Determining the underlying causes of cognitive impairment in individuals living with HIV is an essential for effective management.
Factors implicated in cognitive disorders in people living with HIV
Figure from Moschopoulos et al (2024). Trends in Molecular Medicine (1)
Effective control of HIV infection is imperative both peripherally and within the CNS compartment, necessitating investigation and treatment of potential HIV CSF escape. Reviewing, modifying, and optimizing combination antiretroviral therapy (cART) is crucial to tackle resistance, antiretroviral neurotoxicity, CNS penetration, and adherence challenges. However, in persons presenting with cognitive decline despite well-treated HIV infection the causes are usually multifactorial and, consequently, a model of holistic management is often warranted.
The new approach framed by the International HIV-Cognition Working Group consensus (2) emphasises the importance of clinical assessment, as well as lifestyle, social, mental health and educational factors when investigating low cognitive performance. Importantly, depression and anxiety disorders, which are common in people living with HIV, should be carefully diagnosed and treated.
A multi-disciplinary team is, ideally, needed to address potential comorbidities and provide comprehensive supportive care. In particular, counselling and management for CVD risk factors, such as smoking, hypertension, diabetes, dyslipidemia and obesity, is crucial in order to preserve brain functions. Multimorbidity and accompanying polypharmacy are disproportionately seen in older people with HIV, and are associated with increased risk of frailty, falls, drug-drug interactions, and cognitive decline. Management of geriatric syndromes should ideally be provided by a multidisciplinary HIV/geriatric clinic using the Comprehensive Geriatric Assessment (CGA) approach. CGA includes an early and multidimensional diagnostic process leading to an individualised intervention plan and has been found to improve functional outcomes in the geriatric population. Additionally, given the ageing population with HIV, non-HIV-related causes of dementia, such as Alzheimer’s disease, have to be considered and if suspected referrals to specialised centres should be made.
References:
- Moschopoulos, C. D., Alford, K., Antoniadou, A. & Vera, J. H. Cognitive impairment in people living with HIV: mechanisms, controversies, and future perspectives. Trends in Molecular Medicine (2024).
- Nightingale, S., Ances, B., Cinque, P. et al. Cognitive impairment in people living with HIV: consensus recommendations for a new approach. Nat Rev Neurol 19, 424–433 (2023). https://doi.org/10.1038/s41582-023-00813-2