Journal Article Annotations
2016, 1st Quarter
Annotations by John Grimaldi, MD and Mary Ann Cohen, MD, FAPM
Also of interest:
At the Conference on Retroviruses and Opportunistic Infections (CROI 2016) in Boston in February, the CDC presented new data on lifetime risk of acquiring HIV. Across transmission categories, risk is highest in men who have sex with men (MSM) with 1 in 6 expected to be diagnosed with HIV. By race/ethnicity, blacks continue to be at highest risk across all transmission categories and sexes. 1 in 2 black, 1 in 4 Hispanic and 1 in 11 white MSM will be diagnosed with HIV in their lifetime. Among heterosexuals and individuals who inject drugs, women are at higher risk than men. HIV risk is 1 in 6 among black women who inject drugs compared to 1 in 21 among both Hispanic women and men who inject drugs. These calculations highlight persistent disparities by sex and race/ethnicity and the urgent need to focus prevention efforts on groups most affected.
Also at CROI, the CDC presented compelling support, based on a dynamic model of HIV transmission, for the US National HIV/AIDS Strategy goals of reducing new infections and improving health outcomes. The model predicted that more than 168,000 new infections could be prevented if 80% of all individuals diagnosed with HIV were virologically suppressed. If expanded pre-exposure prophylaxis (PrEP) were added to expanded treatment an additional 17,000 infections could be averted, or a total of 185,000 infections prevented over the next 5 years.
The finding:This study utilized data from the CNS HIV Anti-retroviral Therapy Effects Research (CHARTER) cohort, involving participants enrolled 2004-2007 and followed through 2009 every 6 months, to evaluate the association between CSF HIV RNA and incident moderate-to-severe depression and the effect of CSF HIV RNA on subsequent Beck Depression Inventory II (BDI II) scores. The authors found that the risk of new onset moderate-to-severe depressive symptoms (BDI II >=17) adjusted for plasma HIV RNA and adherence to cART was over 4 times higher in participants with detectable CSF HIV RNA (>50 copies/ml), (adjusted HR 4.76, 95% confidence interval [CI] 1.58-14.3, p=0.006). Similarly, detectable CSF HIV RNA was associated with a BDI II score 2.53 points higher at the subsequent study visit after adjusting for covariates. BDI II scores increase for participants with detectable CSF HIV RNA in contrast to participants with undetectable CSF HIV RNA whose BDI II scores decrease. There was no association between plasma HIV RNA and incident depression or BDI II scores over time.
Strength and weaknesses: This study is one of the largest prospective studies to evaluate CSF HIV RNA over time and its association with depression as well as other CNS-related disorders such as neurocognitive impairment, hepatitis C and alcohol and substance use disorders. Because of the small numbers of participants with detectable CSF HIV RNA at baseline, a dose-response association was not detected. Also the majority of participants were men thus limiting applicability to women who may experience higher rates of depressive symptoms. The prevalence of current substance use disorder was extremely low 0.9% so that applicability to other populations with high prevalence of current use may be limited.
Relevance: This study adds to the expanding body of knowledge linking depression with CNS neuroinflammatory processes. It also further strengthens the rationale for routine depression screening in persons with HIV. CSF testing may also play a role in refining management of worsening depression and depression refractory to conventional treatment.
The finding: Using data from the Multicenter AIDS Cohort Study (MACS) a prospective study of gay and bisexual men, the authors found that from 2007 to 2011 HIV-associated neurocognitive disorders (HAND) are common in HIV-infected individuals receiving cART with rates of between 25% and 33%. The majority of individuals with minor neurocognitive disorder (MND) and HIV-associated dementia (HAD) and virologic suppression did not progress. However, there was a significant increase in frequency of asymptomatic neurocognitive impairment (ANI) from 8% in 2009-2010 to 19% in 20-11-2012 (p=0.016). A diagnosis of ANI conferred a 2-fold associated increase in risk of progressing to MND or HAD compared to a diagnosis of normal cognition.
Strength and weaknesses: This large prospective study of HIV-infected individuals receiving cART used revised 2007 HAND criteria with full neuropsychological test batteries and standardized functional assessments every 2 years to evaluate the frequency of HAND. The MACS cohort included gay and bisexual men only thus results may not be applicable to other demographic groups, especially women. Practice effects from administration of neuropychological batteries on multiple occasions could have reduced overall prevalence rates or rates of progression of neurocognitive dysfunction. Confounding conditions such as hypertension and diabetes may have influenced observed rates of HAND.
Relevance: This study adds to the growing evidence that neurocognitive impairment remains a common problem in chronically HIV-infected individuals despite adequate virologic control. However rates of HAND in the MACS cohort were somewhat lower than that observed in the CHARTER cohort, 25%-33% vs 40%-50%. This difference likely reflects demographic and clinical differences between these cohorts.
The finding: Using qualitative analysis of focus groups comprising medical, psychiatric and community-based organizations serving individuals with severe mental illness (SMI) in Washington D.C., the authors describe patient-related factors, stigma and administrative factors that impede and facilitate HIV testing, prevention and retention in HIV care across the full continuum of psychiatric services. Compared to psychiatric emergency departments and acute psychiatric inpatient and outpatient services, chronic inpatient psychiatric hospitals are better positioned to offer HIV testing without psychiatric complications, and achieve full sustained integration of HIV and psychiatric services and satisfactory virologic and immunologic outcomes. Lessons learned from this model of care can be applied to other less restrictive settings.
Strength and weaknesses: Focus groups offer valuable insight into differences among categories of interviewees that may lead to better coordination of care and improved HIV and mental health outcomes. The results of this DC-based study may not generalize to other urban areas. Also, the study may have been biased in selection of participants and did not include the view point of individuals with SMI.
Relevance: The study adds to the limited evidence base for best practices regarding HIV testing and engagement and retention in care for individuals with SMI. It also may inform future research aimed at developing strategies for integrating HIV and mental health services.