Exploring Substance Use and HIV Treatment Factors Associated with Neurocognitive Impairment among People Living with HIV/AIDS

Comparing the brief Holistic Health for HIV (3H+) to the Holistic Health Recovery Program (HHRP+) among people with HIV and opioid use disorder: Results from a randomized, controlled non-inferiority trial

Few evidence-based interventions have been widely adopted in common clinical settings, particularly for opioid-dependent people with HIV (PWH) seeking drug treatment. We developed a brief evidence-based intervention, Holistic Health for HIV (3H+), specifically for ease of implementation and integration within drug treatment settings. In this study, we compared 3H+ to the gold standard, Holistic Health Recovery Program (HHRP+) using a non-inferiority trial. Between 2012 and 2017, 106 participants were randomly assigned to either the brief 3H+ intervention or the gold standard HHRP+. HIV treatment (ART adherence, viral suppression) and risk behaviors (sharing injection equipment, condom use) were compared between the two arms at baseline, end-of-intervention (EOI-12 weeks) and at follow-up (24 weeks). Average treatment effect was calculated based on the difference-in-difference (DID) estimator and a non-parametric bootstrap was used to assess non-inferiority. At the 12-week EOI point, 3H+ was found to be non-inferior to HHRP+ with respect to multiple outcomes: percent sharing syringes and needles (DID:1.4, 95%CI [-18.6,21.5], p<0.01) and attainment of high ART adherence (DID: 9.7, 95%CI: [-13.1, 32.2], p = 0.04). At the 24-week EOI point, 3H+ was found to be non-inferior to HHRP+ with respect to percent sharing syringes and needles (DID: 8.9, [-10.1, 28.30], p = 0.04) and attainment of viral suppression (DID: 18.9, 95% CI:[-7.1, 42.0], p = 0.01). For other indicators, such as consistent condom use, the hypothesis test for non-inferiority was inconclusive at the 12-week EOI (DID: -20.2, 95%CI [-48.9-10.7], p = 0.51). For HIV treatment as prevention to be effective, PWH need to achieve viral suppression. In the absence of this success, they must reduce HIV risk behaviors. The finding that 3H+ was non-inferior to HHRP+ suggests that brief behavioral interventions can be deployed in real world settings to help more efficiently achieve Ending the HIV Epidemic goals.

The Impact of Cannabis Use on Cognition in People with HIV: Evidence of Function-Dependent Effects and Mechanisms from Clinical and Preclinical Studies

PURPOSE OF REVIEW

Cannabis may have beneficial anti-inflammatory effects in people with HIV (PWH); however, given this population's high burden of persisting neurocognitive impairment (NCI), clinicians are concerned they may be particularly vulnerable to the deleterious effects of cannabis on cognition. Here, we present a systematic scoping review of clinical and preclinical studies evaluating the effects of cannabinoid exposure on cognition in HIV.

RECENT FINDINGS

Results revealed little evidence to support a harmful impact of cannabis use on cognition in HIV, with few eligible preclinical data existing. Furthermore, the beneficial/harmful effects of cannabis use observed on cognition were function-dependent and confounded by several factors (e.g., age, frequency of use). Results are discussed alongside potential mechanisms of cannabis effects on cognition in HIV (e.g., anti-inflammatory), and considerations are outlined for screening PWH that may benefit from cannabis interventions. We further highlight the value of accelerating research discoveries in this area by utilizing translatable cross-species tasks to facilitate comparisons across human and animal work.

Neurocognitive Impairment and Associated Factors Among People Living with HIV: A Systematic Review and Meta-Analysis of African Studies

Background

Neurocognitive impairment (NCI) is one of the most common neurological complications in HIV-positive individuals, particularly in resource-limited countries. Neurocognitive impairments can occur at any stage of HIV infection, although the risk increases as the infection progresses. However, in Africa, there are few studies with highly variable and inconsistent results. Therefore, this study aimed to determine the prevalence and factors associated with NCI among HIV-positive people in Africa.

Methods

For this systematic review and meta-analysis, we used PubMed/Medline, Scopus, Web of Science, the Cochrane Library, Embase, and PsycINFO to comprehensively search a number of papers. Studies reporting the prevalence of NCI and its factors were included in the estimation of the pooled prevalence. A consistent data extraction format was created in Microsoft Excel to extract the data, which was then imported into STATA 11 statistical software for analysis. The heterogeneity was evaluated using the I2 test, and a random effect meta-analysis model was employed to calculate the pooled prevalence of NCI because the included studies showed significant heterogeneity.

Results

In all, Africa had a pooled prevalence of NCI of 45.15% (95% CI: 36.86, 53.43). According to the subgroup analysis of this study, West Africa had the lowest frequency, at 42.40% (95% CI: 22.03, 62.77), whereas Central and South Africa had the highest prevalence, at 49.33% (95% CI: 10.72-87.95).

Conclusion

In Africa, the cumulative prevalence of NCI was high. Being a woman, not having a formal education, those with only an elementary education, being older, having late-stage HIV, and abusing drugs were all often associated with NCI. The average burden of NCI in Africa is high and that would be a significant figure for interventional actions in the area.

A systematic review and meta-analysis of HIV associated neurocognitive disorders (HAND) among people with HIV in Ethiopia

Background

Ethiopia, being in the Sub Saharan region of Africa, is one of the countries with a substantial burden of HIV infection. Because of the high burden of HIV and poor health care settings, HAND is prevalent as demonstrated in various cross-sectional studies. However, no review has been conducted to report the consolidated magnitude of HAND among people with HIV in Ethiopia. Therefore, this systematic review and meta-analysis aimed to estimate the prevalence of HAND in Ethiopia.

Methods

Following the PRISMA guidelines, we systematically reviewed and meta-analyzed studies that investigated the prevalence of HAND in Ethiopia from PubMed, Google Scholar, Science Direct, HINARI, EMBASE, and Cochrane library databases. We also looked at the reference lists of the included studies to include other relevant studies. Subgroup analysis was performed based on publication year, study location, and sample size. Heterogeneity across studies was evaluated using the I2 test. Potential publication bias was assessed using Egger’s test and visual inspection of symmetry in the funnel plots.

Results

In the present meta-analysis, 627 articles were initially identified and evaluated. Of these, 8 studies that met the inclusion criteria were included in the final analysis. The pooled prevalence of HAND in people with HIV in Ethiopia was 39.15% (95% CI 29.36, 48.94). The highest prevalence observed in the Southern Nations, Nationalities, and Peoples’ Region (SNNPR) with 53.20% (95% CI 25.96, 80.44) followed by others 34.87% (Tigray, Addis Ababa, and Oromia) (95% CI 33.49, 36.24) and Amhara 34.07% (95% CI 25.39, 42.74).The funnel plot was asymmetrical. However, Egger’s regression tests provided no evidence of publication bias in the prevalence of HAND.

Conclusion

In this meta-analysis, the pooled prevalence of HAND, in Ethiopia, was high. Older age, substance use, advanced stages of the disease, and lack of education were the main determinants of HAND in Ethiopia. Health education, early screening of people with HIV, and training of health professionals working in hospitals on HAND are highly recommended.

Development of a Nomogram-Based Tool to Predict Neurocognitive Impairment Among HIV-positive Charter Participants

Background:

Despite the widespread use of combination antiretroviral therapy (cART), HIV-associated neurocognitive impairment (NCI) persists in people living with HIV (PLWH). Studies have generated inconsistent results regarding etiological factors for NCI in PLWH. Furthermore, a user-friendly and readily available predictive tool is desirable in clinical practice to screen PLWH for NCI.

Objective:

This study aimed to identify factors associated with NCI using a large and diverse sample of PLWH and build a nomogram based on demographic, clinical, and behavioral variables.

Methods:

We performed Bayesian network analysis using a supervised learning technique with the Markov Blanket (MB) algorithm. Logistic regression was also conducted to obtain the adjusted regression coefficients to construct the nomogram.

Results:

Among 1,307 participants, 21.6% were neurocognitively impaired. During the MB analysis, age provided the highest amount of mutual information (0.0333). Logistic regression also showed that old age (>50 vs. ≤50 years) had the strongest association (OR=2.77, 95% CI=1.99-3.85) with NCI. The highest possible points on the nomogram were 626, translated to a nomogram-predicted probability of NCI to be approximately 0.95. The receiver operating characteristic (ROC) curve's concordance index was 0.75, and the nomogram's calibration plot exhibited an excellent agreement between observed and predicted probabilities.

Conclusion:

The nomogram used variables that can be easily measured in clinical settings and, thus, easy to implement within a clinic or web-interface platform. The nomogram may help clinicians screen for patients with a high probability of having NCI and thus needing a comprehensive neurocognitive assessment for early diagnosis and appropriate management.

Neuroimaging and Cognitive Evidence for Combined HIV-Alcohol Effects on the Central Nervous System: A Review

Alcohol use disorder (AUD) among people living with HIV (PLWH) is a significant public health concern. Despite the advent of effective antiretroviral therapy, up to 50% of PLWH still experience worsened neurocognition, which comorbid AUD exacerbates. We report converging lines of neuroimaging and neuropsychological evidence linking comorbid HIV/AUD to dysfunction in brain regions linked to executive function, learning and memory, processing speed, and motor control, and consequently to impairment in daily life. The brain shrinkage, functional network alterations, and brain metabolite disruption seen in individuals with HIV/AUD have been attributed to several interacting pathways: viral proteins and EtOH are directly neurotoxic and exacerbate each other's neurotoxic effects; EtOH reduces antiretroviral adherence and increases viral replication; AUD and HIV both increase gut microbial translocation, promoting systemic inflammation and HIV transport into the brain by immune cells; and HIV may compound alcohol's damaging effects on the liver, further increasing inflammation. We additionally review the neurocognitive effects of aging, Hepatitis C coinfection, obesity, and cardiovascular disease, tobacco use, and nutritional deficiencies, all of which have been shown to compound cognitive changes in HIV, AUD, and in their comorbidity. Finally, we examine emerging questions in HIV/AUD research, including genetic and cognitive protective factors, the role of binge drinking in HIV/AUD-linked cognitive decline, and whether neurocognitive and brain functions normalize after drinking cessation.

Prevalence and Predictors of Neurocognitive Impairment in Ethiopian Population Living with HIV

BACKGROUND

Modern antiretroviral therapy has extended the life expectancies of people living with HIV; however, the prevention and treatment of their associated neurocognitive decline have remained a challenge. Consequently, it is desirable to investigate the prevalence and predictors of neurocognitive impairment to help in targeted screening and disease prevention.

MATERIALS AND METHODS

Two hundred and forty-four people living with HIV were interviewed in a study using a cross-sectional design and the International HIV Dementia Scale (IHDS). Additionally, the sociodemographic, clinical, and psychosocial characteristics of the patients were recorded. Chi-square and binary logistic regression analysis were used to determine the level of significance among the independent risk factors and probable neurocognitive impairment.

RESULTS

The point prevalence of neurocognitive impairment was found to be 39.3%. Participants' characteristics of being older than 40 years (AOR= 2.81 (95% CI; 1.11-7.15)), having a history of recreational drug use (AOR= 13.67 (95% CI; 6.42-29.13)), and being non-compliant with prescribed medications (AOR= 2.99 (95% CI; 1.01-8.87)) were independent risk factors for neurocognitive impairment.

CONCLUSION

The identification of predictors, in the Ethiopian people living with HIV, may help in the targeted screening of vulnerable groups during cART follow-up visits. This may greatly help in strategizing and implementation of the prevention program, more so, because (i) HIV-associated neurocognitive impairment is an asymptomatic condition for considerable durations, and (ii) clinical trials on neurocognitive impairment therapies have been unsuccessful.

Rationale and design of an integrated bio-behavioral approach to improve adherence to pre-exposure prophylaxis and HIV risk reduction among opioid-dependent people who use drugs: The CHRP-BB study

BACKGROUND

Few primary HIV prevention strategies have successfully integrated both behavioral and biomedical components, with modest HIV risk reduction outcomes among opioid-dependent people who use drugs (PWUD). In response to this unmet need, we developed a brief, bio-behavioral intervention to simultaneously promote PrEP adherence and reduce HIV risk among opioid-dependent PWUD.

METHODS

Using a Hybrid Type I implementation science design, we will examine the efficacy of the integrated bio-behavioral, Community-friendly Health Recovery Program (CHRP-BB) compared to a time-and-attention matched control condition among HIV-negative, opioid-dependent PWUD who are prescribed PrEP and enrolled in a methadone maintenance program (MMP) using a randomized controlled trial (RCT). Participants are assessed at baseline, immediately post-intervention (8 weeks) and follow-ups at weeks 20, 32, and 44 post-intervention. The primary outcome is biomedical (PrEP adherence), with secondary outcomes including behavioral (self-reported drug- and sex-related HIV risk behaviors), ongoing drug use (confirmed with urine drug testing), and related domains of the theoretical information-motivation-behavioral skills (IMB) model of behavior change related to PrEP adherence and HIV-transmission-risk reduction. Additionally, we will conduct a process evaluation of delivery/implementation of the intervention to collect valuable information to be used in future implementation.

CONCLUSIONS

This study will be among the first prospective trial to test an integrated bio-behavioral intervention to improve adherence to PrEP and HIV risk reduction among opioid-dependent PWUD.

Vitamin D deficiency is associated with neurocognitive impairment in HIV-infected subjects

PURPOSE

Low vitamin D levels are associated with higher odds of cognitive dysfunction in the older population, and in subjects with mental disorders or with chronic neurologic diseases. With combination antiretroviral therapy (cART), incidence of HIV-associated dementia has reduced, while the prevalence of milder forms of neurocognitive impairment (NCI) persisted stable over time. Hypovitaminosis D is often found in HIV infection but its association with NCI has not been investigated yet. The aim was to explore this association in a clinic-based HIV-positive population.

METHODS

A retrospective, cross-sectional analysis of an existing monocenter dataset obtained from patients undergoing neuropsychological assessment in routine clinical care between January, 2011 and December, 2016 was carried out. NCI was assessed through a standardized battery of 13 tests on 5 different cognitive domains and HIV-associated neurocognitive deficit (HAND) was classified according to Frascati's criteria. Vitamin D deficiency was defined by 25 hydroxy-vitamin D 25(OH)D levels < 10 ng/mL. Logistic regression was adjusted for main associated covariates and seasonality.

RESULTS

542 patients were included: 96.7% were receiving cART, median CD4 count was 611/mmc (IQR, 421-809), HIV RNA was < 40 cp/mL in 85.8%. Median 25(OH)D was 23.2 ng/mL (IQR, 15.6-29.2), with vitamin D insufficiency 67.7% and deficiency in 9.4%. Overall, NCI was found in 37.1% and HAND in 22.7%. Compared to patients with higher vitamin D levels, subjects with vitamin D deficiency had increased proportions of NCI (52.9% versus 35.4%; p = 0.014) or of HAND (42.9% versus 24.9%; p = 0.012). Median NPZ-8 scores were significantly different based on vitamin D levels (p = 0.021). At multivariable analyses, vitamin D deficiency was the only risk factor of NCI (OR 2.05; 95% CI 1.04-4.05; p = 0.038) or of HAND (OR 2.12; 95% CI 0.99-4.54; p = 0.052).

CONCLUSIONS

In HIV-positive persons, severe hypovitaminosis D was independently associated with a higher risk of neurocognitive impairment in general, and of HIV-associated neurocognitive disorders in particular. Future studies are needed to elucidate causal relationship and whether vitamin D supplementation may reverse this risk.

Prevalence of Cognitive Impairment and Its Predictors among HIV/AIDS Patients on Antiretroviral Therapy in Jimma University Medical Center, Southwest Ethiopia

Background

Cognitive impairment among human immunodeficiency virus (HIV) infected patients can lead to treatment nonadherence, faster progression of the illness, disability, and bed ridden state if we fail to detect it early. However, there is scarcity of previous published studies in Ethiopia on the assessment of cognitive impairment among HIV-positive patients. Hence, this study aimed to determine the prevalence and associated factors of cognitive impairment among HIV-positive patients receiving antiretroviral therapy (ART) at Jimma University Medical Center, Ethiopia.

Methods

Hospital-based cross-sectional study was conducted among 328 HIV-positive patients attending Jimma University Medical Center, Ethiopia. Data were collected from a face-to-face interview and review of medical records using semistructured questionnaire. Validated International HIV Dementia Scale (IHDS) was used to screen for cognitive impairment. Data was analyzed using SPSS version 20.

Results

A total of 328 (191 females and 137 males) HIV-positive patients were included in the study with a response rate of 97.04%. The prevalence of cognitive impairment among HIV-positive patients was 35.7%. Factors significantly associated with cognitive impairment were age group of 41-64 years (adjusted odds ratio [AOR] = 3.1, 95% confidence interval [CI] (1.3, 7.4)], plasma HIV-1 RNA load between 1.7log10 and 3log10 copies/ml [AOR = 2.2, 95% CI (1.1,4.3)] and ≥ 3log10 copies/ml [AOR = 7.5, 95% CI (2.6, 21.5)], khat chewing [AOR = 4.4, 95% CI (2.3, 8.3)], and clinical stage III of the disease [AOR = 5.6, 95% CI (1.7, 19.2)].

Conclusion

Despite the use of ART, the burden of cognitive impairment among HIV patients was high. Older age, khat chewing, advanced stage of the disease, and higher viral load were the independent factors associated with cognitive impairment. Thus, continuous screening of cognitive impairment, identification of the possible risk factors, and proper management strategy should be designed.

Depression, lifestyle factors and cognitive function in people living with HIV and comparable HIV-negative controls

Objectives

We investigated whether differences in cognitive performance between people living with HIV (PLWH) and comparable HIV‐negative people were mediated or moderated by depressive symptoms and lifestyle factors.

Methods

A cross‐sectional study of 637 ‘older’ PLWH aged ≥ 50 years, 340 ‘younger’ PLWH aged < 50 years and 276 demographically matched HIV‐negative controls aged ≥ 50 years enrolled in the Pharmacokinetic and Clinical Observations in People over Fifty (POPPY) study was performed. Cognitive function was assessed using a computerized battery (CogState). Scores were standardized into Z‐scores [mean = 0; standard deviation (SD) = 1] and averaged to obtain a global Z‐score. Depressive symptoms were evaluated via the Patient Health Questionnaire (PHQ‐9). Differences between the three groups and the effects of depression, sociodemographic factors and lifestyle factors on cognitive performance were evaluated using median regression. All analyses accounted for age, gender, ethnicity and level of education.

Results

After adjustment for sociodemographic factors, older and younger PLWH had poorer overall cognitive scores than older HIV‐negative controls (P < 0.001 and P = 0.006, respectively). Moderate or severe depressive symptoms were more prevalent in both older (27%; P < 0.001) and younger (21%; P < 0.001) PLWH compared with controls (8%). Depressive symptoms (P < 0.001) and use of hashish (P = 0.01) were associated with lower cognitive function; alcohol consumption (P = 0.02) was associated with better cognitive scores. After further adjustment for these factors, the difference between older PLWH and HIV‐negative controls was no longer significant (P = 0.08), while that between younger PLWH and older HIV‐negative controls remained significant (P = 0.01).

Conclusions

Poorer cognitive performances in PLWH compared with HIV‐negative individuals were, in part, mediated by the greater prevalence of depressive symptoms and recreational drug use reported by PLWH.

Examining the Acceptability of mHealth Technology in HIV Prevention Among High-Risk Drug Users in Treatment

Despite promising trends of the efficacy of mobile health (mHealth) based strategies to a broad range of health conditions, very few if any studies have been done in terms of the examining the use of mHealth in HIV prevention efforts among people who use drugs in treatment. Thus, the goal of this study was to gain insight into the real-world acceptance of mHealth approaches among high-risk people who use drugs in treatment. A convenience sample of 400 HIV-negative drug users, who reported drug- and/or sex-related risk behaviors, were recruited from a methadone clinic in New Haven, Connecticut. Participants completed standardized assessments of drug- and sex-related risk behaviors, neurocognitive impairment (NCI), and measures of communication technology access and utilization, and mHealth acceptance. We found a high prevalence of current ownership and use of mobile technologies, such as cell phone (91.5%) including smartphone (63.5%). Participants used mobile technologies to communicate mostly through phone calls (M = 4.25, SD = 1.24), followed by text messages (M = 4.21, SD = 1.29). Participants expressed interest in using mHealth for medication reminders (72.3%), receive information about HIV (65.8%), and to assess drug-related (72.3%) and sex-related behaviors (64.8%). Furthermore, participants who were neurocognitively impaired were more likely to use cell phone without internet and show considerable interest in using mHealth as compared to those without NCI. The findings from this study provide empirical evidence that mHealth-based programs, specifically cell phone text messaging-based health programs, may be acceptable to this high-risk population.

Developing an Integrated, Brief Biobehavioral HIV Prevention Intervention for High-Risk Drug Users in Treatment: The Process and Outcome of Formative Research

To date, HIV prevention efforts have largely relied on singular strategies (e.g., behavioral or biomedical approaches alone) with modest HIV risk-reduction outcomes for people who use drugs (PWUD), many of whom experience a wide range of neurocognitive impairments (NCI). We report on the process and outcome of our formative research aimed at developing an integrated biobehavioral approach that incorporates innovative strategies to address the HIV prevention and cognitive needs of high-risk PWUD in drug treatment. Our formative work involved first adapting an evidence-based behavioral intervention-guided by the Assessment-Decision-Administration-Production-Topical experts-Integration-Training-Testing model-and then combining the behavioral intervention with an evidence-based biomedical intervention for implementation among the target population. This process involved eliciting data through structured focus groups (FGs) with key stakeholders-members of the target population (n = 20) and treatment providers (n = 10). Analysis of FG data followed a thematic analysis approach utilizing several qualitative data analysis techniques, including inductive analysis and cross-case analysis. Based on all information, we integrated the adapted community-friendly health recovery program-a brief evidence-based HIV prevention behavioral intervention-with the evidence-based biomedical component [i.e., preexposure prophylaxis (PrEP)], an approach that incorporates innovative strategies to accommodate individuals with NCI. This combination approach-now called the biobehavioral community-friendly health recovery program-is designed to address HIV-related risk behaviors and PrEP uptake and adherence as experienced by many PWUD in treatment. This study provides a complete example of the process of selecting, adapting, and integrating the evidence-based interventions-taking into account both empirical evidence and input from target population members and target organization stakeholders. The resultant brief evidence-based biobehavioral approach could significantly advance primary prevention science by cost-effectively optimizing PrEP adherence and HIV risk reduction within common drug treatment settings.

Correlates of willingness to initiate pre-exposure prophylaxis and anticipation of practicing safer drug- and sex-related behaviors among high-risk drug users on methadone treatment

BACKGROUND

Although people who use drugs (PWUD) are key populations recommended to receive pre-exposure prophylaxis (PrEP) to prevent HIV, few data are available to guide PrEP delivery in this underserved group. We therefore examined the willingness to initiate PrEP and the anticipation of HIV risk reduction while on PrEP among high-risk PWUD.

METHODS

In a cross-sectional study of 400 HIV-negative, opioid dependent persons enrolled in a methadone program and reporting recent risk behaviors, we examined independent correlates of being willing to initiate PrEP.

RESULTS

While only 72 (18%) were aware of PrEP, after being given a description of it, 251 (62.7%) were willing to initiate PrEP. This outcome was associated with having neurocognitive impairment (aOR=3.184, p=0.004) and higher perceived HIV risk (aOR=8.044, p<0.001). Among those willing to initiate PrEP, only 12.5% and 28.2%, respectively, indicated that they would always use condoms and not share injection equipment while on PrEP. Consistent condom use was associated with higher income (aOR=8.315, p=0.016), always using condoms with casual partners (aOR=6.597, p=0.001), and inversely associated with ongoing drug injection (aOR=0.323, p=0.027). Consistent safe injection, however, was inversely associated with age (aOR=0.948, p=0.035), ongoing drug injection (aOR=0.342, p<0.001), and perceived HIV risk (aOR=0.191, p=0.019).

CONCLUSIONS

While willingness to initiate PrEP was high and correlated with being at elevated risk for HIV, anticipated higher risk behaviors in this group even while on PrEP suggests that the next generation of HIV prevention approaches may need to combine biomedical and behavioral components to sustain HIV risk reduction over time.

Treatment Engagement Moderates the Effect of Neurocognitive Impairment on Antiretroviral Therapy Adherence in HIV-Infected Drug Users in Treatment

Neurocognitive impairment (NCI) and treatment engagement (TE) have been shown to significantly predict antiretroviral therapy (ART) adherence, but no studies have explored the ways and the extent to which similar outcomes might occur when these factors operate together, particularly for people who use drugs (PWUDs). We sought to discover whether TE moderated the effect of NCI on adherence to ART in HIV-infected individuals. One hundred sixteen HIV-infected, methadone-maintained people who reported HIV risk behaviors were enrolled in the study. Variables of interest (NCI, ART adherence, TE) were assessed using audio computer-assisted self-interview. Results revealed a significant interactive effect of NCI and TE on ART adherence, which supported the moderation effect. Findings from post hoc analyses showed that NCI was negatively associated with adherence to ART at low levels of TE. Findings suggest the need to accommodate individual NCI and improve TE as a means to enhance ART adherence in HIV-infected PWUDs.

Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions

Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.

Getting into the brain: Potential of nanotechnology in the management of NeuroAIDS

In spite of significant advances in antiretroviral (ARV) therapy, the elimination of human immunodeficiency virus (HIV) reservoirs from the periphery and the central nervous system (CNS) remains a formidable task. The incapability of ARV to go across the blood-brain barrier (BBB) after systemic administration makes the brain one of the dominant HIV reservoirs. Thus, screening, monitoring, and elimination of HIV reservoirs from the brain remain a clinically daunting and key task. The practice and investigation of nanomedicine possesses potentials for therapeutics against neuroAIDS. This review highlights the advancements in nanoscience and nanotechnology to design and develop specific size therapeutic cargo for efficient navigation across BBB so as to recognize and eradicate HIV brain reservoirs. Different navigation and drug release strategies, their biocompatibility and efficacy with related challenges and future prospects are also discussed. This review would be an excellent platform to understand nano-enable multidisciplinary research to formulate efficient nanomedicine for the management of neuroAIDS.

Modeling a Theory-Based Approach to Examine the Influence of Neurocognitive Impairment on HIV Risk Reduction Behaviors Among Drug Users in Treatment

Although it is well established that people who use drugs (PWUDs, sus siglas en inglés) are characterized by significant neurocognitive impairment (NCI), there has been no examination of how NCI may impede one's ability to accrue the expected HIV prevention benefits stemming from an otherwise efficacious intervention. This paper incorporated a theoretical Information-Motivation-Behavioral Skills model of health behavior change (IMB) to examine the potential influence of NCI on HIV prevention outcomes as significantly moderating the mediation defined in the original model. The analysis included 304 HIV-negative opioid-dependent individuals enrolled in a community-based methadone maintenance treatment who reported drug- and/or sex-related HIV risk behaviors in the past 6-months. Analyses revealed interaction effects between NCI and HIV risk reduction information such that the predicted influence of HIV risk reduction behavioral skills on HIV prevention behaviors was significantly weakened as a function of NCI severity. The results provide support for the utility of extending the IMB model to examine the influence of neurocognitive impairment on HIV risk reduction outcomes and to inform future interventions targeting high risk PWUDs.