HIV-associated neurocognitive disorders: Management
- Richard W Price, MD
Richard W Price, MD
- Professor Emeritus (Active)
- Neurology UCSF
- San Francisco General Hospital
Changes in memory, concentration, attention, and motor skills are common in HIV-infected patients . When not clearly attributable to an alternate cause other than HIV infection, such neurocognitive impairments have been collectively classified as HIV-associated neurocognitive disorders (HAND). The main therapeutic approach to HAND is antiretroviral therapy (ART).
The management of HIV-associated neurocognitive disorders will be discussed here. The epidemiology, clinical manifestations, and diagnosis of HIV-associated neurocognitive disorders are discussed elsewhere. (See "HIV-associated neurocognitive disorders: Epidemiology, clinical manifestations, and diagnosis".)
An overview of the range of neuropsychiatric conditions associated with HIV infection and more detailed reviews of other specific conditions are discussed separately. (See "Overview of the neuropsychiatric aspects of HIV infection and AIDS" and "Depression, mania, and schizophrenia in HIV-infected patients" and "Substance abuse and addiction in HIV-infected patients".)
The presence of neurocognitive deficits in certain HIV-infected individuals without alternative explanation other than HIV infection has long been described. However, the terminology to refer to this phenomenon has undergone substantial evolution since its initial characterization.
This topic uses a widely employed classification scheme that groups such neurocognitive deficits under the umbrella term, HIV-associated neurocognitive disorders (HAND). The range of deficits included in this scheme is defined by performance on standardized neuropsychological testing. In general terms, HIV-associated dementia refers to severe neurocognitive deficits that lead to substantial functional impairment. Milder deficits are termed mild neurocognitive disorder (MND) if they lead to minor symptoms or impairment and asymptomatic neurocognitive impairment (ANI) if they do not. This is discussed in detail elsewhere. (See "HIV-associated neurocognitive disorders: Epidemiology, clinical manifestations, and diagnosis", section on 'Terminology'.)
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- GENERAL PRINCIPLES
- Efficacy of ART for HAND
- - ART for HAD
- - ART for milder forms of HAND
- Efficacy of specific regimens
- - CPE rank
- - Efficacy of CPE-based ART
- Antiretroviral agents to avoid
- PATIENTS NOT ON ART
- Regimen selection
- - Patients with HAD
- - Patients with milder deficits
- Treatment response
- PATIENTS WITH VIRAL SUPPRESSION ON ART
- New or progressive severe symptoms
- - Confirming the diagnosis
- - Evaluating CSF for HIV
- Patients with detectable CSF HIV
- Patients with undetectable CSF HIV
- When CSF HIV testing is not available
- Mild or residual symptoms
- PATIENTS VIREMIC ON ART
- ADJUNCTIVE MEASURES
- Neuropsychiatric symptoms
- Safety assessments
- INEFFECTIVE THERAPIES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS