Altered mental status and allied cognitive disorders have devastating consequences for HIV-infected individuals and their carers. Neuropsychological deficits also have a negative impact on the quality of life. These may arise as a direct effect of HIV infection: for example, as part of a spectrum of HIV-associated neurocognitive disorders (HAND) or as a psychiatric comorbidity (e.g., depression or alcohol/substance misuse). While HIV-related opportunistic infections and neoplasms may also present with progressive cognitive decline and personality changes, more often they manifest as an acute or subacute neurological emergency. Patients are also at risk of ischaemic stroke, and this should be considered in the setting of acute neurological deterioration.
Early detection and treatment of HAND improves prognosis; poor performance in neuropsychological tests is associated with increased mortality. Diagnosis and prompt treatment of central nervous system (CNS) opportunistic infections or tumours are important in reducing morbidity and mortality, although patients with CNS opportunistic infections may have a high prevalence of residual cognitive impairment.
In addition to decreasing the incidence of CNS opportunistic infections and prolonging survival, combination antiretroviral therapy (ART) has reduced the prevalence of the most severe form of HIV cognitive impairment (HIV-associated dementia [HAD]), and improved the quality of life of people living with HIV with cognitive problems. ART has also reduced the age-associated risk for HIV-associated dementia (HAD) and may improve psychiatric comorbidity, such as depression. However, the use of ART itself may occasionally result in altered mental status, either directly as a medication adverse event, or as a consequence of therapy-related immune reconstitution inflammatory syndrome.
Psychiatric comorbidity is highly prevalent in HIV-infected individuals. Depression is associated with low compliance with antiretroviral treatments and, potentially, with a more rapid disease progression. Patients who are depressed, have anxiety, or have a substance use disorder at the time of initiating ART have a poorer virological response to treatment. Effective antidepressant therapy improves quality of life and treatment adherence, and decreases cognitive complaints.
A number of resources are available that provide information on the assessment of neurological manifestations in HIV infection, and specific guidance on the diagnosis and treatment of opportunistic infections.
- Asymptomatic neurocognitive impairment
- Mild neurocognitive disorder (MND)
- Antiretroviral adverse effects
- Toxoplasmosis encephalitis/abscess
- Cryptococcal meningitis/abscess
- Mycobacterium tuberculosis meningitis/abscess
- Substance use
- Alcohol-use disorder
- Hepatitis C co-infection
- Hepatitis B co-infection
- HIV-associated dementia (HAD)
- Immune reconstitution inflammatory syndrome
- Cytomegalovirus (CMV) encephalitis
- Progressive multifocal leukoencephalopathy
- Herpes virus encephalitis
- Varicella zoster encephalitis
- Primary central nervous system (CNS) lymphoma
- Vitamin B12 deficiency
- Adrenal insufficiency
- Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV
- EACS guidelines: version 11.0
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