Journal Article Annotations
2021, 4th Quarter
Annotations by John Grimaldi MD, Mary Ann Cohen MD, FAPM, Kelly Cozza MD, DFAPA, FACLP, and Luis Pereira MD
Using a National Health Service case register in South London and Maudsley, United Kingdom, this retrospective, cross-sectional study compared HIV-positive with HIV-negative psychiatric patients diagnosed with bipolar disorder (BD). HIV seroprevalence, clinical and treatment characteristics and outcomes, and temporal relationship between HIV and bipolar diagnoses were determined. Findings were as follows: there was a 1% prevalence of HIV among patients with a diagnosis of BD, comparable to the general population of people with BD. In 65% of patients, a diagnosis of BD preceded HIV diagnosis. There were no between group differences with respect to number of mood episodes, suicidal behavior, number of psychiatric hospitalizations or BD type. Only 85% of the HIV+ BD group were taking antiretroviral medication, which is lower than the 97-98% estimate for the local general HIV population. Compared to the HIV- BD group, a significantly higher proportion of the HIV+ BD group had a lifetime history of psychostimulant, GHB/GBL, and psychedelic use. The 2 groups did not differ in rates of other psychiatric disorders. However, the HIV+ BD group was significantly less likely to be taking antidepressant medication.
Strengths and limitations:
This study fills a significant gap in our understanding of the effect of HIV disease on the course and treatment of bipolar disorder (BD) and the behavioral and neurobiological relationships between the 2 diseases. Another strength is its use of a naturalistic clinical sample. Limitations include its small sample size and retrospective, cross-sectional design, thus it is not possible to make inferences about causality among variables. Because biomarkers of HIV disease severity such as CD4 cell counts and viral loads were not included, the study cannot comment on correlations between course of HIV disease and BD clinical characteristics. Findings may not be generalizable to less densely populated urban areas, rural communities, and less resourced countries.
This study is one of very few recent investigations into HIV seroprevalence in a psychiatric population of patients diagnosed with bipolar disorder (BD). It adds to our understanding of BD as a risk factor for HIV acquisition. Study findings also provide evidence for the need to enhance pre-exposure prophylaxis and treatment as prevention strategies tailored to the needs of this psychiatric population. The striking finding of the relatively high proportion of HIV+ BD patients with lifetime psychostimulant, GHB/GBL and psychedelic use also has important implications for HIV prevention. Although BD preceded HIV in 65% of the sample, BD emerged after HIV was diagnosed in the remaining 35%. This finding confirms the need to continue exploring HIV-related BD phenotypes and the neurobiological and psychosocial determinants of HIV-related mood disorders and associated neurocognitive impairment.
Databases of 3 large, Italian outpatient medical clinics were used to identify 4 cases of Alzheimer Dementia (AD) among over 9,000 people living with HIV (PLWH). Clinical, diagnostic and therapeutic features of each case were described. The investigators concluded that AD can be diagnosed in the setting of HIV disease and should be included in the differential diagnosis of cognitive decline in PLWH. They emphasized the benefits of a multi-subspecialty team from neuropsychology, neurology, radiology, and infectious disease. Structural and functional neuroimaging and CSF biomarkers may be useful in distinguishing between HIV-associated neurocognitive disorders (HAND) and AD. The role and underlying mechanism of antiretroviral medications in promoting and mitigating neurodegeneration deserve further study.
Strengths and Limitations:
This study used a large database of PLWH receiving medical care for whom clinical, historical and laboratory medical information, neuroimaging studies and CSF biomarkers were available. Limitations include the very small number of cases, lack of standardized diagnostic criteria and information about baseline, premorbid cognitive functioning.
Understanding the effect of HIV on the aging brain and risk factors for accelerated cognitive decline has increased in importance with the growing proportion of PLWH who are >50 years old. Additionally, while HIV treatment advances have resulted in a dramatic decline in prevalence of HIV-associated dementia, overall HAND prevalence has not significantly changed. Future research should assist in development of biomedical tools needed to distinguish among the many possible causes of cognitive decline in PLWH, including HAND and AD as well as other neurodegenerative disorders. Effective treatments will help mitigate associated human suffering and the economic costs of caring for this growing population of at risk PLWH.
The US government’s national strategic plan to end the HIV epidemic relies on targeted implementation of evidence-based, biomedical approaches to HIV prevention: Treatment as Prevention (TasP) and HIV Pre-Exposure Prophylaxis (PrEP). Epidemiologic data indicate a steady rise in the percentage of People Living with HIV (PLWH) who are in treatment and virologically suppressed and therefore cannot transmit HIV to sexual partners or through sharing injection drug equipment. It is anticipated that reduced transmittability will result in a fall in HIV incidence rates. Yet HIV surveillance data from 2018 suggest that HIV incidence has plateaued in the recent years. In 2012, the FDA approved the first medication indicated for PrEP, emtricitabine combined with tenofovir isoproxil fumarate (F/TDF or Truvada), for adult men who have sex with men (MSM), transgender women, and heterosexual men and women. More recently, the combination of emtricitabine and tenofovir alafenamide (F/TAF or Descovy) has been approved for use in men and transgender women. The FDA is expected to approve cabotegravir, a long-acting, injectable antiretroviral for use as PrEP in adults in early 2022. Despite its proven efficacy in preventing transmission of HIV, only 18% of those eligible, at-risk persons, have ever been prescribed PrEP. Blacks, Latinos, and women are underrepresented compared to Whites. In response to these biomedical advances and lag in PrEP uptake, especially among women and racial/ethnic minorities, the CDC recently updated their guidelines for HIV PrEP.
Key features of the updated PrEP guidelines are as follows:
Unfortunately, the use of PrEP in psychiatric populations is not discussed. Mental illness is a risk factor for HIV acquisition and HIV disease is associated with mental illness. Therefore, psychiatrists should be aware of PrEP, assess their patients for indications for PrEP, and be ready to prescribe or refer for treatment as appropriate.