OpenUCT :: Browsing by Author "Joska, John A"

Browsing by Author "Joska, John A"

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Open Access
An exploration of sociodemographic and psychosocial determinants of cognitive performance in a peri-urban clinic population of people with HIV in Cape Town, South Africa
(2023) Dreyer, Anna Jane; Joska, John A; Thomas, Kevin G F; Nightingale, Sam
Introduction. Numerous studies, conducted in many different countries, report that cognitive impairment is highly prevalent in people with HIV (PWH). Such impairment can affect adherence to antiretroviral therapy (ART), and adherence is, in turn, essential for PWH to achieve viral suppression. The gold standard to confirm cognitive impairment is a neuropsychological assessment. However, accurate interpretation of neuropsychological test performance requires consideration of, for instance, how impairment is determined and how accurately the contribution of non-HIV factors to poor cognitive test performance is described. These non-HIV factors include sociodemographic variables (e.g., age, sex, educational attainment), psychosocial variables (e.g., socioeconomic status, food security, quality of life), psychiatric variables (e.g., depression, problematic alcohol use), and other medical co-morbidities. Because many existing studies of PWH do not account for (a) the fact that current quantitative methods for defining cognitive impairment may not accurately reflect HIV-associated brain injury, and (b) possible contributions of non-HIV factors to cognitive test performance, it is possible that the reported prevalence rates of cognitive impairment in PWH are inaccurate (or, at least, do not solely reflect the contributions of HIV disease to the impairment). Another uncertainty in the HIV neuropsychology literature concerns sex differences in the cognitive performance of PWH. Some recent studies suggest that women with HIV (WWH) may present with greater cognitive impairment than men with HIV (MWH). Such a sex difference is of potentially significant concern for South African clinicians because two-thirds of the population of PWH in this country are women. However, there is no definitive empirical evidence regarding whether this sex difference exists to a clinically significant degree (in South Africa, specifically, as well as globally) and what its underlying mechanisms might be. To address the knowledge gaps outlined above, this thesis set out to explore the following aims: (1) investigate sex differences in the cognitive performance of PWH by reviewing the current published literature; (2) determine if sex differences exist in a clinic sample of South African PWH; (3) determine how much variation in reported prevalence rates of HIV-associated cognitive impairment are due to the method used to define impairment, and which method correlates best with MRI biomarkers of HIVrelated brain injury in a South African sample of PWH; (4) investigate the contribution of sociodemographic and psychosocial variables, as well as HIV-disease factors and other medical and psychiatric comorbidities, to cognitive performance in a South African sample of PWH; and (5) investigate associations between cognitive performance and ART adherence in 10 a South African sample of PWH. Each of these aims was explored in a separate study. Hence, this thesis reports on findings from five separate journal manuscripts. Method. Study 1 was a systematic review and meta-analysis summarizing the findings of published studies investigating differences in cognitive performance between WWH and MWH. An extensive systematic search of the literature across several databases found 4062 unique articles of potential interest. After thorough screening of that pool of articles, 11 studies (total N = 3333) were included in the narrative systematic review and 6 studies (total N = 2852) were included in the meta-analysis. Effect sizes were calculated to estimate between-sex differences in cognitive performance, both globally and within discrete cognitive domains. Study 2 investigated sex differences in cognitive performance in a sample of PWH with comorbid MDD (N = 105). All participants were attending community clinics in Khayelitsha, a peri-urban community in Cape Town, South Africa, and were part of a larger research program for a randomised controlled trial of a cognitive-behavioral treatment for ART adherence and depression (CBT-AD). As part of this program, they completed baseline neuropsychological, psychiatric, and sociodemographic assessments. T-tests and multivariable regressions controlling for covariates compared baseline cognitive performance of WWH and MWH, both globally and within discrete cognitive domains. Study 3 applied 20 different quantitative methods of determining cognitive impairment to existing data from a different sample of PWH (N = 148). These individuals had also been recruited from community clinics in Khayelitsha, and had completed a comprehensive neuropsychological assessment and a 3T structural MRI and diffusion tensor imaging (DTI) session. Logistic regression models investigated the association between each method and HIV-related neuroimaging abnormalities. Study 4 again used data from the sample of PWH with comorbid MDD who participated in the larger CBT-AD research program. This study investigated which sociodemographic, psychosocial, psychiatric, and medical variables (as measured at baseline) were associated with baseline cognitive performance. Post-baseline, 33 participants were assigned to CBT-AD and 72 to standard-of-care treatment; 81 participants (nCBT-AD = 29) had a follow-up assessment 8 months post-baseline. This study also investigated whether, from baseline to follow-up, depression and cognitive performance improved significantly more in the participants who had received CBT-AD, and examined associations between post-intervention improvements in depression and cognitive performance. Study 5 assessed ART adherence in the same sample of PWH with comorbid MDD. Mixed-effects regression models estimated the relationship between ART adherence (as measured by both self-report and objective measures, and by degree of HIV viral suppression) with cognitive performance 11 and with other sociodemographic, psychosocial, and psychiatric variables at both baseline and follow-up. Results. Study 1: Analyses suggested that, in terms of overall cognitive functioning, there were no significant differences in cognitive performance between WWH and MWH. However, WWH did perform significantly more poorly than MWH in the domains of psychomotor coordination and visuospatial learning and memory. Additionally, the review suggested that cognitive differences between WWH and MWH might be accounted for by sex-based variation in educational and psychiatric characteristics among study samples. Study 2: Analyses suggested that, in our sample of PWH with comorbid MDD, there were no significant differences in cognitive performance between WWH and MWH. Study 3: Findings suggested that there was marked variation in rates of cognitive impairment (20– 97%) depending on which method was used to define impairment, and that none of these methods accurately reflected HIV-associated brain injury. Study 4: Analyses suggested that less education and greater food insecurity were the strongest predictors of global cognitive performance. Improvement in depression severity was not significantly associated with improved cognitive performance, except in the domain of Attention/Working Memory. Overall, factors associated with cognitive performance were unrelated to HIV disease and other medical factors. Study 5: Analyses identified poor global cognitive performance as a potential barrier to achieving HIV suppression. Conclusion. Taken together, the findings from the five studies contained within this thesis suggest that one oft-mooted sociodemographic influence on cognitive performance in PWH, sex, was not a consistent influence on such performance. However, non-biological (mainly psychosocial and socioeconomic) factors were stronger predictors of cognitive performance in PWH than medical factors (including HIV-disease variables). Current quantitative criteria for defining cognitive impairment in PWH also do not accurately reflect the biological effects of HIV in the brain. The implication of these findings is that research studies may be misclassifying PWH as cognitively impaired and consequently overestimating the prevalence of cognitive impairment in this population. When conducting clinical assessments of PWH, future research studies should measure and consider the strong influence of psychosocial and socioeconomic factors on cognitive test performance. Ideally, a diagnosis of impairment should only be made after a comprehensive clinical assessment that includes a detailed history taking. Overall, we need new criteria for defining cognitive impairment in diverse global populations of PWH. Ideally these criteria should be applicable to both research and clinical settings. Assessing for cognitive impairment among PWH and then providing 12 appropriate support could help achieve viral suppression in patients with non-optimal adherence to ART. At public policy levels, addressing larger psychosocial issues (e.g., food insecurity and low educational attainment) may also help improve cognitive performance in PWH.
Open Access
Assessing the efficacy of a modified assertive community-based treatment programme in a developing country
(BioMed Central Ltd, 2010) Botha, Ulla A; Koen, Liezl; Joska, John A; Hering, Linda M; Oosthuizen, Piet P
BACKGROUND: A number of recently published randomized controlled trials conducted in developed countries have reported no advantage for assertive interventions over standard care models. One possible explanation could be that so-called "standard care" has become more comprehensive in recent years, incorporating some of the salient aspects of assertive models in its modus operandi. Our study represents the first randomised controlled trial assessing the effect of a modified assertive treatment service on readmission rates and other measures of outcome in a developing country. METHODS: High frequency service users were randomized into an intervention (n = 34) and a control (n = 26) group. The control group received standard community care and the active group an assertive intervention based on a modified version of the international model of assertive community treatment. Study visits were conducted at baseline and 12 months with demographic and illness information collected at visit 1 and readmission rates documented at study end. Symptomatology and functioning were measured at both visits using the PANSS, CDSS, ESRS, WHO-QOL and SOFAS. RESULTS: At 12 month follow-up subjects receiving the assertive intervention had significantly lower total PANSS (p = 0.02) as well as positive (p < 0.01) and general psychopathology (p = 0.01) subscales' scores. The mean SOFAS score was also significantly higher (p = 0.02) and the mean number of psychiatric admissions significantly lower (p < 0.01) in the intervention group. CONCLUSIONS: Our results indicate that assertive interventions in a developing setting where standard community mental services are often under resourced can produce significant outcomes. Furthermore, these interventions need not be as expensive and comprehensive as international, first-world models in order to reduce inpatient days, improve psychopathology and overall levels of functioning in patients with severe mental illness.
Open Access
The diagnostic yield of computerised tomography in human immunodeficiency virus (HIV) positive psychiatric patients at a tertiary hospital in the Western Cape
(2017) Berwers, Juan; Joska, John A
Background. HIV infection increases the risk for mental illness. Neuroimaging is an important part of the diagnostic workup in HIV+ psychiatric patients; CT is the primary neuroimaging modality available in resource limited settings. Despite advances in neuroimaging no clear guidelines exist for the use of CT in psychiatric settings. Objective. To determine the diagnostic yield of CT brain (CTB) scans in HIV+ psychiatric patients and to describe these abnormalities as well as demographic and clinical variables associated with abnormal CT scans. Methods. A retrospective study was conducted at the Department of Psychiatry and Mental illness at Groote Schuur Hospital, Cape Town, South Africa. Clinical and radiological data for HIV+ psychiatric patients who received a CTB scan during admission were analysed for the period January 2013 - June 2015. Results. A total of 65 patients met the inclusion criteria. The mean age of the participants in this study was 36.2 years (range 18 - 64). The most common presenting psychiatric symptoms were psychosis (81.54%), cognitive deficits (72.41%) and mood symptoms (69.23%). CT scans results consisted of 29 (44.62%) normal scans and 36 (55.38%) abnormal scans. Atrophy was the most common (72%) radiological finding in abnormal CT scans. No associations were found between current proposed CT guidelines in psychiatric patients, although a history of previous traumatic brain injury (TBI) approached significance (p = 0.054). There was a significant correlation between abnormal CT scans and past or current substance use (X² = 5.9508 P = .015). Abnormal CT findings increased with the Centers for Disease Control and Prevention (CDC) HIV immunological stage progression. The management of 9 patients changed; 7 of these CT scans were abnormal. Conclusion. In this study of CTB scans in HIV+ psychiatric inpatients, previously suggested criteria proposed in guidelines for imaging were not associated with significantly higher rates of abnormal CT findings. Current or previous substance use correlated with significant higher rates of abnormal CT findings. Due to the high yield of abnormal CT scans in this study, it is suggested that HIV+ psychiatric inpatients with previous or current substance use, a history of TBI or HIV immunological stages B or C, are considered for imaging. It is recommended that further studies with larger sample sizes, consisting of inpatient and outpatient populations, with control groups be conducted to investigate current or previous substance use as an indication in guidelines for CTB scan in HIV+ psychiatric patients.
Open Access
HIV/AIDS and psychiatry: Towards the establishment of a pilot programme for detection and treatment of common mental disorders in people living with HIV/AIDS in Cape Town
(2008) Joska, John A; Stein, Dan J; Flisher, Alan J
As the roll-out of antiretrovirals (ARVs) to people living with HIV / AIDS (PLWHA) continues to increase in South Africa, so too does the need to integrate mental health services into HIV care. In this editorial, we argue that the role of mental health in ARV programmes is central. The prevalence of mental disorders in PLWHA is higher than in the general population, and the impact of these conditions is substantial. Screening tools for mental disorders are both available and feasible. These should be incorporated into routine ARV care, with support from dedicated HIV mental health services.
Open Access
Needs and services at ward one, Valkenberg hospital
(2004) Joska, John A; Flisher, Alan J
The mental health needs of patients entering the program at ward one, Valkenberg Hospital, are not routinely measured. Their presenting problems are frequently complicated by basic and social needs, which impact on recovery and re-integration into the community. The Camberwell Assessment of Need is a valid and reliable instrument used to measure the mental health needs of psychiatric patients. In this study, this instrument was used with some modifications to assess the needs of patients on admission to ward one. At discharge, these needs were explored to measure the extent to which services and interventions were useful in meeting those needs. Where not, questions aimed at elucidating impediments to care were asked. All 60 patients completing the program agreed to participate. The average number of total needs on admission was 9.2, which included an average of 6.7 unmet needs. Psychiatric needs were the most commonly reported, with a need in the area of "depression" being declared in 59 patients. Help received prior to admission was scant, and patients had high expectations of ward one. Help received from ward one was highest in areas of psychiatric needs, with 89.8% of patients receiving moderate or high help in the area of depression. More than two-thirds of patients reported receiving low help in basic areas such as accommodation, self-care, and sexual expression. The services most often regarded as useful were organised group activities and therapies. Paired t-tests revealed that the patients without borderline personality had more unmet needs on admission. Regression analysis suggests that younger age and lower level of education confer a greater risk of unmet needs on admission and discharge. The routine use of a needs assessment instrument is recommended as an aid to guide clinicians. Attention needs to be given to basic and social needs, such as accommodation, daily activities and company, prior to admission to hospital. Where these needs persist, the active involvement of a social worker and occupational therapist is suggested. The high numbers of unmet needs in domains other than psychiatric problems, requires the input of the multidisciplinary team.
Open Access
Project Khanya: a randomized, hybrid effectiveness-implementation trial of a peer-delivered behavioral intervention for ART adherence and substance use in Cape Town, South Africa
(2020-03-04) Magidson, Jessica F; Joska, John A; Myers, Bronwyn; Belus, Jennifer M; Regenauer, Kristen S; Andersen, Lena S; Majokweni, Sybil; O’Cleirigh, Conall; Safren, Steven A
Abstract Background Substance use is prevalent in South Africa and associated with poor HIV treatment outcomes, yet, it is largely unaddressed in HIV care. Implementing an evidence-based, task-shared intervention for antiretroviral therapy (ART) adherence and substance use integrated into HIV care may be a feasible and effective way to improve HIV treatment outcomes and reduce substance use in this population. Methods Guided by the RE-AIM framework, a randomized, hybrid type 1 effectiveness-implementation trial (n = 60) is being used to evaluate a peer-delivered intervention that integrates evidence-based intervention components, including Life-Steps (problem solving and motivational skills for HIV medication adherence), behavioral activation to increase alternative, substance-free rewarding activities in one’s environment, and relapse prevention skills, including mindfulness. The comparison condition is enhanced standard of care, which includes facilitating a referral to a local substance use treatment clinic (Matrix). Participants are followed for a period of 6 months. Implementation outcomes are defined by Proctor’s model for implementation and include mixed methods evaluations of feasibility, acceptability, and fidelity, and barriers and facilitators to implementation. Primary patient-level effectiveness outcomes are ART adherence (Wisepill) and substance use (WHO-ASSIST and urinalysis); viral load is an exploratory outcome. Discussion Results of this trial will provide important evidence as to whether peer delivery of an integrated intervention for ART adherence and substance use is feasible, acceptable, and effective. Implementation outcomes will provide important insight into using peers as an implementation strategy to extend task sharing models for behavioral health in resource-limited settings globally. Trial registration ClinicalTrials.gov identifier: NCT03529409. Trial registered on May 18, 2018.
Open Access
Renal safety of lithium in HIV-infected patients established on tenofovir disoproxil fumarate containing antiretroviral therapy: analysis from a randomized placebo-controlled trial
(BioMed Central, 2017-02-04) Decloedt, Eric H; Lesosky, Maia; Maartens, Gary; Joska, John A
Background: The prevalence of bipolar disorder in HIV-infected patients is higher than the general population. Lithium is the most effective mood stabiliser, while tenofovir disoproxil fumarate (TDF) is frequently used as part of combination antiretroviral therapy (ART). Both TDF and lithium are associated with renal tubular toxicity, which could be additive, or a pharmacokinetic interaction may occur at renal transporters with a decrease in TDF elimination. Objective: We report on the change in estimated glomerular filtration rate (eGFR) using the modification of diet in renal disease formula in participants who received ART including TDF and were enrolled in a 24 week randomised trial of lithium versus placebo in patients with HIV-associated neurocognitive impairment. Methods: We included HIV-infected adults with cognitive impairment established on ART for at least 6 months with a suppressed viral load attending public sector ART clinics in Cape Town, South Africa. We excluded participants with an eGFR or increase in potassium between the two arms during the 24 weeks. Conclusions: We found that 24-week treatment of HIV-infected patients with lithium and TDF did not result in increased nephrotoxicity.
Open Access
Triple comorbidity of severe mental illness, HIV infection & alcohol abuse in a female population at a community psychiatric clinic in Cape Town: Prevalence and correlates
(2017) Mgweba-Bewana, Lihle; Joska, John A
Introduction: Severe mental illness (SMI), Human immunodeficiency virus (HIV) infection and hazardous alcohol use are global epidemics. Each condition is independently associated with significant adverse health outcomes. The presence of two or more of these conditions in one individual may result in worse health outcomes. A key mediator of poor health outcomes are factors such as medication adherence. In resource-limited countries like South Africa, the impact of psycho-social factors may contribute further to worse health outcomes. These factors include poverty and unemployment; as well as gender. In South Africa, proportionately more women are infected with HIV than men; and they are also vulnerable to the problems of trauma and interpersonal violence. The main aim of this study was to investigate the prevalence of a triple co-morbidity of SMI, HIV infection and hazardous alcohol use in a female population at a community psychiatric clinic in Cape Town South Africa; and the impact of this triple comorbidity on medication adherence. Furthermore, we set out to identify demographic and clinical variables that are predictors of poor adherence to both psychotropic medication and ART where applicable. Methods: We conducted a cross-sectional study of female patients presenting to Gugulethu psychiatric clinic over a ten-month period. Demographics and clinical variables were explored using the Alcohol Use Disorders Identification Test (AUDIT); the adapted Morisky Scale to Assess Adherence to Psychotropic Medications; and an adherence to HIV antiretroviral treatment self-assessment instrument. A descriptive analysis of the demographic and predictor variables was undertaken to explore the prevalence of concurrent HIV infection and hazardous alcohol use in out-patients with SMI; as well as to investigate whether co-morbidity is associated with poor levels of adherence to psychotropic medication, as well as antiretroviral treatment (ART) in HIV positive patients. Results: We interviewed 127 patients, of whom 55 were HIV positive (43.3%). The overall prevalence of a triple comorbidity in this population was 7.9%. Only 20% within this triple comorbidity group were adherent to their psychotropic medication. Out of the 10 participants with a triple comorbidity, only five were on ART. Of these 5 participants, only two were adherent. Individuals with hazardous alcohol use were less adherent to psychotropic medication compared to those without. The seven respondents in the dual diagnosis group (SMI and hazardous alcohol use) had the lowest overall psychotropic adherence levels compared to the other subgroups (0%). Furthermore, concurrent hazardous alcohol use predicted poorer levels of compliance to ART for those with HIV infection. Conclusion: The presence of a triple diagnosis was not found to be a predictor of poorer medication adherence, compared to having one or two diagnoses. Nevertheless, there was evidence that concurrent hazardous drinking in SMI patients predicted poor compliance to both psychotropic and ART treatment regimens (for those living with HIV). These patients should be supported in future interventions to improve medication adherence and reduce hazardous drinking.
Open Access
White matter correlates of neuropsychological function in young adult methamphetamine users
(2016) Freeman, Carla Patricia; Joska, John A; Stein, Dan J
Background: Methamphetamine (MA) abuse is a global health concern due to widespread use and harmful effects, which includes neurotoxicity. This study aimed to describe neurocognitive deficits associated with MA dependence in young adults and to explore whether these deficits correlate with white matter (WM) microstructural abnormalities using diffusion tensor imaging (DTI). Methods: Twenty-one MA dependent individuals recently enrolled in an outpatient rehabilitation program and nineteen healthy controls participated in the study. Each participant completed a neuropsychological evaluation and underwent diffusion tensor imaging within one week of testing. Average whole-brain fractional anisotropy (FA) and mean diffusion (MD) measures derived from DTI data were compared between groups. Group differences in performance within specific neurocognitive domains and in a composite global neurocognitive score (GNS) were tested using non-parametric univariate statistics and within a linear regression framework, adjusting for age and gender. Correlation analyses were conducted to test associations between the neuropsychological data and selected frontal white matter (WM) tracts, including the genu and body of the corpus callosum (CC); right and left cingulum bundle (CB); right and left uncinate fasciculus (UF); right and left anterior corona radiata (CR) and the right and left superior longitudinal fasciculus (SLF). Results: No significant between-group differences were detected for performance in any of the neuropsychological domains assessed. No relationship between FA or MD and the GNS was demonstrated in the tracts of interest. After adjusting for age and gender, significant group differences in FA and MD were detected across several regions of interest (ROI), however, these did not survive corrections for multiple comparisons. Conclusion: Cognitive performance and white matter integrity did not differ between young MA dependent subjects and healthy controls. Whatever differences that were found in white matter did not survive correction for multiple comparisons. These findings may reflect one or more of several possibilities: that brain function and structure is relatively preserved in younger individuals; or that differences were too small to be detected in this sample. Further studies should explore the effects of aging, poly-substance abuse and HIV coinfection on neurocognitive functioning and structural brain integrity in methamphetamine users.

Browsing by Author "Joska, John A"

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