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Speidell A, Agbey C, Mocchetti I. Accelerated neurodegeneration of basal forebrain cholinergic neurons in HIV-1 gp120 transgenic mice: Critical role of the p75 neurotrophin receptor. Brain Behav Immun 2024; 117:347-355. [PMID: 38266662 PMCID: PMC10935610 DOI: 10.1016/j.bbi.2024.01.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 01/26/2024] Open
Abstract
Human Immunodeficiency Virus-1 (HIV) infection of the brain induces HIV-associated neurocognitive disorders (HAND). The set of molecular events employed by HIV to drive cognitive impairments in people living with HIV are diverse and remain not completely understood. We have shown that the HIV envelope protein gp120 promotes loss of synapses and decreases performance on cognitive tasks through the p75 neurotrophin receptor (p75NTR). This receptor is abundant on cholinergic neurons of the basal forebrain and contributes to cognitive impairment in various neurological disorders. In this study, we examined cholinergic neurons of gp120 transgenic (gp120tg) mice for signs of degeneration. We observed that the number of choline acetyltransferase-expressing cells is decreased in old (12-14-month-old) gp120tg mice when compared to age matched wild type. In the same animals, we observed an increase in the levels of pro-nerve growth factor, a ligand of p75NTR, as well as a disruption of consolidation of extinction of conditioned fear, a behavior regulated by cholinergic neurons of the basal forebrain. Both biochemical and behavioral outcomes of gp120tg mice were rescued by the deletion of the p75NTR gene, strongly supporting the role that this receptor plays in the neurotoxic effects of gp120. These data indicate that future p75NTR-directed pharmacotherapies could provide an adjunct therapy against synaptic simplification caused by HIV.
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Affiliation(s)
- Andrew Speidell
- Interdisciplinary Program in Neuroscience, and Department of Neuroscience, NRB WP13, Georgetown University Medical Center, Washington, DC 20057, USA
| | - Christy Agbey
- Interdisciplinary Program in Neuroscience, and Department of Neuroscience, NRB WP13, Georgetown University Medical Center, Washington, DC 20057, USA
| | - Italo Mocchetti
- Interdisciplinary Program in Neuroscience, and Department of Neuroscience, NRB WP13, Georgetown University Medical Center, Washington, DC 20057, USA.
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2
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Thela L, Decloedt E, Zetterberg H, Gisslén M, Lesosky M, Gleich M, Koutsilieri E, Scheller C, Hye A, Joska J. Blood and cerebrospinal fluid biomarker changes in patients with HIV-associated neurocognitive impairment treated with lithium: analysis from a randomised placebo-controlled trial. J Neurovirol 2023; 29:156-166. [PMID: 36790601 DOI: 10.1007/s13365-023-01116-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 12/15/2022] [Accepted: 01/21/2023] [Indexed: 02/16/2023]
Abstract
HIV-associated neurocognitive disorders (HAND) persist in the era of antiretroviral therapy (ART). Thus, ART does not completely halt or reverse the pathological processes behind HAND. Adjuvant mitigating treatments are, therefore, prudent. Lithium treatment is known to promote neuronal brain-derived neurotrophic factors (BDNF). Lithium is also an inhibitor of glycogen synthase kinase-3 beta (GSK-3-β). We analyzed biomarkers obtained from participants in a randomized placebo-controlled trial of lithium in ART-treated individuals with moderate or severe HAND. We assayed markers at baseline and 24 weeks across several pathways hypothesized to be affected by HIV, inflammation, or degeneration. Investigated biomarkers included dopamine, BDNF, neurofilament light chain, and CD8 + lymphocyte activation (CD38 + HLADR +). Alzheimer's Disease (AD) biomarkers included soluble amyloid precursor protein alpha and beta (sAPPα/β), Aβ38, 40, 42, and ten other biomarkers validated as predictors of mild cognitive impairment and progression in previous studies. These include apolipoprotein C3, pre-albumin, α1-acid glycoprotein, α1-antitrypsin, PEDF, CC4, ICAM-1, RANTES, clusterin, and cystatin c. We recruited 61 participants (placebo = 31; lithium = 30). The age baseline mean was 40 (± 8.35) years and the median CD4 + T-cell count was 498 (IQR: 389-651) cells/μL. Biomarker concentrations between groups did not differ at baseline. However, both groups' blood dopamine levels decreased significantly after 24 weeks (adj. p < 002). No other marker was significantly different between groups, and we concluded that lithium did not confer neuroprotection following 24 weeks of treatment. However, the study was limited in duration and sample size.
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Affiliation(s)
- Lindokuhle Thela
- HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, E Floor, Neuroscience Centre, Anzio Road, Groote Schuur Hospital, Observatory, 7925, Cape Town, South Africa.
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK.,UK Dementia Research Institute at UCL, London, UK.,Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
| | - Magnus Gisslén
- Department of Infectious Disease, Institute of Biomedicine, the Sahlngreska Academy at the University of Gothenburg, Gothenburg, Sweden.,Department of Infectious Disease, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Maia Lesosky
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Melanie Gleich
- Institute of Virology and Immunobiology, University of Würzburg, Würzburg, Germany
| | - Eleni Koutsilieri
- Institute of Virology and Immunobiology, University of Würzburg, Würzburg, Germany
| | - Carsten Scheller
- Institute of Virology and Immunobiology, University of Würzburg, Würzburg, Germany
| | - Abdul Hye
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, and NIHR Biomedical Research Centre for Mental Health and Biomedical Research Unit for Dementia at South London and Maudsley NHS Foundation, London, UK
| | - John Joska
- HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, E Floor, Neuroscience Centre, Anzio Road, Groote Schuur Hospital, Observatory, 7925, Cape Town, South Africa
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3
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JAKEMAN B, SCHERRER AU, DARLING KEA, DAMAS J, BIELER-AESCHLIMANN M, HASSE B, SCHLOSSER L, HACHFELD A, GUTBROD K, TARR PE, CALMY A, ASSAL F, KUNZE U, STOECKLE M, SCHMID P, TOLLER G, ROSSI S, DI BENEDETTO C, DU PASQUIER R, CAVASSINI M, MARZOLINI C. Anticholinergic and sedative medications are associated with neurocognitive performance of well-treated people living with HIV. Open Forum Infect Dis 2022; 9:ofac457. [PMID: 36147598 PMCID: PMC9487636 DOI: 10.1093/ofid/ofac457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background We previously showed that anticholinergic (ACH) medications contribute to self-reported neurocognitive impairment (NCI) in elderly people with human immunodeficiency virus (PWH). The current cross-sectional study further evaluated the effect of ACH and sedative drugs on neurocognitive function in PWH who underwent comprehensive neuropsychological evaluation. Methods A medication review was performed in PWH enrolled in the prospective Neurocognitive Assessment in Metabolic and Aging Cohort within the Swiss HIV Cohort Study. Neurocognitive functions were analyzed in 5 domains (motor skills, speed of information, attention/working memory, executive functions, and verbal learning memory). The effect of ACH and sedative medications on neurocognitive functioning was evaluated using linear regression models for the continuous (mean z-score) outcome and multivariable logistic regression models for the binary (presence/absence) outcome. Results A total of 963 PWH (80% male, 92% Caucasian, 96% virologically suppressed, median age 52) were included. Fourteen percent of participants were prescribed ≥1 ACH medication and 9% were prescribed ≥1 sedative medication. Overall, 40% of participants had NCI. Sedative medication use was associated with impaired attention/verbal learning and ACH medication use with motor skills deficits both in the continuous (mean z-score difference −0.26 to −0.14, P < .001 and P = .06) and binary (odds ratio [OR], ≥1.67; P < .05) models. Their combined use was associated with deficits in overall neurocognitive functions in both models (mean z-score difference −0.12, P = .002 and OR = 1.54, P = .03). These associations were unchanged in a subgroup analysis of participants without depression (n = 824). Conclusions Anticholinergic and sedative medications contribute to NCI. Clinicians need to consider these drugs when assessing NCI in PWH.
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Affiliation(s)
- Bernadette JAKEMAN
- Department of Pharmaceutical Practice and Administrative Sciences, University of New Mexico College of Pharmacy , Albuquerque , USA
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, University of Basel , Switzerland
| | - Alexandra U SCHERRER
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich , Switzerland
- Institute of Medical Virology, University of Zurich , Switzerland
| | - Katharine E A DARLING
- Service of Infectious Diseases, Lausanne University Hospital, University of Lausanne , Switzerland
| | - Jose DAMAS
- Service of Infectious Diseases, Lausanne University Hospital, University of Lausanne , Switzerland
| | - Melanie BIELER-AESCHLIMANN
- Service of Neurology, Department of Neurosciences, University Hospital Lausanne, University of Lausanne , Switzerland
| | - Barbara HASSE
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich , Switzerland
| | - Ladina SCHLOSSER
- Department of Neuropsychology, Neurology Clinic, University Hospital Zurich , Switzerland
| | - Anna HACHFELD
- Department of Infectious Diseases, University Hospital Bern, University of Bern , Switzerland
| | - Klemens GUTBROD
- Department of Neurology, University Hospital Bern, University of Bern, Switzerland and Neurozentrum , Bern , Switzerland
| | - Philip E TARR
- University Department of Medicine, Kantonsspital Bruderholz, University of Basel , Switzerland
| | - Alexandra CALMY
- Division of Infectious Diseases, University Hospital Geneva, University of Geneva , Switzerland
| | - Frederic ASSAL
- Service of Neurology, University Hospital Geneva, University of Geneva , Switzerland
| | - Ursula KUNZE
- Memory Clinic, Felix Platter Hospital University Center for Medicine of Aging , Basel , Switzerland
| | - Marcel STOECKLE
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, University of Basel , Switzerland
| | - Patrick SCHMID
- Department of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen , Switzerland
| | - Gianina TOLLER
- Neuropsychology Unit, Department of Neurology, Cantonal Hospital St Gallen , Switzerland
| | - Stefania ROSSI
- Neuropsychology and Speech Therapy Unit, Neurocenter of Southern Switzerland, Regional Hospital Lugano , Switzerland
| | | | - Renaud DU PASQUIER
- Service of Neurology, Department of Neurosciences, University Hospital Lausanne, University of Lausanne , Switzerland
| | - Matthias CAVASSINI
- Service of Infectious Diseases, Lausanne University Hospital, University of Lausanne , Switzerland
| | - Catia MARZOLINI
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, University of Basel , Switzerland
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4
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Jakeman B, Scherrer A, Battegay M, Gunthard HF, Hachfeld A, Calmy A, Schmid P, Bernasconi E, Cavassini M, Marzolini C. Anticholinergic medication use in elderly people living with HIV and self-reported neurocognitive impairment: a prospective cohort study. J Antimicrob Chemother 2021; 77:492-499. [PMID: 34734255 DOI: 10.1093/jac/dkab386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/28/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Anticholinergic (ACH) medications have been associated with neurocognitive impairment, particularly in the elderly. This study determined prospectively the prevalence of prescribed ACH medications and their association with self-reported neurocognitive impairment (SRNI) in elderly people living with HIV (PLWH) of the Swiss HIV Cohort Study (SHCS). METHODS A literature review was performed to identify ACH medications, which were scored 0 to 3 (higher score indicating more ACH burden). Prescriptions were reviewed in July 2019 for all SHCS participants ≥65 years old to assess the prevalence of ACH medications. Association between ACH burden and neurocognitive impairment was evaluated using the SHCS SRNI questions addressing memory loss, attention difficulties and slowing in reasoning. RESULTS One thousand and nineteen PLWH (82% male) with a median age of 70 (IQR = 67-74) years were included. Most participants were on ART (99%). The average number of non-HIV drugs was 5.1 ± 3.6, representing a polypharmacy prevalence of 50%. Two hundred participants (20%) were on ≥1 ACH medication, with an average ACH score of 1.7 ± 1.3. SRNI, adjusted for age, sex, CD4, nadir CD4, viral load, efavirenz use and polypharmacy, was associated with depression (OR = 4.60; 95% CI = 2.62-8.09) and a trend was observed with being on ≥1 ACH medication (OR = 1.69; 95% CI = 0.97-2.95). In a subgroup analysis of participants without depression (n = 911), SRNI was associated with the use of ≥1 ACH medication (OR = 2.51; 95% CI = 1.31-4.80). CONCLUSIONS ACH medication use is common in elderly PLWH and contributes to SRNI. The effect of ACH medications on neurocognitive impairment warrants further evaluation using neurocognitive tests.
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Affiliation(s)
- Bernadette Jakeman
- Department of Pharmaceutical Practice and Administrative Sciences, University of New Mexico College of Pharmacy, Albuquerque, NM, USA.,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexandra Scherrer
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland.,Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Huldrych F Gunthard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland.,Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Anna Hachfeld
- Department of Infectious Diseases, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, University Hospital Geneva, University of Geneva, Geneva, Switzerland
| | - Patrick Schmid
- Department of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Enos Bernasconi
- Division of Infectious Diseases, Regional Hospital Lugano, University of Geneva and University of Southern Switzerland, Lugano, Switzerland
| | - Matthias Cavassini
- Service of Infectious Diseases, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
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5
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Chan T, Marta M, Hawkins C, Rackstraw S. Cognitive and Neurologic Rehabilitation Strategies for Central Nervous System HIV Infection. Curr HIV/AIDS Rep 2020; 17:514-521. [PMID: 32844275 PMCID: PMC7497368 DOI: 10.1007/s11904-020-00515-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Cognitive impairment leading to disability is increasingly seen in people living with human immunodeficiency virus (PLWH). Rehabilitation can alleviate the effects of cognitive impairment upon function. The aim of this paper is to discuss the strategies that have been used in cognitive and neurologic rehabilitation in PLWH. RECENT FINDINGS Studies examining pharmacological and non-pharmacological strategies were analysed. Medical management of HIV and co-morbidities should be optimised. Non-pharmacological strategies, including nerve stimulation techniques, exercise-based interventions, and paper and computer-based cognitive rehabilitation, have some evidence supporting their use in PLWH either as stand-alone interventions or as part of a multidisciplinary approach. Both pharmacological and non-pharmacological rehabilitation strategies have been used with PLWH. More intervention trials are needed to assess cognitive and neurological rehabilitation strategies and further evaluate their potential benefit in PLWH.
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Affiliation(s)
- Terrence Chan
- Mildmay Hospital, 19 Tabernacle Gardens, London, E2 7DZ, UK
| | - Monica Marta
- Grahame Hayton Unit, I&I and Neurology Department, Barts Health NHS Trust, London, UK
- Neurosciences, Blizard Institute, Queen Mary University of London, London, UK
| | | | - Simon Rackstraw
- Mildmay Hospital, 19 Tabernacle Gardens, London, E2 7DZ, UK.
- Grahame Hayton Unit, I&I and Neurology Department, Barts Health NHS Trust, London, UK.
- Neurosciences, Blizard Institute, Queen Mary University of London, London, UK.
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6
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McLaurin KA, Li H, Cook AK, Booze RM, Mactutus CF. S-EQUOL: a neuroprotective therapeutic for chronic neurocognitive impairments in pediatric HIV. J Neurovirol 2020; 26:704-718. [PMID: 32870477 DOI: 10.1007/s13365-020-00886-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/16/2020] [Accepted: 07/22/2020] [Indexed: 12/18/2022]
Abstract
Chronic neurocognitive impairments, commonly associated with pediatric human immunodeficiency virus type 1 (PHIV), are a detrimental consequence of early exposure to HIV-1 viral proteins. Strong evidence supports S-Equol (SE) as an efficacious adjunctive neuroprotective and/or neurorestorative therapeutic for neurocognitive impairments in adult ovariectomized female HIV-1 transgenic (Tg) rats. There remains, however, a critical need to assess the therapeutic efficacy of SE when treatment occurs at an earlier age (i.e., resembling a therapeutic for children with PHIV) and across the factor of biological sex. Utilization of a series of signal detection operant tasks revealed prominent, sex-dependent neurocognitive deficits in the HIV-1 Tg rat, characterized by alterations in stimulus-reinforcement learning, the response profile, and temporal processing. Early (i.e., postnatal day 28) initiation of SE treatment precluded the development of chronic neurocognitive impairments in all (i.e., 100%) HIV-1 Tg animals, albeit not for all neurocognitive domains. Most notably, the therapeutic effects of SE are generalized across the factor of biological sex, despite the presence of endogenous hormones. Results support, therefore, the efficacy of SE as a neuroprotective therapeutic for chronic neurocognitive impairments in the post-cART era; an adjunctive therapeutic that demonstrates high efficacy in both males and females. Optimizing treatment conditions by evaluating multiple factors (i.e., age, neurocognitive domains, and biological sex) associated with PHIV and HIV-1 associated neurocognitive disorders (HAND) affords a key opportunity to improve the therapeutic efficacy of SE.
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Affiliation(s)
- Kristen A McLaurin
- Program in Behavioral Neuroscience, Department of Psychology, University of South Carolina, 1512 Pendleton Street, Columbia, SC, 29208, USA
| | - Hailong Li
- Program in Behavioral Neuroscience, Department of Psychology, University of South Carolina, 1512 Pendleton Street, Columbia, SC, 29208, USA
| | - Anna K Cook
- Program in Behavioral Neuroscience, Department of Psychology, University of South Carolina, 1512 Pendleton Street, Columbia, SC, 29208, USA
| | - Rosemarie M Booze
- Program in Behavioral Neuroscience, Department of Psychology, University of South Carolina, 1512 Pendleton Street, Columbia, SC, 29208, USA
| | - Charles F Mactutus
- Program in Behavioral Neuroscience, Department of Psychology, University of South Carolina, 1512 Pendleton Street, Columbia, SC, 29208, USA.
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7
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Winston A, Spudich S. Cognitive disorders in people living with HIV. Lancet HIV 2020; 7:e504-e513. [PMID: 32621876 DOI: 10.1016/s2352-3018(20)30107-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 12/14/2022]
Abstract
High rates of cognitive disorders in antiretroviral-treated people living with HIV have been described worldwide. The exact prevalence of such cognitive disorders is determined by the definitions used, and the presence of these cognitive disorders significantly impacts the overall wellbeing of people with HIV. With the cohort of people with HIV becoming increasingly older, and having high rates of comorbidities and concomitant medication use, rates of cognitive disorders are likely to increase. Conversely, interventions are being sought to reduce the size of the latent HIV reservoir. If successful, such interventions are likely to also reduce the HIV reservoir in the brain compartment, which could result in improvements in cognitive function and reduced rates of impairment.
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Affiliation(s)
- Alan Winston
- Department of Infectious Disease, Imperial College London, London, UK; HIV Clinical Trials, Winston Churchill Wing, St Mary's Hospital, London, UK.
| | - Serena Spudich
- Department of Neurology, Yale University, New Haven, CT, USA
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8
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Lin SP, Calcagno A, Letendre SL, Ma Q. Clinical Treatment Options and Randomized Clinical Trials for Neurocognitive Complications of HIV Infection: Combination Antiretroviral Therapy, Central Nervous System Penetration Effectiveness, and Adjuvants. Curr Top Behav Neurosci 2020; 50:517-545. [PMID: 33604875 DOI: 10.1007/7854_2020_186] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The etiology and pathogenesis of human immunodeficiency virus type-I (HIV)-associated neurocognitive disorders (HAND) remain undetermined and are likely the produce of multiple mechanisms. This can mainly include neuronal injury from HIV, inflammatory processes, and mental health issues. As a result, a variety of treatment options have been tested including NeuroHIV-targeted regimens based on the central nervous system (CNS) penetration effectiveness (CPE) of antiretroviral therapy (ART) and adjuvant therapies for HAND. NeuroHIV-targeted ART regimens have produced consistent and statistically significant HIV suppression in the CNS, but this is not the case for cognitive and functional domains. Most adjuvant therapies such as minocycline, memantine, and selegiline have negligible benefit in the improvement of cognitive function of people living with HIV (PLWH) with mild to moderate neurocognitive impairment. Newer experimental treatments have been proposed to target cognitive and functional symptoms of HAND as well as potential underlying pathogenesis. This review aims to provide an analytical overview of the clinical treatment options and clinical trials for HAND by focusing on NeuroHIV-targeted ART regimen development, CPE, and adjuvant therapies.
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Affiliation(s)
- Shih-Ping Lin
- Department of Pharmacy Practice, University at Buffalo, Buffalo, NY, USA.,Taichung Veterans General Hospital, Taichung, Taiwan
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Scott L Letendre
- Department of Medicine and Psychiatry, HIV Neurobehavioral Research Center, University of California San Diego, San Diego, CA, USA
| | - Qing Ma
- Department of Pharmacy Practice, University at Buffalo, Buffalo, NY, USA.
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Bougea A, Spantideas N, Galanis P, Gkekas G, Thomaides T. Optimal treatment of HIV-associated neurocognitive disorders: myths and reality. A critical review. Ther Adv Infect Dis 2019; 6:2049936119838228. [PMID: 31001421 PMCID: PMC6454832 DOI: 10.1177/2049936119838228] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 02/25/2019] [Indexed: 01/11/2023] Open
Abstract
Background: The aim of this study was to review the clinical data on the effectiveness of
the pharmacotherapy of HIV-associated neurocognitive disorders (HANDs). Methods: A literature search of PubMed was performed (from January
1996 to October 2018) using the terms: ‘HIV-associated neurocognitive
disorders’, ‘HIV-associated dementia’, ‘mild neurocognitive disorder (MND)’,
‘asymptomatic neurocognitive impairment (ANI)’, ‘adjuvant therapies’,
‘antiretroviral treatment (cART)’, ‘neurotoxicity’, ‘cART intensification’,
‘fluid markers’, ‘cerebrospinal fluid’, ‘protease inhibitors’,
‘nonnucleoside reverse transcriptase inhibitor’, ‘nucleoside reverse
transcriptase inhibitors’, and ‘integrase strand transfer inhibitors’.
Additional references were identified from a review of literature citations.
All English language clinical studies of adjunctive therapies and neuronal
markers were selected in order to evaluate a closer relationship between the
early involvement and the onset of cognitive decline. We identified 407
relevant studies, of which 248 were excluded based on abstract analysis.
Finally, we analyzed 35 articles, organizing the results by cART, adjuvant
and neuronal markers (total of 7716 participants). Results: It is important to inform clinicians about the importance of accurate
phenotyping of HIV patients, incorporating an array of markers relevant to
HAND pathophysiology, in order to assess the individual’s risk and potential
response to future personalized antiretroviral treatment Conclusion: So far, no clinical trials of HAND therapies are effective beyond optimal
suppression of HIV replication in the central nervous system. Combination of
validated neuronal markers should be used to distinguish between milder HAND
subtypes and improve efficiency of clinical trials, after strict control of
confounders.
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Affiliation(s)
- Anastasia Bougea
- National and Kapodistrian University of Athens, Faculty of Medicine, Vassilisis Sofias Avenue 72, Athens, 11527, Greece
| | - Nikolaos Spantideas
- National and Kapodistrian University of Athens Aiginitio Hospital, Athens, Greece
| | - Petros Galanis
- National and Kapodistrian University of Athens, Athinon, Greece
| | - George Gkekas
- 'St. Panteleimon' General State Hospital of Piraeus, Athens, Greece
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Perrotta G, Bonnier G, Meskaldji DE, Romascano D, Aydarkhanov R, Daducci A, Simioni S, Cavassini M, Metral M, Lazeyras F, Meuli R, Krueger G, Du Pasquier RA, Granziera C. Rivastigmine decreases brain damage in HIV patients with mild cognitive deficits. Ann Clin Transl Neurol 2017; 4:915-920. [PMID: 29296621 PMCID: PMC5740253 DOI: 10.1002/acn3.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/25/2017] [Accepted: 09/22/2017] [Indexed: 11/08/2022] Open
Abstract
Rivastigmine has been shown to improve cognition in HIV+ patients with minor neurocognitive disorders; however, the mechanisms underlying such beneficial effect are currently unknown. To assess whether rivastigmine therapy is associated with decreased brain inflammation and damage, we performed T1/T2* relaxometry and magnetization transfer imaging in 17 aviremic HIV+ patients with minor neurocognitive disorders enrolled on a crossed over randomized rivastigmine trial. Rivastigmine therapy was associated with changes in MRI metrics indicating a decrease in brain water content (i.e., edema reabsorption) and/or reduced demyelination/axonal damage. Furthermore, MRI changes correlated with cognitive improvement on rivastigmine therapy.
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Affiliation(s)
- Gaetano Perrotta
- Department of Clinical Neurosciences, Service of Neurology, Neuroimmunology Unit Lausanne University Hospital and University of Lausanne Lausanne Vaud Switzerland
| | - Guillaume Bonnier
- A.A. Martinos Center for Biomedical Imaging Massachusetts General Hospital and Harvard Medical School Charlestown MA USA
| | - Djalel-Eddine Meskaldji
- Institute of Bioengineering École Polytechnique Fédérale de Lausanne Lausanne Vaud Switzerland.,Department of Radiology and Medical Informatics University of Geneva Geneva Switzerland.,Applied Statistics, Institute of Mathematics École Polytechnique Fédérale de Lausanne Lausanne Vaud Switzerland
| | - David Romascano
- Signal Processing Laboratory (LTS5) École Polytechnique Fédérale de Lausanne Lausanne Vaud Switzerland
| | | | - Alessandro Daducci
- Signal Processing Laboratory (LTS5) École Polytechnique Fédérale de Lausanne Lausanne Vaud Switzerland
| | - Samanta Simioni
- Department of Clinical Neurosciences, Service of Neurology, Neuroimmunology Unit Lausanne University Hospital and University of Lausanne Lausanne Vaud Switzerland
| | - Matthias Cavassini
- Department of Infectious Diseases Lausanne University Hospital and University of Lausanne Lausanne Vaud Switzerland
| | - Melanie Metral
- Department of Clinical Neurosciences, Service of Neurology, Neuroimmunology Unit Lausanne University Hospital and University of Lausanne Lausanne Vaud Switzerland
| | - François Lazeyras
- Department of Radiology Geneva University Hospital and University of Geneva Geneva Switzerland
| | - Reto Meuli
- Department of Radiology Lausanne University Hospital and University of Lausanne Lausanne Vaud Switzerland
| | | | - Renaud A Du Pasquier
- Department of Clinical Neurosciences, Service of Neurology, Neuroimmunology Unit Lausanne University Hospital and University of Lausanne Lausanne Vaud Switzerland
| | - Cristina Granziera
- Department of Clinical Neurosciences, Service of Neurology, Neuroimmunology Unit Lausanne University Hospital and University of Lausanne Lausanne Vaud Switzerland.,A.A. Martinos Center for Biomedical Imaging Massachusetts General Hospital and Harvard Medical School Charlestown MA USA
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11
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Muñoz-Moreno JA, Prats A, Moltó J, Garolera M, Pérez-Álvarez N, Díez-Quevedo C, Miranda C, Fumaz CR, Ferrer MJ, Clotet B. Transdermal rivastigmine for HIV-associated cognitive impairment: A randomized pilot study. PLoS One 2017; 12:e0182547. [PMID: 28854283 PMCID: PMC5576750 DOI: 10.1371/journal.pone.0182547] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 07/11/2017] [Indexed: 11/19/2022] Open
Abstract
Objective To assess the efficacy and safety of transdermal rivastigmine for the treatment of HIV-associated cognitive impairment. Methods We recruited HIV-infected patients with cognitive impairment on stable antiretroviral therapy in a randomized controlled pilot trial with a 48-week follow-up. An additional assessment was held at 12 weeks. Participants received transdermal rivastigmine (9.5 mg daily), lithium (400 mg twice daily, titrated progressively), or remained in a control group (no new medication). The primary efficacy endpoint was change in a global cognitive score (NPZ-7). Secondary endpoints included change in specific cognitive measures, domains, and functional parameters. Safety covered the frequency of adverse events and changes in laboratory results. Results Seventy-six subjects were screened, and 29 were finally enrolled. Better cognitive outcomes were observed in all groups, although there were no significant differences between the arms (mean NPZ-7 change [SD]): rivastigmine, 0.35 (0.14); lithium, 0.25 (0.40); control, 0.20 (0.44) (p = 0.78). The rivastigmine group showed the highest positive trend (mean NPZ-7 [SD], baseline vs week 48): rivastigmine, –0.47 (0.22) vs –0.11 (0.29), p = 0.06; lithium, –0.50 (0.40) vs –0.26 (0.21), p = 0.22; control, –0.52 (0.34) vs –0.32 (0.52), p = 0.44. The cognitive domains with the highest positive trends were information processing speed at week 12 and executive function at week 48 (rivastigmine vs control): information processing speed, 0.35 (0.64) vs –0.13 (0.25), p = 0.17, d = 0.96; and executive functioning, 0.73 (0.33) vs 0.03 (0.74), p = 0.09, d = 1.18. No relevant changes were observed regarding functional outcomes. A total of 12 (41%) individuals dropped out of the study: 2 (20%) were due to medication-related effects in the rivastigmine group and 4 (36%) in the lithium group. No severe adverse events were reported. Conclusions The results from this small randomized trial indicate that transdermal rivastigmine did not provide significant cognitive benefits in people with HAND on stable antiretroviral therapy, even though positive trends were found in specific cognitive domains. Relevant tolerability issues were not observed.
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Affiliation(s)
- Jose A. Muñoz-Moreno
- Fundació Lluita contra la SIDA (FLS), Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Facultat de Psicologia i Ciències de l'Educació, Universitat Oberta de Catalunya (UOC), Barcelona, Catalonia, Spain
- * E-mail:
| | - Anna Prats
- Fundació Lluita contra la SIDA (FLS), Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Departament de Psiquiatria i Medicina Legal, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Catalonia, Spain
| | - José Moltó
- Fundació Lluita contra la SIDA (FLS), Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Maite Garolera
- Clinical Research Group for Brain, Cognition and Behavior, Consorci Sanitari Hospital de Terrassa, Terrassa, Catalonia, Spain
- Grup de Recerca Consolidat en Neuropsicologia, Universitat de Barcelona (UB), Barcelona, Catalonia, Spain
| | - Núria Pérez-Álvarez
- Fundació Lluita contra la SIDA (FLS), Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Departament d'Estadística i Investigació Operativa, Universitat Politècnica de Catalunya (UPC), Barcelona, Catalonia, Spain
| | - Crisanto Díez-Quevedo
- Departament de Psiquiatria i Medicina Legal, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Catalonia, Spain
- Servei de Psiquiatria, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Cristina Miranda
- Fundació Lluita contra la SIDA (FLS), Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Carmina R. Fumaz
- Fundació Lluita contra la SIDA (FLS), Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Maria J. Ferrer
- Fundació Lluita contra la SIDA (FLS), Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Bonaventura Clotet
- Fundació Lluita contra la SIDA (FLS), Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Institut per la Recerca de la SIDA IrsiCaixa, Badalona, Catalonia, Spain
- Càtedra de la SIDA i Malalties Relacionades, Universitat de Vic—Universitat Central de Catalunya (UVic), Vic, Catalonia, Spain
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12
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Eggers C, Arendt G, Hahn K, Husstedt IW, Maschke M, Neuen-Jacob E, Obermann M, Rosenkranz T, Schielke E, Straube E. HIV-1-associated neurocognitive disorder: epidemiology, pathogenesis, diagnosis, and treatment. J Neurol 2017; 264:1715-1727. [PMID: 28567537 PMCID: PMC5533849 DOI: 10.1007/s00415-017-8503-2] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/30/2017] [Accepted: 05/02/2017] [Indexed: 01/05/2023]
Abstract
The modern antiretroviral treatment of human immunodeficiency virus (HIV-1) infection has considerably lowered the incidence of opportunistic infections. With the exception of the most severe dementia manifestations, the incidence and prevalence of HIV-associated neurocognitive disorders (HAND) have not decreased, and HAND continues to be relevant in daily clinical practice. Now, HAND occurs in earlier stages of HIV infection, and the clinical course differs from that before the widespread use of combination antiretroviral treatment (cART). The predominant clinical feature is a subcortical dementia with deficits in the domains concentration, attention, and memory. Motor signs such as gait disturbance and impaired manual dexterity have become less prominent. Prior to the advent of cART, the cerebral dysfunction could at least partially be explained by the viral load and by virus-associated histopathological findings. In subjects where cART has led to undetectable or at least very low viral load, the pathogenic virus-brain interaction is less direct, and an array of poorly understood immunological and probably toxic phenomena are discussed. This paper gives an overview of the current concepts in the field of HAND and provides suggestions for the diagnostic and therapeutic management.
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Affiliation(s)
- Christian Eggers
- Department of Neurology, Krankenhaus Barmherzige Brüder, Seilerstätte 2, 4021, Linz, Austria.
| | - Gabriele Arendt
- Neurologische Klinik, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Katrin Hahn
- Neurologische Klinik, Charité, Berlin, Germany
| | - Ingo W Husstedt
- Klinik für Neurologie, Universitätsklinikum Münster, Münster, Germany
| | - Matthias Maschke
- Neurologische Abteilung, Brüderkrankenhaus Trier, Trier, Germany
| | - Eva Neuen-Jacob
- Institut für Neuropathologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Mark Obermann
- Direktor des Zentrums für Neurologie, Asklepios Kliniken Schildautal, Seesen, Germany
| | - Thorsten Rosenkranz
- Neurologische Abteilung, Asklepios-Klinik Hamburg-St. Georg, Hamburg, Germany
| | - Eva Schielke
- Praxis für Neurologie Berlin-Mitte, 10117, Berlin, Germany
| | - Elmar Straube
- HIV-Schwerpunktpraxis, 30890, Barsinghausen, Germany
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13
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Abstract
PURPOSE OF REVIEW As of the year 2016, an estimated 50% of the United States' HIV-Positive population is aged 50 years or older. Due to a combination of increased rates of infection in older adults, and successful anti-retroviral (ART) regimens allowing HIV-positive adults to survive for decades with the disease, we are now faced with a steadily graying HIV-positive population, with only limited knowledge of how the cognitive and physiological effects of aging intersect with those of chronic HIV-infection. RECENT FINDINGS Age-related changes to mood, cognition, and neurological health may be experienced differently in those living with HIV, and research concerning quality of life, mental health, and cognitive aging needs to account for and explore these factors more carefully in the coming years. SUMMARY This review will explore the topic of cognitive aging with HIV: 1. Central nervous system (CNS) infection of HIV and how the virus affects brain integrity and function; 2. Cognitive and behavioral symptoms of HIV-Associated Neurocognitive Disorders (HAND); 3. Neurobiological theories of Cognitive Aging and how these processes may be exacerbated by HIV-infection; 4: Clinical implications and complications of aging with HIV and factors that may result in poorer cognitive outcomes.
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Affiliation(s)
| | - Paul Newhouse
- Vanderbilt University Center for Cognitive Medicine.,Veterans Affairs Tennessee Valley Healthcare System Geriatric Research, Education, and Clinical Center (VA TVHS GRECC)
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14
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Abstract
Combination antiretroviral treatment is associated with clear benefits in HIV-positive subjects, and is also effective in the central nervous system (CNS), meaning HIV-associated dementia is now an uncommon event. Nevertheless, a significant number of patients show symptoms of neurocognitive impairment which may negatively affect their quality of life. Although several risk factors for HIV-associated neurocognitive disorders have been identified, there is no clear recommendation for their prevention and management. In this review, the penetration of drugs into the cerebrospinal fluid/CNS is discussed as well as the viral and clinical consequences associated with higher/lower compartmental exposure. We also review the potential interventions according to the currently identified underlying mechanisms, including persistent CNS immune activation, legacy effects, low-level viral replication and escape, co-morbidities, and antiretroviral-associated direct and indirect 'neurotoxicity'. Adjunctive therapies and interventions (including neuro-rehabilitation) are then briefly discussed. The treatment of HIV infection in the CNS is a complex area of therapeutics requiring multidisciplinary interventions and further study.
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Affiliation(s)
- A Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, c/o Ospedale Amedeo di Savoia, C.so Svizzera 164, 10159, Torino, Italy.
| | - G Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, c/o Ospedale Amedeo di Savoia, C.so Svizzera 164, 10159, Torino, Italy
| | - S Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, c/o Ospedale Amedeo di Savoia, C.so Svizzera 164, 10159, Torino, Italy
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15
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Haubenberger D, Clifford DB. Clinical Trials in Neurovirology: Successes, Challenges, and Pitfalls. Neurotherapeutics 2016; 13:571-81. [PMID: 27194073 PMCID: PMC4965408 DOI: 10.1007/s13311-016-0440-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Clinical trials in neurovirology illustrate the special challenges confronting investigators planning to study these conditions, as well as the contributions of successful trials in establishing appropriate management for these devastating diseases. This article reviews key examples of progress in neurovirology that have been spurred by clinical trials, emphasizing human herpes virus encephalitis, HIV, and JC virus. Clinical trials in the setting of neurovirological diseases are characterized by specific challenges, which may include small sample sizes, clinical presentations from life-threatening conditions to chronic courses of disease, regional and temporally restricted outbreaks scenarios, and the unavailability of validated diagnostic tests that can be rapidly deployed at the bedside. This review aims to highlight these methodological challenges and pitfalls in designing and executing clinical neurovirology trials, as well as to outline innovative trial designs, which could be useful in addressing common challenges.
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Affiliation(s)
- Dietrich Haubenberger
- Clinical Trials Unit, Office of the Clinical Director, NINDS Intramural Research Program, National Institutes of Health, 9000 Rockville Pike, Rm 6-5700, Bethesda, MD, 20892, USA.
| | - David B Clifford
- Departments of Neurology and Medicine, Washington University in St Louis, Box 8111, 660 S Euclid Ave, Saint Louis, MO, 63110, USA
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16
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Treatment of HIV in the CNS: effects of antiretroviral therapy and the promise of non-antiretroviral therapeutics. Curr HIV/AIDS Rep 2015; 11:353-62. [PMID: 25063356 DOI: 10.1007/s11904-014-0223-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The growing recognition of the burden of neurologic disease associated with HIV infection in the last decade has led to renewed efforts to characterize the pathophysiology of the virus within the central nervous system (CNS). The concept of the AIDS-dementia complex is now better understood as a spectrum of HIV-associated neurocognitive disorders (HAND), which range from asymptomatic disease to severe impairment. Recent work has shown that even optimally treated patients can experience not only persistent HAND, but also the development of new neurologic abnormalities despite viral suppression. This has thrown into question what the impact of antiretroviral therapy has been on the incidence and prevalence of neurocognitive dysfunction. In this context, the last few years have seen a concentrated effort to identify the effects that antiretroviral therapy has on the neurologic manifestations of HIV and to develop therapeutic modalities that might specifically alter the trajectory of HIV within the CNS.
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17
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Abstract
PURPOSE OF REVIEW People with HIV continue to live with the health consequences of an episodic illness that limits their ability to fully participate in society, particularly for the growing number of older people living with HIV. The present review describes the recent evidence exploring the psychosocial challenges facing older adults living with HIV. RECENT FINDINGS Aging for people with HIV may be more challenging than for the general population because of HIV-related stigma, loss of friends and social networks, and the detrimental effects that HIV and antiretroviral treatment have on normal aging processes. Older people with HIV are more likely to experience mental health and neurocognitive impairment than their HIV-negative counterparts, as well as more social isolation as a result of decreased social participation and engagement. People develop different approaches for coping with the challenges associated with aging with HIV. SUMMARY As this field of research evolves, many research gaps need to be addressed, including a better conceptualization and measurement of successful aging and the development of high-quality integrated care, programs, and services tailored to the needs of older people with HIV. A more integrated policy response is needed to improve the psychosocial and economic well being of older people with HIV.
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18
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McGuire JL, Barrett JS, Vezina HE, Spitsin S, Douglas SD. Adjuvant therapies for HIV-associated neurocognitive disorders. Ann Clin Transl Neurol 2014; 1:938-52. [PMID: 25540809 PMCID: PMC4265066 DOI: 10.1002/acn3.131] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 09/15/2014] [Accepted: 09/16/2014] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE HIV-associated neurocognitive disorder (HAND) is a frequent and heterogeneous complication of HIV, affecting nearly 50% of infected individuals in the combined antiretroviral therapy (cART) era. This is a particularly devastating statistic because the diagnosis of HAND confers an increased risk of HIV-associated morbidity and mortality in affected patients. While cART is helpful in the treatment of the more severe forms of HAND, there is a therapeutic gap in the milder forms of HAND, where cART is less effective. Multiple adjuvant therapies with various mechanisms of action have been studied (N-methyl D-aspartate [NMDA]-receptor antagonists, MAO-B inhibitors, tetracycline-class antibiotics, and others), but none have shown a clear positive effect in HAND. While this lack of efficacy may be because the appropriate therapeutic targets have not yet been determined, we aimed to discuss that study results may also influenced by clinical trial design. METHODS This report is a systematic review of clinical trials of adjuvant therapies for HAND performed from January 1996 through June 2014. RESULTS Possible drawbacks in study design, including lack of standardized case definitions, poorly defined target populations, inappropriate dose selection and measurable outcomes, and brief study durations may have masked true underlying mechanistic effects of previously investigated adjuvant therapies for HAND in specific patient populations. CONCLUSIONS A proposal for streamlining and maximizing the likelihood of success in future clinical studies using a 'learning and confirming' investigational paradigm, incorporating stronger adaptive Phase I/II study designs, computerized modeling, and population/goal of treatment-specific Phase III clinical trials is presented.
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Affiliation(s)
- Jennifer L McGuire
- Division of Neurology, The Children’s Hospital of
PhiladelphiaPhiladelphia, Pennsylvania
- Department of Neurology, The Perelman School of Medicine
at the University of PennsylvaniaPhiladelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics,
Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, Pennsylvania
| | - Jeffrey S Barrett
- Laboratory for Applied PK/PD, Division of Clinical
Pharmacology & Therapeutics, The Children’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania
| | - Heather E Vezina
- Laboratory for Applied PK/PD, Division of Clinical
Pharmacology & Therapeutics, The Children’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania
| | - Sergei Spitsin
- The Children’s Hospital of Philadelphia Research
InstitutePhiladelphia, Pennsylvania
| | - Steven D Douglas
- The Children’s Hospital of Philadelphia Research
InstitutePhiladelphia, Pennsylvania
- Division of Allergy & Immunology, The
Children’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania
- Department of Pediatrics, The Perelman School of Medicine
at the University of PennsylvaniaPhiladelphia, Pennsylvania
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19
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Clifford DB, Ances BM. HIV-associated neurocognitive disorder. THE LANCET. INFECTIOUS DISEASES 2014; 13:976-86. [PMID: 24156898 DOI: 10.1016/s1473-3099(13)70269-x] [Citation(s) in RCA: 424] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Neurological involvement in HIV is often associated with cognitive impairment. Although severe and progressive neurocognitive impairment has become rare in HIV clinics in the era of potent antiretroviral therapy, most patients with HIV worldwide have poor outcomes on formal neurocognitive tests. In this Review, we describe the manifestations of HIV-associated neurocognitive disorder in the era of effective HIV therapy, outline diagnosis and treatment recommendations, and explore the research questions that remain. Although comorbid disorders, such as hepatitis C infection or epilepsy, might cause some impairment, their prevalence is insufficient to explain the frequency with which it is encountered. HIV disease markers, such as viral load and CD4 cell counts, are not strongly associated with ongoing impairment on treatment, whereas cardiovascular disease markers and inflammatory markers are. New cerebrospinal fluid and neuroimaging biomarkers are needed to detect and follow impairment. Ongoing research efforts to optimise HIV therapy within the CNS, and potentially to intervene in downstream mechanisms of neurotoxicity, remain important avenues for future investigation. Ultimately, the full control of virus in the brain is a necessary step in the goal of HIV eradication.
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Affiliation(s)
- David B Clifford
- Department of Neurology and Medicine, Washington University in St Louis, St Louis, MO, USA.
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20
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Granziera C, Daducci A, Simioni S, Cavassini M, Roche A, Meskaldji D, Kober T, Metral M, Calmy A, Helms G, Hirschel B, Lazeyras F, Meuli R, Krueger G, Du Pasquier RA. Micro-structural brain alterations in aviremic HIV+ patients with minor neurocognitive disorders: a multi-contrast study at high field. PLoS One 2013; 8:e72547. [PMID: 24039777 PMCID: PMC3769352 DOI: 10.1371/journal.pone.0072547] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 07/10/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Mild neurocognitive disorders (MND) affect a subset of HIV+ patients under effective combination antiretroviral therapy (cART). In this study, we used an innovative multi-contrast magnetic resonance imaging (MRI) approach at high-field to assess the presence of micro-structural brain alterations in MND+ patients. METHODS We enrolled 17 MND+ and 19 MND- patients with undetectable HIV-1 RNA and 19 healthy controls (HC). MRI acquisitions at 3T included: MP2RAGE for T1 relaxation times, Magnetization Transfer (MT), T2* and Susceptibility Weighted Imaging (SWI) to probe micro-structural integrity and iron deposition in the brain. Statistical analysis used permutation-based tests and correction for family-wise error rate. Multiple regression analysis was performed between MRI data and (i) neuropsychological results (ii) HIV infection characteristics. A linear discriminant analysis (LDA) based on MRI data was performed between MND+ and MND- patients and cross-validated with a leave-one-out test. RESULTS Our data revealed loss of structural integrity and micro-oedema in MND+ compared to HC in the global white and cortical gray matter, as well as in the thalamus and basal ganglia. Multiple regression analysis showed a significant influence of sub-cortical nuclei alterations on the executive index of MND+ patients (p = 0.04 he and R² = 95.2). The LDA distinguished MND+ and MND- patients with a classification quality of 73% after cross-validation. CONCLUSION Our study shows micro-structural brain tissue alterations in MND+ patients under effective therapy and suggests that multi-contrast MRI at high field is a powerful approach to discriminate between HIV+ patients on cART with and without mild neurocognitive deficits.
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Affiliation(s)
- Cristina Granziera
- Department of Clinical Neurosciences, Neuroimmunology Unit, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Vaud, Switzerland
- Department of Clinical Neurosciences, Laboratoire de Recherche En Neuroimagerie (LREN), Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Vaud, Switzerland
- Advanced Clinical Imaging Technology, Centre d’imagerie biomédical, École Polytechnique Fédérale de Lausanne, Lausanne, Vaud, Switzerland
- * E-mail:
| | - Alessandro Daducci
- Advanced Clinical Imaging Technology, Centre d’imagerie biomédical, École Polytechnique Fédérale de Lausanne, Lausanne, Vaud, Switzerland
- Signal Processing Laboratory (LTS5), École Polytechnique Fédérale de Lausanne, Lausanne, Vaud, Switzerland
| | - Samanta Simioni
- Department of Clinical Neurosciences, Neuroimmunology Unit, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Vaud, Switzerland
| | - Matthias Cavassini
- Department of Infectious Diseases, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Vaud, Switzerland
| | - Alexis Roche
- Advanced Clinical Imaging Technology, Centre d’imagerie biomédical, École Polytechnique Fédérale de Lausanne, Lausanne, Vaud, Switzerland
| | - Djalel Meskaldji
- Signal Processing Laboratory (LTS5), École Polytechnique Fédérale de Lausanne, Lausanne, Vaud, Switzerland
| | - Tobias Kober
- Advanced Clinical Imaging Technology, Centre d’imagerie biomédical, École Polytechnique Fédérale de Lausanne, Lausanne, Vaud, Switzerland
| | - Melanie Metral
- Department of Clinical Neurosciences, Neuropsychology Unit, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Alexandra Calmy
- Department of Infectious diseases, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Gunther Helms
- MR-Forschung in der Neurologie und Psychiatrie, Georg-August-Universität Göttingen, Germany
| | - Bernard Hirschel
- Department of Infectious diseases, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - François Lazeyras
- Department of Radiology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Reto Meuli
- Department of Radiology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Vaud, Switzerland
| | - Gunnar Krueger
- Advanced Clinical Imaging Technology, Centre d’imagerie biomédical, École Polytechnique Fédérale de Lausanne, Lausanne, Vaud, Switzerland
- Healthcare, Siemens Schweiz AG, Renens, Vaud, Switzerland
| | - Renaud A. Du Pasquier
- Department of Clinical Neurosciences, Neuroimmunology Unit, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Vaud, Switzerland
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