Módulo 3 – Curso pós-graduado – VIH e Envelhecimento

Neurocognitive Disorders in HIV Infected Patients

Clinical management of HIV-related neurological disorders

Autor: Prof. Doutor Richard W. Price, MD PhD (San Francisco General Hospital, University of California, San Francisco, USA)

Key massages

  • The clinical evaluation of neurological disorders requires, at a first step, the evaluation of HIV disease status and treatment history, as well as the evaluation of AIDS and non-AIDS related conditions.
  • Neurology deals with localization of lesions, an important key to identify the nature of the problem. MRI is the most used imaging technique because it provides more definition and an easier diagnosis.
  • The character of CNS HIV infection changes with systemic progression.
  • In equilibrated CSF infection, the virus populations in the CSF are the same as those found in the blood (initial infection).
  • Clonal expansions in the CSF are bursts of local replication from T-cell.
  • Diverse compartmentalized corresponds to an autonomous CNS infection, with a diverse virus population within macrophages.
  • CNS escape is defined as treated patients with plasma HIV RNA suppression but with detectable CSF virus. Escape can be classified in:
  • Asymptomatic or incidental escape, uncommon
  • Neurosymptomatic, clinically important but rare
  • Secondary, with temporary detectable CSF virus due to the presence of another CNS infection.
  • Some factors may contribute to CNS escape: an earlier establishment of CNS reservoir, in patients with a low nadir TCD4+; long-term infection with multidrug exposure and resistance; incomplete treatment adherence; poor CNS penetration; CNS HIV drug resistance, among others.
  • Treatment of CNS escape requires switch to drugs without resistance, and also take into account the CNS exposure and CNS penetration (i.e., two or more drugs should be CNS-active, with adequate penetration, and acting on the CSF virus).
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