Módulo 3 – Curso pós-graduado – VIH e Envelhecimento

Neurocognitive Disorders in HIV Infected Patients

Risk factors for neurocognitive disorders in the setting of HIV infection

Autor: Prof. DoutorVictorValcour, MD PhD (Memory and Aging Center, University of California, San Francisco, USA)

Control of HIV Infection as a major risk factor for cognitive impairment

Heaton et al. observed that, among 1500 people followed at five centers across the United States of America, 50% of them had cognitive impairment criteria for HAND.1 There are some confounding factors that may have contributed to this high prevalence. In fact, almost 60% of the patients did not have suppressed plasma HIV RNA. This is a very high proportion, taking into account that some studies in Africa found rates of 30% of people not suppressed and accessing care. Nevertheless, when considering risk factors for cognitive impairment, virus and suppression of virus in plasma should always be the first step in the treatment. In fact, lack of treatment, poor adherence and failure to suppress plasma HIV RNA should be addressed as major risk factors.

Regarding antiretroviral treatment (ART) and its impact on cerebrospinal fluid (CSF) HIV RNA, there have been two trials with augmentation of antiretrovirals, i.e. aiming that drugs penetrate more in the CNS, and neither were successful in improving cognitive impairment. Marra et al. evaluated 101 individuals with advanced HIV beginning or changing to a new potent ART, classifying drugs according to their central nervous system penetration effectiveness (CPE) score. Patients receiving antiretroviral regimens with good central nervous system (CNS) penetration seem to be more effective in controlling CSF viral replication, although associated with poorer neuropsychological performance.2 In clinical practice, we may also observe that, among older patients, one must consider if changing antiretroviral regimens could increase side effects, for example lead to liver toxicity or anemia. One must also consider if the cognitive impairment itself justifies the use of more simple regimens to control HIV infection (i.e. fewer pills and simplified regimens supporting better adherence).

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