HIV-associated neurocognitive disorders …

Payal B Patel MD

Infectious Disorders

Updated 05.24.2024
Released 04.01.1994
Expires For CME 05.24.2027

HIV-associated neurocognitive disorders

Author: Payal B Patel MD

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Editor: Christina M Marra MD

HIV-associated neurocognitive disorders

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Introduction

Overview

In this review, we will describe the history of HIV-associated neurocognitive disorders (HAND), an umbrella term that includes memory, processing speed, and concentration and attentional deficits in persons living with HIV, important terminology and classification systems used to diagnose HIV-associated neurocognitive disorders, and the clinical manifestations and management of HIV-associated neurocognitive disorders.

Key points

	• HIV-associated neurocognitive disorder (HAND) is a clinical syndrome with varied presentation of cognitive impairment and clinical fluctuation that occurs in association with or as a primary manifestation of HIV infection.
	• Combination antiretroviral therapy has resulted in improved survival of persons living with HIV. This, in combination with the compound effects of age-related cognitive changes including increased prevalence of non-HIV related comorbidities, has resulted in an increasing prevalence of cognitive impairment in persons living with HIV.
	• Recommended approaches for diagnosis of HIV-associated neurocognitive disorder allow for the categorization of individuals ranging from mild to severe cognitive impairment with or without impairment in activities of daily living. These categories have important prognostic implications.
	• Effective control of HIV viral replication with combination antiretroviral therapy is an important management tool for HIV-associated neurocognitive disorders but may not be sufficient for prevention of neurocognitive impairment or decline in persons living with HIV.

Historical note and terminology

Prior to antiretroviral therapy (1980-1990s). Following the discovery of HIV and the most severe manifestation of HIV, AIDS (or acquired immunodeficiency syndrome), Navia and Price subsequently introduced the term "AIDS dementia complex" (48), which referred to cognitive, behavioral, and motor deficits that occurred frequently in patients living with AIDS. The term "HIV encephalopathy" was added to the list of terms used to describe neurologic features associated with AIDS dementia complex (36).

In 1991, the American Academy of Neurology AIDS Task Force developed definitional criteria for AIDS dementia (26). The terms "AIDS dementia complex," "HIV dementia," and "HIV encephalopathy," and "HIV-1-associated cognitive/motor complex" were considered synonymous conditions. Before antiretroviral therapy was available, 20% to 30% of patients with severe HIV disease experienced HIV-associated dementia, the most severe cognitive complication associated with HIV (20; 29).

After development of and increased accessibility to combination antiretroviral therapy (1996 and beyond). With the introduction of combination antiretroviral therapy the incidence of HIV-associated dementia, the most severe form of HIV-associated neurocognitive disorders, has decreased but the absolute prevalence of HIV-associated neurocognitive disorder has increased every decade given the longer life expectancy of individuals with HIV on combination antiretroviral therapy. Approximately 40% of persons living with HIV have some degree of HIV-associated neurocognitive impairment (62; 56; 40; 02) and the incidence of neurocognitive impairment in persons living with HIV has remained stable from the pre-antiretroviral therapy to post-antiretroviral therapy era, though there has been a notable decrease in the incidence of the most severe form of cognitive impairment, HIV-associated dementia (25).

In 2007, Antinori and colleagues developed classification criteria to standardize nomenclature surrounding neurocognitive diagnosis in persons living with HIV. The Frascati criteria consist of three separate clinical entities (02) and are detailed in Table 1. Asymptomatic neurocognitive impairment includes individuals with cognitive performance one standard deviation below the mean in two or more cognitive domains without documented impairment in activities of daily living. Mild neurocognitive disorder includes individuals with cognitive performance one standard deviation below the mean in two or more cognitive domains with mild documented difficulties in activities of daily living. HIV-associated dementia includes those with cognitive performance falling two standard deviations below the mean in two or more domains and severe difficulties in performance of activities of daily living. Other confounding factors or non-HIV related diagnoses must be excluded in order to attribute cognitive impairment to HIV infection. These alternative diagnoses may include substance abuse, other causes of dementia, or pseudo-dementia associated with a psychiatric condition. A key point of differentiation is between asymptomatic neurocognitive impairment and symptomatic disorders (mild neurocognitive disorder and HIV-associated dementia), which differ based on impairment in activities of daily living.

Table 1. Frascati Criteria for Diagnosis of HIV-Associated Neurocognitive Disorders

HIV-associated asymptomatic neurocognitive impairment*
	(1) Two or more neurocognitive domains** with performance at least 1.0 SD below the mean for age and education-appropriate norms on standardized neuropsychological tests.
	(2) No impact on everyday function.
	(3) No evidence of alternative diagnoses or delirium.
HIV-associated mild neurocognitive disorder*
	(1) Two neurocognitive domains** with performance at least 1.0 SD below the mean for age and education appropriate norms on standardized neuropsychological tests.
	(2) The cognitive impairment mildly interferes with activities of daily living.
	(3) No evidence of alternative diagnoses or delirium.
HIV-associated dementia*
	(1) Two neurocognitive domains** with performance at least 2.0 SD below the mean for age and education appropriate norms on standardized neuropsychological tests.
	(2) The cognitive impairment significantly interferes with activities of daily living.
	(3) No evidence of an alternative diagnoses or delirium.
If there is a prior diagnosis of HIV-associated neurocognitive disorder but currently the individual does not meet criteria, the diagnosis of HIV-associated neurocognitive disorder in remission can be made. *The neuropsychological assessment must survey at least the following abilities: verbal/language; attention/working memory; abstraction/executive; memory (learning, recall); speed of information processing; sensory perception; motor skills.

Since the advent of combination antiretroviral therapy, most patients present with mild forms of HIV-associated neurocognitive disorder resulting in a shift from severe to milder HIV-associated neurocognitive disorder subtypes in the posttreatment era (57). Milder forms of HIV-associated neurocognitive disorder have important prognostic implications, as individuals with asymptomatic neurocognitive impairment have an increased risk of meeting criteria for symptomatic impairment (mild neurocognitive disorder and HIV-associated dementia) over the next few years (21). Although only a small subset of patients may progress to frank dementia, even patients with the mildest of symptoms can have their quality of life affected by disruption in their ability to perform activities of daily living and, importantly, in their adherence to medication (40).

The term "HIV encephalitis" should be reserved for the pathological features of multinucleated giant cell encephalitis with HIV identified in the brain and not used to describe the clinical syndrome. Similarly, although HIV-associated dementia can develop concurrently with other HIV-associated neurologic disorders, such as myelopathy and neuropathy, these diseases are discrete clinical entities separate from HAND with distinct manifestations, courses, and pathogenic mechanisms.

Clinical manifestations

Presentation and course

Prior to the availability of combination antiretroviral therapy, the clinical manifestations of HIV-associated dementia included signs and symptoms associated with predominantly subcortical brain injury (47; 46). Typically, patients presented with psychomotor slowing, apathy, depressive symptoms, and withdrawal from usual activities. Memory loss was selective for impaired retrieval, and impaired manipulation of acquired knowledge. Initial symptoms were often subtle and were confused with psychiatric complaints. Considerable variability in presentation was reported.

Subjectively, patients complained of losing track of conversations and the plots of books and films. They noted increased time needed to complete more complex daily tasks. Impaired short-term memory caused difficulty with remembering appointments, medications, and telephone numbers. Friends and partners reported shifts in personality; most notable symptoms included apathy, social withdrawal, and blunting of emotional responsiveness. Motor complaints were also common and included poor handwriting and impaired balance. Progression of cognitive impairment was often accompanied by severe psychomotor slowing and mutism. Terminally, patients would become bed-bound, incontinent, abulic, and mute.

Since the advent of combination antiretroviral therapy, findings of impaired cognition are subtle, and motor impairment is uncommon, generally seen only in patients with severe, end-stage AIDS. In patients with milder disease, routine neurologic examination may be normal and detailed neurocognitive testing is required for the diagnosis of HIV-associated neurocognitive disorder (02). The predominant domains of cognitive impairment have also shifted from impaired motor skills, processing speed and verbal fluency in the pre-combination antiretroviral therapy era to more working memory and executive function impairment in the post-combination antiretroviral therapy era (25). For a review, see Table 1.

Prognosis and complications

The severity of cognitive impairment in persons living with HIV (PLWH) often fluctuates and is dependent on the duration of disease, demographic and treatment related factors, and non-HIV comorbidities (54). Neurologic and cognitive complications diagnosed in acute or primary infection (within the first year following transmission) often resolve following initiation of combination antiretroviral therapy but may persist in some individuals as subtle neurocognitive abnormalities only found on detailed cognitive testing (12; 31). Individuals with chronic HIV who are virally suppressed on antiretroviral therapy typically display stable cognitive scores in the short term, at least over the course of four years of follow-up in large, multicenter cohort studies (61). Exceptions include those with a diagnosis of asymptomatic neurocognitive impairment, which is associated with a 2-fold increased risk of developing symptomatic HIV-associated neurocognitive disorders (mild neurocognitive disorder and HIV-associated dementia) over four years independent of treatment status (21). Patients with untreated chronic HIV infection, particularly those presenting with low CD4 nadirs, are at highest risk of developing HIV-associated neurocognitive disorders and neurocognitive decline, suggesting that prolonged, unsuppressed viral replication may predispose patients to poor neurologic outcomes (24). Other demographic risk factors for cognitive decline include older age, prolonged duration of HIV (≥ 15 years), and education level of less than 12 years (61; 73). Comorbidities such as hepatitis C and elevated cholesterol levels are associated with an increased risk of developing HIV-associated neurocognitive disorders, as well as advancement to more severe stages of HIV-associated neurocognitive disorders (68; 61). In the CHARTER cohort, nearly a quarter (23.4%) of participants with HIV experienced cognitive decline during follow-up of up to 12 years. Cognitive decline was associated with multiple comorbid conditions, including methamphetamine use, chronic lung disease, hypertension, diabetes, and lifetime cannabis use, but not age or HIV-related factors (45; 23).

Biological basis

Etiology and pathogenesis

HIV enters the central nervous system early in infection, likely through trafficking of infected leukocytes across the blood-brain and blood-CSF barriers or, less likely, through direct transmission into the CNS due to increased permeability of the blood-brain barrier (27; 71; 13; 30). Early pathologic studies consistently show that HIV-1 infection in brain tissue occurs more frequently in perivascular macrophages and monocytes, particularly in the deep white matter and basal ganglia (32). Although there is no evidence that HIV directly infects neurons (20), direct HIV infection of astrocytes has been proven in in vitro and in vivo studies. Astrocytic HIV infection has potential injurious consequences, as astrocytes are responsible for blood-brain barrier integrity and cerebral homeostasis.

Genetically, in early infection, HIV strains isolated in cerebrospinal fluid have similar sequences compared to viral strains in the blood. Over time, compartmentalized, genetically differentiated HIV strains evolve in the CNS. These viral subtypes may be more macrophage tropic, allowing for persistence in the CNS, particularly in microglia (20; 67; 28). It appears likely that following entry of HIV into the CNS, activation of macrophages and microglia occurs, resulting in the release of cytokines into the brain parenchyma. The cytokine-mediated inflammatory cascade may cause secondary effects, including the amplification of HIV replication, stimulation of astrocytosis, and additional production of proinflammatory mediators. Activated and HIV-infected astrocytes may play a role in modulating the release of neurotoxic substances including N-methyl-D-aspartate and oxidative metabolites, which may be the final common pathway for neuronal damage (64; 01). Additionally, HIV heightens inflammatory cytokine and glutamate secretion from infected astrocytes (01). Compartmentalization of the HIV-strain specific to the CSF is associated with worse global cognitive performance and worse self-reported functioning (04).

Cerebral atrophy was common in patients with HIV dementia in the pre-combination antiretroviral therapy era and often occurred in a frontotemporal distribution. Pathologic evaluation of brains of patients with HIV dementia revealed multiple small nodules containing macrophages, lymphocytes, and microglia (termed microglial nodules) scattered throughout the brain, appearing more commonly in white matter and the subcortical gray matter of the thalamus, basal ganglia, and brainstem (15). These inflammatory nodules were not specific for HIV-1 infection and occur in other CNS infections, including toxoplasmosis and cytomegalovirus encephalitis. Multinucleated giant cells, reflecting active HIV replication, and fusion of macrophages were also characteristically seen (07). The combination of multinucleated giant cells, microglial nodules, and perivenular inflammation are the pathologic basis of "HIV encephalitis" (08) and were identified in 30% to 90% of patients dying with AIDS (15).

These pathogenic CNS findings are variably present in patients with HIV-related neurocognitive disorders and not consistent with clinical disease. Even in advanced dementia, there may only be relatively mild pathologic changes (15; 50) and only a small fraction of cells contains viral antigens (19). This discrepancy between the small amounts of replicating HIV-1 and the severity of the dementia suggests that other factors besides direct cellular damage by HIV-1 may be of importance in the pathogenesis of HIV-associated neurocognitive disorder (27).

Cerebrospinal fluid biomarkers reflecting inflammatory-mediated changes in the CNS are seen in all stages of HIV infection and correlate with clinical and pathologic abnormalities (16). Several cerebrospinal fluid biomarkers are associated with cognitive impairment including neopterin, a marker of macrophage activation, and neurofilament light chain, a marker of axonal injury (05; 65). These markers correlate with HIV-associated neurocognitive disorder severity and HIV-related mortality, suggesting that chronic CNS inflammation related to persistent HIV infection may lead to increased morbidity and mortality in persons living with HIV. Differences in viral neurotropism, in rates of replication among CNS-specific strains of HIV-1, or in individual variation of inflammatory responses may underlie the clinical variability in the development and severity of HIV-associated neurocognitive disorder in persons living with HIV.

Chronic inflammation secondary to HIV infection may predispose persons living with HIV to premature aging and age-related comorbidities, such as cerebrovascular disease. Markers of vascular progenesis, indicated by increased plasma angiotensin-2 and vascular endothelial growth factor levels as well as increased pulse pressure, are associated with worse cognitive function in older individuals living with virally suppressed HIV (43). Additionally, higher scores on the Framingham cardiovascular disease risk assessment are associated with poor cognitive performance (09). Cognitive and physiologic reserve (ie, an increased capacity of organs to withstand external stressors that lead to the development of frailty in older age) are protective factors against cognitive decline in older persons living with HIV (63). These data suggest that modifiable risk factors could be identified that decrease the likelihood of poor cognition in persons living with HIV.

Epidemiology

According to 2021 UNAIDS estimates, approximately 38.4 million people are living with HIV worldwide, with approximately 1.5 million new infections occurring each year (United Nations AIDS 2023). Higher rates of survival among persons living with HIV have resulted in an aging population living with HIV-related comorbidities and concurrent cognitive effects of age-related changes and conditions (ie, Alzheimer dementia or cerebrovascular disease) (70). Prior to the development of combination antiretroviral therapy, HIV-associated dementia was common, affecting 20% to 30% of persons living with HIV (20). After combination antiretroviral therapy became widely available, the incidence of HIV-associated dementia decreased to less than 5%. Despite this trend, the absolute prevalence of HIV-associated neurocognitive disorder has steadily increased given the longer life expectancy of individuals with HIV on combination antiretroviral therapy (25). Large multicenter cohort studies have found that up to 50% of persons living with HIV on antiretroviral therapy have some degree of HIV-associated neurocognitive impairment (56; 40; 02; 24). Additionally, the incidence of cognitive impairment in persons living with HIV has remained stable from the pre-combination antiretroviral therapy to post-combination antiretroviral therapy era (24).

International studies show tremendous variability in the prevalence of country-specific HIV-associated neurocognitive disorders. These epidemiologic estimates are complicated by differences in confounding factors, inclusion criteria and differing methodology for the diagnosis and categorization of cognitive impairment. Despite the availability of the formal Frascati criteria, limited access to trained neuropsychologists and availability of local norms leads to difficulty in determining the true prevalence of HIV-associated neurocognitive disorders globally and in comparisons of HIV-associated neurocognitive disorder prevalence between international cohorts. For example, older studies had found that the prevalence of HIV-associated dementia was significantly higher in a Ugandan cohort compared to other African countries, and these rates did not decrease following improved access to antiretroviral therapy (60; 58). In contrast, follow-up studies have shown similar rates of HIV-associated dementia among individuals with moderate to severe immunosuppression in Uganda in comparison to other international cohorts (59), leading to the conclusion that population-specific cognitive measures and larger research studies, which include normative populations, are needed to determine the true prevalence of neurocognitive dysfunction among international cohorts living with HIV. An international study through the AIDS Clinical Trials Group utilized the Frascrati criteria and local norms to establish the global prevalence of HIV-associated neurocognitive disorders and found that 45% of participants had a diagnosis of HIV-associated neurocognitive disorder at baseline. Following initiation of antiretroviral therapy, the estimated odds of cognitive impairment reduced by 12% every 24 weeks after beginning combination antiretroviral therapy (52).

Diagnostic workup

Establishing the diagnosis of HIV-associated neurocognitive disorder involves careful clinical and laboratory assessment. Neuropsychological testing is imperative to establish the presence of cognitive impairment and quantify the severity of impairment. Longitudinal neurocognitive evaluation in individuals with HIV and HIV-associated neurocognitive disorder may be warranted to define the patterns of involvement, such as loss of memory or executive function, and to screen for neurocognitive decline. All persons living with HIV with subjective cognitive complaints should be screened for cognitive impairment with consideration for repeat screening approximately every other year in cognitively stable individuals or sooner if clinical deterioration occurs. Screening tools may aid in earlier diagnosis and psychosocial intervention and should be tailored to the clinicians’ training and comfort with using the measure. Follow-up neuropsychologic testing in those who screen positive for cognitive symptoms should span a minimum of 5, but preferably 7, cognitive domains (41).

Neurologic examination in individuals with asymptomatic neurocognitive impairment and mild cognitive impairment are often normal. In patients with HIV dementia, psychomotor slowing, delayed saccades, and other neurologic abnormalities on examination are often seen. Neuropsychological testing is important but not a replacement for the neurologic examination because abnormalities on neuropsychological testing are not necessarily specific for HIV-associated neurocognitive disorders. Evaluation for focal neurologic signs on detailed neurologic examination may uncover non-HIV related neurologic conditions such as head trauma or stroke, diagnoses that are common in persons living with HIV; therefore, a neurologic examination is needed to correctly interpret results of neuropsychological testing.

Table 4. Clinical Features Useful for Diagnosis of HIV-Associated Neurocognitive Disorders (HAND)

• HIV-1 seropositivity (Western blot confirmation).
• Longitudinal neurocognitive testing (to diagnose HIV-associated neurocognitive disorders and to evaluate for progressive cognitive decline.
• Neurologic examination.
• Imaging studies such as MRI with contrast to exclude alternative diagnoses should be considered prior to lumbar puncture to avoid herniation risks.
• CSF evaluation, including analysis for opportunistic infections such as neurosyphilis or cryptococcal meningitis, and measurement of CSF HIV RNA concentration.
• Screening for major psychiatric disorders or substance abuse.
• Screening for metabolic derangement or alternative causes of mental status disturbances, eg, hyponatremia, urinary tract infection.

Screening for comorbid substance abuse and psychiatric disorders is important to guide therapeutic options and prevent cognitive decline. Additionally, screening for opportunistic CNS infections with imaging and CSF examination, as noted above, should be undertaken in individuals with HIV presenting with cognitive complaints.

Imaging studies are useful in evaluating for alternative causes of cognitive impairment but are not useful for the diagnosis of HIV-associated neurocognitive disorders. Nonspecific radiologic features of HAND include cortical atrophy and white matter lesions, which appear as ill-defined areas of increased signal intensity on T2-weighted images (Levy et al 1986; 48). Functional MRI (fMRI), which employs rapid, dynamic imaging to evaluate regional changes in blood flow that accompany brain activation, demonstrates potentially compensatory increased cerebral blood volume in cortical and deep gray matter structures in individuals with HIV in a few studies (22). This activation is task-specific, with increased parietal and frontal activation occurring with simpler and more complex tasks, respectively, when compared to uninfected controls (10). The clinical implications of these findings remain to be determined as well as long-term regional fMRI changes following initiation of antiretroviral therapy (22).

In most patients with HIV-associated neurocognitive disorders, routine CSF studies are normal and there is no single cerebrospinal fluid biomarker or combination of tests that can reliably diagnose HIV-associated neurocognitive disorders. The clinical relevance of detectable HIV RNA concentrations in CSF, especially in the setting of undetectable HIV RNA in plasma (defined as CNS escape), has yet to be determined. If CNS escape is present, evaluation for CSF antiretroviral drug resistance may be undertaken in order to tailor antiretroviral therapeutic regimens (49).

Management

Given the unresolved questions regarding pathogenesis, no treatment exists for HIV-associated neurocognitive disorders. Management revolves around prevention through early initiation of optimal combination antiretroviral therapy and identification of reversible comorbid conditions (12; 31). Evaluation and treatment of coexisting substance abuse, medical comorbidities, and psychiatric conditions may result in better quality of life and reduce impairment in tasks of daily living.

Optimal antiretroviral therapy for HIV-associated neurocognitive disorders should control CNS HIV infection. Some antiretroviral drugs penetrate poorly from blood into CSF. It is not clear whether antiretroviral therapy levels in CSF accurately reflect cerebral drug concentrations (34). Approaches that provide a numerical estimation of the effectiveness with which a single drug or drug combination may penetrate into the CNS, such as the CNS penetration effectiveness (CPE) score, allow for the formulation of regimens that may be more CNS penetrant and, therefore, potentially more effective in individuals with neurocognitive impairment (35; 33; 66).

High CPE scores have been linked to lower CSF HIV RNA concentrations (35; 11), but not necessarily better cognitive function (53). Most observational studies following people living with HIV at onset of antiretroviral therapy initiation do not demonstrate a clear benefit of antiretroviral regimens with improved CNS penetration, although all regimens in these studies had high CPE scores (scores > 7). Two randomized trial of persons living with HIV and diagnosed with HIV-associated neurocognitive disorder who either initiated or switched to an antiretroviral therapy regimen with a high CPE score versus continued on their regimen with a low CPE score showed no significant difference in follow-up cognitive scores between the two groups, although the power of the study was limited by lower than anticipated enrollment (17; 38). In contrast, the largest randomized controlled trial to date, the ACTG Longitudinal Linked Randomized Trials (ALLRT) found that higher CPE at antiretroviral therapy initiation was associated with better cognitive functioning at 4.7 year follow-up (66). The addition of maraviroc, a highly CNS penetrant antiretroviral drug and CCR5 antagonist, to combination antiretroviral regimens improved cognitive function in the CINNAMON study, an open-label pilot study (03). Another prospective study found that lower CPE at baseline and at follow-up visits were independently associated with cognitive decline at the 22-month follow-up (72). Other studies have demonstrated an association between higher CPE and poorer cognitive performance possibly related to antiretroviral therapy neurotoxicity (39). Therefore, the utility of the CPE score and neurointensification of antiretroviral therapy regimens for treatment of HIV-associated neurocognitive disorder remains to be determined.

HIV drug resistance testing in the CSF is not uniformly recommended in persons living with virally-suppressed HIV and cognitive impairment but has been included in clinical guidelines published by the European AIDS Clinical Society (EACS) and Mind Exchange working group (41; 18). The yield of drug resistance testing via HIV RNA PCR on CSF may be low and the laboratory test can be expensive. Therefore, more work is needed to establish a cost-effective approach to evaluating drug resistance patterns in compartmentalized CNS HIV and the clinical benefit of tailoring antiretroviral therapy based on drug resistance testing remains to be determined (49).

Neurologic dysfunction secondary to combination antiretroviral therapy toxicity is an important area of clinical concern. A large observational study found that virally suppressed participants on a median of 4.5 years of combination antiretroviral therapy demonstrated improvement in cognitive scores up to two years following antiretroviral therapy interruption. These findings were significant even after accounting for participant dropout and practice effect (55). Efavirenz use has been associated with worse cognitive outcomes as well as psychiatric side effects, such as symptoms related to depression and anxiety. Psychiatric symptoms may also be a side effect of dolutegravir and other newer antiretroviral drugs, although to a lesser extent than efavirenz. These side effects are often transient and resolve in the first four weeks following initiation of therapy. An important consideration is to screen patients on efavirenz for suicidal ideation, as an AIDS Clinical Trials Group multicenter study found that participants taking efavirenz had a 2-fold increased hazard of suicidality (42). These results suggest that antiretroviral therapy regimens with fewer neurologic or psychiatric side effects should be initiated in patients newly diagnosed with HIV who have premorbid psychiatric or cognitive conditions. Additionally, the U.S. Department of Health and Human Services Panel on Adult and Adolescent Antiretroviral Treatment Guidelines explicitly recommends avoidance of efavirenz in individuals with HIV-associated dementia or with underlying psychiatric disorders (44).

Symptomatic treatment of adverse effects or switching to alternative antiretroviral therapy regimen are important considerations for patients experiencing neurologic side effects of combination antiretroviral therapy. Patients with HIV-associated neurocognitive disorders may be more susceptible to the adverse effects of psychoactive drugs, and polypharmacy can be particularly problematic. In patients with progressive neurocognitive decline, medico-legal issues such as establishing a power of attorney, household safety, and completion of a living will should be discussed before the cognitive difficulties begin to impair memory and decision-making capabilities.

References

01: Al-Harti L, Joseph J, Nath A. Astrocytes as an HIV CNS reservoir: highlights and reflections of an NIMH-sponsored symposium. J Neurovirol 2018;24(6):665-9. PMID 30397827
02: Antinori A, Arendt G, Becker JT, et al. Updated research nosology for HIV-associated neurocognitive disorders. Neurology 2007;69:1789-99.** PMID 17914061
03: Barber TJ, Imaz A, Boffito M, et al. CSF inflammatory markers and neurocognitive function after addition of maraviroc to monotherapy darunavir/ritonavir in stable HIV patients: the CINAMMON study. J Neurovirol 2018;24(1):98-105. PMID 29280108
04: Bowman NM, Joseph SB, Kincer LP, et al. HIV compartmentalization in the CNS is associated with neurocognitive impairment [CROI Abstract 401]. In Special Issue: Abstracts From the 2016 Conference on Retroviruses and Opportunistic Infections. Top Antiv Med 2016;24(e-1):153.
05: Brew BJ, Dunbar N, Pemberton L, Kaldor J. Predictive markers of AIDS dementia complex: CD4 cell count and cerebrospinal fluid concentrations of beta 2-microglobulin and neopterin. J Infect Dis 1996;174(2):294-8. PMID 8699058
06: Buchacz K, Lau B, Jing Y, et al. Incidence of AIDS-defining opportunistic infections in a multicohort analysis of HIV-infected persons in the United States and Canada, 2000-2010. J Infect Dis 2016;214(6):862-72. PMID 27559122
07: Budka H. Multinucleated giant cells in brain: a hallmark of the acquired immune deficiency syndrome (AIDS). Acta Neuropathol (Berl) 1986;69:253-8.
08: Budka H, Wiley CA, Kleihues P, et al. HIV-associated disease of the nervous system: review of nomenclature and proposal for neuropathology-based terminology. Brain Pathol 1991;1:143-52. PMID 1669703
09: Calon M, Menon K, Carr A, et al. Additive and synergistic cardiovascular disease risk factors and HIV disease markers' effects on white matter microstructure in virally suppressed HIV. J Acquir Immune Defic Syndr 2020;84(5):543-51. PMID 32692114
10: Chang L, Speck O, Miller EN, et al. Neural correlates of attention and working memory deficits in HIV patients. Neurology 2001;57:1001-7. PMID 11571324
11: Cusini A, Vernazza PL, Yerly S, et al. Higher CNS penetration-effectiveness of long-term combination antiretroviral therapy is associated with better HIV-1 viral suppression in cerebrospinal fluid. J Acquir Immune Defic Syndr 2013;62(1):28-35. PMID 23018371
12: Cysique LA, Vaida F, Letendre S, et al. Dynamics of cognitive change in impaired HIV-positive patients initiating antiretroviral therapy. Neurology 2009;73(5):342-8.** PMID 19474412
13: de Almeida SM, Rotta I, Ribeiro CE, et al. Blood-CSF barrier and compartmentalization of CNS cellular immune response in HIV infection. J Neuroimmunol 2016;301:41-8. PMID 27836178
14: D'Antoni ML, Byron MM, Chan P, et al. Normalization of soluble CD163 levels after institution of antiretroviral therapy during acute HIV infection tracks with fewer neurological abnormalities. J Infect Dis 2018;218(9):1453-63. PMID 29868826
15: de la Monte SM, Ho DD, Schooley RT, Hirsch MS, Richardson EP Jr. Subacute encephalomyelitis of AIDS and its relation to HTLV-III infection. Neurology 1987;37:562-9. PMID 3561770
16: Eden A, Marcotte TD, Heaton RK, et al. Increased intrathecal immune activation in virally suppressed HIV-1 infected patients with neurocognitive impairment. PLoS One 2016;11(6):e0157160.** PMID 27295036
17: Ellis RJ, Letendre S, Viada F, et al. Randomized trial of central nervous system-targeted antiretrovirals for HIV-associated neurocognitive disorder. Clin Infect Dis 2014;58(7):1015-22. PMID 24352352
18: European AIDS Clinical Society Guidelines. Version 9.1. October 2018. Accessed June 26, 2019. Available at: www.eacsociety.org. 2018.
19: Gabuzda DH, Ho DD, de la Monte SM, Hirsch MS, Rota TR, Sobel RA. Immunohistochemical identification of HTLV-III antigen in brains of patients with AIDS. Ann Neurol 1986;20:289-95. PMID 3532930
20: Gonzalez-Scarano F, Martin-Garcia J. The neuropathogenesis of AIDS. Nat Rev Immunol 2005;5(1):69-81.** PMID 15630430
21: Grant I, Franklin DR Jr, Deutsch R, et al. Asymptomatic HIV-associated neurocognitive impairment increases risk for symptomatic decline. Neurology 2014;82(23):2055-62.** PMID 24814848
22: Hakkers CS, Arends JE, Barth RE, Du Plessis S, Hoepelman AI, Vink M. Review of functional MRI in HIV: effects of aging and medication. J Neurovirol 2017;23(1):20-32. PMID 27718211
23: Heaton RK, Ellis RJ, Tang B, et al. Twelve-year neurocognitive decline in HIV is associated with comorbidities, not age: a CHARTER study. Brain 2023;146(3):1121-31. PMID 36477867
24: Heaton RK, Franklin DR, Deutsch R, et al. Neurocognitive change in the era of HIV combination antiretroviral therapy: the longitudinal CHARTER study. Clin Infect Dis 2015;60(3):473-80.** PMID 25362201
25: Heaton RK, Franklin DR, Ellis RJ, et al. HIV-associated neurocognitive disorders before and during the era of combination antiretroviral therapy: differences in rates, nature, and predictors. J Neurovirol 2011;17(1):3-16. PMID 21174240
26: Janssen RS, Cornblath DR, Epstein LG, et al. Nomenclature and research case definitions for neurological manifestations of human immunodeficiency virus type-1 (HIV-1) infection. Report of a Working Group of the American Academy of Neurology AIDS Task Force. Neurology 1991;41:778-85.
27: Johnson RT, McArthur JC, Narayan O. The neurobiology of human immunodeficiency virus infections. FASEB J 1988;2:2970-81. PMID 2846395
28: Joseph SB, Kincer LP, Bowman NM, et al. HIV-1 RNA detected in the CNS after Years of suppressive antiretroviral therapy can originate from a replicating CNS reservoir of clonally expanded cells. Clin Infect Dis 2019;69(8):1345-52. PMID 30561541
29: Kaul M, Lipton SA. Experimental and potential future therapeutic approaches for HIV-1 associated dementia targeting receptors for chemokines, glutamate and erythropoietin. Neurotox Res 2005;8(1-2):167-86. PMID 16260394
30: Kincer LP, Schnell G, Swanstrom R, et al. HIV-1 is Transported into the central nervous system by trafficking infected cells. Pathog Immun 2023;7(2):131-42. PMID 36865569
31: Kore I, Ananworanich J, Valcour V, et al. Neuropsychological impairment in acute HIV and the effect of immediate antiretroviral therapy. J Acquir Immune Defic Syndr 2015;70(4):393-9. PMID 26509933
32: Kure K, Weidenheim KM, Lyman WD, Dickson DW. Morphology and distribution of HIV-1 gp41-positive microglia in subacute AIDS encephalitis. Pattern of involvement resembling a multisystem degeneration. Acta Neuropathol (Berl) 1990;80:393-400.
33: Letendre S. Central nervous system complications in HIV disease: HIV-associated neurocognitive disorder. Top Antivir Med 2011;19(4):137-42. PMID 22156215
34: Letendre SL, Capparelli EV, Ellis RJ, McCutchan JA. Indinavir population pharmacokinetics in plasma and cerebrospinal fluid. The HIV Neurobehavioral Research Center Group. Antimicrob Agents Chemother 2000;44:2173-5. PMID 10898694
35: Letendre S, Marquie-Beck J, Capparelli E, et al. Validation of the CNS Penetration-Effectiveness rank for quantifying antiretroviral penetration into the central nervous system. Arch Neurol 2008;65(1):65-70. PMID 18195140
36: Levy RM, Bredesen DE. Central nervous system dysfunction in acquired immunodeficiency syndrome. J Acquir Immune Defic Syndr 1988;1(1):41-64. PMID 3063805
37: Levy RM, Rosenbloom S, Perrett LV. Neuroradiologic findings in AIDS: a review of 200 cases. AJR Am J Roentgenol 1986;147:977-83. PMID 3490168
38: Lin SP, Calcagno A, Letendre SL, Ma Q. Clinical treatment options and randomized clinical trials for neurocognitive complications of HIV infection: combination antiretroviral therapy, central nervous system penetration effectiveness, and adjuvants. Curr Top Behav Neurosci 2021;50:517-45. PMID 33604875
39: Marra CM, Zhao Y, Clifford DB, et al. Impact of combination antiretroviral therapy on cerebrospinal fluid HIV RNA and neurocognitive performance. AIDS 2009;23(11):1359-66. PMID 19424052
40: McArthur JC. HIV dementia: an evolving disease. J Neuroimmunol 2004;157(1-2):3-10. PMID 15579274
41: Mind Exchange Working Group. Assessment, diagnosis, and treatment of HIV-associated neurocognitive disorder: a consensus report of the mind exchange program. Clin Infect Dis 2013;56(7):1004-17. PMID 23175555
42: Mollan KR, Smurzynski M, Eron JJ, et al. Association between efavirenz as initial therapy for HIV-1 infection and increased risk for suicidal ideation or attempted or completed suicide: an analysis of trial data. Ann Intern Med 2014;161(1):1-10. PMID 24979445
43: Montoya JL, Iudicello J, Fazeli PL, et al. Elevated markers of vascular remodeling and arterial stiffness are associated with neurocognitive function in older HIV+ adults on suppressive antiretroviral therapy. J Acquir Immune Defic Syndr 2017;74(2):134-41. PMID 27828873
44: National Institute of Health. Guidelines for the use of antiretroviral agents in - adults and adolescents with HIV. Available at: Adverse Effects of Antiretroviral Agents. Accessed May 4, 2023.
45: Naveed Z, Fox HS, Wichman CS, et al. An assessment of factors associated with neurocognitive decline in people living with HIV. Int J STD AIDS 2022;33(1):38-47. PMID 34565257
46: Navia BA, Cho ES, Petito CK, Price RW. The AIDS dementia complex: II. Neuropathology. Ann Neurol 1986b;19:525-35. PMID 3014994
47: Navia BA, Jordan BD, Price RW. The AIDS dementia complex: I. Clinical features. Ann Neurol 1986a;19:517-24. PMID 3729308
48: Navia BA, Price RW. The acquired immunodeficiency syndrome dementia complex as the presenting or sole manifestation of human immunodeficiency virus infection. Arch Neurol 1987;44:65-9. PMID 23087202
49: Nightingale S, Winsto A, Letendre S, et al. Controversies in HIV-associated neurocognitive disorders. Lancet Neurol 2014;13(11):1139-51. PMID 25316020
50: Price RW, Brew BJ. The AIDS dementia complex. J Infect Dis 1988;158:1079-83. PMID 3053922
51: Price RW, Navia BA. Infections in AIDS and in other immunosuppressed patients. In: Kennedy PG, Johnson RT, editors. Infections of the nervous system. London: Butterworth, 1987.
52: Robertson KR, Jiang H, KumwendaJ, et al. HIV associated neurocognitive impairment in diverse resource limited settings. Clin Infect Dis 2019;68(10):1733-8. PMID 30219843
53: Robertson K, Jiang H, Kumwenda J, et al. Improved neuropsychological and neurological functioning across three antiretroviral regimens in diverse resource-limited settings: AIDS Clinical Trials Group study a5199, the International Neurological Study. Clin Infect Dis 2012;55(6):868-76. PMID 22661489
54: Robertson KR, Smurzunski M, Parsons TD, et al. The prevalence and incidence of neurocognitive impairment in the HAART era. AIDS 2007;21(14):1915-21. PMID 17721099
55: Robertson KR, Su Z, Margolis DM, et al. Neurocognitive effects of treatment interruption in stable HIV-positive patients in an observational cohort. Neurology 2010;74(16):1260-6. PMID 20237308
56: Sacktor N. The epidemiology of human immunodeficiency virus-associated neurological disease in the era of highly active antiretroviral therapy. J Neurovirol 2002;8(Suppl 2):115-21. PMID 12491162
57: Sacktor N, Haughey N, Cutler R, et al. Novel markers of oxidative stress in actively progressive HIV dementia. J Neuroimmunol 2004;157(1-2):176-84. PMID 15579295
58: Sacktor N, Nakasujja N, Okonkwo O, et al. Longitudinal neuropsychological test performance among HIV seropositive individuals in Uganda. J Neurovirol 2013;19(1):48-56. PMID 23315423
59: Sacktor N, Nakasujja N, Redd AD, et al. HIV subtype is not associated with dementia among individuals with moderate and advanced immunosuppression in Kampala, Uganda. Metab Brain Dis 2014;29(2):261-8. PMID 24515303
60: Sacktor N, Nakasujja N, Skolasky R, et al. Antiretroviral therapy improves cognitive impairment in HIV+ individuals in sub-Saharan Africa. Neurology 2006;67(2):311-4. PMID 16864825
61: Sacktor N, Skolasky RL, Seaberg E, et al. Prevalence of HIV-associated neurocognitive disorders in the Multicenter AIDS Cohort Study. Neurology 2016;86(4):334-40. PMID 26718568
62: Sacktor N, Tarwater PM, Skolasky RL, et al. CSF antiretroviral drug penetrance and the treatment of HIV-associated psychomotor slowing. Neurology 2001;57(3):542-4. PMID 11502933
63: Saloner R, Lobo JD, Paolillo EW, et al. Cognitive and physiologic reserve independently relate to superior neurocognitive abilities in adults aging with HIV. J Acquir Immune Defic Syndr 2022;90(4):440-8. PMID 35364601
64: Saylor D, Dickens A, Sacktor N, et al. HIV-associated neurocognitive disorder - pathogenesis and prospects for treatment. Nat Rev Neurol 2016;12(5):309. PMID 27080521
65: Skillback T, Farahmand B, Bartlett JW, et al. CSF neurofilament light differs in neurodegenerative diseases and predicts severity and survival. Neurology 2014;83(21):1945-53. PMID 25339208
66: Smurzynski M, Wu K, Letendre S, et al. Effects of central nervous system antiretroviral penetration on cognitive functioning in the ALLRT cohort. AIDS 2011;25(3):357-65. PMID 21124201
67: Sturdevant CB, Joseph SB, Schnell G, Price RW, Swanstrom R, Spudich S. Compartmentalized replication of R5 T cell-tropic HIV-1 in the central nervous system early in the course of infection. PLoS Pathog 2015;11(3):1-24. PMID 25811757
68: Tozzi V, Balesta P, Bellagamba R, et al. Persistence of neuropsychologic deficits despite long-term highly active antiretroviral therapy in patients with HIV-related neurocognitive impairment: prevalence and risk factors. J Acquir Immue Defic Syndr 2007;45(2):174-82. PMID 17356465
69: United Nations AIDS. Global HIV and AIDS statistics – Fact sheet. Available at: https://www.unaids.org/en/resources/fact-sheet. Accessed April 11, 2023.
70: Valcour V. HIV, aging and cognition: emerging issues. Top Antivir Med 2013;21(3):119-23. PMID 23981600
71: Valcour V, Chalermchai T, Sailasuta N, et al. Central nervous system viral invasion and inflammation during acute HIV infection. J Infect Dis 2012;206(2):275-82. PMID 22551810
72: Vassallo M, Fabre R, Durant J, et al. A decreasing CD4/CD8 ratio over time and lower CSF-penetrating antiretroviral regimens are associated with a higher risk of neurocognitive deterioration, independently of viral replication. J Neurovirol 2017;23(2):216-25. PMID 27815816
73: Yuen T, Broillette MJ, Fellows L, et al. Personalized risk index for neurocognitive decline among people with well-controlled HIV infection. J Acquir Immune Defic Syndr 2017;76(1):48-54. PMID 28797021

Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Payal B Patel MD

Dr. Patel of University of Washington received research funding from Bayer Pharmaceuticals as a co-investigator.
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Editor

Christina M Marra MD

Dr. Marra of the University of Washington School of Medicine has no relevant financial relationships to disclose.
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Former Authors

Justin McArthur MD (original author), Walter Royal III MD, and Diana L Vargas MD

Patient Profile

Age range of presentation: All ages
Sex preponderance: No sex preponderance
Heredity: none
Population groups selectively affected: none selectively affected
Occupation groups selectively affected: none selectively affected

ICD & OMIM codes

ICD-10: HIV dementia: B22.0

Dementia in human immunodeficiency virus [HIV] disease: F02.4
ICD-11: Dementia due to human immunodeficiency virus: 6D85.3

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HIV-associated neurocognitive disorders

Associated Disorders

HIV myelopathy
HIV neuropathy
ART neurotoxicity

Differential Diagnosis

depression
mania
anxiety disorders
adjustment disorders
effects of psychoactive substances
- nutrition disorders
- vitamin B12 deficiency
- thiamine deficiency
- CNS opportunistic infections
- infections
- cerebral toxoplasmosis
- neurosyphilis
- cryptococcal meningitis
- tuberculous meningitis
- cytomegalovirus encephalitis
- toxoplasmosis
- lymphoma
- progressive multifocal leukoencephalopathy
- Cryptococcus
- vascular dementia

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HIV-associated neurocognitive disorders …

HIV-associated neurocognitive disorders

Introduction

Overview

Key points

Historical note and terminology

Table 1. Frascati Criteria for Diagnosis of HIV-Associated Neurocognitive Disorders

Clinical manifestations

Presentation and course

Prognosis and complications

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Diagnostic workup

Table 4. Clinical Features Useful for Diagnosis of HIV-Associated Neurocognitive Disorders (HAND)

Management

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

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HIV-associated neurocognitive disorders

Introduction

Overview

Key points

Historical note and terminology

Table 1. Frascati Criteria for Diagnosis of HIV-Associated Neurocognitive Disorders

Clinical manifestations

Presentation and course

Prognosis and complications

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Diagnostic workup

Table 4. Clinical Features Useful for Diagnosis of HIV-Associated Neurocognitive Disorders (HAND)

Management

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Prion diseases

Rabies

Malaria

Neuropathies associated with cytomegalovirus infection

Genital herpes: neurologic complications

Neurocysticercosis

Trichinosis

Metal neurotoxicity

This is an article preview.
Start a Free Account
to access the full version.