Behavioral and Clinical Risk Factors Associated with Performance on Neuropsychological Screening...
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Behavioral and Clinical Risk Factors Associated with Performance on Neuropsychological Screening Tests for HIV-1-Associated Dementia in an Incarcerated Population 1 Kimberley D. Lucas, 2 Joseph A. Bick, 1 Jennifer Baham, 2 Deborah Harris, 1 Seema Mittal, and 1 Juan D. Ruiz 1 California Department of Health Services, Office of AIDS, 2 California Department of Corrections Mean and standard deviation E XIT and H D S scores by selected dem ographic and clinicalcharacteristics EXITHDSN m ean+ s.d. p-value N m ean+s.d. p-value 234 6.7+ 3.8 R aw score 236 11.4+ 3.1 Age (years) 50 6.3+ 3.9 0.47 <35 50 12.4+ 2.9 0.01 162 6.7+ 3.4 35-49 164 11.3+ 3.1 22 7.5+ 5.3 > 50 22 10.2+ 2.5 Educationallevel 56 5.1+ 2.8 <.0001 atleastsome college 56 12.6+ 2.8 <.0001 156 6.8+ 3.5 9th to 12th grade 157 11.3+ 2.9 22 10.7+ 5.1 1stto 8th grade 22 9.3+ 3.4 Race/ethnicity 75 5.9+ 3.2 0.10 W hite 75 12.3+ 3.0 0.01 103 7.2+ 4.0 African American 104 10.9+ 3.0 18 7.7+ 5.8 Hispanic 18 11.3+ 3.4 37 6.6+ 3.1 Other 38 11.0+ 3.0 Frequency ofalcoholconsumption 49 5.7+2.8 0.02 < once permonth 50 11.7+ 2.9 0.63 79 6.4+3.1 once/tw ice perw eek 80 11.5+ 3.0 106 7.4+4.5 daily drinker 106 11.2+ 3.2 Quantity ofalcoholconsumed peroccasion 108 6.1+ 3.4 0.02 < 3 drinks 108 11.9+ 3.0 0.03 126 7.2+ 4.1 > 4 drinks 128 11.0+ 3.0 AID S diagnosis100 6.8+4.1 0.74 No 100 11.6+ 3.2 0.61 127 6.6+3.6 Yes 129 11.4+ 3.0 C urrentCD 4 count166 6.7+3.9 0.75 >200 137 11.8+ 3.1 0.06 60 6.5+3.7 < 200 91 11.0+ 3.1 N adirCD 4 C ountperpatient98 6.8+ 3.9 0.28 >200 99 12.0+ 3.0 0.06 110 6.3+ 3.1 < 200 114 11.1+ 3.0 CurrentART131 6.3+ 3.7 0.10 HAART 133 11.4+ 3.2 0.77 94 7.2+ 4.1 N one 94 11.5+ 3.0 HC V status 109 6.2+ 3.7 0.09 Negative 110 11.5+ 3.3 0.62 113 7.1+ 4.0 Positive 117 11.3+ 3.0 History ofany psychiatric disorderperpatient 97 6.2+ 3.2 0.04 No 98 11.4+ 3.1 0.97 137 7.1+ 4.2 Yes 138 11.4+ 3.1 H istory ofnon-seizure LOC perpatient101 6.5+ 4.0 0.52 No 102 11.9+ 3.0 0.06 131 6.9+ 3.7 Yes 132 11.1+ 3.1 History ofseizures 135 6.5+ 4.1 0.06 N o neurologic disorders 136 11.7+3.0 0.10 32 8.1+ 4.4 Yes 32 10.7+3.7 PossibleEXIT scores range from 0 to 25 w ith higherscore indicating increasing cognitive impairm ent. Possible H DS scores range from 0 to 16 with low erscores indicating increasing cognitive impairm ent. H istory ofany AIDS-defining illness as defined by the C enters forDisease Control and Prevention HIV disease stage C classification. CD 4 T-lymphocyte count (X 10/L). Antiretroviral Therapy (ART). Loss ofconsciousness (LOC).T-tests w ere used to compare means forclass variables with 2 levels.Analysis ofvariance w as used forclass variables having greaterthan 2 levels. Inter-correlations between E XIT and H D S scores and selected dem ographic,behavioral,and clinicalcharacteristics HDS EXIT A ge Edu A frican H ispanic Time to CD4 N adir HAART HCV Alcohol IDU (years) level Am erican AID S count CD4 (quantity) HDS -- EXIT -0.38 a -- A ge (years) -0.18 b 0.05 -- Educatonal level 0.27 a -0.33 a 0.15 b -- A frican A m erican -0.25 b 0.17 b 0.15 b 0.03 -- H ispanic -0.14 0.09 -0.20 b -0.19 c -- -- Tim e to A ID S 0.10 -0.14 0.10 0.02 -0.01 0.07 -- CD4 count 0.09 0.01 -0.12 b -0.12 c -0.03 0.11 -0.03 -- N adirCD4 count 0.13 c 0.07 -0.18 b -0.16 b -0.08 0.15 0.08 -- -- HAART -0.02 -0.12 c 0.09 0.20 b -0.05 -0.06 0.05 -0.17 b -0.26 b -- HCV -0.04 0.12 c 0.26 a -0.15 b -0.28 b -0.20 c 0.09 0.05 0.1 -0.11 -- A lcohol (quantity) -0.14 b 0.13 b -0.13 b -0.18 b -0.05 -0.12 -0.21 b -0.03 -0.01 -0.09 0.10 -- IDU 0.04 -0.01 0.12 b -0.09 -0.40 a -0.18 c -0.11 0.04 0.08 -0.03 0.63 a 0.16 b -- Spearman correlation coefficients: a significant atthe <.0001 level, b significant atthe 0.05 level, c significantatthe 0.10 level. HDS (HIV Dementia Scale)and EX IT (E xecutive Interview )raw scores.Educationallevelclass variable (0-8,9-12,>12 years formal education). Time to A ID S in years from firstH IV -postive test. NadirCD4 countby patienthistory.H A AR T vs.no antiretroviral treatmentat time ofinterview .H CV co-infected. A lcohol quantity consumed peroccasion (> 4 drinks s.< 4 drinks).H istory ofID U (Injection Drug Use). M ultivariate linearregression m odels predicting EXIT and H D S continuous score outcom es EXIT (N = 115) H D S (N = 119) C oefficient SE a p-value Variable C oefficient SE a p-value -0.24 2.89 0.93 Intercept 18.81 2.22 <.0001 0.03 0.04 0.44 A ge (years) -0.09 0.04 0.02 R ace/ethnicity (vs.W hite) 1.31 0.70 0.06 African American -1.20 0.62 0.06 -0.94 1.73 0.59 Hispanic -1.80 1.43 0.21 -0.76 0.92 0.41 Other 0.25 0.80 0.76 Years education (vs.> 12) 2.37 0.73 0.002 9 -12 -0.81 0.65 0.21 5.83 1.27 <.0001 0 -8 -3.35 1.10 0.003 Quantity ofalcoholconsum ed (vs.< 4 drinks) 0.02 0.63 0.97 4 -0.49 0.56 0.38 -0.28 0.71 0.70 A ID S diagnosis b -0.14 0.65 0.82 0.22 0.10 0.03 Years with H IV 0.03 0.09 0.74 -0.32 0.11 0.006 Tim e to A ID S c 0.06 0.10 0.55 -- -- -- C D 4 count< 300 -1.15 0.57 0.05 0.74 0.59 0.21 C D 4 count< 200 -- -- -- -- -- -- H istory ofnon-seizure LOC perpatient d -1.22 0.55 0.03 0.50 0.90 0.58 H istory ofhead traum a (chartreview) -- -- -- 0.56 0.67 0.41 H C V co-infection -- -- -- 0.75 0.61 0.22 H istory ofany psychiatric disorderperpatient -- -- -- a Standard Error, b H istory ofany AID S-defining illness as defined by the C enters forD isease C ontrol and Prevention H IV disease stage C classification, excluding those w ith C D 4 countbelow 200 as sole AID S diagnosis, c years from first H IV -positive testto firstAID S-defining illness, d Loss ofconsciousness (LO C ). --indicates variable notincluded in m odel. EX IT m odel:R 2 = 0.30,Adjusted R 2 = 0.20,F = 3.1 (p = 0.0006) HDS m odel:R 2 = 0.21,Adjusted R 2 = 0.12,F = 2.3 (p = 0.01) B ackground • H IV-Associated D em entia (H AD )is a progressive neurological and AID S-defining disordercharacterized by cognitive im pairm ent,psychom otorslow ing,and behaviorabnorm alities affecting 25 to 65% ofAID S patients and up to 15% of asym ptom atic H IV-1-infected persons. • The diagnosis ofH AD by criteria developed by the Am erican Academ y ofN eurology requires a typical clinicalpresentation and a com bination ofcom plex,costly and tim e consum ing neuropsychological,radiologicaland cerebrospinalfluid diagnostic testing.The H IV D em entia Scale (H D S)and Executive Interview (EXIT)are tw o briefneuropsychological screening tests thathave been validated as highly sensitive and specific fordetecting H AD . • Affected individuals often dem onstrate poorcom pliance w ith m edical appointm ents and treatm ents,and m any patients and doctors m istake signs ofdem entia fordepression orH IV-related stress. • W hile H AAR T has prevented and even partially reversed H AD , recently there has been a resurgence likely associated w ith prolonged survival and treatm entfailures due to drug resistance. • Incarcerated individuals m ay be athigherrisk forH IV- associated cognitive im pairm entdue to history ofinjection drug use and co-infections such as H C V,and low er“cognitive reserve”associated w ith lim ited educational and occupational experience. • H AD is particularly challenging in the correctionalsetting,and has notpreviously been studied in an incarcerated population. M ethods • C ross-sectional study design • 1 C alifornia D epartm entofC orrections m edical referral facility • 236 know n H IV-positive inm ates • Face-to-face dem ographic,behavioral,and clinical risk assessm entquestionnaire • 2 briefneuropsychological screens forH AD Executive Interview (EXIT) H IV D em entia Scale (H D S) • M edical chartreview Study Population (N = 236) • M ale inm ates • 104 (44% )African Am erican,18 (8% )Hispanic,75 (32% )W hite,and 38 (16% )ofotherrace/ethnicity • M ean age 39.6 (SD 7.1,range 23 -62) • 22 (9% ),157 (67% ),and 56 (24% )w ith 0 -8,9 -12, and > 12 years education respectively • 127 (54% )history ofID U • 88 (38% )history ofalcoholism • 115 (51% )H C V co-infected • 129 (56% )history ofAID S -defining illness • M ean C D 4 count396 (SD 236,range 6 – 1247) R ace/Ethnicity by Age (years) 0 10 20 30 40 50 60 70 80 African A m erican H ispanic W hite % in age group < 39 > 39 EducationalLevelby Age G roup Statified by R ace/E thnicity 0 10 20 30 40 50 60 70 80 African American < 39African Am erican > 39 Hispanic < 39 Hispanic > 39 W hite < 39 W hite > 39 R ace/Ethnicity and A ge Group % ateducationallevel 0 -8 9 -12 > 12 yearseducation H AAR T by EducationalLevelStratified by R ace/Ethnicity 0 10 20 30 40 50 60 70 80 A frican A m erican H ispanic W hite E ducationalLevel % on HAART 0 -8 9 -12 > 12 yearseducation C rude R R s for low E X IT and H DS scores by selected dem ographic and clinicalcharacteristics Low E XITN ormalEXIT C rude R R 95% CI Low HDSNormalH D S C rude R R 95% CI N(% ) N(% ) N(% ) N(% ) 38(16.2) 196(83.8) 89(37.7) 147(62.3) Age (years) 7(14.0) 43(86.0) 1.0 <35 15(30.0) 35(70.0) 1.0 25(15.4) 137(84.6) 1.0 (0.5,2.4) 35-49 52(37.4) 87(62.6) 1.2 (0.8,2.0) 6(27.3) 16(72.7) 1.9 (0.7,5.1) > 50 13(59.1) 9(40.9) 2.0 (1.1,3.4) Educationallevel 5(8.9) 51(91.1) 1.0 atleastsome college 14(25.0) 42(75.0) 1.0 21(13.6) 134(86.5) 1.5 (0.6,3.8) 9th to 12th grade 62(39.5) 95(60.5) 1.6 (1.0,2.6) 12(54.6) 10(45.5) 6.1 (2.4,15.3) 1stto 8th grade 13(59.1) 9(40.9) 2.4 (1.3,4.2) R ace/ethnicity 7(9.3) 68(90.7) 1.0 White 17(22.3) 58(77.3) 1.0 21(20.4) 82(79.6) 2.2 (1.0,4.9) African American 48(46.2) 56(53.9) 2.0 (1.3,3.2) 5(27.8) 13(72.2) 3.0 (1.1,8.3) Hispanic 7(38.9) 11(61.1) 1.7 (0.8,3.5) 5(13.1) 32(86.5) 1.4 (0.5,4.3) O ther 17(44.7) 21(55.3) 2.0 (1.1,3.4) Frequency ofalcoholconsumption 2(4.1) 47(95.9) < once permonth 17(34.0) 33(66.0) 1.0 13(16.5) 66(83.5) 4.0 (1.0,17.1) once/tw ice perw eek 31(38.8) 49(61.3) 1.4 (0.7,1.8) 23(21.7) 83(78.3) 5.3 (1.3,21.7) daily drinker 41(38.7) 65(61.3) 1.4 (0.7,1.8) Quantity ofalcoholconsumed peroccasion 13(12.0) 95(88.0) 1.0 < 3 drinks 35(32.4) 73(67.6) 1.0 25(19.8) 101(80.2) 1.6 (0.9,3.1) > 4 drinks 54(42.2) 74(57.8) 1.3 (0.9,1.8) AID S diagnosis20(20.0) 80(80.0) 1.0 No 37(37.0) 63(63.0) 1.0 16(12.6) 111(87.4) 0.6 (0.3,1.2) Yes 48(37.2) 81(62.8) 1.0 (0.7,1.4) C urrentC D4 count27(16.3) 139(83.7) 1.0 >200 63(37.7) 104(62.3) 1.0 9(15.0) 51(85.0) 0.9 (0.5,1.8) < 200 21(34.3) 40(65.6) 0.9 (0.6,1.4) NadirC D 4 C ountperpatient18(18.4) 80(81.6) 1.0 >200 30(30.6) 68(69.4) 13(11.8) 97(88.2) 0.6 (0.3,1.2) < 200 44(39.3) 68(60.7) 1.3 (0.9,1.9) CurrentAR T18(13.7) 113(86.3) 1.0 HAART 51(38.4) 82(61.7) 1.0 18(19.2) 76(80.9) 1.4 (0.8,2.5) N one 33(35.1) 61(64.9) 0.9 (0.6,1.3) H C V status 12(11.0) 97(90.0) 1.0 Negative 38(34.9) 71(61.7) 1.0 24(21.2) 89(78.8) 1.9 (1.0,3.7) Positive 44(38.3) 71(61.7) 1.1 (0.8,1.6) History ofpsychiatric disorderperpatient 12(12.4) 85(87.6) 1.0 No 38(38.8) 60(61.2) 1.0 26(19.0) 111(81.0) 1.5 (0.8,2.9) Yes 51(37.0) 87(63.0) 1.0 (0.7,1.3) Non-seizure LOC perpatient16(15.8) 85(84.2) 1.0 No 30(29.4) 72(70.6) 1.0 21(16.0) 110(84.0) 1.0 (0.6,1.8) Yes 58(43.9) 74(56.1) 1.5 (1.0,2.1) History ofseizures 19(14.1) 116(85.9) 1.0 N o neurologic disorders 48(35.3) 88(64.7) 1.0 9(28.1) 23(71.9) 2.0 (1.1,4.0) Yes 14(43.8) 18(56.3) 1.2 (0.8,2.0) EXIT score > 11. HDS score < 10. H istory ofany AID S-defining illness as defined by the C enters forD isease C ontrol and P revention H IV disease stage C classification. C D 4 T-lymphocyte count(X 10/L). Antiretroviral Therapy (AR T). Loss ofconsciousness (LOC ). Purpose • Estim ate associations betw een behavioral and clinical covariates and perform ance on neuropsychological screening tests forH AD • Estim ate the prevalence ofH AD in an incarcerated population • Assess the utility ofneuropsychological screening for cognitive im pairm entin an incarcerated population A djusted (m ultivariate) • Educational level w as the m ostsignificantpredictorof both EXIT and H D S continuous score outcom es • Years w ith H IV and years to progress to AID S w ere additional significantpredictors ofEXIT score • O lderage,C D 4 count< 300,and history on non- seizure LO C w ere additional significantpredictors of H D S score R eferences BerghuisJP ,U ldallKK,LalondeB .Validity oftw o scales in identifying H IV-associated dementia. J Acquir Immune Defic S y ndr1999,21:134-140. Eggers C .H IV-1 associated encephalopathy and myelopathy. J Neurol 2002,249:1132-1136. FarinpourR,MillerEN,SatzP,SelnesOA,Cohen BA,B eckerJT,Skolasky JrR L,VisscherBR.Psychosocialrisk factors ofH IV morbidity and mortality:findings from theMulticenterAID S CohortStudy (MAC S ). J ournal of C linical and E xpe rimental N europsychology 2003,25(5):654-670. Langford TD ,LetendreS L,LarreaGL,MasliahE.C hanging patterns in theneuropathogenesis ofH IV during the H A ART era. Brain P athology2003,13:195-210. N omenclature and research case definitions forneurologicmanifestations ofhuman immunodeficiency virus-type 1 (H IV-1) infection.Reportofa W orking Group ofthe American Academy of N eurology AID S Task Force. Neurology 1991,41:778- 785. PowerC ,SelnesOA,Grim JA,McArthurJC .HIV D ementia Scale:a rapid screeningtest. J A c quir Immune D efic S y ndr Hum R etrovirol 1995,8:273-278. SatzP,Morgenstern H ,MillerEN,SelnesOA ,McA rthurJC ,C ohen BA ,W eschJ,BeckerJT,Jacobson L,D’EliaLF,van GorpW ,VisscherB.Low education as a possible risk factorforcognitive abnormalities in H IV-1:findings from the multicenterAIDS C ohortStudy (MAC S ).JA cquirImmuneD efic Syndr1993,6:503-511. Stern R A,Silva SG,C haissonN ,Evans D L.Influence ofcognitive reserve on neuropsychological functioning in asymptomatic H uman Immunodeficiency Virus-1 infection. A rch Neur1996,53:148-153. Results U nadjusted • M ean E XIT and/orH D S scores differed by age,educational level,race/ethnicity,alcohol consum ption,and history ofany psychiatric disorderperpatient(p < 0.05) • M ean E XIT and/orH D S scores differed by currentC D 4 count, nadirC D 4 countperpatient,treatm entw ith H AA R T,H C V co- infection,and history ofseizures (p < 0.10) • > 50 years old,< 8 years education,non-W hite race/ethnicity, daily alcoholuse,H C V co-infection,history ofnon-seizure LO C, and history ofseizures w ere associated w ith increased risk for H AD -positive screen by E X IT and/orH D S based on the previously validated cut-offscores C onclusions • 16% screened positive forH AD by the EX IT and 38% by the HDS • Disagreem entbetw een screening outcom es and higher prevalence ofH A D estim ated by the H D S are likely due to low er educational level and otherpsychosocialvariables com m on in incarcerated populations • B oth the E XIT and the H D S w ere quickly and easily adm inistered by non-clinical staffand w ell-tolerated by study participants • B riefneuropsychologicalscreening,once standardized forthis population,has potential fordetecting possible H A D as w ell as m onitoring an individual’s neurocognitive function overtim e Future D irections • Furtherinvestigation involving an incarcerated H IV-seronegative controlgroup is underw ay to betterestim ateneurocognitive im pairm entattributable to H IV • A follow -up group ofH IV-infected participants are currently being retested to determ ine factors associated w ith progression and im provementinneurocognitivefunction
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Transcript of Behavioral and Clinical Risk Factors Associated with Performance on Neuropsychological Screening...
Behavioral and Clinical Risk Factors Associated with Performance on Neuropsychological Screening Tests for HIV-1-Associated Dementia in an Incarcerated Population
1Kimberley D. Lucas, 2Joseph A. Bick, 1Jennifer Baham, 2Deborah Harris, 1Seema Mittal, and 1Juan D. Ruiz1California Department of Health Services, Office of AIDS, 2California Department of Corrections
Mean and standard deviation EXIT and HDS scores by selected demographic and clinical characteristics
EXITa HDSb
N mean+s.d. p-value N mean+s.d. p-value
234 6.7+3.8 Raw score 236 11.4+3.1
Age (years)
50 6.3+3.9 0.47 <35 50 12.4+2.9 0.01
162 6.7+3.4 35-49 164 11.3+3.1
22 7.5+5.3 >50 22 10.2+2.5
Educational level
56 5.1+2.8 <.0001 at least some college 56 12.6+2.8 <.0001
156 6.8+3.5 9th to 12th grade 157 11.3+2.9
22 10.7+5.1 1st to 8th grade 22 9.3+3.4
Race/ethnicity
75 5.9+3.2 0.10 White 75 12.3+3.0 0.01
103 7.2+4.0 African American 104 10.9+3.0
18 7.7+5.8 Hispanic 18 11.3+3.4
37 6.6+3.1 Other 38 11.0+3.0
Frequency of alcohol consumption
49 5.7+2.8 0.02 < once per month 50 11.7+2.9 0.6379 6.4+3.1 once/twice per week 80 11.5+3.0
106 7.4+4.5 daily drinker 106 11.2+3.2
Quantity of alcohol consumed per occasion
108 6.1+3.4 0.02 <3 drinks 108 11.9+3.0 0.03
126 7.2+4.1 >4 drinks 128 11.0+3.0AIDS diagnosisc
100 6.8+4.1 0.74 No 100 11.6+3.2 0.61127 6.6+3.6 Yes 129 11.4+3.0
Current CD4 countd
166 6.7+3.9 0.75 >200 137 11.8+3.1 0.0660 6.5+3.7 <200 91 11.0+3.1
Nadir CD4 Count per patientd
98 6.8+3.9 0.28 >200 99 12.0+3.0 0.06110 6.3+3.1 <200 114 11.1+3.0
Current ARTe
131 6.3+3.7 0.10 HAART 133 11.4+3.2 0.7794 7.2+4.1 None 94 11.5+3.0
HCV status
109 6.2+3.7 0.09 Negative 110 11.5+3.3 0.62113 7.1+4.0 Positive 117 11.3+3.0
History of any psychiatric disorder per patient
97 6.2+3.2 0.04 No 98 11.4+3.1 0.97137 7.1+4.2 Yes 138 11.4+3.1
History of non-seizure LOC per patientf
101 6.5+4.0 0.52 No 102 11.9+3.0 0.06131 6.9+3.7 Yes 132 11.1+3.1
History of seizures
135 6.5+4.1 0.06 No neurologic disorders 136 11.7+3.0 0.1032 8.1+4.4 Yes 32 10.7+3.7
a Possible EXIT scores range from 0 to 25 with higher score indicating increasing cognitive impairment. b Possible HDS scores range from 0 to 16 with lower scores indicating increasing cognitive impairment. C History of any AIDS-defining illness as defined by the Centers for Disease Control and Prevention HIV disease stage C classification. d CD4 T-lymphocyte count (X 106/L). e Antiretroviral Therapy (ART). f Loss of consciousness (LOC). T-tests were used to compare means for class
variables with 2 levels. Analysis of variance was used for class variables having greater than 2 levels.
Inter-correlations between EXIT and HDS scores and selected demographic, behavioral, and clinical characteristics
HDS EXIT Age Edu African Hispanic Time to CD4 Nadir HAART HCV Alcohol IDU(years) level American AIDS count CD4 (quantity)
HDS --
EXIT -0.38a --
Age (years) -0.18b 0.05 --
Educatonal level 0.27a -0.33a 0.15b --
African American -0.25b 0.17b 0.15b 0.03 --
Hispanic -0.14 0.09 -0.20b -0.19c -- --
Time to AIDS 0.10 -0.14 0.10 0.02 -0.01 0.07 --
CD4 count 0.09 0.01 -0.12b -0.12c -0.03 0.11 -0.03 --
Nadir CD4 count 0.13c 0.07 -0.18b -0.16b -0.08 0.15 0.08 -- --
HAART -0.02 -0.12c 0.09 0.20b -0.05 -0.06 0.05 -0.17b -0.26b --
HCV -0.04 0.12c 0.26a -0.15b -0.28b -0.20c 0.09 0.05 0.1 -0.11 --
Alcohol (quantity) -0.14b 0.13b -0.13b -0.18b -0.05 -0.12 -0.21b -0.03 -0.01 -0.09 0.10 --
IDU 0.04 -0.01 0.12b -0.09 -0.40a -0.18c -0.11 0.04 0.08 -0.03 0.63a 0.16b --
Spearman correlation coefficients: asignificant at the <.0001 level, bsignificant at the 0.05 level, csignificant at the 0.10 level. HDS (HIV Dementia Scale) and EXIT (Executive Interview) raw scores. Educational level class variable (0-8, 9-12, >12 years formal education). Time to AIDS inyears from first HIV-postive test. Nadir CD4 count by patient history. HAART vs. no antiretroviral treatment at time of interview. HCV co-infected. Alcohol quantityconsumed per occasion (> 4 drinks s. < 4 drinks). History of IDU (Injection Drug Use).
Multivariate linear regression models predicting EXIT and HDS continuous score outcomes
EXIT (N = 115) HDS (N = 119)
Coefficient SEa p-value Variable Coefficient SEa p-value
-0.24 2.89 0.93 Intercept 18.81 2.22 <.00010.03 0.04 0.44 Age (years) -0.09 0.04 0.02
Race/ethnicity (vs. White)1.31 0.70 0.06 African American -1.20 0.62 0.06-0.94 1.73 0.59 Hispanic -1.80 1.43 0.21-0.76 0.92 0.41 Other 0.25 0.80 0.76
Years education (vs. > 12)2.37 0.73 0.002 9 - 12 -0.81 0.65 0.215.83 1.27 <.0001 0 - 8 -3.35 1.10 0.003
Quantity of alcohol consumed (vs. < 4 drinks)0.02 0.63 0.97 > 4 -0.49 0.56 0.38
-0.28 0.71 0.70 AIDS diagnosisb -0.14 0.65 0.820.22 0.10 0.03 Years with HIV 0.03 0.09 0.74
-0.32 0.11 0.006 Time to AIDSc 0.06 0.10 0.55-- -- -- CD4 count < 300 -1.15 0.57 0.05
0.74 0.59 0.21 CD4 count < 200 -- -- --
-- -- -- History of non-seizure LOC per patientd -1.22 0.55 0.030.50 0.90 0.58 History of head trauma (chart review) -- -- --0.56 0.67 0.41 HCV co-infection -- -- --0.75 0.61 0.22 History of any psychiatric disorder per patient -- -- --
a Standard Error, b History of any AIDS-defining illness as defined by the Centers for Disease Control and Prevention HIV disease stage C classification,
excluding those with CD4 count below 200 as sole AIDS diagnosis, c years from first HIV-positive test to first AIDS-defining illness, d Loss of consciousness (LOC).
-- indicates variable not included in model.
EXIT model: R2 = 0.30, Adjusted R2 = 0.20, F = 3.1 (p = 0.0006)
HDS model: R2 = 0.21, Adjusted R2 = 0.12, F = 2.3 (p = 0.01)
Background
• HIV-Associated Dementia (HAD) is a progressive neurological and AIDS-defining disorder characterized by cognitive impairment, psychomotor slowing, and behavior abnormalities affecting 25 to 65% of AIDS patients and up to 15% of asymptomatic HIV-1-infected persons.
• The diagnosis of HAD by criteria developed by the American Academy of Neurology requires a typical clinical presentation and a combination of complex, costly and time consuming neuropsychological, radiological and cerebrospinal fluid diagnostic testing. The HIV Dementia Scale (HDS) and Executive Interview (EXIT) are two brief neuropsychological screening tests that have been validated as highly sensitive andspecific for detecting HAD.
• Affected individuals often demonstrate poor compliance with medical appointments and treatments, and many patients and doctors mistake signs of dementia for depression or HIV-related stress.
• While HAART has prevented and even partially reversed HAD, recently there has been a resurgence likely associated with prolonged survival and treatment failures due to drug resistance.
• Incarcerated individuals may be at higher risk for HIV-associated cognitive impairment due to history of injection druguse and co-infections such as HCV, and lower “cognitive reserve” associated with limited educational and occupational experience.
• HAD is particularly challenging in the correctional setting, andhas not previously been studied in an incarcerated population.
Methods
• Cross-sectional study design• 1 California Department of Corrections medical
referral facility• 236 known HIV-positive inmates• Face-to-face demographic, behavioral, and clinical
risk assessment questionnaire• 2 brief neuropsychological screens for HAD
Executive Interview (EXIT)HIV Dementia Scale (HDS)
• Medical chart review
Study Population (N = 236)• Male inmates• 104 (44%) African American, 18 (8%) Hispanic, 75
(32%) White, and 38 (16%) of other race/ethnicity• Mean age 39.6 (SD 7.1, range 23 - 62) • 22 (9%), 157 (67%), and 56 (24%) with 0 - 8, 9 - 12,
and > 12 years education respectively• 127 (54%) history of IDU• 88 (38%) history of alcoholism• 115 (51%) HCV co-infected• 129 (56%) history of AIDS-defining illness• Mean CD4 count 396 (SD 236, range 6 – 1247)
Race/Ethnicity by Age (years)
0
10
20
30
40
50
60
70
80
African American Hispanic White
% i
n a
ge
gro
up
< 39
> 39
Educational Level by Age Group Statified by Race/Ethnicity
0
10
20
30
40
50
60
70
80
African American < 39 African American > 39 Hispanic < 39 Hispanic > 39 White < 39 White > 39
Race/Ethnicity and Age Group
% a
t ed
uca
tio
na
l le
vel
0 - 8 9 - 12 > 12 years education
HAART by Educational Level Stratified by Race/Ethnicity
0
10
20
30
40
50
60
70
80
African American Hispanic White
Educational Level
% o
n H
AA
RT
0 - 8 9 - 12 > 12 years education
Crude RRs for low EXIT and HDS scores by selected demographic and clinical characteristics
Low EXITaNormal EXIT Crude RR 95% CI Low HDSb
Normal HDS Crude RR 95% CI
N(%) N(%) N(%) N(%)
38(16.2) 196(83.8) 89(37.7) 147(62.3)Age (years)
7(14.0) 43(86.0) 1.0 <35 15(30.0) 35(70.0) 1.0
25(15.4) 137(84.6) 1.0 (0.5,2.4) 35-49 52(37.4) 87(62.6) 1.2 (0.8,2.0)
6(27.3) 16(72.7) 1.9 (0.7,5.1) >50 13(59.1) 9(40.9) 2.0 (1.1,3.4)Educational level
5(8.9) 51(91.1) 1.0 at least some college 14(25.0) 42(75.0) 1.0
21(13.6) 134(86.5) 1.5 (0.6,3.8) 9th to 12th grade 62(39.5) 95(60.5) 1.6 (1.0,2.6)
12(54.6) 10(45.5) 6.1 (2.4,15.3) 1st to 8th grade 13(59.1) 9(40.9) 2.4 (1.3,4.2)Race/ethnicity
7(9.3) 68(90.7) 1.0 White 17(22.3) 58(77.3) 1.0
21(20.4) 82(79.6) 2.2 (1.0,4.9) African American 48(46.2) 56(53.9) 2.0 (1.3,3.2)
5(27.8) 13(72.2) 3.0 (1.1,8.3) Hispanic 7(38.9) 11(61.1) 1.7 (0.8,3.5)
5(13.1) 32(86.5) 1.4 (0.5,4.3) Other 17(44.7) 21(55.3) 2.0 (1.1,3.4)
Frequency of alcohol consumption
2(4.1) 47(95.9) < once per month 17(34.0) 33(66.0) 1.0
13(16.5) 66(83.5) 4.0 (1.0,17.1) once/twice per week 31(38.8) 49(61.3) 1.4 (0.7,1.8)
23(21.7) 83(78.3) 5.3 (1.3,21.7) daily drinker 41(38.7) 65(61.3) 1.4 (0.7,1.8)Quantity of alcohol consumed per occasion
13(12.0) 95(88.0) 1.0 <3 drinks 35(32.4) 73(67.6) 1.0
25(19.8) 101(80.2) 1.6 (0.9,3.1) >4 drinks 54(42.2) 74(57.8) 1.3 (0.9,1.8)AIDS diagnosisc
20(20.0) 80(80.0) 1.0 No 37(37.0) 63(63.0) 1.0
16(12.6) 111(87.4) 0.6 (0.3,1.2) Yes 48(37.2) 81(62.8) 1.0 (0.7,1.4)Current CD4 countd
27(16.3) 139(83.7) 1.0 >200 63(37.7) 104(62.3) 1.0
9(15.0) 51(85.0) 0.9 (0.5,1.8) <200 21(34.3) 40(65.6) 0.9 (0.6,1.4)Nadir CD4 Count per patientd
18(18.4) 80(81.6) 1.0 >200 30(30.6) 68(69.4)
13(11.8) 97(88.2) 0.6 (0.3,1.2) <200 44(39.3) 68(60.7) 1.3 (0.9,1.9)Current ARTe
18(13.7) 113(86.3) 1.0 HAART 51(38.4) 82(61.7) 1.0
18(19.2) 76(80.9) 1.4 (0.8,2.5) None 33(35.1) 61(64.9) 0.9 (0.6,1.3)HCV status
12(11.0) 97(90.0) 1.0 Negative 38(34.9) 71(61.7) 1.0
24(21.2) 89(78.8) 1.9 (1.0,3.7) Positive 44(38.3) 71(61.7) 1.1 (0.8,1.6)History of psychiatric disorder per patient
12(12.4) 85(87.6) 1.0 No 38(38.8) 60(61.2) 1.0
26(19.0) 111(81.0) 1.5 (0.8,2.9) Yes 51(37.0) 87(63.0) 1.0 (0.7,1.3)Non-seizure LOC per patientf
16(15.8) 85(84.2) 1.0 No 30(29.4) 72(70.6) 1.0
21(16.0) 110(84.0) 1.0 (0.6,1.8) Yes 58(43.9) 74(56.1) 1.5 (1.0,2.1)History of seizures
19(14.1) 116(85.9) 1.0 No neurologic disorders 48(35.3) 88(64.7) 1.0
9(28.1) 23(71.9) 2.0 (1.1,4.0) Yes 14(43.8) 18(56.3) 1.2 (0.8,2.0)
a EXIT score >11. b HDS score <10. c History of any AIDS-defining illness as defined by the Centers for Disease Control and
Prevention HIV disease stage C classification. d CD4 T-lymphocyte count (X 106/L). e Antiretroviral Therapy (ART).f Loss of consciousness (LOC).
Purpose
• Estimate associations between behavioral and clinical covariates and performance on neuropsychological screening tests for HAD
• Estimate the prevalence of HAD in an incarcerated population
• Assess the utility of neuropsychological screening for cognitive impairment in an incarcerated population
Adjusted (multivariate)
• Educational level was the most significant predictor of both EXIT and HDS continuous score outcomes
• Years with HIV and years to progress to AIDS were additional significant predictors of EXIT score
• Older age, CD4 count < 300, and history on non-seizure LOC were additional significant predictors of HDS score
ReferencesBerghuis JP, Uldall KK, Lalonde B. Validity of two scales in identifying HIV-associated dementia. J Acquir Immune Defic Syndr 1999,21:134-140.
Eggers C. HIV-1 associated encephalopathy and myelopathy. J Neurol 2002,249:1132-1136.
Farinpour R, Miller EN, Satz P, Selnes OA, Cohen BA, Becker JT, Skolasky Jr RL, Visscher BR. Psychosocial risk factors of HIV morbidity and mortality: findings from the Multicenter AIDS Cohort Study (MACS). Journal of Clinical and Experimental Neuropsychology 2003,25(5):654-670.
Langford TD, Letendre SL, Larrea GL, Masliah E. Changing patterns in the neuropathogenesis of HIV during the HAART era. Brain Pathology 2003,13:195-210.
Nomenclature and research case definitions for neurologic manifestations of human immunodeficiency virus-type 1 (HIV-1) infection. Report of a Working Group of the American Academy of Neurology AIDS Task Force. Neurology 1991,41:778-785.
Power C, Selnes OA, Grim JA, McArthur JC. HIV Dementia Scale: a rapid screening test. J Acquir Immune Defic SyndrHum Retrovirol 1995,8:273-278.
Satz P, Morgenstern H, Miller EN, Selnes OA, McArthur JC, Cohen BA, Wesch J, Becker JT, Jacobson L, D’Elia LF, vanGorp W, Visscher B. Low education as a possible risk factor for cognitive abnormalities in HIV-1: findings from themulticenter AIDS Cohort Study (MACS). J Acquir Immune Defic Syndr 1993,6:503-511.
Stern RA, Silva SG, Chaisson N, Evans DL. Influence of cognitive reserve on neuropsychological functioning in asymptomatic Human Immunodeficiency Virus-1 infection. Arch Neur 1996,53:148-153.
ResultsUnadjusted
• Mean EXIT and/or HDS scores differed by age, educational level, race/ethnicity, alcohol consumption, and history of any psychiatric disorder per patient (p < 0.05)
• Mean EXIT and/or HDS scores differed by current CD4 count, nadir CD4 count per patient, treatment with HAART, HCV co-infection, and history of seizures (p < 0.10)
• > 50 years old, < 8 years education, non-White race/ethnicity, daily alcohol use, HCV co-infection, history of non-seizure LOC, and history of seizures were associated with increased risk for HAD-positive screen by EXIT and/or HDS based on the previously validated cut-off scores
Conclusions
• 16% screened positive for HAD by the EXIT and 38% by the HDS
• Disagreement between screening outcomes and higher prevalence of HAD estimated by the HDS are likely due to lower educational level and other psychosocial variables common in incarcerated populations
• Both the EXIT and the HDS were quickly and easily administered by non-clinical staff and well-tolerated by study participants
• Brief neuropsychological screening, once standardized for this population, has potential for detecting possible HAD as well as monitoring an individual’s neurocognitive function over time
Future Directions
• Further investigation involving an incarcerated HIV-seronegativecontrol group is underway to better estimate neurocognitiveimpairment attributable to HIV
• A follow-up group of HIV-infected participants are currently being retested to determine factors associated with progression and improvement in neurocognitive function
Background
• HIV-Associated Dementia (HAD) is a progressive neurological and AIDS-defining disorder characterized by cognitive impairment, psychomotor slowing, and behavior abnormalities affecting 25 to 65% of AIDS patients and up to 15% of asymptomatic HIV-1-infected persons.
• The diagnosis of HAD by criteria developed by the American Academy of Neurology requires a typical clinical presentation and a combination of complex, costly and time consuming neuropsychological, radiological and cerebrospinal fluid diagnostic testing. The HIV Dementia Scale (HDS) and Executive Interview (EXIT) are two brief neuropsychological screening tests that have been validated as highly sensitive and specific for detecting HAD.
• Affected individuals often demonstrate poor compliance with medical appointments and treatments, and many patients and doctors mistake signs of dementia for depression or HIV-related stress.
• While HAART has prevented and even partially reversed HAD, recently there has been a resurgence likely associated with prolonged survival and treatment failures due to drug resistance.
• Incarcerated individuals may be at higher risk for HIV-
associated cognitive impairment due to history of injection drug use and co-infections such as HCV, and lower “cognitive reserve” associated with limited educational and occupational experience.
• HAD is particularly challenging in the correctional setting, and has not previously been studied in an incarcerated population.
Methods
• Cross-sectional study design• 1 California Department of Corrections medical
referral facility• 236 known HIV-positive inmates• Face-to-face demographic, behavioral, and clinical
risk assessment questionnaire• 2 brief neuropsychological screens for HAD
Executive Interview (EXIT)HIV Dementia Scale (HDS)
• Medical chart review
Purpose
• Estimate associations between behavioral and clinical covariates and performance on neuropsychological screening tests for HAD
• Estimate the prevalence of HAD in an incarcerated population
• Assess the utility of neuropsychological screening for cognitive impairment in an incarcerated population
Study Population (N = 236)• Male inmates• 104 (44%) African American, 18 (8%) Hispanic, 75
(32%) White, and 38 (16%) of other race/ethnicity• Mean age 39.6 (SD 7.1, range 23 - 62) • 22 (9%), 157 (67%), and 56 (24%) with 0 - 8, 9 - 12,
and > 12 years education respectively• 127 (54%) history of IDU• 88 (38%) history of alcoholism• 115 (51%) HCV co-infected• 129 (56%) history of AIDS-defining illness• Mean CD4 count 396 (SD 236, range 6 – 1247)
Race/Ethnicity by Age (years)
0
10
20
30
40
50
60
70
80
African American Hispanic White
% i
n a
ge
gro
up
< 39
> 39
Educational Level by Age Group Statified by Race/Ethnicity
0
10
20
30
40
50
60
70
80
African American < 39 African American > 39 Hispanic < 39 Hispanic > 39 White < 39 White > 39
Race/Ethnicity and Age Group
% a
t ed
uca
tio
nal
leve
l
0 - 8 9 - 12 > 12 years education
HAART by Educational Level Stratified by Race/Ethnicity
0
10
20
30
40
50
60
70
80
African American Hispanic White
Educational Level
% o
n H
AA
RT
0 - 8 9 - 12 > 12 years education
Mean and standard deviation EXIT and HDS scores by selected demographic and clinical characteristics
EXITa HDSb
N mean+s.d. p-value N mean+s.d. p-value
234 6.7+3.8 Raw score 236 11.4+3.1
Age (years)
50 6.3+3.9 0.47 <35 50 12.4+2.9 0.01
162 6.7+3.4 35-49 164 11.3+3.1
22 7.5+5.3 >50 22 10.2+2.5
Educational level
56 5.1+2.8 <.0001 at least some college 56 12.6+2.8 <.0001
156 6.8+3.5 9th to 12th grade 157 11.3+2.9
22 10.7+5.1 1st to 8th grade 22 9.3+3.4
Race/ethnicity
75 5.9+3.2 0.10 White 75 12.3+3.0 0.01
103 7.2+4.0 African American 104 10.9+3.0
18 7.7+5.8 Hispanic 18 11.3+3.4
37 6.6+3.1 Other 38 11.0+3.0
Frequency of alcohol consumption
49 5.7+2.8 0.02 < once per month 50 11.7+2.9 0.63
79 6.4+3.1 once/twice per week 80 11.5+3.0
106 7.4+4.5 daily drinker 106 11.2+3.2
Quantity of alcohol consumed per occasion
108 6.1+3.4 0.02 <3 drinks 108 11.9+3.0 0.03
126 7.2+4.1 >4 drinks 128 11.0+3.0AIDS diagnosisc
100 6.8+4.1 0.74 No 100 11.6+3.2 0.61
127 6.6+3.6 Yes 129 11.4+3.0Current CD4 countd
166 6.7+3.9 0.75 >200 137 11.8+3.1 0.06
60 6.5+3.7 <200 91 11.0+3.1Nadir CD4 Count per patientd
98 6.8+3.9 0.28 >200 99 12.0+3.0 0.06
110 6.3+3.1 <200 114 11.1+3.0Current ARTe
131 6.3+3.7 0.10 HAART 133 11.4+3.2 0.77
94 7.2+4.1 None 94 11.5+3.0
HCV status
109 6.2+3.7 0.09 Negative 110 11.5+3.3 0.62
113 7.1+4.0 Positive 117 11.3+3.0
History of any psychiatric disorder per patient
97 6.2+3.2 0.04 No 98 11.4+3.1 0.97
137 7.1+4.2 Yes 138 11.4+3.1History of non-seizure LOC per patientf
101 6.5+4.0 0.52 No 102 11.9+3.0 0.06
131 6.9+3.7 Yes 132 11.1+3.1
History of seizures
135 6.5+4.1 0.06 No neurologic disorders 136 11.7+3.0 0.10
32 8.1+4.4 Yes 32 10.7+3.7
a Possible EXIT scores range from 0 to 25 with higher score indicating increasing cognitive impairment. b Possible HDS scores
range from 0 to 16 with lower scores indicating increasing cognitive impairment. C History of any AIDS-defining illness as
defined by the Centers for Disease Control and Prevention HIV disease stage C classification. d CD4 T-lymphocyte count
(X 106/L). e Antiretroviral Therapy (ART). f Loss of consciousness (LOC). T-tests were used to compare means for class
variables with 2 levels. Analysis of variance was used for class variables having greater than 2 levels.
Crude RRs for low EXIT and HDS scores by selected demographic and clinical characteristics
Low EXITaNormal EXIT Crude RR 95% CI Low HDSb
Normal HDS Crude RR 95% CI
N(%) N(%) N(%) N(%)
38(16.2) 196(83.8) 89(37.7) 147(62.3)Age (years)
7(14.0) 43(86.0) 1.0 <35 15(30.0) 35(70.0) 1.0
25(15.4) 137(84.6) 1.0 (0.5,2.4) 35-49 52(37.4) 87(62.6) 1.2 (0.8,2.0)
6(27.3) 16(72.7) 1.9 (0.7,5.1) >50 13(59.1) 9(40.9) 2.0 (1.1,3.4)Educational level
5(8.9) 51(91.1) 1.0 at least some college 14(25.0) 42(75.0) 1.0
21(13.6) 134(86.5) 1.5 (0.6,3.8) 9th to 12th grade 62(39.5) 95(60.5) 1.6 (1.0,2.6)
12(54.6) 10(45.5) 6.1 (2.4,15.3) 1st to 8th grade 13(59.1) 9(40.9) 2.4 (1.3,4.2)Race/ethnicity
7(9.3) 68(90.7) 1.0 White 17(22.3) 58(77.3) 1.0
21(20.4) 82(79.6) 2.2 (1.0,4.9) African American 48(46.2) 56(53.9) 2.0 (1.3,3.2)
5(27.8) 13(72.2) 3.0 (1.1,8.3) Hispanic 7(38.9) 11(61.1) 1.7 (0.8,3.5)
5(13.1) 32(86.5) 1.4 (0.5,4.3) Other 17(44.7) 21(55.3) 2.0 (1.1,3.4)
Frequency of alcohol consumption
2(4.1) 47(95.9) < once per month 17(34.0) 33(66.0) 1.0
13(16.5) 66(83.5) 4.0 (1.0,17.1) once/twice per week 31(38.8) 49(61.3) 1.4 (0.7,1.8)
23(21.7) 83(78.3) 5.3 (1.3,21.7) daily drinker 41(38.7) 65(61.3) 1.4 (0.7,1.8)Quantity of alcohol consumed per occasion
13(12.0) 95(88.0) 1.0 <3 drinks 35(32.4) 73(67.6) 1.0
25(19.8) 101(80.2) 1.6 (0.9,3.1) >4 drinks 54(42.2) 74(57.8) 1.3 (0.9,1.8)AIDS diagnosisc
20(20.0) 80(80.0) 1.0 No 37(37.0) 63(63.0) 1.0
16(12.6) 111(87.4) 0.6 (0.3,1.2) Yes 48(37.2) 81(62.8) 1.0 (0.7,1.4)Current CD4 countd
27(16.3) 139(83.7) 1.0 >200 63(37.7) 104(62.3) 1.0
9(15.0) 51(85.0) 0.9 (0.5,1.8) <200 21(34.3) 40(65.6) 0.9 (0.6,1.4)Nadir CD4 Count per patientd
18(18.4) 80(81.6) 1.0 >200 30(30.6) 68(69.4)
13(11.8) 97(88.2) 0.6 (0.3,1.2) <200 44(39.3) 68(60.7) 1.3 (0.9,1.9)Current ARTe
18(13.7) 113(86.3) 1.0 HAART 51(38.4) 82(61.7) 1.0
18(19.2) 76(80.9) 1.4 (0.8,2.5) None 33(35.1) 61(64.9) 0.9 (0.6,1.3)HCV status
12(11.0) 97(90.0) 1.0 Negative 38(34.9) 71(61.7) 1.0
24(21.2) 89(78.8) 1.9 (1.0,3.7) Positive 44(38.3) 71(61.7) 1.1 (0.8,1.6)History of psychiatric disorder per patient
12(12.4) 85(87.6) 1.0 No 38(38.8) 60(61.2) 1.0
26(19.0) 111(81.0) 1.5 (0.8,2.9) Yes 51(37.0) 87(63.0) 1.0 (0.7,1.3)Non-seizure LOC per patientf
16(15.8) 85(84.2) 1.0 No 30(29.4) 72(70.6) 1.0
21(16.0) 110(84.0) 1.0 (0.6,1.8) Yes 58(43.9) 74(56.1) 1.5 (1.0,2.1)History of seizures
19(14.1) 116(85.9) 1.0 No neurologic disorders 48(35.3) 88(64.7) 1.0
9(28.1) 23(71.9) 2.0 (1.1,4.0) Yes 14(43.8) 18(56.3) 1.2 (0.8,2.0)
a EXIT score >11. b HDS score <10. c History of any AIDS-defining illness as defined by the Centers for Disease Control and
Prevention HIV disease stage C classification. d CD4 T-lymphocyte count (X 106/L). e Antiretroviral Therapy (ART).f Loss of consciousness (LOC).
Multivariate linear regression models predicting EXIT and HDS continuous score outcomes
EXIT (N = 115) HDS (N = 119)
Coefficient SEa p-value Variable Coefficient SEa p-value
-0.24 2.89 0.93 Intercept 18.81 2.22 <.00010.03 0.04 0.44 Age (years) -0.09 0.04 0.02
Race/ethnicity (vs. White)1.31 0.70 0.06 African American -1.20 0.62 0.06-0.94 1.73 0.59 Hispanic -1.80 1.43 0.21-0.76 0.92 0.41 Other 0.25 0.80 0.76
Years education (vs. > 12)2.37 0.73 0.002 9 - 12 -0.81 0.65 0.215.83 1.27 <.0001 0 - 8 -3.35 1.10 0.003
Quantity of alcohol consumed (vs. < 4 drinks)0.02 0.63 0.97 > 4 -0.49 0.56 0.38
-0.28 0.71 0.70 AIDS diagnosisb -0.14 0.65 0.820.22 0.10 0.03 Years with HIV 0.03 0.09 0.74
-0.32 0.11 0.006 Time to AIDSc 0.06 0.10 0.55-- -- -- CD4 count < 300 -1.15 0.57 0.05
0.74 0.59 0.21 CD4 count < 200 -- -- --
-- -- -- History of non-seizure LOC per patientd -1.22 0.55 0.030.50 0.90 0.58 History of head trauma (chart review) -- -- --0.56 0.67 0.41 HCV co-infection -- -- --0.75 0.61 0.22 History of any psychiatric disorder per patient -- -- --
a Standard Error, b History of any AIDS-defining illness as defined by the Centers for Disease Control and Prevention HIV disease stage C classification,
excluding those with CD4 count below 200 as sole AIDS diagnosis, c years from first HIV-positive test to first AIDS-defining illness, d Loss of consciousness (LOC).
-- indicates variable not included in model.
EXIT model: R2 = 0.30, Adjusted R2 = 0.20, F = 3.1 (p = 0.0006)
HDS model: R2 = 0.21, Adjusted R2 = 0.12, F = 2.3 (p = 0.01)
Inter-correlations between EXIT and HDS scores and selected demographic, behavioral, and clinical characteristics
HDS EXIT Age Edu African Hispanic Time to CD4 Nadir HAART HCV Alcohol IDU
(years) level American AIDS count CD4 (quantity)
HDS --
EXIT -0.38a --
Age (years) -0.18b 0.05 --
Educatonal level 0.27a -0.33a 0.15b --
African American -0.25b 0.17b 0.15b 0.03 --
Hispanic -0.14 0.09 -0.20b -0.19c -- --
Time to AIDS 0.10 -0.14 0.10 0.02 -0.01 0.07 --
CD4 count 0.09 0.01 -0.12b -0.12c -0.03 0.11 -0.03 --
Nadir CD4 count 0.13c 0.07 -0.18b -0.16b -0.08 0.15 0.08 -- --
HAART -0.02 -0.12c 0.09 0.20b -0.05 -0.06 0.05 -0.17b -0.26b --
HCV -0.04 0.12c 0.26a -0.15b -0.28b -0.20c 0.09 0.05 0.1 -0.11 --
Alcohol (quantity) -0.14b 0.13b -0.13b -0.18b -0.05 -0.12 -0.21b -0.03 -0.01 -0.09 0.10 --
IDU 0.04 -0.01 0.12b -0.09 -0.40a -0.18c -0.11 0.04 0.08 -0.03 0.63a 0.16b --
Spearman correlation coefficients: asignificant at the <.0001 level, bsignificant at the 0.05 level, csignificant at the 0.10 level. HDS (HIV Dementia Scale) and EXIT (Executive Interview) raw scores. Educational level class variable (0-8, 9-12, >12 years formal education). Time to AIDS inyears from first HIV-postive test. Nadir CD4 count by patient history. HAART vs. no antiretroviral treatment at time of interview. HCV co-infected. Alcohol quantityconsumed per occasion (> 4 drinks s. < 4 drinks). History of IDU (Injection Drug Use).
Unadjusted
• Mean EXIT and/or HDS scores differed by age, educational level, race/ethnicity, alcohol consumption, and history of any psychiatric disorder per patient (p < 0.05)
• Mean EXIT and/or HDS scores differed by current CD4 count, nadir CD4 count per patient, treatment with HAART, HCV co-infection, and history of seizures (p < 0.10)
• > 50 years old, < 8 years education, non-White race/ethnicity, daily alcohol use, HCV co-infection, history of non-seizure LOC, and history of seizures were associated with increased risk for HAD-positive screen by EXIT and/or HDS based on the previously validated cut-off scores
Adjusted (multivariate)
• Educational level was the most significant predictor of both EXIT and HDS continuous score outcomes
• Years with HIV and years to progress to AIDS were additional significant predictors of EXIT score
• Older age, CD4 count < 300, and history on non-seizure LOC were additional significant predictors of HDS score
Conclusions
• 16% screened positive for HAD by the EXIT and 38% by the HDS
• Disagreement between screening outcomes and higher prevalence of HAD estimated by the HDS are likely due to lower educational level and other psychosocial variables common in incarcerated populations
• Both the EXIT and the HDS were quickly and easily administered by non-clinical staff and well-tolerated by study participants
• Brief neuropsychological screening, once standardized for this population, has potential for detecting possible HAD as well as monitoring an individual’s neurocognitive function over time
Future Directions
• Further investigation involving an incarcerated HIV-seronegative control group is underway to better estimate neurocognitive impairment attributable to HIV
• A follow-up group of HIV-infected participants are currently being retested to determine factors associated with progression and improvement in neurocognitive function
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