Neurologic Complications in Persons With HIV Infection in the Era of Antiretroviral Therapy

Abstract

Neurologic complications in persons with HIV infection are less severe in the era of potent antiretroviral therapy but remain highly prevalent. Prior to the use of antiretroviral therapy, opportunistic infections of the central nervous system (CNS) and CNS malignancy were common. Progressive multifocal leukoencephalopathy (PML), however, remains a diagnostic challenge in HIV-infected individuals, and no effective antiviral treatment for PML is currently available. Primary neurologic complications of acute HIV infection include aseptic meningitis and acute inflammatory demyelinating polyneuropathy. Among the neurologic complications of chronic HIV infection, HIV-associated neurocognitive disorders (HAND) remain most prevalent. The use of antiretroviral therapy has greatly reduced the severity of HAND, under which progressive HIV-associated dementia once predominated, to a milder chronic form of potentially disabling neurocognitive impairment. The persistence of HAND in individuals with virologic suppression suggests a need for adjunctive therapies for limiting its morbidity. This article summarizes a presentation by Dennis Kolson, MD, PhD, at the IAS-USA continuing education program, Improving the Management of HIV Disease, held in Chicago, Illinois, in May 2017.

Figure.

The primary neurologic complication of acute HIV infection prior to seroconversion is meningitis. Acute inflammatory polyneuropathy (AIDP) occurs around the time of seroconversion. Later neurologic complications include immune reconstitution inflammatory syndrome (IRIS), which is initiated by introduction of antiretroviral therapy, chronic inflammatory polyneuropathy (CIDP), distal symmetric polyneuropathy (DSP), HIV-associated neurocognitive disorders (HAND), and progressive multifocal leukoencephalopathy (PML). The grey ribbon depicts the detection of biomarkers of inflammation, immune activation, and oxidative stress in the cerebrospinal fluid during the course of infection. The relative time course for the development of these disorders is shown on the x-axis. The grey ribbon depicts the detection of biomarkers of inflammation, immune activation, and oxidative stress in the cerebrospinal fluid during the course of infection The relationship to plasma HIV RNA level and CD4+ cell count are shown in the left and right y-axes, respectively.