Mixed evidence for the combined impact of alcohol use and HIV infection on memory functioning may be attributable to different stratifications of alcohol use , presence of co-occurring substance use and mental health conditions, as well as assessment method. For example, standardized laboratory-based neuropsychological testing tends to assess performance at a single time point and in a highly specific contextual setting. Indeed, the ecological validity of using neuropsychological tests to assess cognitive function having been questioned due to the nature of laboratory settings for neuropsychological testing, the potential for interactive effects of increased demands on cognition in everyday settings and cognitive deficits, and compensatory strategies that may be effective for a laboratory-based task but are not reflected in self-reported memory skills. Although neuropsychological tests provide objective data for specific cognitive deficits, it has been argued that subjective cognitive measures are more sensitive indices for everyday memory functioning [see], such as patients’ experience of everyday memory failures or milder, more variable cognitive struggles that fluctuate over time [e.g., ]. Use of self-report measures may therefore provide a complimentary lens through which to examine the effects of problematic alcohol use on memory functioning among individuals with HIV. For instance,grow rack self-reported memory functioning has been shown to explain variance in self-reported medication management over and beyond that accounted for by neuropsychological test measures. At present there is a general dearth of empirical investigation of the impact of varying levels of alcohol use on self-reported and everyday memory functioning among those with HIV.
This is unfortunate given the well-established associations between memory dysfunction and poor HIV-related outcomes and lower perceived quality of life among individuals with HIV. Further, because even moderate alcohol use may be harmful in this vulnerable population, such questions are relevant for the effective implementation of interventions that heavily tax memory, learning and attention. It is also important to examine these relations in the context of cooccurring substance use and mood disorders, which are common in this population. Accordingly, the primary objective of the current study is to examine the extent to which problematic patterns of alcohol use impact different facets of self-reported everyday memory functioning among a sample of HIV-infected individuals. We hypothesize that problematic alcohol use will be associated with greater perceived memory dysfunction among individuals with HIV, even after controlling for medication adherence, depression, and co-occurring substance use. Given that problematic alcohol use and memory functioning are known to independently influence HIV outcomes, our secondary aim is to assess the extent to which poor perceived memory functioning may serve as an indirect pathway between problematic alcohol use and HIV symptom severity. specifically, we hypothesize that self-reported memory functioning will mediate the association between problematic alcohol use and HIV symptom severity.The Alcohol Use Disorder Identification Test is a 10-item self-report measure developed by the World Health Organization to identify individuals with alcohol problems. The AUDIT assesses three domains: alcohol dependence, harmful drinking , and hazardous drinking . Most items are rated on a 5-point Likert scale ranging from never to daily or almost daily. In the present study, items were summed to generate an index of total alcohol problems. A wealth of literature attests to the strong psychometric properties of the AUDIT [see], in addition to its use for the detection of problematic drinking in HIV-infected samples. Alcohol abuse and dependence were determined by the Structured Clinical Interview-Non-Patient Version for DSM-IV .
Criteria for cannabis dependence were consistent with DSM-IV criteria with the addition of withdrawal as proposed for DSM-5. Participants were classified as non-dependent cannabis users if they reported any cannabis use in the past 30 days, but did not meet criteria for cannabis dependence. Participants with no cannabis use in the past 6 months were classified as nonusers. The Marijuana Smoking History Questionnaire is a 21-item measure that assesses the frequency, patterns, and history of cannabis use. Participants who reported any cannabis use in the past 6 months were asked to provide additional information indicating the number of times they had used cannabis during the month prior to assessment. In the present study, cannabis use status was included as a covariate in all analyses and the MSHQ was used to describe frequency of cannabis use.Participants were recruited via informational flyers posted throughout a VA Medical Center and in numerous San Francisco Bay Area outpatient HIV clinics. Upon contacting the research team, individuals were provided with a detailed description of the study. Interested individuals were screened on the phone for eligibility and, if eligible, scheduled for a study appointment where they provided written consent to participate in the research study. The SCID-I–N/P was administered by trained research assistants and all interviews were audio-recorded and diagnoses were confirmed by the last author following a review of recorded interviews. Participants then completed the above-described measures. All study procedures were approved by a university Institutional Review Board .Descriptive statistics and alpha reliability coefficients were calculated for all measures. Number of cigarettes smoked per day, problematic alcohol use and memory functioning were log-transformed to correct for positive skew. A valueof 1 was added to variables including zero prior to their transformation. Bivariate Pearson correlations were conducted to examine relations between the EMQ total score and sub-scale scores, problematic alcohol use, and HIV symptom severity. Bivariate spearman and pears on correlations were then performed to assess associations between memory functioning, HIV symptom severity and potential covariates .
Based on these analyses, level of education, cannabis dependence and current depression diagnosis were included as covariates in all regression models. Self-reported adherence, although unrelated to memory functioning or HIV symptom severity, was included in the model to ensure that we accounted for variance in outcomes that could be explained by poor medication adherence. Six hierarchical linear regressions were performed to determine the impact of problematic alcohol use on total memory functioning as well as each individual facet of memory functioning. For the five individual memory facets we used a Bonferroni correction with alpha set at 0.01 for an overall rejection level of 0.05. Self-reported medication adherence was entered as a covariate on step 1. Level of education was entered as a covariate in Step 2. In step 3, two dummy coded variables were entered for cannabis use status . In step 4, current depression diagnosis was entered. Finally in step 5, problematic alcohol use was entered to determine how much additional variance in memory functioning was explained by problematic alcohol use after controlling for all covariates.Previous research has implicated memory functioning as a potential pathway through which problematic alcohol use may be related to HIV symptom severity [e.g., ]. Given that both alcohol problems and self-reported memory functioning correlated with HIV symptom severity in the present sample, a series of regression models were performed to determine whether memory functioning mediated the relation between problematic alcohol use and HIV symptom severity. Self-reported medication adherence, highest level of education, cannabis dependence and current depression diagnosis were entered as covariates at steps 1, 2, 3 and 4 respectively, in all models to ensure any relations observed were not accounted for by these variables. First, to test for mediation, problematic alcohol use was regressed on HIV symptom severity . Second, to reduce redundancy, results from the primary analyses were used to determine pathway A, the relation between problematic alcohol use and self-reported total memory functioning . Third, total self-reported memory functioning was regressed on the outcome variable , after controlling for problematic alcohol use . Last,microgreens shelving both bootstrapping and Sobel tests [see] were used to confirm findings from the Baron and Kenny mediational tests. Finally, as the mediational analyses were conducted among cross-sectional data, an additional model was tested to comprehensively assess directionality of the observed effect whereby the proposed mediator and criterion variable were reversed. To account for potential overlap of cognitive symptoms on the HIV symptom severity measure and the EMQ, mediation analyses were also conducted using a HIV symptom severity score that excluded cognitive symptoms. No differences emerged between models using the different scoring systems and thus the results presented represent all HIV symptoms.The present study sought to determine the influence of problematic alcohol use on self-reported memory functioning, and to assess relations with HIV symptom severity among a sample of HIV-infected individuals. Consistent with hypotheses and previous research, problematic alcohol use was associated with lower ratings of overall everyday memory functioning as well as increased difficulty with retrieval and memory for activities. Importantly, this pattern of results suggests that problematic alcohol use tended to specifically impact retrieval-based over processing-based aspects of memory functioning. Also of note, problematic alcohol use exhibited a direct and potent effect on these aspects of perceived memory functioning even after accounting for co-occurring substance use and depression . Finally, perceived memory functioning mediated the relation between problematic alcohol use and HIV symptom severity, though the direction of this relation was unclear and possibly reciprocal.
Findings from the present study lend support to clinical researchers’ call for initiatives to tailor substance abuse treatment and HIV risk-reduction programs to better address impediments posed by cognitive impairment. For instance, techniques to improve multi-modal encoding of clinical information may be particularly beneficial in helping to reduce retrieval-failures observed in the current study. External cueing systems and environmental supports in treatment clinics can also be employed. In addition, although the cross-sectional nature of these data does not permit us to draw conclusions about causality, interventions to remediate cognitive functioning may also improve outcomes in this particularly vulnerable population. For instance, computerized neuroscience-based cognitive remediation programs that target attention, memory and executive functioning could help augment existing treatments by enhancing patients’ cognitive reserve and mental flexibility to adhere to complex treatment regimens and encode, retrieve and employ HIV transmission-prevention skills. As hypothesized, perceived memory functioning provided an indirect pathway for the relation between problematic alcohol use and HIV symptom severity. Thus, one possibility is that the deleterious effects of problematic alcohol use on memory functioning explain the relation between problematic alcohol use and HIV symptom severity. For instance, problematic alcohol use may negatively impact memory for events and retrieval that may increase HIV-risk behaviors and reduce adherence and general self-care and ultimately, increase HIV symptom severity. Importantly though, reversal of the mediational model indicated that HIV symptom severity explained the relation between problematic alcohol use and self-reported memory functioning. As such, HIV symptom severity and memory functioning were interrelated and the extent to which memory functioning offers a distinct mediational pathway between problematic alcohol use and HIV symptom severity is unclear. The blurred directionality observed in our mediation models is believed to highlight the complexity associated with comorbid health conditions that commonly characterize this population, and their impact on HIV health outcomes. More likely, and as articulated in previous work, the relations between memory functioning, HIV outcomes and alcohol use are reciprocal. Among HIV infected individuals, problematic alcohol use is associated with worse HIV health outcomes which ostensibly result in increased HIV symptom severity and lower overall quality of life. Adding to the clinical profile, HIV disease progression is commonly associated with neurocognitive impairment. Given the high prevalence of alcohol problems among HIV-infected individuals coupled with its observed negative impact on memory functioning, routine screening for problematic alcohol use in HIV care settings is thus imperative. In the current sample, problematic alcohol use and all domains of self-reported memory functioning were associated with higher HIV symptom severity. Accordingly, this research combines with previous work to suggest that HIV symptom severity is intricately related to both alcohol consumption and memory functioning and that they should be considered collectively in clinical settings. Results from the current study are consistent with the literature in several respects. Previous research indicates that alcohol and drug use exert greater effects on neurocognitive function in HIV-infected versus non-infected individuals and, thus, HIV is posited to potentiate and exacerbate the impact of alcohol and drug use on neurocognitive functioning. Although no comparison group was available, our findings appear to support this notion and indicate that both problematic alcohol use and HIV symptom severity are associated with lower everyday memory functioning among individuals with HIV. In addition, HIV-infected individuals with a current depression diagnosis were at increased risk for reduced memory functioning and heightened HIV symptom severity, which is also consistent with previous research. Findings here also broadly align with research employing animal models of HIV infection which have shown that HIV can cause neuroplastic changes that impair cellular learning process implicated in memory.