Journal Article Annotations
2021, 3rd Quarter

HIV Psychiatry

Annotations by John Grimaldi MD, Mary Ann Cohen MD, FAPM, Kelly Cozza MD, DFAPA, FACLP, and Luis Pereira MD
September, 2021

A systematic review of psychosocial interventions for older adults living with HIV.
The Relationship Between Social Support and Experienced and Internalized HIV-Related Stigma Among People Living with HIV in the Deep South.
Asymptomatic neurocognitive impairment is a risk for symptomatic decline over a 3-year study period.

PUBLICATION #1 — HIV Psychiatry

A systematic review of psychosocial interventions for older adults living with HIV.

Amir Bhochhibhoya, Sayward Harrison, Stephanie Yonce, Daniela B Friedman, Pragya Sharma Ghimire, Xiaoming Li

Abstract: AIDS Care. 2021 Aug;33(8):971-982. doi: 10.1080/09540121.2020.1856319. Epub 2020 Dec 10.

The rapidly growing segment of older adults living with HIV faces unique set of psychosocial challenges that may differ from their younger counterparts. The objective of this review is to systematically examine current published literature on interventions designed to improve the psychosocial wellbeing of older adults living with HIV. A pre-specified search strategy was applied to four databases: PubMed, CINAHL Plus with Text, PsycINFO, and Health Source. Authors reviewed published studies on psychosocial interventions for older adults with HIV and reported psychosocial variables as primary outcomes of the interventions. The final review included nine intervention studies. Psychosocial outcomes measured across multiple studies included depression, quality of life, social support, cognitive functioning, and coping skills. Some studies also measured physical activity, HIV-related discrimination, lack of affordable housing, and access to substance abuse treatment. Our study suggests a paucity of psychosocial intervention research on adults aging with HIV. This review suggests that most psychosocial interventions had small to moderate effects in improving the psychosocial wellbeing of older people living with HIV. Findings highlight the need for clinical, community, and home-based interventions to ensure that individuals can achieve a higher quality of life while aging with HIV.

Annotation

Findings:
An evidence-based search strategy was used to review published literature on psychosocial interventions designed to improve wellbeing of older adults living with HIV. Databases were limited to PubMed, CINAHL Plus with Full Text, PsycINFO, and Health Sources. Nine studies were identified that met review criteria. Outcome measures of the individual studies included depression, loneliness, self-efficacy, cognitive functioning, social support, emotional wellbeing, life stressor burden and quality of life. The article’s major finding was the paucity of studies examining psychosocial interventions in this population. Most studies demonstrated intervention effect for depression, stress, loneliness and cognitive functioning. Interestingly, teleconference technology and home-based interventions were common and suggest the feasibility of these modalities in overcoming treatment barriers such as lack of transportation and physical immobility. None of the studies examined approaches to preventing psychosocial problems.

Strengths and limitations:
This study’s major strength is its objective to understand the current state of psychosocial treatments for older adults, a group that represents a growing proportion of people living with HIV. It is the first systematic review of interventions that addresses psychosocial aspects of older individual living with HIV. This review is limited by the small convenience samples and brief follow-up periods used in individual studies. The study designs varied; only 5 out of the 9 studies utilized randomized, controlled design. There was also wide variation in the interventions among studies, outcome measures, and inclusion and exclusion criteria. The majority of studies used self-report instruments which are susceptible to bias and inaccurate results.

Relevance:
This study fills a significant gap in current knowledge about evidence-based approaches to psychosocial problems faced by an aging HIV population. Psychosocial factors may have significant effects, both positive and negative, along the entire HIV continuum of care. Additionally, HIV combined with older age create a set of problems unique to older individuals. For example, older individuals may experience “triple stigma” associated with HIV, age, and sexual and gender minority status. Also, depression may be more common in older individuals living with HIV. They are also more likely to be socially isolated and lonely. These psychosocial conditions, in contrast to structural factors such as educational and socioeconomic status, may offer more realistic opportunities to positively influence social determinants of health.

PUBLICATION #2 — HIV Psychiatry

The Relationship Between Social Support and Experienced and Internalized HIV-Related Stigma Among People Living with HIV in the Deep South.

Reif, S., Wilson, E., McAllaster, C., Pence, B., & Cooper, H. (2021).

Abstract: https://doi.org/10.1037/sah0000271

The Deep South has experienced disproportionately high HIV diagnosis and death rates compared to other U.S. regions. Stigma experiences and perceptions are particularly high among individuals living with HIV in the Deep South and are consistently associated with negative health outcomes including poorer medication adherence. This study included a survey of 201 individuals living with HIV in the Deep South and examined the relationship between social support and internalized stigma with a focus on individuals who had recent experiences of verbal HIV stigma related to HIV. Study participants were recruited from HIV medical care clinics and community-based organizations. Over one-third of study participants reported experiencing verbal stigma related to HIV in the last 3 months such as being “insulted” because of their HIV

status (25%). Internalized stigma, as measured by the HIV Stigma Scale, was also prevalent among study participants. Multivariate analyses identified that higher internalized stigma was predicted by recent verbal stigma experiences and social support was found to be a statistically significant modifier of the relationship of recent verbal stigma experiences and internalized stigma (p<.01). These findings emphasize the critical need for effective interventions that build and enhance social support and address internalized HIV-related stigma among individuals living with HIV in the U.S. Deep South.

Annotation

Findings:
This survey-based study of 201 people living with HIV in Alabama, Mississippi, North Carolina, and South Carolina examined the relationship between social support and internalized HIV-related stigma. Subjects were recruited from HIV medical settings and community-based organizations and were primarily African American and 53% female. Interestingly, 24% of subjects scored >9 on the PHQ-9 indicating probable depression. Over one-third of participants reported experiencing verbal stigma related to HIV in the past 3 months. A substantial minority responded affirmatively to survey items indicating internalized stigma. 36% of participants agreed with the statement, “I feel guilty because I have HIV,” and 56% disagreed with the statement, “I never feel ashamed of having HIV.” There was a statistically significant association between having experienced verbal stigma and having greater internalized stigma. Social supports had a statistically significant moderating effect on the association between experienced verbal stigma and internalized stigma. Those participants who experienced verbal stigma were less likely to demonstrate internalized stigma if they had greater social supports.

Strengths and limitations:
A major strength of this study is its recognition that the Southern United States has a unique history and culture that has a significant effect on the spread, prevention and public health aspects of HIV. It is one of the first studies of its kind to examine social support and stigma in the South. The study also focuses on internalized stigma whereas previous studies assessed perceived stigma alone. This study is limited by its small sample size and lack of generalizability to people living with HIV who are not receiving either medical care or are not connected to social service organizations. The study’s cross-sectional design limits its ability to predict the direction of associations between variables. For example, individuals with greater internalized stigma may avoid sources of social support.

Relevance:
The Southeastern (SE) region of the US has been disproportionately affected by HIV when compared to other regions. The SE region has higher rates of HIV diagnoses, prevalence, and HIV-related deaths, and lower rates of viral suppression and linkage to medical care following HIV diagnosis. Overall rates of receipt of medical care and pre-exposure prophylaxis uptake are also reduced. Among factors contributing to this discrepancy, HIV-related stigma is a modifiable target at the individual level, unlike structural racism, poverty and limited access to healthcare. Research has shown a link between stigma and adherence to antiretroviral medications, which is essential to better health outcomes and HIV prevention strategies. Ample research and clinical practice have identified social support as a critical element in promoting adaptation to HIV and good mental health. This study’s findings support the hypothesis that greater social support may mitigate the damaging effect of perceived stigma and development of internalized stigma. This study also supports allocation of resources to develop more effective models of enhancing social support that are tailored to meet the needs of specific subpopulations of people living with HIV.

PUBLICATION #3 — HIV Psychiatry

Asymptomatic neurocognitive impairment is a risk for symptomatic decline over a 3-year study period.

Rourke, Sean B.a,b; Bekele, Tsegayec; Rachlis, Anitad,e; Kovacs, Colinf; Brunetta, Jasonf; Gill, M. Johng,h; Carvalhal, Adrianab,i; Cysique, Lucette A.a,j,k; Marcotte, Thomasl,m; Power, Christopherg,n

Abstract: AIDS: doi 10.1097/QAD.0000000000002709

Objective:
To examine whether persons with asymptomatic neurocognitive impairment (ANI) were more likely to show progression to mild neurocognitive disorder or HIV-associated dementia than those who were neuropsychologically normal (NP-N).

Design:
Longitudinal observational cohort study.

Methods:
Study sample included 720 HIV-1 seropositive persons (317 with ANI and 403 NP-N) receiving care in Toronto, Canada [83% were on antiretroviral treatment; 71% had undetectable (<50 copies/ml) plasma HIVRNA]. Neuropsychological assessments were conducted at 12 months intervals for a median follow-up time of 34 months. Neuropsychological data were corrected for age, education, sex, and race/ethnicity, and corrected for practice effect at follow-ups. Progression to mild neurocognitive disorder and HIV-associated dementia at each time point was determined using the Global Deficit Score and presence of cognitive symptoms.

Results:
Over the follow-up period, 170 individuals (24%) progressed to symptomatic HIV-associated neurocognitive disorders (HAND). Persons with ANI were more likely to progress to symptomatic HAND than persons with NP-N after adjusting for baseline and time-varying confounders (adjusted hazards ratio: 1.88; 95% confidence interval: 1.37-2.60; P < 0.001). Female sex, depression, and cigarette smoking were associated with higher risk of progression to symptomatic HAND, but traditional HIV markers and antiretroviral treatment were not.

Conclusion:
ANI is associated with a two-fold increased risk of progression to symptomatic HAND in a cohort with universal healthcare access. This represents the largest replication of comparable US results. Reproducibility of these findings indicate that routine monitoring of persons with ANI and exploration of clinical interventions to prevent or delay progression to symptomatic HAND are imperative.

Annotation

Findings:
This longitudinal, observational cohort study of 720 HIV-1 seropositive persons, followed subjects for a median time of 34 months. Neuropsychological testing, obtained at baseline and at 12 months intervals, was used to classify participants into 4 categories: 1) neuropsychologically normal, 2) asymptomatic neurocognitive impairment (NCI), 3) mild neurocognitive disorder, and 4) HIV-associated dementia. 24% of subjects with asymptomatic neurocognitive impairment at baseline progressed to symptomatic neurocognitive disorder over the course of the study period. This proportion was two-fold greater than in the group that was neuropsychologically normal at baseline, a statistically significant difference. Cigarette smoking, female sex, and depression were significantly associated with progression to symptomatic neurocognitive disorder whereas CD4+ cell count and plasma HIV viral load were not.

Strengths and limitations:
The study utilized data from a large, ongoing, Canadian cohort study of individuals who had universal access to healthcare. Compared to similar studies, the sample had high rates of HIV viral suppression and antiretroviral coverage. The study sample was drawn from tertiary care HIV clinics in Canada, thus limiting generalizability to underresourced areas and areas with higher HIV prevalence. An abbreviated neuropsychological battery was used which may have performed less well than the gold standard of full neuropsychological testing. A self-report scale was used to detect cognitive symptoms and was subject to bias and inaccuracies. The study did not account for cardiovascular risk factors such as metabolic abnormalities, traumatic brain injury, and learning disabilities which may influence neurocognitive performance.

Relevance:
Although the overall prevalence of HIV-associated Neurocognitive Disorder (HAND) has remained stable over the course of the HIV epidemic, asymptomatic and mild symptomatic neurocognitive impairment (NCI) have increased to constitute the large majority of cases. Two US cohort studies demonstrated that having asymptomatic neurocognitive impairment increases the odds of progressing to symptomatic impairment. This study is the first study to replicate these previous findings. There is currently no generally accepted, standardized screening instrument to identify HIV-1 seropositive persons with mild neurocognitive impairment. The findings of this study support the urgent need to develop a reliable, bedside screening tool for asymptomatic and mild neurocognitive impairment. The lack of an association between HIV viral suppression and CD4+ cell count and progression to symptomatic NCI is intriguing. The positive association between development of symptomatic NCI and being female, depression, and smoking cigarettes raises interesting questions about the possible role of hormonal influences and mental health and stress-related factors in the neurophysiology underpinning the development of symptomatic NCI. These findings also reinforce the important role that psychiatry can play in the prevention and treatment of HAND.