Thinking and Memory Problems in People With HIV

Study Overview
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Brief Summary
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Background: - People with human immunodeficiency virus (HIV) can sometimes develop thinking and memory problems. These problems can vary widely, from few symptoms to severe problems with memory and concentration. It initially was thought that good HIV treatment could prevent almost all HIV-related memory problems. However, even people with low HIV viral loads can have these problems. It may be caused by HIV affecting the brain and spinal fluid. It is not yet clear why HIV causes these problems and why they may be worse in some people than others. Researchers want to study people with HIV and healthy volunteers to see how HIV may affect people with only small amounts of the virus in their blood. Objectives: - To study thinking and memory problems in individuals with HIV that is otherwise controlled with medications. Eligibility: Individuals between 18 of age or older whose HIV has been controlled with medications for at least 1 year. Healthy volunteers between 18 of age or older. Design: Participants will be screened with a physical exam and medical history. Blood and urine samples will be collected. A neurological test will also be given. Participants will have a baseline imaging study of the brain. Within 12 weeks of the first visit, participants will have a second visit. Additional blood samples will be drawn. Another brain imaging study will be performed. Within 8 weeks of the second visit, participants will have a third visit to collect more blood samples. They will also provide spinal fluid samples, either as a single visit or a longer procedure. After this visit, participants will return every 12 months for up to 10 years. Blood samples will be collected as needed at these visits. Thinking and memory tests and imaging studies may also be given as needed. Spinal fluid may be collected at one visit a year.

Detailed Description
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The natural history of neurocognitive impairment in human immunodeficiency virus (HIV)-infected individuals remains poorly understood. While the advent of highly active antiretroviral therapy (HAART) has led to a decreased incidence of the most severe form of HIV associated neurocognitive disorders (HAND), HIV-associated dementia, it does not appear to have impacted overall prevalence of HAND. Existing evidence suggests that the central nervous system (CNS) could be an important reservoir for HIV regardless of cumulative time on treatment. This 20 year multi-institute natural history protocol will identify approximately 500 HIV-infected individuals and 250 healthy volunteers for enrollment in multiple HAND studies at the National Institutes of Health (NIH). Subjects will undergo a screening and evaluation assessment, which will include blood and urine collection, neuropsychological testing, Client Diagnostic Questionnaire (CDQ), and brain magnetic resonance imaging (MRI) with optional lumbar puncture and ophthalmology exam to repeat yearly for up to ten years. The option to have a lumbar drain is only on the first visit and extended to HIV positive individuals only. Participants will have the option of doing a positron emission tomography/computed tomography (PET/CT) imaging if they have previously had a PET/CT scan under this study. Cerebrospinal fluid (CSF) markers of immune activation, chronic monocyte activation, cytomegalovirus/Epstein-Barr virus (CMV/EBV) infection/reactivation, and neuronal injury will be collected. In addition, HIV viral load and genotype, genetic susceptibility factors and CNS penetration-effectiveness score (CPE) and CSF levels of antiretroviral drugs may be assessed. A repository of cryopreserved biological samples will be developed and used for validation of candidate biomarkers in future studies. Collection and analysis of these data will not only enhance understanding of the CNS as a potential HIV reservoir in virally-controlled individuals but will further define the association among cortical thickness, biomarkers and neurocognitive function in an aging HIV-infected population.

Official Title
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An Evaluation of HIV-associated Neurocognitive Disorders (HAND) in Virologically Controlled Patients

Conditions
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HIV Positive

Participation Criteria
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Eligibility Criteria
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INCLUSION CRITERIA: All Subjects (HIV-infected and HIV-negative Controls): While different individual HIV neurocognitive studies have specific selection criteria, especially related to HIV viral load and antiretroviral therapy, inclusion criteria for this overarching protocol will be flexible in order to identify the broadest base of potential enrollees possible. Men and women, 18 years of age and older Ability to sign informed consent by the subject At least seventh grade educational level and ability to speak, read, and understand English. Education level will be assessed by subject self-report. Because many of the neuropsychological subtests were validated using United States norms, subjects must be native English speakers or if foreign-born, demonstrate ability to understand the English language at the time of protocol consent and neuropsychological testing. Consent to store blood and tissue Willing to participate in this study for 10 years HIV-infected Only: HIV-1 infection, as documented by OraQuick rapid test using venipuncture whole blood, or fingerstick whole blood; or with HIV-1/HIV-2 Multispot rapid test and Western Blot as determined by NIH Clinical Pathology Laboratory or Leidos Biomedical Research. Monitoring Laboratory. Outside primary medical doctor who provides care Plasma HIV-RNA <50 copies/mm3 or BLD for greater than one year. Patients who experience transitory episodes of an HIV viral load > 50 copies/mm3 preceded and followed by plasma viremia < 50 copies/mm3 may be included. At least one year of continuous ART HIV-negative Controls Only: 1.HIV-antibody negative EXCLUSION CRITERIA: Illness or other condition that, in the opinion of the PI, may interfere with study participation at the time of enrollment, including, but not limited to those listed below: CNS infections: this includes but is not limited to Varicella zoster virus (VZV) encephalitis, CNS lymphoma and toxoplasmosis. Subjects who have recovered from effectively treated CNS infections may be considered once they resume baseline daily activities. Non-CNS opportunistic infections: subjects who recovered from or are completing treatment for non-CNS opportunistic infections (OIs) (e.g., Pneumocystis pneumonia, Candida esophagitis, or pulmonary TB) can be enrolled if they have returned to self-reported baseline activity and functional level. Conditions other than HAND associated with cognitive impairment or dementia such as Alzheimer s, Parkinson s disease, head injury with loss of consciousness >30 minutes, untreated sleep apnea with day-time sleepiness, or seizure disorders. Subjects with a history of seizure disorder with no seizure activity that are on a stable, non-sedating anti-seizure regimen for >6 months may be enrolled. Concurrent severe, unstable psychiatric illness that, in the opinion of the investigators, may interfere with study participation and/or data interpretation. Subjects on psychotropic anxiolytic, attention deficit-hyperactivity disorder (ADHD), and other psychiatric medications may be included if clinically stable for >6 months. Concurrent substance abuse that, in the opinion of the investigators may interfere with study participation and/or data interpretation. Active substance abuse includes illegal drug use and/or excessive narcotic or alcohol use as determined by the investigator. Urine drug screen will be performed on all subjects. Use of nicotine containing products will not be an exclusion criterion. Contraindication to MRI/ MRS scanning, including pacemakers or other implanted electrical devices, brain stimulators, some types of dental implants, aneurysm clips (metal clips on the wall of a large artery), metallic prostheses (including metal pins and rods, heart valves, and cochlear implants), implanted delivery pump, or shrapnel fragments. Patients requiring a low dose oral benzodiazepine for mild to moderate claustrophobia will be allowed to participate. Pregnancy testing will be performed in enrolled participants of childbearing potential 48 hours prior to any MRI. Medications: narcotics, psychiatric, and anti-seizure medications will not be allowed except under certain conditions as noted above. Corticosteroids may be permitted for subjects on stable short-term therapy without CNS disease (i.e., resolving Pneumocystis pneumonia). Participants must be willing not to take the following medications within 48 hours of neuropsychological testing : sedating antihistamines such as diphenhydramine, zolpidem and other drugs identified by the study team that are associated with altered alertness or impaired memory. Inability to refrain from use of anticoagulant/antiplatelet medication, such as dipyridamole (Persantine), clopidogrel (Plavix), dabigatran (Pradaxa), or warfarin (Coumadin) for at least 72 hours prior to invasive procedures (lumbar puncture [LP], lumbar drain). Aspirin does not need to be held. Prior or planned/anticipated exposure to radiation due to clinical care or participation in other research protocols, which would exceed the recommended acceptable annual limit of radiation exposure once accounting for the requirements of the current study. Pregnant or Lactating females are excluded due to exposure to the radioactive compound for PET/CT scans, which may be excreted in the breast milk and could be potentially harmful to breast-fed infants. There is also exposure to radiation from the CT part of the PET/CT scan and the lumbar puncture if done under fluoroscopy. Women of childbearing potention must have a negative serum or urine pregnancy 48 hours prior to any radiation exposure.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 110 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| DOD<br>Participants that are from IDCRP | |
| HIV negative controls<br>Participants that do not have HIV infection | |
| HIV positive<br>Participants that have HIV infection | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| To characterize in detail the natural course of HAND in subjects with prolonged plasma HIV virologic suppression (<50 copies/mL). | The prevalence of neurocognitive impairment in this cohort will be high despite HIV plasma viremia below the limit of detection (BLD) in the blood as chronic activation may be mediating neuronal damage and result in cognitive impairment. | Annually | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Healthy Controls, HIV Positive, Neuropyschological Testing, Thinking and Memory, Lumbar Drain/Puncture, Natural History