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 Results

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 ) 22 (9%), 157 (67%), and 56 (24%) with 0 - 8, , 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)

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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