1. Comorbidity and Aging with HIV. An observational study.
2. AGEhIV substudy nr 1

1) Use of combination antiretroviral therapy (cART) has resulted in a major
decline of HIV-related morbidity and mortality. As a result, the life
expectancy of patients with HIV has increased and in the Netherlands currently
20% of patients have reached an age over 50, and approximately another 40% of
patients is 40-50 years old. Unfortunately, this major success of cART does
come at a cost. Several studies have demonstrated an increased incidence of
heart disease, diabetes mellitus, kidney disease, liver disease, osteoporosis,
malignancies (other than Kaposi*s sarcoma and non-Hodgkin*s lymphoma
traditionally associated with HIV), cognitive disorders and possibly chronic
obstructive pulmonary disease in HIV-infected individuals when compared to in
age matched HIV-uninfected controls. Although increasing age and other
traditional risk factors have been found to independently affect these
respective co-morbidities in a similar manner in both HIV-infected and
uninfected persons, there is increasing evidence that, over and above the
effects of age, both HIV-related factors and adverse effects of cART also
independently contribute to the risk. This has lead to the hypothesis that
aging, which is known to be associated with an increased incidence of each of
these respective co-morbidities, in fact may be accelerated in the setting of
concomitant HIV infection. Direct effects of the virus infection, residual
immune activation and immunodeficiency even in the context of suppressive cART,
as well as specific effects of individual (classes of) antiretrovirals may all
contribute.
In view of the above, timely recognition and management of these various
co-morbidities, the burden of which can be expected to increase over the coming
years, in a manner which is specifically tailored towards HIV-infected
individuals is urgently needed. This can be expected to ensure the gains in
life expectancy achieved by cART, and also result in better quality of care for
and quality of life of HIV-infected individuals.

2) The introduction of cART has also contributed to a reduction in direct and
indirect effects of HIV-infection within the central nervous system (CNS), and
as a result the incidence of HIV dementia has reduced remarkably. However, the
occurrences of milder forms of neurocognitive dysfunction persist and are
frequently seen in HIV-infected patients with sustained suppression of viral
replication on cART. In recent years a new terminology has been developed to
classify this broadening clinical spectrum of neurocognitive impairment,
including milder abnormalities. The umbrella term nowadays is HIV Associated
Neurocognitive Disorders (HAND) which comprises three subcategories:
Asymptomatic Neurocognitive Impairment (ANI), Mild Neurocognitive Disorder
(MND) and HIV Associated Dementia (HAD). Until now the exact prevalence of such
neurocognitive disorders is unknown, in particular among HIV-infected patients
with sustained suppression of viral replication on cART. Also the pathogenic
mechanisms underlying HAND remain to be fully elucidated. A variety of factors
may cause such neurocognitive disorders, which includes suboptimal penetration
of antiretrovirals into the CNS possibly resulting in ongoing viral replication
within this compartment, neurotoxic effects of antiretrovirals, chronic
residual immune activation and inflammation within the CNS, progressive
physiological ageing of the HIV-1-infected population, CNS damage resulting
from cerebrovascular abnormalities, and depressive and other psychiatric
disorders. Structural abnormalities in the retina such as thinning of the
retinal nerve fibre layer (RNFL) also seems to occur more often in HIV-infected
patients compared to HIV-negative persons. The pathogenic mechanism of such
changes in the retina are yet unknown. It is possible that the above mentioned
factors possibly causing HAND can also be held responsible for causing such
retinal abnormalities. Eventually, the eye is functionally and anatomically
closely related tot het brain.

The availability of an objective reliable non-invasive biomarker of subtle
CNS-damage would offer the ability to detect neurocognitive disorders at an
early stage. In addition, such a biomarker could also enable monitoring of
disease progression. Early detection as well as monitoring of disease
progression is of importance as even mild cognitive disorders can contribute to
decreased quality of life, diminished work capacity and poor medication
adherence (which is related to higher mortality rates).

Integrating the data of this sub study to the data already collected in the
AgehIV cohort study provides essential information of the possible contributing
role of comorbidities (e.g. cardiovascular disease, metabolic disorders,
depression) on neurocognitive and visual impairment

1A) To implement a screening-protocol for HIV related co-morbidities and their
risk factors, based on multidisciplinary expert consultation, in a large HIV
outpatient clinic and among an HIV-uninfected control group.

1B) To assess the prevalence and incidence of co-morbidity and organ system
dysfunction in the setting of HIV infection and to evaluate whether the burden
is increased compared to a comparable group of HIV-uninfected healthy
individuals.

1C) To compare quality of life both at baseline and over time, between patients
with and without co-morbidity, who are HIV-infected or HIV-uninfected.

2A) To determine the value of a range of neuroimaging parameters, CSF markers
and ophthalmologic metrics to serve as biomarkers of cerebral dysfunction and
predictors of cognitive- and visual impairment.

2B) To provide more insight in the pathogenetic mechanism underlying HAND by
closely studying markers in the cerebrospinal fluid.

2C) To examine to what extend the neurocognitive disorders and retinal
abnormalities found in both HIV-infected and HIV-negative elderly are
associated with demographic characteristics (e.g. age, gender, ethnicity),
behavioural factors (e.g. alcohol and drug abuse), psychological factors (major
depression, anxiety disorders) and co-morbidities (e.g. hypertension, diabetes
mellitus-type II, dyslipidemia, chronic viral hepatitis).

1) This is an observational longitudinal study in which we will assess the
prevalence and incidence of a broad range of co-morbidities and known risk
factors for these co-morbidities in HIV-infected patients age 45 and older. A
control group of HIV-uninfected persons attending the Amsterdam Municipal
Health Service (PHSA) either as participants of the existing Amsterdam HIV
Cohort Studies or the STD clinic , as much as possible comparable for age,
gender, ethnicity and lifestyle, will be recruited to determine the extent to
which co-morbidities and their risk factors differ between HIV-infected and
uninfected groups.

Participants will be evaluated once every 2 years for the duration of this
study.

2) Within a subgroup of the participants of this agehIV-cohort study (75
HIV-infected patients with a sustained viral suppression on cART of the AMC and
50 HIV-negative controls of the PHSA), we will assess the prevalence, incidence
and prognosis of HAND and subtle visual deficits. Furthermore, we will assess
the validity of advanced neuroimaging techniques and ophthalmological measures
as potential biomarkers for neurocognitieve- and visual impairment.
Additionally, we will evaluate cerebrospinal fluid (CSF) biomarkers to provide
more insight in the pathophysiological mechanism (such as the ability of
antiretrovirals to reach the central nervous system or the role of monocyte
activation). The control group of 50 HIV-negative participants form the PHSA
will allow us to adjust for the effects of normal aging and other conditions
such as depression, cerebrovascular disease resulting from conditions such as
hypertension and diabetes mellitus, to cognitive impairment and subtle visual
impairment in HIV-1-infected patients. participation.

WIJZIGING INCLUSIE SUBSTUDIE NR 1 PER JUNI/JULI 2012:
AFTER INCLUSION OF THE INITIAL 50 HIV-NEGATIVE AND 75 HIV-POSITIVE
PARTICIPANTS, EXTRA INCLUSIONS WILL TAKE PLACE. THE AIM OF THESE EXTRA
INCLUSIONS IS TO ULTIMATELY HAVE AS MUCH AS POSSIBLE A COMPLETE DATASET
AVAILABLE ON NEUROIMAGING, NEUROPSYCHOLOGICAL ANALYSIS AND CSF-ANALYSIS FROM 50
HIV-NEGATIVE AND 75 HIV-POSITIVE PARTICIPANTS. THE LUMBAR PUNCTURE IS NO LONGER
OPTIONAL IN THESE *EXTRA* INCLUSIONS, BUT WILLINGNESS/POSSIBILITY TO UNDERGO
THE LUMBAR PUNCTURE (ASIDE FROM NEURO-IMAGING, NEUROPSYCHOLOGICAL ANALYSIS AND
OPHTHALMOLOGICAL ANALYSIS) WILL BE MANDATORY FOR PARTICIPATION.

The AGEhIV substudy nr. 1 including all relevant analyses has finished 5th of
july 2017.

Het screeningsprtocol zal geïmplementeerd worden in de HIV-polikliniek in het AMC en zal zoveel mogelijk worden geïntegreerd in de reguliere polikliniek. Gedurende een routine bezoek aan de polikliniek zal de patiënt 2 maal gescreend worden: een keer op baseline, en opnieuw na een tijdsinterval van 2 jaar. Hetzelfde screeningsprotocol, op baseline en na 2 jaar, zal voor zover het logistiek haalbaar is, worden geïmplementeerd in een cohort van HIV-negatieve gezonde vrijwilligers op de GGD. Een verpleegkundige of dokter zal de personen benaderen om deel te nemen aan deze studie, waarneer zij de SOA-polikliniek bezoeken of gedurende een bezoek aan de GGD in het kader van de Amsterdam Cohort Studie.

Tijdens beide bezoeken zullen alle benodigde gegevens verzameld worden betreffende co-morbiditeiten, risico-factoren, HIV-infectie en behandeling (voor AMC-patienten), levensstijl (roken, alcohol, drugs gebruik), familie-geschiedenis (cardiovasculaire ziekten, maligniteiten, fracturen) en kwaliteit van leven gebruik maken van gestandaardiseerde en gevalideerde vragenlijsten. Lengte, gewicht en bloeddruk zal worden gemeten. Naast een uitgebreidere reguliere bloedafname in het kader van screening naar bijkomende ziekten (vetmetabolisme, glucose-metabolisme, nierfunctie, leverfunctie en botmetabolisme) en risicofactoren zullen wij extra bloed (serum, heparine-plasma, EDTA-plasma, citraat-plasma en PBMC's) afnemen en urine verzamelen voor opslag. Deze opslag van samples is voor toekomstig onderzoek naar biomarkers van inflammatie en veroudering, en meer uitgebreide en specifieke onderzoeken naar orgaanfunctie. Dit zal verder inzicht verschaffen in de mechanismen die betrokken zijn bij het ontstaan van co-morbiditeit en veroudering. Tijdens deze bezoeken zal er in totaal ongeveer 320 mL (per bezoek 160 mL) extra bloed worden afgenomen. Daarnaast zullen wij in een portie urine de nierfunctie en eiwitverlies onderzoeken.

Zowel tijdens het eerste bezoek, als het vervolg bezoek na 2 jaar, zal ook een electrocardiogram (ECG) worden gemaakt, een longfunctie worden verricht en een DEXA-scan worden vervaardigd. Met behulp van de DEXA-scan kan de botdichtheid worden gemeten in de heup en het onderste deel van de wervelkolom. De deelnemers zullen een extra keer het ziekenhuis moeten bezoeken voor de DEXA-scan en de longfunctie. Tot slot zal met behulp van een korte gestandaardiseerde neuropsychologische screenings test het geheugen en concentratie in kaart worden gebracht en zal bepaald worden in hoeverre er sprake is van een depressie.

1) The screening protocol will be implemented in the outpatient HIV clinic of
the AMC and will be as much as possible integrated into regular outpatient
clinic care. During a visit to the outpatient clinic the patient will be
screened every two years. The same screening protocol will as much as
logistically feasible also be implemented every two years in a cohort of
uninfected individuals at the PHSA. A nurse or physician will ask eligible
visitors of the STI-clinic or participants of the Amsterdam Cohort Studies to
participate in this study.
During a study visit all necessary data concerning co-morbidities, risk
factors, HIV-infection and treatment (for AMC -patients), lifestyle (smoking,
alcohol use, drug use), family history (cardiovascular disease, malignancies,
fractures) and quality of life will be collected using standardized and
validated questionnaires. Height, weight and blood pressure will be measured.
Blood (serum, heparin-plasma, EDTA-plasma, citrate-plasma, PBMC*s), will be
drawn to assess lipid metabolism, glucose/insulin, renal function, liver
function and bone metabolism, in HIV-positive participants 80 mL blood per
study visit and in HIV-negative participants 70mL per study visit. Besides the
laboratory assessments for monitoring co-morbidities and their risk factors,
blood, urine and fecal samples will be stored for future assessment of for
instance biomarkers of inflammation, more sophisticated measures of various
organ functions, and aging that may provide further insight in the mechanisms
involved. Urine-analysis will be performed to detect protein loss. An EKG and
pulmonary function studies will be assessed to detect cardiac ischemia and
chronic lung disease. A DEXA scan will be performed to assess bone mineral
density. A neuropsychological test will be performed to assess cognitive
disorders and depression. The patient need to make a separate appointment to
visit the hospital for the DEXA-scan and pulmonary function.

None of the extra assessments are detrimental for patients' health. As with the
taking of *regular* blood samples patients may experience some discomfort like
bruising or swelling due to the taking of blood samples at the site of blood
drawing. The ECG, pulmonary function and DEXA are painless and no contrast
fluids are needed. However, during the DEXA scan a participant will receive
some radioactive radiation. Per study visit study participants will receive
maximally 9 microsievert of radiation. In comparison, the so-called background
radiation (radiation each of us is normally exposed to in our environment) is
2500 microsievert per year in the Netherlands.

A major benefit of this study is that it will hopefully result in better
knowledge in order to improve medical care and quality of life for the ageing
HIV-infected patients.

2) A subgroup of 75 HIV-infected patients of the AMC and 50 HIV-uninfected
individuals of the PHSA who fulfill additional eligibility criteria and provide
written informed consent will requested to undergo four extra
examinations/study procedures both at baseline and after two year follow up
measurement. These four extra examinations/procedures requires additional
visits to the AMC and consist of a neuropsychological assessment (NPA) to
evaluate the prevalence of HAND, a MRI of the brain including advanced
techniques e.g. Diffusion Tensor Imaging (DTI), MR Spectroscopie (MRS) en
Arterial Spin Labeling (ASL) and an ophthalmological examination to detect
retinal dysfunction. In addition, blood and cerebrospinal fluid samples will be
collected from both HIV-infected patients of the AMC and HIV-negative controls
from the PHSA. Blood and cerebrospinal fluid samples will be collected both at
baseline and follow up measurement for HIV-infected patients of the AMC,
whereas these samples will be collected only once, at baseline, for the
HIV-negative controls of the PHSA. Accurate evaluation of cerebrospinal
fluid-markers, in particular of markers of monocyte activation could provide
more insight in the pathophysiological mechanism of cognitive impairment in
HIV. Conducting all four study procedures of this sub study 1 at one time point
takes about six hours. Therefore participating in the entire sub study 1 will
take about 12 hours in total, depending on the group the subject is in. The
NPA (~120 minutes) is mainly time consuming. The MRI (~60 minutes) is also time
consuming and some people might experience lying in the scanner as
uncomfortable. The risks associated with having a MRI are the known risks, and
are minimal. The risks associated with ophthalmological examination (~120
minutes) are risks associated with the use of dilating eye drops which could
cause an allergic reaction of temporary redness of the eye. In addition, these
dilating drops cause slightly blurred vision for several hours. The risks
associated with blood and CSF withdrawal are the known risks. For blood
withdrawal that is bruising or swelling and for CSF withdrawal that is
postpunctional headache (~30%). Very rare complications of the lumbar puncture
are meningitis or a subdural hematoma. There are no direct benefits for
participation in this study for the subject. All subjects will be informed of
coincidental findings of adverse effects for one*s health. A major benefit of
this study is that it could provide more insight into the risk factors of HIV
associated neurocognitive disorders. In addition it could lead to the detection
of a non-invasive reliable biomarker which enables monitoring of HIV
encephalopathy. Furthermore, the insights in the pathophysiology provided by
this study may lead to new targets for interventions to decrease incidence of
HAND in aging HIV infected individuals.