Experts Offer Advice on Managing HIV Neurocognitive Impairment

Since effective antiretroviral therapy (ART) for HIV-infected people was introduced in 1996, some remarkable things have happened.

Life expectancy at age 20 increased from nine years in the period 1993-1995 to 24 years in 2002-2004, several years after ART became a routine part of treatment for HIV-infected individuals. Deaths due to HIV/AIDS-related causes decreased from 3.79 per 100 person-years in 1996 to 0.32 per 100 person-years in 2004. Some individuals who were on the verge of death from AIDS and who were treated with ART managed to rebound and are still alive 15 years later. People who are newly infected with HIV may even be capable of achieving a normal lifespan if they rigorously adhere to ART treatment and can tolerate the unpleasant and sometimes pernicious side effects it can produce.

In addition, once clinicians started to vigorously treat HIV-infected patients with ART early in their illness, the incidence rate of HIV-related dementia, which was previously between 10 percent and 20 percent, dropped to between 3 percent and 5 percent.

But the fight against the disease's ravages is not over.

Even in this era of ART treatment, about half of HIV-infected patients will experience mild to moderate neurocognitive impairment, a large national study published in the December 2010 Neurology indicated.

Two HIV experts—Justin McArthur, M.D., of Johns Hopkins University and Bruce Brew, M.D., of St. Vincent's Hospital in Darlinghurst, Australia—referred to this prevalence of neurocognitive impairment in ART users as a "hidden epidemic" in the June 1, 2010, issue of AIDS.

Another HIV expert, psychiatrist Karl Goodkin, M.D., Ph.D., concurred during a recent interview. "Psychiatrists, neurologists, infectious disease specialists, and primary care physicians are not as aware of this epidemic as they should be." Goodkin is director of Mental Health Services at the AIDS Healthcare Foundation, the nation's largest provider of HIV/AIDS medical care, and director of clinical research, psychiatry, and behavioral neurosciences at Cedars-Sinai Medical Center in Los Angeles.

However, ART users who are afflicted with neurocognitive problems are certainly aware of how serious these problems are, Marshall Forstein, M.D., an associate professor of psychiatry at Harvard Medical School and another HIV authority, said. "Unlike the kind of cognitive disorders we see with, say, Alzheimer's or multiinfarct dementia, which are diseases of the cortical structures of the brain, HIV tends to initially infect the subcortical areas of the brain that have less to do with intellect and more to do with the management of information and the processing of information and the use of memory for doing things—including what we call ‘working memory,’" he explained. "So people are acutely aware of these losses. For instance, it could be difficulty in handling finances or in preparing meals. It could be impairment in driving. It could be problems at work."

Francisco Fernandez, M.D., of psychiatry at the University of South Florida and also an HIV expert, said that he would rate the neurocognitive impairments that ART users experience as just as burdensome as the depressive spectrum disorders that they also often experience. "They are different because their features are different, but in terms of human suffering, both can cause an enormous amount of despair and dysfunction."