Successful aging with HIV
Successful aging has become a priority among people living with HIV as they live longer with this chronic condition. There are three proposed components of successful aging: high cognitive and physical functioning, low levels of disease and disability, and active engagement in life [
1]. It is estimated that 30–60% of people living with HIV experience cognitive difficulties [
2‐
4]; however, these estimates are susceptible to selection bias and may overestimate the prevalence of cognitive difficulties [
5]. Given the proportion of people living with HIV with poor brain health, strategies are needed to help these individuals age successfully.
Lifestyle interventions
High quality evidence from HIV-negative individuals shows that healthy lifestyle changes including physical activity [
6‐
11], diet [
12], social activity [
13], and cognitive training [
14] can protect or improve brain health. There is also evidence that lifestyle change can improve cognitive ability in people living with HIV [
15‐
20]. A cross-sectional study of 139 people living with HIV determined that an increasing number of active lifestyle factors (physical activity, social activity, and employment) was associated with 41% lower prevalence of HIV-associated neurocognitive impairment [
17]. Furthermore, the investigators determined that each of the lifestyle factors (physical activity, Cohen’s d = 0.58; social activity, Cohen’s d = 0.41; employment, Cohen’s d = 0.57) was associated with better cognition.
Despite the evidence that lifestyle factors are associated with better cognitive ability, only 51% of people living with HIV are meeting the World Health Organization physical activity recommendations, compared to 65% of HIV-negative individuals [
21]. Relative to other chronic conditions, people living with HIV are among the most physically inactive, taking only 5899 steps per day on average, according to a meta-analysis of 24 studies [
22]. Three meta-analyses [
23‐
25] have reported variable adherence (61–100%) and high withdrawal rates (20–29%) among people living with HIV who participate in aerobic and resistance exercise trials. Sustained lifestyle change is difficult for everyone, but may be harder for those with executive dysfunction, including many people living with HIV [
26]. Thus, the key question is how we can improve adherence to the most promising interventions in people living with HIV experiencing cognitive difficulties.
Goal management training (GMT) has become a recommended cognitive rehabilitation strategy to improve executive function among older adults [
27]. GMT is a standardized program delivered over 9 weeks in small groups that targets executive dysfunction by teaching goal-directed behaviour, self-management, and mindfulness [
28]. GMT also trains participants to use explicit strategies to reduce cognitive load in everyday tasks, and methods to cue attention to maintain focus on specific tasks, through weekly 2 h sessions and home practice. A systematic review and meta-analysis of 15 studies determined that GMT had a small to moderate effect on executive function immediately following the intervention (Hedges’
g = 0.227) and at follow-up (Hedges’
g = 0.549) among healthy individuals and those with conditions affecting cognitive performance [
27].
GMT has been tested very little among people living with HIV. A study of 90 people living with HIV who were randomized to a single session of GMT, GMT plus metacognitive training, or control (education and origami task) found moderate effects of the combined GMT groups on everyday multitasking performance and metacognitive tasks compared to controls [
29]. GMT has not been used to augment goal-directed lifestyle changes among people living with HIV.
This study will test an innovative approach to enhance adherence to lifestyle interventions, building on feasibility evidence from pilot trials in the Brain Health Now cohort study, where we have tested three brain-health-promoting interventions, including computerized cognitive training, GMT, and exercise. Feasibility was demonstrated for both GMT and exercise, based on the success of recruitment and retention, improvements in brain health outcomes, and participant feedback [
30,
31]. The varied adherence observed in these pilot trials suggests that people living with HIV who have cognitive difficulties may need more assistance to make and sustain behaviour changes. While GMT was developed to improve goal-directed behaviour in general, we recognized that this cognitive rehabilitation approach could be applied to improve the ability to achieve health-promoting lifestyle goals in particular. We therefore hypothesize that GMT priming before a personalized healthy lifestyle program (HLP) will improve adherence to the program and subsequently improve health outcomes, compared to the HLP without GMT priming in people living with HIV experiencing cognitive difficulties.
Study objectives
The overall objective of Action for Brain Health Now is to understand, empower, and act to protect and improve brain health in HIV, and equip patients to take charge of their brain health. This sub-study is directed to the third aim, act. This proposed study addresses the real-world challenge of implementing tailored recommendations, recognizing that individuals with cognitive difficulties who would benefit the most from lifestyle changes are less equipped to successfully adopt and sustain healthy behaviours. We will trial a novel cognitive rehabilitation approach using GMT to boost adherence to a tailored active living intervention.
Specific objective
To estimate the extent to which goal management training before a personalized healthy lifestyle program is associated with greater uptake of health recommendations, achievement of health-related goals, and better brain health and general health outcomes compared to the healthy lifestyle program alone.