Neurocognitive considerations in older ethnically-diverse HIV-seropositive adults
By Caitlin Miranda, Armando Fuentes, and Monica Rivera Mindt
The number of older adults (i.e., ≥ 50 years of age) living with HIV has increased over recent years. This is due both to the longer life expectancies of adults already diagnosed with HIV and new diagnoses in older adults (CDC, 2008). In fact, adults over the age of 50 constituted 16 percent of all new HIV diagnoses in 2007 (CDC, 2007) and the percentage of older adults living with HIV/AIDS increased from 17 percent in 2001 to 24 percent in 2005 (CDC, 2008). Estimates suggest that this trend will continue (Effros et al. 2008) and will contribute to the “graying of HIV.”
Not only has the HIV/AIDS population aged overall, but this group is increasingly ethnically diverse. African Americans account for 46 percent of all HIV diagnoses among older adults (CDC, 2013). Among people 50 years or older in the United States, Latinas/os are five times as likely as their white counterparts to be living with HIV (CDC, 2008). Moreover, outside of the context of HIV, racial/ethnic minority populations also suffer significant health disparities, including higher rates of stroke, diabetes, obesity and hypertension (CDC, 2012; CDC, 2012) that may place them at elevated risk for HIV-related neurocognitive sequelae, particularly in the context of advanced age. Considering the rapid growth of this older, racially/ethnically diverse group, it is necessary to explore potential risk factors for neurocognitive impairment in adults aging with HIV.
Neurocognition remains an important health outcome for HIV-seropositive individuals. The development of combination antiretroviral therapy (cART) has vastly altered the face of HIV, turning a fatal illness into a “chronic disease requiring long-term medical management” (Ances & Ellis, 2007, p. 86). Despite the fact that many cART-treated patients achieve viral suppression of HIV replication and restored immune function, HIV-associated Neurocognitive Disorders (HAND) remain a significant problem for people living with HIV (Robertson et al., 2007). In one large-scale study, 44 percent of HIV-infected adults without severe comorbidities experienced neuropsychological impairment, a figure consistent with pre-cART estimates (Heaton et al., 2010). Older adults living with HIV may be at even higher risk for developing HAND (Cherner et al., 2004; Valcour, 2004).
As discussed in Hinkin and Thames’ (2013) recent Psychology and AIDS Exchange Newsletter article "Neurocognition in HIV-infected older adults", the neurocognitive effects of HIV are actually quite similar to the changes in cognition associated with normal aging. Both HIV and aging are risk factors for cognitive decline (Ciccarelli et al., 2012; Cysique, 2011; Scott, 2011; Valcour, 2011; Morgan, 2011). Specifically, HIV-positive older adults tend to perform more poorly across multiple neurocognitive domains (e.g., learning, memory, executive functions, motor speed) than their younger HIV-seropositive counterparts and are at elevated risk for meeting criteria for HAND (e.g., Scott, 2011; Sacktor, 2007; Wendelken and Valcour 2012; Valcour, 2004; Ciccarelli et al., 2012).
With increasing age, older adults are also at elevated risk for vascular disorders and degenerative disease, as well as immunological changes and expression of apolipoprotein E4 (APOE4), all of which may adversely impact neurocognitive functioning (Kilander, Nyman, Boberg, Hansson, & Lithell, 1998; See Hardy & Vance, 2009 for review). This is especially relevant for HIV-seropositive older adults as co-morbidities are common in this population (Goulet, et al. 2007). Neurocognitive impairment in HIV-infected older adults is an area of significant concern and one that becomes even more complex when addressing older racial/ethnic minority adults living with HIV who experience many other health disparities.
Once infected, racial/ethnic minority HIV-seropositive adults (i.e., Latinas/os, African Americans, etc.) carry greater disease burden compared to HIV-seropositive non-Hispanic white adults (Centers for Disease Control and Prevention, 2010; U.S. Census Bureau, 2008). For instance, beginning with diagnosis, Latinas/os tend to present for care later in the course of the disease as compared to non-Hispanic whites, with males and foreign-born persons at the greatest risk for late diagnosis (Chen 2013). Once diagnosed, racial/ethnic minority adults are less likely to receive immediate care for their HIV disease, less likely to receive the pharmacological standard of care (cART), and suffer from worse health outcomes than their HIV-seropositive non-Hispanic white counterparts, including higher mortality rates and younger age at death (Cargill & Stone, 2005; McGinnis et al., 2003; Morgello et al., 2002; Turner et al., 2000). Indeed, data from the Veterans Aging Cohort 3-Site Study suggest that, nationally, HIV-seropositive African American and Latina/o veterans have greater burdens of medical comorbidities, poorer health outcomes and higher mortality rates compared to their non-Hispanic white counterparts (McGinnis et al. 2003). In this study, there was no evidence of significant racial/ethnic differences in clinical care management or in adherence to HIV medication, but African American and Latina/o veterans were more likely than non-Hispanic white veterans to have been diagnosed later in the course of their illness and were sicker by the time they were diagnosed. Such findings highlight the presence of health disparities among racial/ethnic minority adults living with HIV, even in the presence of equal health coverage through the VA system.
Older HIV-seropositive racial/ethnic minority adults (particularly those from underrepresented groups) may be uniquely at risk for deleterious neuropathological and neurocognitive sequelae within the context of aging. Despite the disproportionate representation of racial/ethnic minority populations within the HIV/AIDS epidemic, the role of HAND has not been well characterized within these groups. Of the scant evidence that is available, some studies suggest higher rates of neurocognitive impairment (particularly in executive functioning) and HIV-associated Dementia in HIV-seropositive Latina/o and African-American adults (Rivera Mindt et al., 2008; Wojna et al., 2006). These higher rates of impairment may reflect higher rates of HIV-related sequelae and comorbidities, but research also underscores the importance of examining the role of sociocultural factors on HAND within these diverse patient populations (i.e., quality of education, literacy, acculturation, language fluency, etc.; Richardson 2002; Ryan 2005). In order to improve HAND diagnosis, treatment and ultimately better health outcomes, understanding both the unique health disparities and sociocultural factors involved in racial/ethnic minorities’ neurocognitive test performance is critical.
Taken together, racial/ethnic minorities’ overrepresentation in the HIV/AIDS epidemic, higher rates of HAND and health disparities make it important to examine the neurocognitive effects of HIV and aging particularly within racial/ethnic minority populations. To our knowledge, little has been done to address these questions from a longitudinal perspective in these populations. However, preliminary research (Rivera Mindt et al., 2013) portends that older HIV-seropositive Latina/o adults may be at increased risk for HAND compared to their older non-Hispanic white counterparts. Clearly, HAND remains a serious dilemma for people living with HIV, even in the cART era. Given the high burden of health disparities among racial/ethnic minority groups (detailed above), these individuals may be at elevated risk for HAND. Research is needed to better inform HAND-related treatment for older HIV-seropositive racial/ethnic minority adults.
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About the Authors
Caitlin Miranda is a third-year doctoral student in the clinical psychology doctoral program at Fordham. Caitlin’s MA work examined the relationship between language dominance and neuropsychological performance in HIV-positive Latino adults. Her research interests include the relationship between bilingualism and other sociocultural factors and cognition, and the resulting implications for culturally competent assessment and treatment. Prior to her graduate training, Caitlin worked as a research assistant at Kessler Foundation Research Center.
Armando Fuentes is currently a fifth-year student in the clinical psychology doctoral program at Fordham. Armando has worked in HIV research since 2004, including his MA thesis which explored the relationship between neurocognitive functioning and health beliefs in a cohort of HIV-positive Latinos. His additional research interests include examining the relationship neurocognitive functioning has with health behavior and clinical treatment outcomes, as well as cultural considerations in assessment and treatment.
Monica Rivera Mindt, PhD, ABPP-CN, is a board certified clinical neuropsychologist and a tenured professor in the department of psychology and the Latino American and Latino studies institute at Fordham University in New York City, with a joint appointment in the departments of neurology and psychiatry at the Icahn School of Medicine at Mount Sinai. Rivera Mindt’s research is funded by the National Institutes of Health, and is dedicated to investigating the effects of HIV, substance use and substance use treatment on the brain, functional outcomes and health disparities, particularly among HIV+ Latinas/os. She has published numerous articles, and has served as a grant reviewer for the National Institute of Mental Health, the National Academy of Neuropsychology and the Alzheimer’s Association; and sits on the editorial board of the Journal of the International Neuropsychological Society.