HIV subtype D is associated with dementia, compared with subtype A, in immunosuppressed individuals at risk of cognitive impairment in Kampala, Uganda

Abstract

Background: In the United States, clade B is the predominant human immunodeficiency virus (HIV) subtype, whereas in sub-Saharan Africa, clades A, C, and D are the predominant subtypes. HIV subtype may have an impact on HIV disease progression. The effect of HIV subtype on the risk of dementia has, to our knowledge, not been examined. The objective of this study was to examine the relationship between HIV subtype and the severity of HIV-associated cognitive impairment among individuals initiating antiretroviral therapy in Uganda.

Methods: Sixty antiretroviral-naive HIV-infected individuals with advanced immunosuppression who were at risk of HIV-associated cognitive impairment underwent neurological, neuropsychological, and functional assessments, and gag and gp41 regions were subtyped. Subtype assignments were generated by sequence analysis using a portion of the gag and gp41 regions.

Results: Thirty-three HIV-infected individuals were infected with subtype A, 2 with subtype C, 9 with subtype D, and 16 with A/D recombinants. Eight (89%) of 9 HIV-infected individuals with subtype D had dementia, compared with 7 (24%) of 33 HIV-infected individuals with subtype A (P = .004).

Conclusions: These results suggest that, in untreated HIV-infected individuals with advanced immunosuppression who are at risk of developing HIV-associated cognitive impairment, HIV dementia may be more common among patients infected with subtype D virus than among those infected with subtype A virus. These findings provide the first evidence, to our knowledge, to demonstrate that HIV subtypes may have a pathogenetic factor with respect to their capacity to cause cognitive impairment. Additional studies are needed to confirm this observation and to define the mechanism by which subtype D leads to an increased risk of neuropathogenesis.

Figure 1

Frequency of human immunodeficiency virus (HIV)–associated cognitive impairment among antiretroviral-naive individuals in Uganda infected with HIV subtype A (n = 33), C (n = 2), D (n = 9), and A/ D recombinant (n = 16). HIV dementia stage was defined using the Memorial Sloan Kettering (MSK) stages of 0 (normal; ie, normal neurocognitive function), 0.5 (equivocal or subclinical; ie, equivocal symptoms or signs without impairment in capacity to perform activities of daily living; equivalent to asymptomatic neurocognitive impairment or mild neurocognitive disorder [19]), and ≥1 (HIV dementia; ie, unequivocal evidence [symptoms or signs including performance on neuropsychological tests] and mild-moderate functional impairment) [12].