David Moore, PhD, of UC San Diego HIV Neurobehavioral Research Program, presents "Understanding and Evaluating the Neuropsychological Functioning of HIV-infected Persons"

1. AIDS CLINICAL ROUNDS
The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
researchers. The goal of these presentations is to provide the most
current research, clinical practices and trends in HIV, HBV, HCV, TB
and other infectious diseases of global significance.
The slides from the AIDS Clinical Rounds presentation that you are
about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.

2. Neuropsychology of HIV
for Non-Neuropsychologists
David J. Moore, Ph.D.
Associate Professor, Department of Psychiatry
University of California, San Diego
HIV Neurobehavioral Research Program
djmoore@ucsd.edu
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

3. This training is sponsored in part by the American Psychological
Association’s HIV Office for Psychology Education (HOPE) Program
funded by the Center for Mental Health Services (CMHS) of the
Substance Abuse and Mental Health Services Administration
(SAMHSA) under contract number HHSS280200900004C.
Views expressed do not necessarily reflect the official policies of the
Department of Health and Human Services.
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

4. Brief
Outline
 HIV-Associated Neurocognitive
Disorders (HAND)
 HIV Disease Indicators
 Impact of Comorbidities
 Daily Functioning
 Emerging Treatments for
Neurocognitive Complications
 Summary &
Recommendations
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

5. Meet Joe
 43 y.o., African American male, one yr of college
education, man who has sex with men, HIV+
 Dr. Smith is treating Joe with Cognitive
Behavioral Therapy (CBT) for depression
 Progress in therapy has been slow
 Dr. Smith, having heard that some HIV+ may
have neurocognitive difficulties, wonders if this
is impacting their progress
 She’s observed: 1) slow processing of
instructions, 2) difficulty learning new strategies,
and 3) ineffective problem solving
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

6. HIV NEUROBEHAVIORAL DISTURBANCES
NEUROCOGNITIVE (NC)
Primary
EMOTIONAL & OTHER
BEHAVIORAL
New Onset
Asymptomatic NC Impairment
Mild Neurocognitive Disorder
HIV-associated Dementia
Secondary
Infection
Neoplasia
Cerebrovascular
Nutritional
Treatment Related
Depression
Anxiety
Adjustment Disorders
HIV Mania
HIV Psychosis
Recurrent/Comorbid
Mood Disorders
Substance Use Disorders
Other Mental Disorders
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

7. HIV Associated Neurocognitive Disorders
(HAND) Criteria
ASYMPTOMATIC
NEUROCOGNITIVE
IMPAIRMENT
MILD
NEUROCOGNITIVE
DISORDER
(ANI)
(MND)
HIVASSOCIATED
DEMENTIA
(HAD)
NEUROCOGNITIVE
IMPAIRMENT
> Mild
> Mild
> Moderate
FUNCTIONAL
IMPAIRMENT
None
> Mild
> Moderate
• Impairment must be attributed to HIV, at least in part
• Neurocognitive impairment required in 2 domains to receive overall
impairment
Antinori, et al., Neurology 2007, 69 (18):1789-99
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

8. COMORBID CONDITIONS
 MINIMAL: may have minor effects on NP test
results, but unlikely to cause even mild global
impairment, e.g., hypertension
 MODERATE: likely to have at least mild effects
on NP results but unlikely to cause clinically
significant global NP impairment by itself, e.g.,
current Hepatitis C infection (HCV)
 SEVERE: likely to have major effects on NP
test results, with significant neurocognitive
impairment and functional disability, or NP
results invalid due to poor effort, e.g., mental
retardation, severe TBI
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
HAND
Diagnosis
Possible
Precludes
HAND
Diagnosis

9. Despite ART Benefits on Morbidity and Mortality
HAND remains prevalent
50%
46%
Pre-CART
Percent Impaired
43%
p=.03
40%
36%
29%
30%
20%
CART
19%
16%
10%
0%
N=179
N=94
HIV-
N=516
N=336
Non-AIDS
N=162
N=507
AIDS
Heaton et al, Journal of Neurovirology, 2011
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

10. Neurocognitive Impairment (NCI) by Domain in
HIV+ from Pre-ART and Post-ART Eras
Pre-CART
70%
Post-CART
*
Percent Impaired
60%
**
50%
40%
**
***
***
30%
20%
10%
0%
Verbal
* p<.05; ** p<.01; ***p<.001
SIP
Learn
Recall
Attn/WM
Exec
Motor
Heaton et al, Journal of Neurovirology, 2011
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

11. How Do HIV Disease Factors Impact
HAND?
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

12. Higher nadir CD4  Lower Risk of Impairment
Ellis et al., AIDS, 2011
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

13. CHARTER: Neurocognitive Impairment Related
to HIV Disease Factors only in Minimal
Comorbidity Group
NC Impaired
n = 339
NC Normal
n = 504
% AIDS *
64.6%
57.1%
% Nadir (lowest ever) CD4 < 200 *
59.6%
50.6%
* P < 0.05
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

14. Joe’s HIV Disease
Characteristics






Current CD4: 420 cells/µL
Nadir CD4: 174 cells/µL
Plasma Viral Load: Undetectable
Duration of HIV infection: 10 years
ART on/off: On
Meets Criteria for AIDS
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

15. Risk and Protective Factors for Joe’s
Neurocognitive (NC) Functioning
HIV Disease Factors
Con: AIDS, Nadir CD4 <200,
Chronic HIV
Pro: On ART, VL Undetectable
Joe’s
NC
Fxn
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

16. How Do Comorbidities Influence
HAND?
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

17. % Impairment is Related to Disease Factors
only with Minimal Comorbidity (Pts on ART)
Severe
1.0
Probability of Impairment
Moderate
0.8
N+/VL+
N-/VL+
N=27
N=62
Minimal
N-/VLN+/VLN=65
N=14
0.6
N-/VLN-/VL+N+/VL- N=98
N+/VL+ N=129 N=36
N=60
0.4
0.2
0.0
N-/VL+
N=210N+/VL- N-/VLN=68 N=111
N+/VL+
N=111
N+: Nadir CD4 ≥ 200
N-: Nadir CD4 < 200
VL+: Undet Plasma VL
VL-: Det Plasma VL
Heaton et al., Neurology, 2010
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

18. % GLOBAL NP Impairment
Rates of NP Impairment
by Number of Risk Factors HIV, HCV, Meth
n=8
0
n=186
n=99
n=35
Cherner et al., Neurology, 2005
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

19. Incident Depression Does Not  NCI in HIV
BDI Total Score
18
16
1
Incident Depression
Global Deficit Score
20
No Incident Depression
14
12
10
8
6
4
2
0.9
0.8
Incident Depression
No Incident Depression
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0
Baseline
Follow-up
Baseline
Follow-up
Cysique et al., JINS, 2007
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

20. Joe’s Comorbidities
 Substance Use Diagnoses:
»
»
»
»
Lifetime Hx. of Methamphetamine dependence
Lifetime Hx. of Cannabis abuse
No current substance use disorder
Last used Methamphetamine 8 years ago
 Mood Disorders:
» Lifetime Major Depressive Disorder (MDD)
» Current MDD
» Beck Depression Inventory–II Total = 19
 Medical Comorbidities
» Hypertension
» Remote mild Traumatic Brain Injury (mTBI)
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

21. Risk and Protective Factors for Joe’s
Neurocognitive (NC) Functioning
Comorbidities
Con: LT Hx. Meth Dep, Past mTBI
Pro: No current Sub Use dep; no
HCV
HIV Disease Factors
Con: AIDS, Nadir CD4 <200,
Chronic HIV
Pro: On ART, VL Undetectable
Joe’s
NC
Fxn
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

22. Does Joe Have Neurocognitive
Complaints?
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

23. Joe’s Neurocognitive
Complaints
 Dr. Smith asks him about his cognitive
abilities
 Joe has some recent cognitive complaints
that are a change from his normal
functioning:
»
»
»
»
Loses track of time
Forgets to do things he’s agreed to do
Has some difficulty coming up with correct words
Difficulty planning and organizing activities
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

24. Risk and Protective Factors for Joe’s
Neurocognitive (NC) Functioning
Comorbidities
Con: LT Hx. Meth Dep, Past mTBI
Pro: No current Sub Use dep; no
HCV
HIV Disease Factors
Con: AIDS, Nadir CD4 <200,
Chronic HIV
Pro: On ART, VL Undetectable
Joe’s
NC
Fxn
Cognitive Complaints
Con: Loses track of time, forgetting
some things, problems planning
Pro: Only four complaints where
many more possible
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

25. How is Joe Performing
Neurocognitively?
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

26. Example Neuropsychological (NP) Test Battery
 Verbal Fluency
 Executive Functioning
» Animals
» Letter
» WCST-64 PR
» Trail Making Test B
 Attn/Working Memory
» PASAT-50
» Letter-Number Sequencing
 Processing Speed
» WAIS-III Digit Symbol
» WAIS-III Symbol Search
» Trail Making Test A
= 15 individual NP measures
 Learning
» Verbal (HVLT-R) Total
» Visual (BVMT-R) Total
 Recall
» Verbal (HVLT-R) Recall
» Visual (BVMT-R) Recall
 Motor
» Grooved Pegboard DH
» Grooved Pegboard NDH
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

27. Joe’s Objective Neurocognitive
Performance
 Impaired:
» Learning
» Executive Functioning
 Within Normal Limits:
»
»
»
»
»
Verbal functioning
Speed of Information Processing
Recall
Motor
Attention/Working Memory
 His global neuropsychological performance is
mildly impaired (impairment ≥ 2 Domains)
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

28. Risk and Protective Factors for Joe’s
Neurocognitive (NC) Functioning
Comorbidities
Con: LT Hx. Meth Dep, Past mTBI
Pro: No current Sub Use dep; no
HCV
HIV Disease Factors
Con: AIDS, Nadir CD4 <200,
Chronic HIV
Pro: On ART, VL Undetectable
Joe’s
Mild
NCI
Cognitive Complaints
Con: Loses track of time, forgetting
some things, problems planning
Pro: Only four complaints where
many more possible
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

29. Do Joe’s Neurocognitive
Impairments Impact His Daily
Functioning?
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

30. Comorbidity Group Comparisons for
Daily Functioning
Minimal
Moderate
Severe
843 (54%)
473 (31%)
239 (15%)
% Impaired
41%
59%
84%
Min<Mod<Sev
% Employed
33.0%
19.7%
13.0%
Min>Mod,Sev
Cognitive Symptoms
4.9 (6.3)
7.4 (8.0)
9.3 (9.0)
Min<Mod<Sev
IADL Declines
1.3 (1.8)
1.9 (2.1)
2.1 (2.3)
Min<Mod, Sev
 Unemployment, increased cognitive symptoms, and increased
Instrumental Activities of Daily Living (IADL) Declines
significantly correlated with worse levels of neurocognitive
impairment (p <0.01)
Heaton et al., Neurology, 2010
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

31. Methamphetamine Increases Risk of
Unemployment in HIV
* p < .01
90
80
% Unemployed
70
60
50
40
30
20
10
0
HIV-/MA-
HIV-/MA+
HIV+/MA-
n=217
n=237
N=155
HIV+/MA+
n=189
Blackstone et al., JAM, 2013
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

32. Agreement between self report (SR) and
performance based (PB) functional measures
80%
70%
Agreement rate (%)
60%
50%
40%
30%
20%
10%
0%
Agree: No Functional
Impairment (n=156)
Agree: Functional
Impairment (n=20)
Disagree: Impaired by
Self-report Only (n=37)
Disagree: Impaired by
Performance-based Only
(n=20)
Blackstone, et al., JINS, 2012, 18: 79-88
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

33. How is Joe doing in everyday life?
 Joe is unemployed
 Previously worked as a manager of an
apartment complex but stopped about 6
years ago
 He has some declines from his baseline
(pre-HIV) with managing his medications
and finances
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

34. Risk and Protective Factors for Joe’s
Neurocognitive (NC) Functioning
Comorbidities
Con: LT Hx. Meth Dep, Past mTBI
Pro: No current Sub Use dep; no
HCV
HIV Disease Factors
Con: AIDS, Nadir CD4 <200,
Chronic HIV
Pro: On ART, VL Undetectable
Joe’s
Mild
NCI
Cognitive Complaints
Con: Loses track of time, forgetting
some things, problems planning
Pro: Only four complaints where
many more possible
Daily Functioning
Con: Unemployed, Med and
Financial mgmt problems
Pro: Still maintains social
relationships
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

35. What’s Joe’s HAND Diagnosis
 NP: Definite mild impairment
 Daily functioning:
» Unemployed
» Declines from baseline with managing
medications and finances
» Some cognitive complaints (although have to be
careful of these in context of depression)
 Diagnosis is:
» Mild Neurocognitive Disorder (MND)
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

36. Risk and Protective Factors for Joe’s
Neurocognitive (NC) Functioning
Comorbidities
Con: LT Hx. Meth Dep, Past mTBI
Pro: No current Sub Use dep; no
HCV
HIV Disease Factors
Con: AIDS, Nadir CD4 <200,
Chronic HIV
Pro: On ART, VL Undetectable
Joe’s
Mild
NCI
Cognitive Complaints
Con: Loses track of time, forgetting
some things, problems planning
Pro: Only four complaints where
many more possible
Daily Functioning
Con: Unemployed, Med and
Financial mgmt problems
Pro: Still maintains social
relationships
HAND Dx.
MND
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

37. How Might You Screen for NP
Impairment If Joe Was In Your Office?
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

38. Classification Accuracy of the
HIV Dementia Scale (HDS)
100%
92%
90%
80%
69%
70%
57%
60%
Sensitivity
50%
Specificity
40%
30%
27%
20%
10%
0%
Raw cutpoint (≤ 10)
*Overall Accuracy: Raw = 57% Norms = 63%
Norms
CHARTER study, N = 1580
Sakamoto et al., JAIDS, 2013
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

39. Brief Screening Predicts Larger NP Battery
Minutes
•
•
•
•
Action Fluency
Stroop Color
PASAT
HVLT-R Learning
• Trail Making Test A
• PASAT
• Grooved Pegs Nondominant
Sensitivity
Specificity
18
86.5 (71.1–95.0
87.1 (80.8–91.7)
9
76.3 (60.0–88.2)
80.1 (73.5–85.9)
 Less intensive NP assessment can provide a screen
 Requires some expertise; when in doubt refer
Moore et al., PLoS ONE, 2012
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

40. Can We Improve Joe’s HAND?
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

41. Neurocognitive Rehabilitation of Real-World
Problems in HIV: A Call To Action
 HAND persists despite effective ART
» Non-ARV pharmacological approaches have not held up in trials
 Few studies to date examined NC Rehab in HIV
» Large literature in other conditions
Slide Courtesy of S.P. Woods
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

42. Neurocognitive Rehabilitation of HAND:
Memory
 Neurocognitive remediation
rooted in models of changing
specific neuropsychological
deficits
 Interventions often NC
domain specific
 Few studies using these NC
rehabilitation techniques in
HIV but growing
interest/demand
Weber et al., 2012
Slide Courtesy of S.P. Woods
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

43. Executive Functioning Training
Executive
Dysfunction
(planning,
monitoring, setshifting)
Compensatory
Strategy
Application
(e.g., alarm)
Antiretroviral
Antiretroviral NonAdherence
adherence
Impaired
Metacognition
Metacognitive deficits  Poorer rehabilitation outcomes and motivation and poorer
vocational attainment
Blackstone Dissertation
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

44. Computerized Speed of Processing Training
 All participants HIV+
1000
 Intervention group
900
significantly increased
800
their speed of
700
processing compared
600
to control (p <.05)
500
 Also improved their
performance on a
400
timed IADL measure
300
 Self-reported that
200
“games” improved their 100
mental functioning
0
Control Δ = 115.21 ms
Intervention Δ = 212.41 ms
Intervention
Control
Pre Training
Post Training
Vance et al., J Assoc Nurses AIDS Care, 2013
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

45. Directly Target Daily Functioning
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

46. Mean Dose Delay (min)
Time from Target Dose by Group
Antiretroviral
N=25
N=25
Psychotropic
N=25
N=25
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

47. % with Neurocognitive Impairment
Exercise and NP Functioning in HIV
35
30.95
30
25
20
15
15.66
10
5
0
Exercisers
n=83
Non-Exercisers
n=252
Dufour et al., JNV, 2013
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

48. Text Messaging for Physical Activity
Neurobiological
Mechanisms
Outcome
Measures
Inflammation
Physical Activity
Neurocognition
Cerebral blood flow
Everyday function
Neurogenesis
Quality of life
Metabolic function
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

49. Joe Makes a Nice Story…
but what about others?
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

50. John












58 y.o., Caucasian male, one yr of college
education, man who has sex with men, HIV+
Current CD4: 790 cells/µL
Nadir CD4: 256 cells/µL
Plasma VL: Undetectable
ART on/off: On
Substance Use Diagnoses: Lifetime Hx. Meth
dependence, No Current Substance Use Dx.
Mood Disorders: Lifetime Hx. MDD
Medical Comorbidity: HCV+
Global Neurocognitive Impairment
Classification: Within normal limits
Neurocognitive Impaired Domains: 0
Daily Functioning and Cognitive Complaints: 0
HAND Dx: None
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

51. Gabe












29 y.o., Hispanic male, college graduate, man
who has sex with men, HIV+
Current CD4: 360 cells/µL
Nadir CD4: 354 cells/µL
Plasma VL: Detectable
ART on/off: On
Substance Use Diagnoses: Lifetime Hx.
Alcohol Abuse
Mood Disorders: None
Medical Comorbidity: None
Global Neurocognitive Impairment
Classification: Mild-to-Moderate Impairment
Impaired Neurocognitive Domains: Learning,
Executive Function, Attention/Working
Memory
Daily Functioning and Cognitive Complaints:
None
HAND Dx: ANI
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

52. Actions to
Take with
HIV+
Clients
with
Possible
NCI
 Determine severity of disease
» In cases without comorbidities nadir
CD4, off ART, detectable VL, AIDS
related to increased NCI
 Ask about changes in:
» Cognitive Functioning
» Daily Functioning
» Recognize that cognitive complaints
may be elevated in persons with MDD
 Identify comorbidities
 If trained, screen for HAND, if not
make referral for screening
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

53. Take Away
Message
 Despite improved HIV survival,
neurocognitive complications
persist and can impact everyday
functioning
 Comorbidities can complicate and
worsen neurocognitive problems in
HIV, but HIV-related neurocognitive
problems exist even in those
without comorbidities
 Need to find effective treatments
for HAND
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

54. Acknowledgments
 SAMHSA
 Funding Support
»
»
»
»
NIMH
NIDA
California HIV/AIDS Research Program
Henry M. Jackson Foundation
 HNRP Co-Investigators/Collaborators
»
»
»
»
»
»
»
»
»
»
J. Hampton Atkinson, M.D.
Mariana Cherner, Ph.D.*
Ronald J. Ellis, M.D.
Igor Grant, M.D.
Robert K. Heaton, Ph.D.
Scott Letendre, M.D.
Thomas Marcotte, Ph.D.
Erin Morgan, Ph.D.
Maiko Sakamoto, Ph.D.
Steven P. Woods, Psy.D.
 Trainees
»
»
»
»
»
Kaitlin Blackstone, M.S.
Catherine Dufour
Pariya Fazeli, Ph.D.
Maria Marquine, Ph.D.
Jessica Montoya
 Staff
»
»
»
»
Candy Carson
Matthew Dawson
Ben Gouaux
Alexandra Rooney
 Contact Information
» David J. Moore, Ph.D.
» djmoore@ucsd.edu
» 619-543-5093
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

55. Your feedback is important to us. Please visit
http://survey.abtassociates.com/s/APANeuropsych/
to provide an evaluation of this training.
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

56. Neuropsychology of HIV
for Non-Neuropsychologists
David J. Moore, Ph.D.
Associate Professor, Department of Psychiatry
University of California, San Diego
HIV Neurobehavioral Research Program
djmoore@ucsd.edu
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

57. Age: 56
Education:
7
Sex: Male
Ethnicity: Native American
Current CD4: 433
Nadir CD4: 184
Plasma VL: Undetectable
ART on/off: On
Substance Use Diagnoses: Lifetime Alcohol
Dependence, Cannabis Dependence, Inhalant
Dependence
 Mood Disorders: Major Depressive Disorder,
Panic Disorder with Agoraphobia, Generalized
Anxiety Disorder
 Global Impairment Classification: Mild-toModerate Impairment (6)
 Impaired Domains: Learning, Working
Memory
 IADL Complaints: 2
 HAND Dx: ANI
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Chris
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58. Raul
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Age: 34
Education:
15
Sex: Male
Ethnicity: Hispanic
Current CD4: 294
Nadir CD4:
255
Plasma VL:
0
ART on/off:
On
Substance Use Diagnoses: None
Mood Disorders:
None
Global Impairment Classification: Definite
Mild Impairment (5)
Impaired Domains: Learning, Memory,
Executive Function
IADL Complaints: 0
PAOFI Complaints: 0
HAND Dx. ANI
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

59. HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

60. David J. Moore et al. (P21)
• Does individualized Texting for Adherence Building (iTAB) improve med
adherence and dose timing for HIV-infected persons with bipolar disorder?
Mean % MEMS
Adherence
Improve Overall Adherence? Maybe
Mean Dose Delay
(min.)
Improve Dose Timing? YES!
*
CTRL (n = 25)
iTAB (n = 25)
* p < 0.05
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

61. Comorbidity Group Comparisons
Minimal
473 (31%)
239 (15%)
41%
Depression (BDI)
Severe
843 (54%)
% Impaired
Moderate
59%
84%
Min<Mod<Sev
12.3 (10.0)
15.7 (11.1)
16.5 (11.9)
Min<Mod, Sev
Heaton et al., 2010
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

62. METH Abuse and HIV Combine to Increase
Neurocognitive Impairment
Percent Neurocognitively Impaired
80
70
60
50
40
30
20
10
0
HIV-
HIV+
Non-Meth Abusing Group
HIV-
HIV+
Meth Abusing Group
Rippeth et al., J Int Neuropsychol, Soc, 2004,10(1): 1-14
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

63. FUNCTIONAL IMPAIRMENT CRITERIA
(NEED 2)
1.
IADL dependence, after person became HIV+, attributed
to cognitive (not physical) impairment,
2.
Unable to work, or significantly reduced work efficiency,
attributed to HIV related cognitive changes,
3.
Complaints of increased cognitive difficulties in everyday
life (cannot use this if person has clinically significant
depression),
4.
Impaired performance on objective everyday functioning tasks:
standardized work samples or medication management (available
only for CHARTER longitudinal cohort).
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

64. HIV+ with Bipolar Disorder More NP Impaired
HIV+/BD+
HIV+/BD-
1.00
0.90
NP Deficit Scores
0.80
0.70
0.60
0.50
Impairment
0.40
0.30
0.20
0.10
0.00
Speed of Info.
Processing
Learning**
Recall**
Executive
functions*
Verbal Fluency
Attn/Working
Memory
Motor
Global Deficit
Score**
*p<0.05; **p<0.01
Moore et al., in prep
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO

65. General Association of NC Impairment
with Everyday Functioning in CHARTER
p-value
Unemployment
.005
IADL Dependence
.0002
Cognitive Complaints
<.0001
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO