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Neurobehavioral and Neuropsychiatric Aspects of HIV/AIDS: An Update

Neurobehavioral and Neuropsychiatric Aspects of HIV/AIDS: An Update. Eileen Martin, PhD Departments of Psychiatry and Neurology University of Illinois at Chicago Supported by HHS DA R01 12828 and DA R01 13800. Objectives.

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Neurobehavioral and Neuropsychiatric Aspects of HIV/AIDS: An Update

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  1. Neurobehavioral and Neuropsychiatric Aspects of HIV/AIDS:An Update Eileen Martin, PhD Departments of Psychiatry and Neurology University of Illinois at Chicago Supported by HHS DA R01 12828 and DA R01 13800

  2. Objectives • Review recent findings in psychiatric and neurocognitive aspects of HIV/AIDS • Impact of introduction of HAART on research and clinical questions • Changes in the face of the epidemic

  3. Cumulative US Reported AIDS Cases1997 9% 32% 49%

  4. 2005 US AIDS SurveillanceMales 8% 11% 59% 20%

  5. US AIDS Surveillance 2005Women 33% 65%

  6. Previous Questions • Dementia • Diagnosis • Prognostic indicators • Time to death

  7. New Questions • Vulnerability and Risk Factors • Critical outcomes • Aging • Multidisciplinary Perspective

  8. NeuroAIDS: Overview

  9. NeuroAIDS – General Comments • HIV has an affinity for the CNS • Neuropathology Highlights • Basal Ganglia – highest viral load • Cerebral White Matter • Prefrontal cortical neuron loss • Hippocampus

  10. Continuing problem in the era of HAART • No effective treatment for neuroAIDS • Interaction with age and other risks • Outcome variables have changed

  11. Caudate Amygdala * * * Hippocampus

  12. State of the Art 1988

  13. Abnormal Brain Activity Precedes Cognitive Problems

  14. Neurocognitive Effects of HIV

  15. Grant, 2005 HIV-associated cognitive impairment

  16. Criteria for HIV-related dementia • Marked acquired impairment in at least 2 ability domains (attention, memory, mental or motor speed) • Marked interference with daily functioning • Present for at least one month • Does not meet criteria for delirium • No evidence of a preexisting condition that could cause the cognitive deficits Grant & Atkinson, 1995

  17. McArthur et al., 1997

  18. Model Patient’s Copy Time: 14 minutes

  19. NeuroAIDS and Cognition • Mental/Motor Slowing • Impaired Attention • Episodic Memory • Executive Deficits

  20. Functional Consequences of NeuroAIDS

  21. Driving

  22. Standardized Work Samples Heaton et al, 1994

  23. Activities of Daily Living Heaton et al., 1994

  24. Employment * HIV+ NP normal HIV- HIV+ NP abnormal Women’s Interagency HIV Study – Chicago Consortium

  25. Medication Management Albert et al, 1999

  26. Comorbid Conditions

  27. Direct and Indirect Effects on Brain IDU IFN/RBV Depression

  28. Rates of NP Abnormality - HIV and HCVWomen’s Interagency HIV Study * * Richardson et al., AIDS, 2006

  29. Mental Processing is Slowerwith Coinfection * p < .05

  30. What are the Risk Factors for Cognitive Impairment Among HIV+ Persons? • Age • Education – “Cognitive Reserve” • Head Trauma • Antiretroviral Status

  31. Aging and HIV • Greater non-HIV dementia risk • Diabetes, Hypertension, etc • Menopause • Increased prevalence of depression • Vulnerable executive functions Increase from 1000 to 10000 in past decade Estimated 50% of all cases by 2015

  32. Youth and NP Issues • Brain development is incomplete • Increasing rates among minority youth • Higher propensity for risk taking • 45% are MSM • View AIDS as chronic but not deadly

  33. NP Performance of HIV+ Women and HIV-Controls - Women’s Interagency Study p < .01 HIV+ ARV HIV+ No ARV HIV- Richardson et al., JINS 2002

  34. And then there’s substance dependence

  35. Substance Dependence and HIVGeneral Points • Not All IDU, not all Illegal • Alcohol, Prescription Meds • Does Not Explain All HIV NP deficits • Does SD add to or interact with neuroAIDS?

  36. Perceived poor adherence risk by providers • Active alcohol abuse or IDU • Homelessness • Depression > 50% • History of IDU • History of alcohol abuse 21-49% • Mother of small children • Low education • Ethnic minority or low income 10-20%

  37. Methamphetamine • Synthetic CNS stimulant drug • 12.3 million (5.2%) Americans > 12 years old have tried it NSDUH, 2003 • Relatively easy to make

  38. Club Drugs • Controversy over MDMA neurotoxicity • Superseded by CM • Difficult to study - Polydrug use

  39. Working Memory Performance

  40. New Cognitive Topics:Decision-Making • Ability to Make Choices in the Present Leading to the Best Outcome in the Future • Orbitofrontal, ventromedial prefrontal cortex

  41. Decision-Making for Medical Students • Current Choices • Partying • Sleeping • Sex • Studying • Best Outcome in Future • GRADUATING

  42. The Iowa Gambling Task Bechara et al., 1997

  43. HIV+ Drug Users Make More Risky Decisions * p < .05 Martin et al., JINS, 2004

  44. Prospective Memory • “Remembering to remember” • Memory for a Future Action • Implications for Adherence

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