We arrived in DC to a bit of “indian Summer” with highs in the upper 70s, so in spite of the hours of travel I felt right at home with San Diego weather. It won’t last, but it made for a nice transition.

The first day of the conference was very productive and a number of topics of interest were discussed. One of that primary reasons I like this conference is that they put young researchers just getting started front and center. This is where great new ideas and a fresh perspective come from and I want to do whatever I can to support and influence the direction and approach to research that these young people adopt as their careers progress

[This blog is a work in progress and a collaboration between Michael Donovan and Jerry Turner who attended remotely. He will be adding slides from the day over the next few days as I couldn’t get a good view of the projected material to share.]

Key learnings from the day.

• For those infected perinatally (in the womb or at birth) the impact of HIV related accelerated aging starts early. Many of them need to be tracked by physicians at least 10 years earlier than the rest of the HIV population. For example, women may experience menopause symptoms as early as their late 30s.

• The next topics focused on predictors and indicators of early dementia and cognitive decline. A good predictor that is easy to implement is gait testing (8 ft out and back). Smoking, diabetes and carrying extra weight (BMI) are common attributes of those who progress more quickly.

• From an international perspective, getting people on ART and controlling viral load (replication) is key to a reduction in symptoms of neurocognitive decline.

• Resilience, or the impact of support on a person’s well-being, is important in managing healthy aging and cognitive decline. This includes personal resilience, social group participation and community support.

• NIH discussed the impact of loneliness on disease progression and cognitive decline. This parallels a paper published by the Surgeon General on the subject.

• Sleep patterns are different in PLWH. No real understanding of why or direct impact, but more study required.

Overall, there was consensus among researchers on faster cognitive decline in PLWH. Exercise, nutrition and social support structures seem to be key differentiators that we can each address.

Session Summaries.

The conference opened with a session on the unique issues faced by those who were born with HIV, known as lifetime survivors. We all deal with accelerated aging, but theirs start at birth, so they face conditions most won’t see until their 50s and 60s as early as their 30’s. One of the key needs presented by a member of this community is to educate medical providers of the unique challenges they face, from sensitivity to medical trauma from an early age to how to evaluate their aging related issues with sensitivity and understanding of early onset. The lifetime survivors group has also developed tools to help the community ask the right questions about their unique challenges when receiving or looking for care.

The discussion moved on to present that transmission at birth (perinatally acquired) can be prevented by ART treatment of the mother and short term treatment of the newborn. Most cases occurred early in the epidemic prior to effective treatment. Studies have shown that early treatment < 2 years of age shows significant results in the health of the person’s immune systems and minimizes the HIV viral reservoir, activation and inflammation.

The session progressed with an abstract on predictors of frailty. This longitudinal study of people over the age of 40 at entry in 2013 looked at social, demographic HIV comorbidities and behavior. The study found 55% non frail, 39% pre-frail, 6% frail out of 976 participants. Weakness, exhaustion and low activity were the most common indicators. CVD, diabetes, smoking, drinking and low activity levels as well as age were the predictors.

Next were predictors of physical function decline. REPRIEVE predicted stations have an anti-inflammatory effect that may slow the decline in physical function, but no statistical difference was shown. 52% of participants did show a decline in physical function, Females and non white race were at greater relative risk of decline. History of depression, BMI > 30, frailty and CVD were at greater risk as well. The differences in women may be reflective of higher rates of other risk factors.

The next discussion was a study of gait speed as a predictor of cognitive decline. Studies do show that gait speed is a predictor, although there are limited studies directly comparing people living with HIV to those without HIV. The proposal is that accelerated aging may be reflected in earlier changes in gait speed. The observational study did show evidence of gait speed as a predictor in people with HIV but not defined well enough to develop a predictive tool.

The next topic is around the neurocognitive effects of HIV. A Kaiser study of patient health records showed that people with hIV were 26% in PLWH vs 14% of those without. Even after adjustment for comorbidities, there was a 58% higher rate of dementia among PLWH. This group were all on ART. Follow on studies showed that there is undiagnosed cognitive impairment in PLWH over and above the health records based study. Next steps include a better understanding of risk factors and possible interventions.

In a discussion of health care and cognitive issues internationally, it was brought up using a case study of a person who had significant impairment and an inabiity to perform basic tasks, Care is most often provided by parents or other older family members. Based on a viral load, here regimen was changed to a modern ARV therapy and the change in functioning was significant. There is also evidence that different subtypes of HIV found across the globe may impact the risk for cognitive impairment. The point was made that it is important to include the impact of normal aging and other comorbidities when assessing neurocognitive decline

The next abstract presentation discussed individual, interpersonal and community resources to promote resilience and whether these could mediate healthy aging and reduce cognitive decline in the study group of aging men who have sex with men., measuring loneliness and depressive symptoms. Individual resilience was a key factor in depression while interpersonal and community resilience were factors in mediating loneliness.

So how does social adversity impact self reported cognitive difficulties? In a canadian study of 846 participants 16% saw a change across up to 3 visits. Socal adversity did have an impact in cognitive difficulties without regard to other factors.

The next abstract discussed the impact of comorbidities on cognitive decline in persons living with HiV. A detectable viral load was associated with a significantly worse trajectory in cognitive decline. The study focused on hypertension, diabetes and hep-C. There is evidence that these comorbidities may affect neurocognitive decline in spite of suppressed viral load.

NIH and Office of AIDS research presented a symposium to discuss the intersection of NIH funded programs covering mental health and HIV.

A study on Loneliness highlighted the difference between social and emotional loneliness. This covered the recent Surgeon General advisory on the implications of loneliness and isolation. the prevalence of loneliness in PLWH was 33.9% compared to 28.5% in the general population.

The next presentation looked at whether any of several models of determining biological age reflected accelerated aging in people with HIV. Some of these models were predictive of accelerated aging, but the results across all models were less conclusive.

A study of the correlation between COPD and neurocognitive function. Given the correlation shown between acceleration in dementia among smokers, this may show some relationship. there is a higher rate of COPD in PLWH.

The final paper was a discussion of translating research questions to models of care for PLWH aging with HIV! One question was on the effectiveness of various care models, via referrals, bringing specialists into the HIV care ecosystems and a true mixed model where specialty care is embedded in the hiv care model. An interdisciplinary approach in NYC was discussed as a potential model, including a community health worker (think case manager) to bring patients into the care model, led by a geriatrician. Using a case manager showed significant improvement in compliance with the care plan.

At the end of the NIMH/OAR session, some noisy person from POZabilities challenged the researchers to answer the question, So What? and find a way to more rapidly turn what they learn into something that directly improves the lives of those aging with HIV. While the question was met with silence from the panel, it started some good offline conversations on how much of this is truly happening, including direct follow up from the Office of AIDS research and several researchers.

Perfect for after lunch, the next discussion was about HIV and sleep. Sleep apnea and other sleep disorders are more common among HIV_ folks htan the general population. There was a measurable and observable impact on sleep patterns in those with HIV.

Finally, there was a discussion on what could be detected in MRI imaging in PWH. Low energy brain scans showed similarity between PLWH and people without HIV who showed mile cognitive impairment.

Lightning sessions.

Predicting frailty in PLWH

Measuring exercise intervention (went mainly back to baseline after return to self guidance)

Trajectory of disability factors - self mastery and social support important factors

Association of gender stigma consciousness among older women with HIV

Smoking cessation in PLWH - no identified co-factors appeared to be significant in actual cessation

Hazardous alcohol consumption association with falls in HIV