Significant sex differences in these domain summary scores were followed by analyses of covariance adjusting for covariates and biopsychosocial factors. Lastly, among HIV-positive and HIV-negative participants, we examined the moderating role of sex in the relationship between HIV serostatus and the likelihood of NCI in two logistic regression approaches: inclusion of an HIV-serostatus by sex interaction term and examination of the HIV and NCI relationship in sex-stratified analyses. Significant effects were followed by stepwise logistic regressions adjusting for covariates and individual biopsychosocial factors . Significance was set at P value less than 0.05. Analyses were performed using SPSS . Given race/ethnicity differences in the prevalence of biopsychosocial factors and NCI, analyses were repeated within nonhispanic whites and blacks.Our findings present evidence supporting greater NCI among HIV-positive women than HIV-positive men. Race/ethnicity-stratified analyses indicated that this sex difference was primarily due to a higher proportion of black women in the HIV-positive, versus HIV-negative, group. We extend previous findings by determining whether discrepancies in biopsychosocial factors may explain higher rates of HIV-associated NCI in women. In partial support of hypotheses, adjusting for low reading level eliminated the sex difference in HIV-associated NCI. The race disparity in findings may be due to the overall higher rates and larger sex difference in biopsychosocial factors in blacks versus whites. The race disparity may also be partially due to race/ethnicity differences in health literacy, which have accounted for racial disparities in age-associated cognitive decline. Perhaps sex differences in HIV-associated NCI are more common in the context of low health literacy possibly due to sub-optimal engagement in HIV care/treatment. Alternatively, reading level may represent other NCI risk factors that show a female preponderance among black, HIV-positive individuals but were unmeasured.
Our race/ethnicity differences may explain inconsistent findings. Because our sample included more black women with lower reading level,grow cannabis the sex differences in HIV-related NCI may be more evident than in predominantly white samples. Low reading level was the only biopsychosocial factor to attenuate the sex difference in HIV-associated NCI in the overall sample and blacks. This may be because, among the biopsychosocial factors, low reading level demonstrated the strongest relationship with NCI and the largest sex difference. Low education was not associated with NCI likely because NCI was determined using education-adjusted, neurocognitive T-scores. SUDs were not associated with NCI possibly because most SUDs in our sample were not current . Furthermore, reading level may better reflect education quality than years of education, especially in lower socioeconomic populations because of the many factors impacting education quality. Notably, low reading level, but not education, was a risk factor for cognitive decline among ethnically diverse elders in the general population. In addition, reading level is associated with health outcomes, including hospitalizations and outpatient doctor visits, and, thus, may be a proxy for biopsychosocial factors underlying general health . Although mean syndemic count was higher in HIV positive women versus HIV-positive men, adjustment for syndemic count did not attenuate the sex difference in HIV-associated NCI, suggesting that the other biopsychosocial factors dilute the sex-related variance explained by reading level.Given findings that stress is more strongly associated with trajectories of cognitive impairment than depression in HIV-positive women, a syndemic count that included factors such as early life trauma and perceived stress may better capture biopsychosocial differences between HIV-positive men and women. Sex differences in the profile of HIV-associated NCI were only observed within race/ethnicity groups. Among whites, women demonstrated poorer learning than men, and this difference was attenuated after adjusting for reading level. White women also demonstrated poorer verbal fluency than white men and this difference was unchanged after adjustments. The sex difference in HIV associated NCI among blacks was not driven by specific cognitive domains. In fact, in contrast to whites, black women outperformed black men in verbal fluency and this difference was unchanged after adjustments. Sex differences in verbal fluency were likely masked in the overall sample due to differing associations within race/ ethnicity groups.
The sex by HIV interaction was not significant; however, sex-stratified analyses suggest a moderating role of sex in the HIV and NCI association, particularly in blacks. Compared with their HIV- counterparts, NCI was 3.5 times more likely in black, HIV-positive men but six times more likely in black, HIV-positive women. Adjustment for reading level marginally attenuated the HIV and NCI association in black women, suggesting that the large discrepancy in reading level between HIV positive and HIV-negative black women contributes to the higher risk of NCI in HIV-positive black women. Conversely, the HIV and NCI association was unchanged with adjustments in black men. Previously reported sex differences in disease characteristics unmeasured herein may contribute to sex differences in HIV and NCI associations. Overall, results suggest that HIV-positive black women are at the highest risk for NCI. Our study has limitations including the small proportion of women and, thereby, the potential of being under powered to detect an HIV by sex interaction. We were also unable to explore certain biopsychosocial factors . Study strengths include the large sample, an HIV-control group, race/ethnicity-stratified analyses and a comprehensive test battery that defined NCI. Demographically adjusted T-scores based on HIV- data allowed us to examine sex differences in HIV-specific cognitive profiles; however, by restricting this analysis to HIV-positive individuals with NCI, our statistical power was limited. In conclusion, we contribute evidence that HIV associated NCI is more prevalent in women versus men and indicate that this difference is accounted for by a lower reading level among HIV-positive women. The frequent sub-optimal educational experience of HIV positive women and the resulting lower cognitive reserve may make HIV-positive women more susceptible to HIV-associated NCI. The effect of HIV on NCI was also greater in women versus men, particularly among blacks. Adjusting for education quality rather than years of education may improve the specificity of neuropsychological tests for measuring cerebral dysfunction and sex differences in HIV. Clinically, practitioners should be advised that black HIV-positive women appear to be particularly at risk for NCI and provide resources to accommodate for these possible impairments.Alcohol and SUDs in general are associated with dysfunction, primarily in the domains of learning/memory, working memory, and other executive-based skills, including cognitive/inhibitory control . Persons with alcohol use disorder have been studied most, with the nature and level of impairment showing considerable variability. Approximately 55% of AUD manifest clinically significant neurocognitive deficits after acute detoxification , but some degree of recovery from these deficits is apparent with short-term , intermediate-term , and long-term abstinence from alcohol .
Some dysfunction has been reported to persist into long-term abstinence from alcohol, particularly in the domains of executive and visuospatial skills, learning and memory, and postural stability . The degree of cognitive dysfunction and the rate of recovery during abstinence appear to be influenced by many factors such as age, sex, family history of AUD, treatment history, pretreatment alcohol consumption level, number of detoxifications, nutritional status, comorbidpsychiatric and biomedical conditions, and comorbid SUD . Most treatment-seeking substance users today concurrently and/or simultaneously consume more than one illicit/licit compound, so-called poly substance users . Among PSU, comorbid tobacco use disorder is most prevalent in AUD , and chronic cigarette smoking itself is associated with significant neurocognitive deficiencies in both AUD and non-AUD cohorts . Smoking AUD performed worse than their nonsmoking counterparts on domains of auditory verbal learning and memory, processing speed, cognitive efficiency, and working memory during the first month of abstinence from alcohol . Smoking AUD also demonstrated poorer neurocognition with increasing age than never-smoking AUD, and the performance of former-smoking AUD on several domains was intermediate to that of never-smoking and actively smoking AUD . Particularly common among PSU is the simultaneous and/or concurrent abuse of alcohol, tobacco, and psychostimulants . Therefore, in many published research reports on the neurobiological and neurocognitive consequences of AUD, many individuals were also likely nicotine-dependent, and in studies of cocaine use disorder, participants were also likely heavy drinkers. This was both likely and most apparent in literature before about 2010, when poly substance abuse had not been attended to more widely in substance abuse research, and other substance use was largely treated as a nuisance variable. More recently,indoor cannabis grow system poorer health outcomes and greater treatment resistance have been reported for PSU compared to monosubstance users . Despite its prevalence, however, few studies have directly examined the neuropsychological or neurobiological consequences of poly substance abuse. In early studies, cocaine-dependent individuals with and without AUD showed cognitive deficits at 3 months of abstinence , and decision-making was still impaired in similar individuals abstinent for 8 months . Even after several years of abstinence, psycho stimulant-related deficits of episodic memory, planning, and cognitive flexibility were persistent in PSU . These relatively persistent cognitive deficits were associated with the amount of cocaine and cannabis consumed as well as with relapse risk .
Cognitive efficiency, processing speed, and visuospatial learning were less impaired in 1-month-abstinent PSU who continued to abstain versus those who subsequently relapsed between 1 and 4 months of abstinence ; similarly, 1-month-abstinent AUD with the lowest processing speed showed a significantly increased risk for relapse following treatment . In comparisons to 1-month-abstinent AUD, 1-month-abstinent PSU performed worse on measures of auditory verbal memory and learning and general intelligence , suggesting a diminished capacity of learning, memorizing, and integrating new skills presented in clinical treatment settings. In addition, PSU exhibited worse decision-making and higher self-reported impulsivity than AUD, potentially placing them at a greater relapse risk during early recovery. Finally, PSU between the ages of 25 and 70 years showed greater age-related declines in processing speed, general intelligence, cognitive efficiency, and global intelligence than controls, indicating the detrimental cumulative effects of poly substance use on neurocognition . As described, the degree and nature of neurocognitive deficits varies considerably among substance-using groups investigated, critically related to the combination of both illicit and licit substances abused and their use histories. However, it is noteworthy that even mild neurocognitive deficits can impact quality of life and relapse risk . Impaired neurocognition and inhibition may adversely affect maintenance of abstinence during treatment and long-term treatment efficacy ; specifically, neurocognitive deficits can interfere with treatment efficacy by reducing the individual’s ability to encode, process, recall, integrate, and apply program information during and following treatment . As such, assessment of cognitive abilities during treatment may improve treatment outcomes by providing clinicians an understanding of the individual’s capabilities during treatment and inform appropriate post treatment follow-up care . Studies of longitudinal neurocognitive changes during abstinence from alcohol and other substances are far less common than cross-sectional studies . Most longitudinal studies assessed neurocognition several weeks after detoxification and then 6–12 months later; they demonstrated several neurocognitive functions improve at least partially during sustained abstinence, whereas some cognitive dysfunction persists for years after detoxification . Psychological changes in AUD during a residential rehabilitation program have recently been documented and include significant decreases in anxiety, depression, and psychological distress within about 1 month of detoxification in those with substance-induced mood disorders . In studies on the effects of comorbid tobacco use on neurocognitive recovery in AUD , we found that smoking was associated with significantly diminished improvement of visuospatial learning and processing speed within the first year of abstinence from alcohol . We analyzed neurocognition across three different time points during abstinence from alcohol and as a function of smoking status . Over 8 months of abstinence, AUD as a group showed significant improvements of visuospatial learning and memory, processing speed, and working memory, with less pronounced changes in executive functions, postural stability, and auditory verbal learning and memory. Overall, the recovery rates were nonlinear over time, showing faster recovery between 1 and 4 weeks than between 1 and 8 months of abstinence. Improvements in the foregoing domains in AUD were driven by never-smoking AUD, where both former-smoking and actively smoking AUD showed significantly less recovery than never-smoking AUD. Additionally, active smokers showed significantly less improvement with increasing age than never-smoking AUD over 8 months on measures of processing speed and learning and memory. At 8 months of abstinence, currently smoking AUD remained inferior to controls and never-smoking AUD on multiple measures, former smokers performed worse than never-smoking AUD on several tests, but never-smoking AUD were not significantly different from controls on any measure.