HIV 相关精神状态改变的评估

意识状态改变和伴随的认知障碍会对 HIV 感染患者和看护者产生破坏性后果。神经心理缺陷也会对生活质量产生负面影响。[1]Pandya R, Krentz HB, Gill MJ, et al. HIV-related neurological syndromes reduce health-related quality of life. Can J Neurol Sci. 2005 May;32(2):201-4. http://www.ncbi.nlm.nih.gov/pubmed/16018155?tool=bestpractice.com 这些可能是 HIV 感染的直接后果：例如，是 HIV 相关神经认知障碍（HIV-associated neurocognitive disorders, HAND）表现，或者是精神疾病合并症（例如，抑郁或酒酒/药物滥用）。虽然 HIV 相关机会性感染和肿瘤也可能表现为进行性认知能力下降和人格改变，更多情况下，他们表现为急性或亚急性神经急症。患者也有发生缺血性脑卒中的危险，在发生急性神经系统病情恶化的情况下应考虑到这点。

及早发现 HIV 相关神经认知障碍并给予治疗可改善预后；神经心理测试的较差表现与死亡率增高有关。[2]Wilkie FL, Goodkin K, Eisdorfer C, et al. Mild cognitive impairment and risk of mortality in HIV-1 infection. J Neuropsychiatry Clin Neurosci. 1998 Spring;10(2):125-32. http://www.ncbi.nlm.nih.gov/pubmed/9608401?tool=bestpractice.com 中枢神经系统 (CNS) 机会性感染或肿瘤的诊断及快速治疗在降低并发症发病率和死亡率方面具有重要意义，但中枢神经系统机会性感染患者的残留认知障碍患病率较高。[3]Levine AJ, Hinkin CH, Ando K, et al. An exploratory study of long-term neurocognitive outcomes following recovery from opportunistic brain infections in HIV+ adults. J Clin Exp Neuropsychol. 2008 Oct;30(7):836-43. http://www.ncbi.nlm.nih.gov/pubmed/18608693?tool=bestpractice.com

除了降低 CNS 机会性感染的发病率和延长生存期外，联合抗逆转录病毒治疗（antiretroviral therapy, ART）还可降低最严重类型 HIV 认知损害（HIV 相关性痴呆 [HIV-associated dementia, HAD]）的患病率，并改善有认知问题的 HIV 感染者的生活质量。[4]Heaton RK, Clifford DB, Franklin DR Jr, et al. HIV-associated neurocognitive disorders persist in the era of potent antiretroviral therapy: CHARTER Study. Neurology. 2010 Dec 7;75(23):2087-96. https://www.doi.org/10.1212/WNL.0b013e318200d727 http://www.ncbi.nlm.nih.gov/pubmed/21135382?tool=bestpractice.com [5]Gray F, Chrétien F, Vallat-Decouvelaere AV, et al. The changing pattern of HIV neuropathology in the HAART era. J Neuropathol Exp Neurol. 2003 May;62(5):429-40. http://www.ncbi.nlm.nih.gov/pubmed/12769183?tool=bestpractice.com [6]Antinori A, Arendt G, Becker JT, et al. Updated research nosology for HIV-associated neurocognitive disorders. Neurology. 2007 Oct 30;69(18):1789-99. http://www.ncbi.nlm.nih.gov/pubmed/17914061?tool=bestpractice.com [7]Parsons TD, Braaten AJ, Hall CD, et al. Better quality of life with neuropsychological improvement on HAART. Health Qual Life Outcomes. 2006 Feb 24;4:11. http://www.hqlo.com/content/4/1/11 http://www.ncbi.nlm.nih.gov/pubmed/16504114?tool=bestpractice.com ART 也可降低 HIV 相关性痴呆 (HAD) 的年龄相关风险，并可能改善精神合并症，例如抑郁。[8]Gibbie T, Mijch A, Ellen S, et al. Depression and neurocognitive performance in individuals with HIV/AIDS: 2-year follow-up. HIV Med. 2006 Mar;7(2):112-21. http://www.ncbi.nlm.nih.gov/pubmed/16420256?tool=bestpractice.com [9]Larussa D, Lorenzini P, Cingolani A, et al. Highly active antiretroviral therapy reduces the age-associated risk of dementia in a cohort of older HIV-1-infected patients. AIDS Res Hum Retroviruses. 2006 May;22(5):386-92. http://www.ncbi.nlm.nih.gov/pubmed/16706614?tool=bestpractice.com [10]Joska JA, Gouse H, Paul RH, et al. Does highly active antiretroviral therapy improve neurocognitive function? A systematic review. J Neurovirol. 2010 Mar;16(2):101-14. http://www.ncbi.nlm.nih.gov/pubmed/20345318?tool=bestpractice.com 不过，ART 应用本身可能有时会引起意识状态改变，或者直接以药物治疗不良事件的形式出现，或者是治疗相关免疫重建炎症综合征的后果。

精神合并症在 HIV 感染个体中高度流行。抑郁与抗逆转录病毒治疗较低的依从性有关，有时可能出现更为快速的疾病进展。[11]Lima VD, Geller J, Bangsberg DR, et al. The effect of adherence on the association between depressive symptoms and mortality among HIV-infected individuals first initiating HAART. AIDS. 2007 May 31;21(9):1175-83. http://www.ncbi.nlm.nih.gov/pubmed/17502728?tool=bestpractice.com [12]Leserman J. HIV disease progression: depression, stress, and possible mechanisms. Biol Psychiatry. 2003 Aug 1;54(3):295-306. http://www.ncbi.nlm.nih.gov/pubmed/12893105?tool=bestpractice.com 开始 ART 时有抑郁、焦虑或物质使用障碍的患者，对治疗的病毒学反应更差。[13]Pence BW, Miller WC, Gaynes BN, et al. Psychiatric illness and virologic response in patients initiating highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2007 Feb 1;44(2):159-66. http://www.ncbi.nlm.nih.gov/pubmed/17146374?tool=bestpractice.com 有效的抗抑郁治疗可改善生活质量和治疗依从性，并可减少认知主诉。[14]Elliott AJ, Russo J, Roy-Byrne PP. The effect of changes in depression on health related quality of life (HRQoL) in HIV infection. Gen Hosp Psychiatry. 2002 Jan-Feb;24(1):43-7. http://www.ncbi.nlm.nih.gov/pubmed/11814533?tool=bestpractice.com [15]Claypoole KH, Elliott AJ, Uldall KK, et al. Cognitive functions and complaints in HIV-1 individuals treated for depression. Appl Neuropsychol. 1998;5(2):74-84. http://www.ncbi.nlm.nih.gov/pubmed/16318457?tool=bestpractice.com

目前有关评估 HIV 感染神经系统表现的资源有很多，也有关于机会性感染诊断和治疗的针对性指导意见。[16]The Panel on Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Aug 2020 [internet publication]. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/whats-new-guidelines

New York State Department of Health AIDS Institute: mental health screening Opens in new window

National HIV/AIDS Clinicians' Consultation Center: guidelines Opens in new window

European AIDS Clinical Society: guidelines Opens in new window

Mind Exchange Working Group: assessment, diagnosis and treatment of human immunodeficiency virus (HIV)-associated neurocognitive disorders (HAND) Opens in new window

New York State Department of Health AIDS Institute: HIV infection in older adults Opens in new window