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Persistence of Neuropsychologic Impairment After Starting ART

More than 60% of patients with HIV-related neurocognitive impairment at baseline continued to have persistent neuropsychologic deficits while receiving ART. Baseline severity of impairment was identified as the major determinant.

HIV-related neurocognitive impairment (NCI — previously termed "AIDS dementia") is a feared complication of advanced HIV infection. Although potent antiretroviral therapy (ART) can reverse such impairment, it does not always do so completely, and many patients are left with persistent neuropsychologic deficits.

To evaluate the prevalence of such persistent deficits, investigators prospectively followed 94 patients who had evidence of HIV-related NCI at baseline (as determined by a battery of neuropsychologic tests after other conditions had been ruled out). Per enrollment criteria, all patients had symptomatic HIV infection or CD4 counts <200 cells/mm³ (mean nadir CD4 count, 158 cells/mm³; mean baseline CD4 count, 257 cells/mm³). Thirty-two patients were treatment-experienced, and the other 62 initiated ART at enrollment. Initial regimens were PI-based for 51 patients and NNRTI-based for 38. Twenty patients met the criteria for HIV-related dementia at baseline.

During an average follow-up of 63 months, persistent neuropsychologic deficits were noted in 63% of patients. Mean CD4 count at the last follow-up visit was 451 cells/mm³. Age, sex, disease stage, CD4-cell count (baseline or most recent), viral load, and use of CNS-penetrating drugs were not associated with persistent neuropsychologic deficits. In a multivariate analysis, baseline severity of NCI was the only factor significantly associated with persistent neuropsychologic deficits (odds ratio, 3.07).

Comment: This study provides further evidence to support starting potent ART earlier, as the chances for reversing neuropsychologic impairment during ART appeared to diminish with worsening baseline NCI. Given that the range of nadir CD4 counts extended above 300 cells/mm³ and that CD4-cell recovery alone did not guarantee full neuropsychologic recovery, we clearly need better strategies for identifying and treating patients who have NCI at higher CD4-cell counts.

— Keith Henry, MD

Published in AIDS Clinical Care June 25, 2007

Citation(s):

Tozzi V et al. Persistence of neuropsychologic deficits despite long-term highly active antiretroviral therapy in patients with HIV-related neurocognitive impairment: Prevalence and risk factors. J Acquir Immune Defic Syndr 2007 Jun 1; 45:174-82.

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