Cognitive Deficits in HIV Infected Children

Plasma galectin-9 relates to cognitive performance and inflammation among adolescents with vertically acquired HIV

OBJECTIVE

Adolescents with perinatally acquired HIV (AWH) are at an increased risk of poor cognitive development yet the underlying mechanisms remain unclear. Circulating galectin-9 (Gal-9) has been associated with increased inflammation and multimorbidity in adults with HIV despite antiretroviral therapy (ART); however, the relationship between Gal-9 in AWH and cognition remain unexplored.

DESIGN

A cross-sectional study of two independent age-matched cohorts from India [AWH on ART ( n  = 15), ART-naive ( n  = 15), and adolescents without HIV (AWOH; n  = 10)] and Myanmar [AWH on ART ( n  = 54) and AWOH ( n  = 22)] were studied. Adolescents from Myanmar underwent standardized cognitive tests.

METHODS

Plasma Gal-9 and soluble mediators were measured by immunoassays and cellular immune markers by flow cytometry. We used Mann-Whitney U tests to determine group-wise differences, Spearman's correlation for associations and machine learning to identify a classifier of cognitive status (impaired vs. unimpaired) built from clinical (age, sex, HIV status) and immunological markers.

RESULTS

Gal-9 levels were elevated in ART-treated AWH compared with AWOH in both cohorts (all P  < 0.05). Higher Gal-9 in AWH correlated with increased levels of inflammatory mediators (sCD14, TNFα, MCP-1, IP-10, IL-10) and activated CD8 + T cells (all P  < 0.05). Irrespective of HIV status, higher Gal-9 levels correlated with lower cognitive test scores in multiple domains [verbal learning, visuospatial learning, memory, motor skills (all P  < 0.05)]. ML classification identified Gal-9, CTLA-4, HVEM, and TIM-3 as significant predictors of cognitive deficits in adolescents [mean area under the curve (AUC) = 0.837].

CONCLUSION

Our results highlight a potential role of Gal-9 as a biomarker of inflammation and cognitive health among adolescents with perinatally acquired HIV.

Cognitive impairment in children and adolescents living with perinatal HIV disease in the ART era: a meta-analysis

Background

Despite improved survival and overall health outcomes from modern antiretroviral therapy (ART), children and adolescents living with HIV are facing pervasive impairments in neurodevelopment including cognitive impairment, but there remains a lack of consensus on the cognitive domains that are affected in those children and adolescents. The objective of this meta-analysis was to evaluate the impact of perinatal HIV-infection on executive function, working memory, and speed of information processing in the ART era.

Methods

The PubMed database was searched for studies published between 1997 and 2024, plus additional search with the ScienceDirect, bioRxiv, and medRxiv databases. A meta-analysis was conducted on thirty-five studies published between 2012 and 2023 that encompassed a total of 4066 perinatally-infected HIV patients, 2349 HIV-exposed uninfected (HEU) controls, and 2466 HIV-unexposed, uninfected (HUU) controls. Performance scores on executive function, working memory, and processing speed were pooled using random-effects meta-analysis.

Findings

Compared to HEU and HUU controls, perinatally HIV-infected children and adolescents presented with significant impairments in processing speed (Hedges g = -0.64, p < 0.00001), working memory (Hedges g = -0.69, p < 0.00001), and to a lesser degree, executive function (Hedges g = -0.35, p = 0.02). Meta-regression analysis suggested that the effect estimate of processing speed impairment negatively correlated with Gross National Income (GNI) per capita of the study countries (CALHIV vs HUU, p = 0.0016; CALHIV vs HEU, p = 0.0019), even though HIV-infected cases were compared to sociodemographically matched HUU controls from the same countries. Sub-group meta-analyses with participants from high-income or low-/middle-income countries provided further evidence suggesting that the performance gap between HIV-infected cases and HUU/HEU controls may be larger in low-/middle-income countries than high-income countries.

Interpretation

In the ART era, cognitive impairment (especially reduced processing speed and working memory) persists in children and adolescents living with HIV. These impairments may be more pronounced among those children and adolescents living with HIV in low-income countries, suggesting that there may be global health inequities in treatment outcomes with perinatal HIV-infection. However, meta-analysis and meta-regression analysis have their limitations, which calls for future collaborative multi-country international studies to directly investigate this important topic. Nevertheless, there is an unmet need to assure equity in timely assessments and interventions to optimize neurocognitive development and outcomes among children and adolescents with perinatal HIV globally.

Funding

This research was supported in part by NIH R01MH108466, NIH R56NS124422, and NIH R01NS124422.

Neurocognitive deficits and socioeconomic risk factors among children and adolescents living with HIV in sub-Saharan Africa: a systematic review

INTRODUCTION

Children and adolescents living with HIV (C/ALHIV) are at a risk for significant neurocognitive deficits. There is limited literature that addresses the role of socioeconomic factors in neurocognitive deficits among CALHIV in Sub Saharan Africa (SSA), as it is very difficult to establish this causal relationship. Our systematic review was guided by the biodevelopmental framework that assumes that foundations of health and adversity affect later development and life outcomes. This systematic review aims to assess available evidence on the relationship between neurocognitive deficits and socioeconomic factors among HIV children and adolescents in SSA region.

METHOD

Using a pre-determined search strategy, we searched electronic databases including PubMed, web of Science and EBSCOhost (CINAHL and MEDLINE). Peer-reviewed publications that address neurocognitive deficits, psychosocial and socioeconomic risk factors among children and adolescents living with HIV in SSA were included in review.

RESULTS

Out of 640 articles, 17 studies from SSA met the inclusion criteria. Four studies reported no significant differences in the neurocognitive measures comparing children and adolescents with HIV infection to those uninfected. However, 10 studies suggest that C/ALHIV scored significantly low in general intellectual functions as compared to their uninfected peers. C/ALHIV were found to have substantial deficits in specific cognitive domains such as sequential processing, simultaneous processing, and learning. In addition, deficits in visuo-spatial processing, visual memory and semantic fluency were mentioned. Socioeconomic factors such as lower socioeconomic status (income, education and occupation), child orphanhood status and under-nutrition were linked with neurocognitive deficits.

CONCLUSION

Our findings suggest that CALHIV presented with poorer neurocognitive outcomes when compared to other populations which were associated with specific socioeconomic factors.

Executive function in HIV-affected children and adolescents: a systematic review and meta-analyses

This review aimed to determine: whether EF is affected in children and adolescents (2-24-years-old) with perinatal HIV infection, perinatal HIV exposure without infection, and behaviourally acquired HIV. A systematic review (PROSPERO number: CRD42017067813) was conducted using 11 electronic databases (01.01.1981-09.07.2019) and 8 conference websites. Primary quantitative studies with EF scores on cognitive tasks and/or behavioural report measures were included. Meta-analyses were performed by EF subtype and subpopulations compared. 1789 records were found. Sixty-one studies were included in the narrative synthesis; 32 (N = 7884 participants) were included in meta-analyses. There was a distinct pattern of reduced EF in those with perinatal HIV infection on antiretroviral therapy compared to controls: pooled effect sizes were largest for verbal and visuospatial working memory, with smaller effects on planning, inhibitory control and set-shifting. Data were limited for other HIV-affected subpopulations. Perinatal HIV infection is associated with reduced EF with varying effect sizes for the different EF subtypes.

Development of a computerised neurocognitive battery for children and adolescents with HIV in Botswana: study design and protocol for the Ntemoga study

INTRODUCTION

Neurodevelopmental delays and cognitive impairments are common in youth living with HIV. Unfortunately, in resource-limited settings, where HIV infection impacts millions of children, cognitive and neurodevelopmental disorders commonly go undetected because of a lack of appropriate assessment instruments and local expertise. Here, we present a protocol to culturally adapt and validate the Penn Computerized Neurocognitive Battery (PennCNB) and examine its validity for detecting both advanced and subtle neurodevelopmental problems among school-aged children affected by HIV in resource-limited settings.

METHODS AND ANALYSIS

This is a prospective, observational cohort study. The venue for this study is Gaborone, Botswana, a resource-limited setting with high rates of perinatal exposure to HIV and limited neurocognitive assessment tools and expertise. We aim to validate the PennCNB in this setting by culturally adapting and then administering the adapted version of the battery to 200 HIV-infected, 200 HIV-exposed uninfected and 240 HIV-unexposed uninfected children. A series of analyses will be conducted to examine the reliability and construct validity of the PennCNB in these populations.

ETHICS AND DISSEMINATION

This project received ethical approval from local and university Institutional Review Boards and involved extensive input from local stakeholders. If successful, the proposed tools will provide practical screening and streamlined, comprehensive assessments that could be implemented in resource-limited settings to identify children with cognitive deficits within programmes focused on the care and treatment of children affected by HIV. The utility of such assessments could also extend beyond children affected by HIV, increasing general access to paediatric cognitive assessments in resource-limited settings.

Association of anthropometric status and residential locality factors with cognitive scores of 4-6-year-old children in Kwazulu-Natal, South Africa

Background

The Asenze study has the long-term goal of promoting better physical, cognitive and psychosocial functioning of children in a rural area in KwaZulu-Natal, 50 km from Durban with a view to planning interventions to promote growth and development for very young children. The specific objective in this paper was to provide information for the Child Health and Development project of the Valley Trust to assist with intervention planning. The broader goal was to assess developmental delays in communities ravaged by the HIV epidemic.The Asenze study was designed in two phases from 2008 and 2012. The current paper reports on 1581 4-6years old children in the baseline phase (2008-2010) in the five adjacent tribal areas in the study area.

Method

The participants included all the 4 - 6 year olds whose parents had consented to inclusion in the project and their caregivers. Data were derived from a brief questionnaire administered in the homes of participants, and subsequently from medical and psychological assessments of the children and their caregivers at the Asenze clinic. The association between child factors and other factors (geographic area, socioeconomic status (SES), parental level of education, the child's pre-school education) on the one hand and, the child's cognitive performance (as measured by the Grover Counter and subtests of the KABC-11) were analysed. Linear regression models were employed to determine which predictor variables of interest in a model were associated with the children's cognitive scores as the dependent variables.

Results

Based on the data, the principal factors associated with children's cognitive outcomes were height-for-age z-score (HAZ), preschool education and the area of residence, Generally children who had low cognitive scores were more often stunted (as defined by the WHO anthropometric tables), had not had pre-school education, and came from areas less favourable in terms of local infrastructure and access to employment opportunities and arable land.

Conclusion

The finding from this cross-sectional analysis of baseline data showed that in addition to height for age and pre-school education, which are commonly thought to impact on cognition, the local authority area where the children lived was associated with their scores on cognitive tests. This has implications for intervention planning. The functioning of local government in promoting the type of community development which will protect the rights of children should be taken into account.

Assessment of neurological soft signs in pediatric patients with HIV infection

BACKGROUND

Children and adolescents comprise a significant proportion of people living with HIV. The effects of HIV on the growing brain have generated interest among researchers in this field. Deficits arising during this crucial phase of neuromaturation due to HIV infection need to be assessed and addressed. Neurological soft signs (NSSs) can act as a proxy marker for underlying neuropsychological deficits. The present study aims to study the NSSs in pediatric patients with HIV and compare with healthy controls (HCs).

MATERIALS AND METHODS

Forty-eight children aged between 6 and 16 years diagnosed with HIV were selected by purposive sampling, and the Physical and Neurological Examination of Soft Signs (PANESS) scale was applied. Fifty children matched by age and sex were recruited from a nearby school, and the PANESS scale was applied. Children were divided into age- and gender-specific groups. The outcome scores of cases and controls groups were compared.

RESULTS

Males and females aged 13-16 years with HIV showed more soft signs as compared to HCs, with respect to gait errors, dysrhythmia, impersistence, speed of repetitive and sequenced movements, overflow with gaits, overflow with sequenced movements, total overflow, and overflow in excess of age. The differences in scores were less marked in younger age groups among both the genders.

CONCLUSIONS

The persistence of NSSs in older age group in HIV-infected children may point toward the presence of HIV-associated neurological disorder.

Neurocognitive functioning of HIV positive children attending the comprehensive care clinic at Kenyatta national hospital: exploring neurocognitive deficits and psychosocial risk factors

Children and adolescents are affected in different ways by HIV/AIDS. Neurocognitive deficits are one of the most significant long term effects on HIV infected children and adolescents. Several factors are thought to influence cognitive outcomes and this include immune status, Highly Active Antiretroviral Therapy (HAART), education and social support. The aim of the study was to assess the neurocognitive function of HIV infected children and adolescents and correlate it with psychosocial factors. A cross sectional study was carried out involving a sample of 90 children living with HIV between 8 and 15 years (M = 11.38, SD = 2.06) attending Comprehensive Care Clinic (CCC) at Kenyatta National Hospital (KNH). Samples were selected by using purposive sample technique. Kaufman Assessment Battery for Children-Second Edition was used to assess cognitive function and psychosocial issues were assessed using HEADS-ED. Data was analyzed using SPSS v23 and independent T-tests, Pearson's correlation and linear regression were used. The prevalence of neurocognitive deficits among HIV positive children attending CCC at KNH was 60% with neurocognitive performance of 54 children being at least 2SD below the mean based on the KABC-II scores. There was no significant correlation between mental processing index and CD4 count (Pearson's rho =  -0.01, p = 0.39). There was no significant association between Mental Processing Index and viral load (p = 0.056) and early ARV initiation (0.27). Using the HEADS-ED, risks factors related to education (β =  -5.67, p = 0.02) and activities and peer support (β =  -9.1, p = 0.002) were significantly associated with poor neurocognitive performance. Neurocognitive deficits are prevalent among HIV positive children attending CCC-KNH. This extent of the deficits was not associated with low CD4 count, high viral load or early initiation in HIV care. However, poor school performance and problem with peers was associated with poor neurocognitive performance.

A study of neuropsychological profile of human immunodeficiency virus-positive children and adolescents on antiretroviral therapy

AIMS

The aim is to study the neuropsychological and functional profile of children and adolescents with human immunodeficiency virus (HIV) infection on antiretroviral therapy (ART) and the association between the neuropsychological status and medical illness variables, treatment variables, and functional status in the cases of the sample and compare with normal controls.

MATERIALS AND METHODS

Forty-two HIV-positive children and adolescents on ART were evaluated and compared with 40 matched controls not known to be HIV-positive. The tools used were the Wechsler Intelligence Scale for Children-III R for neuropsychological evaluation, the Brief Impairment Scale to assess functional impairment, and a semi-structured questionnaire to obtain other relevant details.

RESULTS

There were significant differences between the verbal, performance intelligence quotients (IQs), global IQ score, and several individual subtests between cases and controls. The HIV group was also found to have a significant functional impairment.

CONCLUSION

Our findings show that HIV infection is associated with significant cognitive and functional impairment. The role of ART in these impairments requires further study. Such understanding can help to introduce wholesome and relatively safer management strategies for youngsters with HIV infection and improve their quality of life.

Cross-cultural assessment of HIV-associated cognitive impairment using the Kaufman assessment battery for children: a systematic review

INTRODUCTION

Despite improved efficacy of, and access to, combination antiretroviral therapy (cART), HIV-associated cognitive impairments remain prevalent in both children and adults. Neuropsychological tests that detect such impairment can help clinicians formulate effective treatment plans. The Kaufman Assessment Battery for Children (KABC), although developed and standardized in the United States, is used frequently in many different countries and cultural contexts to assess paediatric performance across various cognitive domains. This systematic review investigated the cross-cultural utility of the original KABC, and its 2nd edition (KABC-II), in detecting HIV-associated cognitive impairment in children and adolescents.

METHODS

We entered relevant keywords and MeSH terms into the PubMed, PsycInfo, EBSCOHost, ProQuest, and Scopus databases, with search limits set from 1983-2017. Two independent reviewers evaluated the retrieved abstracts and manuscripts. Studies eligible for inclusion in the review were those that (a) used the KABC/KABC-II to assess cognitive function in children/adolescents aged 2-18 years, (b) featured a definition of cognitive impairment (e.g. >2 SD below the mean) or compared the performance of HIV-infected and uninfected control groups, and (c) used a sample excluded from population on which the instruments were normed.

RESULTS AND DISCUSSION

We identified nine studies (eight conducted in African countries, and one in the United Kingdom) to comprise the review's sample. All studies detected cognitive impairment in HIV-infected children, including those who were cART-naïve or who were cART treated and clinically stable. KABC/KABC-II subtests assessing simultaneous processing appeared most sensitive. Evaluation of the methodological quality of the selected studies by two independent reviews suggested that shortcomings included reporting and selection biases.

CONCLUSIONS

This systematic review provides evidence for the cross-cultural utility of the KABC/KABC-II, particularly the simultaneous processing subtests, in detecting cognitive impairment in HIV-infected children (including those who are clinically stable). Although the current results suggest there is justification for using the KABC/KABC-II primarily in East Africa, further investigation is required to explore the instrument's utility in other HIV-prevalent regions of the globe.

HIV-Associated Cognitive Impairment in Perinatally Infected Children: A Meta-analysis

CONTEXT

Research shows, conclusively, that perinatal HIV infection has negative effects on cognitive functioning of children and adolescents. However, the extent of these cognitive impairments is unknown. Current literature does not document specific cognitive domains most affected in HIV-infected children and adolescents.

OBJECTIVE

To systematically review and meta-analyze the degree of cognitive impairment, and the specific cognitive domains affected, in children and adolescents with perinatally acquired HIV infection.

DATA SOURCES

We systematically searched 5 electronic bibliographic databases, namely: PubMed, PsychINFO, Academic Search Premier, Scopus, and WorldCat, by using a search protocol specifically designed for this study.

STUDY SELECTION

Studies were selected on the basis of set a priori eligibility criteria. Titles, abstracts, and full texts were assessed by 2 independent reviewers.

DATA EXTRACTION

Data from included studies were extracted into Microsoft Excel by 2 independent reviewers.

RESULTS

Twenty-two studies were identified for inclusion in the systematic review and of this, 6 studies were included in the meta-analysis. Results from the meta-analysis indicated that working memory and executive function were the domains most affected by the HIV virus.

LIMITATIONS

Only 27% of the included studies were suitable to enter into the meta-analysis. There was significant geographic bias in published studies, with only 32% (7/22) of included studies from sub-Saharan Africa.

CONCLUSIONS

The evidence supports an association between HIV infection in children and adolescents and cognitive impairment in the domains of working memory, executive function and processing speed, with effect size estimates also providing some support for deficits in visual memory and visual-spatial ability.

Perinatal HIV Status and Executive Function During School-Age and Adolescence: A Comparative Study of Long-Term Cognitive Capacity Among Children From a High HIV Prevalence Setting

The aim of this study was to determine whether perinatal HIV infection (PHIV), HIV-exposed uninfected (PHEU) versus HIV-unexposed (PHU) status predicted long-term executive function (EF) deficit in school-aged Ugandan children.Perinatal HIV status was determined by 18 months via DNA polymerase chain reaction test and confirmed at cognitive assessment between 6 and 18 years using HIV rapid-diagnostic test. Primary outcome is child EF measured using behavior-rating inventory of executive function questionnaire across 8 subscales summed to derive the global executive composite (GEC). EF was proxy-reported by caregivers and self-reported by children 11 years or older. Descriptive analyses by perinatal HIV status included derivation of mean, standard deviations (SD), number, and percent (%) of children with EF deficits warranting clinical vigilance. Raw scores were internally standardized by age and sex adjustment. EF scores warranting clinical vigilance were defined as ≥ mean + 1.5SD. t Tests for mean score differences by perinatal HIV status and linear-regression models were implemented in SAS version 9.4 to derive HIV status-related EF deficits (β) and 95% confidence intervals (CIs).Proxy-reported and self-reported EF were assessed in 166 and 82 children, respectively. GEC deficit was highest for PHIV (mean = 121.9, SD = 29.9), intermediate for PHEU (mean = 107.5, SD = 26.8), and lowest for PHU (mean = 103.4, SD = 20.7; P-trend < 0.01). GEC deficit levels warranting clinical vigilance occurred in 9 (15.8%), 5 (9.3%) and 0 (0%) PHIV, PHEU, and PHU children, respectively (P-trend = 0.01). Nineteen percent (n = 32) children had deficits requiring clinical vigilance in ≥2 proxy-reported EF subscales. Of these, multisubscale deficits occurred in 35.1%, 13.0%, and 9.3% of PHIV, PHEU, and PHU respectively (P-trend = 0.001). Multivariable analyses find significantly higher GEC deficits for PHIV compared with PHU and PHEU children regardless of respondent (all P values <0.01). Proxy-reported EF performance was similar for PHEU compared with PHU; however, child self-reported GEC scores were elevated by 12.8 units (95% CI: 5.4-25.5) for PHEU compared with PHU.PHIV had long-term EF deficits compared with other groups. Furthermore, PHEU ≥11 years may have long-term EF deficits compared with PHU, but future studies are needed to clarify this relationship. Cognitive remediation interventions with emphasis on EF may translate to improvements in long-term functional survival in HIV-affected children from sub-Saharan Africa.