Management issues in HIV-associated neurocognitive disorders

Lucette A Cysique,1,3,4 Margaret P Bain,1 Tammy A Lane,2 Bruce J Brew1,41Department of Neurology, St Vincent's Hospital, Darlinghurst, NSW, Australia; 2AIDS Dementia and HIV Psychiatry Service (ADAHPTS) Sydney Hospital and Sydney Eye Hospital, Sydney, Australia; 3St Vincent's Hospital Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia; 4St Vincent's Applied Medical Research Centre, Sydney, AustraliaAbstract: The incidence of human immunodeficiency virus (HIV)-associated neurocognitive disorder (HAND) decreased with the introduction of combined antiretroviral therapy (cART), but there is now evidence that HAND is persisting and developing despite effective HIV suppression and the absence of other confounds. HAND in the cART era is different. The main issues are: (1) HIV disease is now a chronic disorder spanning decades. While acute and subacute presentations of HAND still occur, there is mounting evidence that it is based on cumulative brain damage. Furthermore, the pathogenetic significance of continuing HIV replication as the main factor in such brain damage is still unclear. (2) As HIV disease is a chronic disorder with increased life expectancy, the effects of aging are now becoming important. Their impact and significance on the pathogenesis of HAND are only beginning to be grasped. (3) In addition to aging, there is the increased risk of the effects of comorbid conditions (eg, cardiovascular and kidney diseases). The optimal treatment of HAND in the context of cART has not yet been established with any certainty. As a general principle, systemic HIV disease must be well controlled. There is increasing evidence that central nervous system disease should also be well controlled and may require specific antiretroviral drugs that have the ability to effectively penetrate the central nervous system. The role of adjunctive therapies remains hypothetical. Research to date has shown that all adjunctive therapies have thus far failed to show any significant benefit. In this paper, we provide an updated review of the clinical presentation and neuropsychological profile in the cART era. We also review the current HAND diagnostic nomenclature in respect to both its recommendations and limitations. This is followed by discussion of the main management issues for persisting HAND, including screening algorithms and optimal therapeutic options. Finally, we explore the use of everyday life assessment methods and recommendations.Keywords: HIV/AIDS, antiretroviral treatment, neurological complications, neuropsychological funct