CSF iron and transferrin with race/ethnicity as well as CSF VL, for transferrin with sex and ART, and for H-ferritin with plasma virus detectability and significant comorbidity (all p < 0.05).

Conclusions

CSF iron biomarkers are associated with demographic factors, ART, and CSF VL in HIV+ adults. Future studies should investigate a role for CNS iron dysregulation, to which an altered blood-CSF barrier may contribute, in HAND.

Electronic supplementary material

The online version of this article (doi:10.1186/s12987-017-0058-1) contains supplementary material, which is available to authorized users.

Validating Harmful Alcohol Use as a Phenotype for Genetic Discovery Using Phosphatidylethanol and a Polymorphism in ADH1B

BACKGROUND

Although alcohol risk is heritable, few genetic risk variants have been identified. Longitudinal electronic health record (EHR) data offer a largely untapped source of phenotypic information for genetic studies, but EHR-derived phenotypes for harmful alcohol exposure have yet to be validated. Using a variant of known effect, we used EHR data to develop and validate a phenotype for harmful alcohol exposure that can be used to identify unknown genetic variants in large samples. Herein, we consider the validity of 3 approaches using the 3-item Alcohol Use Disorders Identification Test consumption measure (AUDIT-C) as a phenotype for harmful alcohol exposure.

METHODS

First, using longitudinal AUDIT-C data from the Veterans Aging Cohort Biomarker Study Cohort (VACS-BC), we compared 3 metrics of AUDIT-C using correlation coefficients: (i) AUDIT-C closest to blood sampling (closest AUDIT-C), (ii) the highest value (highest AUDIT-C), (iii) and longitudinal trajectories generated using joint trajectory modeling (AUDIT-C trajectory). Second, we compared the associations of the 3 AUDIT-C metrics with phosphatidylethanol (PEth), a direct, quantitative biomarker for alcohol in the overall sample using chi-square tests for trend. Last, in the subsample of African Americans (AAs; n = 1,503), we compared the associations of the 3 AUDIT-C metrics with rs2066702 a common missense (Arg369Cys) polymorphism of the ADH1B gene, which encodes an alcohol dehydrogenase isozyme.

RESULTS

The sample (n = 1,851, 94.5% male, 65% HIV+, mean age 52 years) had a median of 7 AUDIT-C scores over a median of 6.1 years. Highest AUDIT-C and AUDIT-C trajectory were correlated r = 0.86. The closest AUDIT-C was obtained a median of 2.26 years after the VACS-BC blood draw. Overall and among AAs, all 3 AUDIT-C metrics were associated with PEth (all p < 0.05), but the gradient was steepest with AUDIT-C trajectory. Among AAs (36% with the protective ADH1B allele), the association of rs2066702 with AUDIT-C trajectory and highest AUDIT-C was statistically significant (p < 0.05), and the gradient was steeper for the AUDIT-C trajectory than for the highest AUDIT-C. The closest AUDIT-C was not statistically significantly associated with rs2066702.

CONCLUSIONS

EHR data can be used to identify complex phenotypes such as harmful alcohol use. The validity of the phenotype may be enhanced through the use of longitudinal trajectories.

Lipids profile among ART-naïve HIV infected patients and men who have sex with men in China: a case control study

Background

Dyslipidemia is commonly seen in human immunodeficiency virus (HIV) infected patients. Understanding the risk factors of abnormal lipid profiles is urgent for proposing targeted approaches to prevention. Our objective was to assess the incidence and associated factors of abnormal lipid profiles and atherogenic index of plasma (AIP) among antiretroviral therapy (ART) naïve men who have sex with men (MSM) acute HIV infection (AHI) and chronic HIV infection (CHI) patients in China.

Methods

We compared lipids parameters such as triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C) and AIP between MSM HIV-infected patients and MSM HIV negative controls. Multivariable linear regression was used to evaluate risk factors of higher AIP.

Results

We performed a case control analysis of 110 AHI, 110 CHI and 100 HIV negative MSM participants. The TC, HDL-C and LDL-C levels were decreased in the AHI and CHI groups compared to the controls (3.90 ± 0.73 mmol/L and 3.72 ± 0.74 mmol/L versus 4.49 ± 0.91 mmol/L, p < 0.001; 1.00 ± 0.25 mmol/L and 1.01 ± 0.30 mmol/L versus 1.19 ± 0.29 mmol/L, p < 0.001; 2.11 ± 0.57 mmol/L and 2.22 ± 0.58 mmol/L versus 2.75 ± 0.78 mmol/L, p < 0.001). The AIP score was higher in the AHI patients compared to the control group [0.08 (−0.05–0.20) versus−0.04 (−0.21–0.22), p = 0.039]. In total groups, AIP was associated with AHI and TG positively (β = 0.029 ± 0.012, p = 0.015;β = 0.273 ± 0.009, p < 0.001) and correlated with HDL-C inversely (β = -0.444 ± 0.023, p < 0.001).

Conclusions

HIV infection contributed to decreased TC, LDL-C and HDL-C. AHI contributed to higher AIP level. An urgent need exists for earlier HIV diagnosis and better prevention of dyslipidemia in China.

Depression and human immunodeficiency virus infection are risk factors for incident heart failure among veterans: Veterans Aging Cohort Study

BACKGROUND

Both HIV and depression are associated with increased heart failure (HF) risk. Depression, a common comorbidity, may further increase the risk of HF among adults with HIV infection (HIV+). We assessed the association between HIV, depression, and incident HF.

METHODS AND RESULTS

Veterans Aging Cohort Study (VACS) participants free from cardiovascular disease at baseline (n=81 427: 26 908 HIV+, 54 519 without HIV [HIV-]) were categorized into 4 groups: HIV- without major depressive disorder (MDD) [reference], HIV- with MDD, HIV+ without MDD, and HIV+ with MDD. International Classification of Diseases, Ninth Revision codes from medical records were used to determine MDD and the primary outcome, HF. After 5.8 years of follow-up, HF rates per 1000 person-years were highest among HIV+ participants with MDD (9.32; 95% confidence interval [CI], 8.20-10.6). In Cox proportional hazards models, HIV+ participants with MDD had a significantly higher risk of HF (adjusted hazard ratio, 1.68; 95% CI, 1.45-1.95) compared with HIV- participants without MDD. MDD was associated with HF in separate fully adjusted models for HIV- and HIV+ participants (adjusted hazard ratio, 1.21; 95% CI, 1.06-1.37; and adjusted hazard ratio, 1.29; 95% CI, 1.11-1.51, respectively). Among those with MDD, baseline antidepressant use was associated with lower risk of incident HF events (adjusted hazard ratio, 0.76; 95% CI, 0.58-0.99).

CONCLUSIONS

Our study is the first to suggest that MDD is an independent risk factor for HF in HIV+ adults. These results reinforce the importance of identifying and managing MDD among HIV+ patients. Future studies must clarify mechanisms linking HIV, MDD, antidepressants, and HF and identify interventions to reduce HF morbidity and mortality in those with both HIV and MDD.

Vitamin D deficiency is common in HIV-infected southern Australian adults

BACKGROUND

Vitamin D deficiency can have serious health consequences and may be particularly important for those living with HIV. It is unknown whether HIV infection is a risk factor for vitamin D deficiency. The aim of the study was to determine whether vitamin D deficiency is more common in HIV-infected than in HIV-uninfected individuals.

METHODS

This was a cross-sectional study of HIV-infected and uninfected individuals. A total of 997 HIV-infected participants were from a sexual health clinic in Melbourne with 25(OH)D measurements taken between 2008 and 2012. 3,653 HIV-uninfected individuals were participants in a statewide Victorian survey with 25(OH)D measurements taken between 2009 and 2010. Logistic regression models evaluated the association of HIV status with vitamin D deficiency (25[OH]D<50 nmol/l).

RESULTS

The frequency of vitamin D deficiency was significantly more common in HIV-infected (39% [95% CI 36%, 42%]) compared with HIV-uninfected individuals 23% (95% CI 15%, 31%). In multivariable analysis, males (adjusted odds ratio [aOR] 0.8; 95% CI 0.6, 0.9; P=0.001), Caucasian country of origin (aOR 0.4; 95% CI 0.3, 0.4; P<0.001), summer/autumn (aOR for autumn 0.2; 95% CI 0.1, 0.3; P<0.001), total cholesterol to high-density lipoprotein ratio >5 (aOR 1.4; 95% CI 1.2, 1.8; P<0.001) and HIV infection (aOR 1.7; 95% CI 1.4, 2.1; P<0.001) were associated with vitamin D deficiency.

CONCLUSIONS

Adults living in southern Australia with HIV were more likely to be vitamin D deficient than the general population.

Short-term weight gain after antiretroviral therapy initiation and subsequent risk of cardiovascular disease and diabetes: the D:A:D study

OBJECTIVES

The aim of the study was to assess the impact of the gain in body mass index (BMI) observed immediately after antiretroviral therapy (ART) initiation on the subsequent risk of cardiovascular disease (CVD) and diabetes.

METHODS

We analysed data from the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) cohort study. Outcomes were development of (i) CVD (composite of myocardial infarction/stroke/coronary procedure) and (ii) diabetes. The main exposure variable was change in BMI from ART initiation (pre-ART) to 1 year after initiation (continuous variable) in treatment-naïve individuals initiating ART with no history of CVD or diabetes (for respective outcomes). BMI [weight (kg)/(height (m))(2)] was categorized as underweight (< 18.5), normal (18.5-25), overweight (25-30) and obese (> 30). Poisson regression models were fitted stratified for each pre-ART BMI category to allow for category-specific estimates of incidence rate ratio (IRR). Models were adjusted for pre-ART BMI and CD4 count, key known risk factors (time-updated where possible) and calendar year.

RESULTS

A total of 97 CVD events occurred in 43,982 person-years (n = 9321) and 125 diabetes events in 43,278 person-years (n = 9193). In fully adjusted analyses for CVD, the IRR/unit gain in BMI (95% confidence interval) in the first year of ART, by pre-ART BMI category, was: underweight, 0.90 (0.60-1.37); normal, 1.18 (1.05-1.33); overweight, 0.87 (0.70-1.10), and obese, 0.95 (0.71-1.28) (P for interaction = 0.04). For diabetes, the IRR/unit gain in BMI was 1.11 (95% confidence interval 1.03 to 1.21), regardless of pre-ART BMI (P for interaction > 0.05).

CONCLUSIONS

Short-term gain in BMI following ART initiation appeared to increase the longer term risk of CVD, but only in those with pre-ART BMI in the normal range. It was also associated with increased risk of diabetes regardless of pre-ART BMI.

Ultraviolet index and location are important determinants of vitamin D status in people with human immunodeficiency virus

This study aimed to document the vitamin D status of HIV-infected individuals across a wide latitude range in one country and to examine associated risk factors for low vitamin D. Using data from patients attending four HIV specialist clinics across a wide latitude range in Australia, we constructed logistic regression models to investigate risk factors associated with 25(OH)D < 75 nmol L(-1). 1788 patients were included; 87% were male, 76% Caucasian and 72% on antiretroviral therapy. The proportion with 25(OH)D < 50 nmol L(-1) was 27%, and <75 nmol L(-1) was 54%. Living in Melbourne compared with Cairns (adjusted odds ratio (aOR) 3.30; 95% CI 2.18, 4.99, P < 0.001) and non-Caucasian origin (aOR 2.82, 95% CI 2.12, 3.75, P < 0.001) was associated with an increased risk, while extreme UV index compared with low UV index was associated with a reduced risk (aOR 0.33; 95% CI 0.20, 0.55, P < 0.001) of 25(OH)D < 75 nmol L(-1). In those with biochemistry available (n = 1117), antiretroviral therapy was associated with 25(OH)D < 75 nmol L(-1); however, this association was modified by serum cholesterol status. Location and UV index were the strongest factors associated with 25(OH)D < 75 nmol L(-1). Cholesterol, the product of an alternative steroid pathway with a common precursor steroid, modified the effect of antiretroviral therapy on serum 25(OH)D.