HIV-related mental status changes and associated cognitive disorders have profound consequences for people living with HIV, and their caregivers.
Neuropsychologic deficits have a negative impact on the quality of life of people living with HIV, and are associated with increased risk of mortality.[1] [2] Neuropsychologic deficit may arise as a direct effect of HIV infection, for example, as part of the spectrum of HIV-associated neurocognitive disorders (HAND), or as a psychiatric comorbidity (e.g., depression or alcohol/substance misuse).
Central nervous system (CNS) HIV-related opportunistic infections and neoplasms may present, acutely or subacutely, with progressive cognitive decline and personality changes. Patients with CNS opportunistic infections, such as CNS toxoplasmosis, may have a high prevalence of residual cognitive impairment (up to seven years following CNS opportunistic infection recovery).[3] [4]
People living with HIV are at higher risk of ischemic stroke compared with people without HIV due to more rapid atherosclerosis and neurovascular inflammation.[5] Stroke should, therefore, be considered in any person living with HIV who presents with acute neurologic deterioration.[6]
Psychiatric comorbidities are highly prevalent among people living with HIV. Depression is associated with nonadherence or partial adherence with antiretroviral therapy (ART), potentially leading to more rapid disease progression.[7] [8] Patients who are depressed, have anxiety, or have a substance use disorder at the time of initiating ART have a poorer virologic response to treatment.[9] Effective antidepressant treatment improves quality of life and treatment adherence, and decreases cognitive complaints.[10] [11]
ART reduces the incidence of CNS opportunistic infections, the prevalence of HIV-associated dementia (HAD; the most severe form of HIV neurocognitive impairment), and age-associated risk for HAD.[12] [13] [14] ART may improve the quality of life of people living with HIV with cognitive impairment and psychiatric comorbidity (such as depression).[15] [16] [17] [18] However, the use of ART may occasionally result in altered mental status, either directly as a drug adverse effect, or as a consequence of therapy-related immune reconstitution inflammatory syndrome (IRIS) of the CNS (a paradoxical deterioration in clinical status associated with rapid improvement in CD4 counts and a decrease in viral loads within the first few months after ART initiation).
Poor performance in neuropsychologic tests is associated with increased mortality.[19] Diagnosis and prompt treatment of CNS opportunistic infections or tumors can contribute to improved outcomes.[20] Early detection and treatment of HAND improves prognosis.[2] [21]
A number of resources are available that provide information on the assessment of neurologic manifestations in HIV infection, and specific guidance on the diagnosis and treatment of opportunistic infections.[22]
