Journal Article Annotations
2023, 2nd Quarter
Annotations by John A R Grimaldi MD, Mary Ann Cohen MD, FAPM, Kelly Cozza MD, DFAPA, FACLP and Luis Pereira MD
July, 2023
Findings:
Medicaid claims records drawn from a large, national, longitudinal cohort were used to examine HIV testing rates among patients with schizophrenia compared to a frequency-matched control group. Over the 10-year study period (2002-2012), overall HIV testing rates doubled nationally, from 3.8% – 7.5%, with testing rates consistently higher in the schizophrenia group, compared to the control group. There was an upward trend in HIV testing rates following the 2016 CDC recommendation for expanded testing. This trend was more prominent in the control group than in the schizophrenia group. As expected, among the schizophrenia group, testing rates were highest among individuals with comorbid drug use, and certain medical conditions such as HCV, HSV, and syphilis. Having at least one annual nonpsychiatric outpatient medical visit, or, comorbid STI, tripled the likelihood HIV testing. Among individuals with no substance use disorder or STIs, HIV testing rates were lower in the schizophrenia group compared to the control group. Interestingly, among the schizophrenia group, only one HIV test was performed in a community mental health center in 2002 and none in 2012.
Strengths and limitations:
The use of a large, national, cohort of Medicaid enrollees with schizophrenia ensured a representative sample that was sufficiently powered to examine state-level geographic differences and individual-level demographic characteristics that may influence HIV testing. The study’s longitudinal design allowed identification of national growth patterns during a time when government issued testing recommendations were changing. This study fills a significant gap in research about HIV testing in people with schizophrenia. The data is greater than 10 years old which limits its applicability to current situations and does not reflect contemporary testing practices. For some states, billing data is excluded for behavioral health carveouts and does not include managed care plans which may result in missing data. Additionally, the data was limited to Medicaid-only enrollees and relied on clinician assessment for diagnosis of schizophrenia.
Relevance:
Patients with schizophrenia have elevated prevalence rates for HIV infection and have increased risk factors for acquiring HIV, compared to the general population. Findings in this study have major policy implications for Medicaid and public mental health authorities. Patients with schizophrenia who have co-occurring medical conditions or other HIV risk factors such as STIs and substance use have not benefitted from expanded HIV testing guidelines compared to matched patients who do not have schizophrenia. The additional finding that HIV testing occurring in community mental health setting was minimal, suggests that a targeted approach to this vulnerable population is needed to improve HIV testing rates. Development of interventions to improve HIV testing rates in mental health settings and integration of mental health services in primary care are needed. Future HIV testing guidelines should consider inclusion of people with serious mental illness as a population at risk. Guidelines for treatment of people with serious mental illness should consider including HIV testing along with metabolic monitoring.
Findings:
Data from neurocognitive and neuromedical examinations in the CNS HIV Antiretroviral Therapy Effects Research (CHARTER) program, over a 12-year period, were analysed to determine the effect of HIV on neurocognitive decline, and whether decline could be accounted for by age, comorbid neuromedical conditions, such as cardiovascular disease, and psychiatric conditions, such as depression and substance use. The cohort was divided into younger (<60) and older (>60) age groups for comparison. In both cohorts, neurocognitive decline was greater than would be expected based on typical aging. Contrary to expectations, the younger and older subgroups did not differ in degree of neurocognitive decline over the 12-year follow-up, and decline was not significantly related to age. Medical management of HIV disease was generally adequate without a between age-group difference. Also contrary to expectations, there was no significant difference between subgroups in the observed increase in neuromedical comorbidities at follow-up. The following conditions were found to predict worse neurocognitive decline: cardiovascular risk factors (hypertension and diabetes), pulmonary disease, neuropathic pain, frailty, liver disease, depression, substance use disorders.
Strengths and limitations:
The strengths of this study include the use of data from a large, ongoing, cohort of people with HIV. Its longitudinal design permitted comparison of data and detection of change over time. The study used standardized measures of neurocognitive functioning, HIV clinical parameters and other variables such as depression and substance use. The study’s lack of a control group of people without HIV limits concluding that the comorbidity findings are specific to HIV. Information about deaths is lacking which may introduce survivor bias. The 12-year separation of data points provides no information about when medical comorbidities first appeared, their course of illness or treatment course. Information about lifestyle factors, economic status, and access and use of healthcare is lacking which may have influenced medical and neurocognitive outcomes.
Relevance:
Improvements in HIV treatment and declining morbidity and mortality have resulted in expansion of proportion of older people living with HIV. Increased longevity in people with HIV has created a growing need to understand the effect of HIV on normal brain aging and its relationship to age-related disorders, specifically neurodegenerative disorders, and other comorbidities such as cardiovascular disease, diabetes, and hypertension. Better understanding the relationship between HIV CNS involvement and psychiatric illness is also important given the higher than expected prevalence of HIV in people with psychiatric disorders, specifically depression and substance use disorders. Existing studies of neurocognitive decline and ageing in people with HIV are inconclusive whether and to what extent HIV contributes to neurocognitive impairment. This study’s long-term design and consideration of other neuromedical and psychiatric conditions provides a perspective that has been missing in other related research. The study provides insight into reasons for the unchanging high prevalence of HIV-associated neurocognitive impairment in the setting of good HIV virologic control. The study also suggests interventions for preventing neurocognitive decline in people with HIV.
Findings:
This longitudinal cohort study of older adults living with HIV described cannabis user profiles and the effect of current cannabis use on cognitive and everyday functioning. Frequent cannabis was defined as greater than weekly use and occasional use was defined as equal to or less than weekly use. 7.7% of the cohort reported frequent cannabis use while 28.0% reported occasional use. Those participants with THC+ urine toxicology at the time of study visit had worse global cognitive performance (GCP) compared to participants with THC-negative urine at time of study visit. Both occasional and frequent cannabis users had better GCP when compared to cannabis non-users. However, when adjusted for covariables such as HIV characteristics, occasional users still preformed better than cannabis non-users, whereas global cognition was not better for frequent users compared to non-users. There was no significant difference in rate of cognitive decline among the cannabis use groups, in both adjusted and unadjusted analyses. The better global cognitive performance in the occasional use group, compared to the cannabis non-use group, was driven primarily by the domains of attention, learning and verbal fluency. Neither frequent nor occasional cannabis use predicted level of functional status, IADL decline or self-reported cognitive difficulties. There was no association between days of cannabis use in the past month and level of functional status and IADL decline at each study visit. Findings suggest that cannabis use in the ranges observed in this cohort, was not a risk factor for early cognitive decline in any neuropsychological domain.
Strengths and limitations:
The study’s major strength was its analyses of both average between-person and short-term within-person effects of cannabis use on overall cognition, cognitive decline, and visit-to-visit changes in cognitive performance. Results were adjusted for many variables known to affect cognition in people with HIV and correlates of cannabis use. Additionally, cannabis use measures relied on both self-report and urine drug screening, unlike previous similar, population-based studies which relied on self-report alone. This study also had several limitations: The observational design of the study does not permit assessment of causation. The lack of a control group of people without HIV precludes insight into the role that HIV plays in the effect of cannabis use on cognition and everyday functioning. The participants were predominantly male, White and middle-aged to older. Therefore, results may not generalize to more demographically diverse and older populations. The study lacked data on other factors known to affect cognition such as history of major surgeries and use of anesthesia, degree of alcohol and tobacco use, and potency, purpose and route of administration of cannabis use.
Relevance:
This study fills an important gap in our knowledge about cannabis use as a risk factor for cognitive decline in an older people living with HIV. It is the first study to explore longitudinal patterns of cannabis use and their relationships to cognitive functioning over time in an older HIV cohort. The need for future research in this area is highlighted by the ageing of the HIV population, the persistently high prevalence of HIV-associated neurocognitive disorders (HAND) despite adequate virologic control, and the absence of effective interventions to prevent the occurrence of and slow the progression of HAND. Legalization of recreational cannabis use and expanding medical use further support exploration of the risks and benefits of cannabis. Cannabis use is increasing in older adults faster than in any other age group and older adults are more likely to use medical marijuana compared to other age groups. In vitro and human studies demonstrating the beneficial effect of cannabis on HIV replication and peripheral and central inflammation lend further relevance to this study’s findings.