In the JournalsPerspective

Treatment may prevent progressive brain injury in patients with HIV

Patients with HIV may experience changes in cognition and brain structure soon after seroconversion, but effective treatment can prevent or minimize progressive brain injury, recent study findings suggest.

“The introduction of combination antiretroviral therapy (cART) has transformed HIV from a fatal disease to a chronic condition,” D. Louis Collins, PhD, professor of biomedical engineering and neurology and neurosurgery at McGill University in Montreal, and colleagues wrote in JAMA Neurology. “However, HIV-associated neurocognitive disorders (HAND) are still prevalent, affecting up to 40% of HIV-positive individuals despite effective viral suppression. The possible cause of this mild brain dysfunction that limits quality of life remains unclear.”

Collins and colleagues compared the brain function and structure of patients with HIV who were involved in an ongoing study at Washington University in St. Louis with demographically similar HIV-negative individuals they recruited from the St. Louis area. A total of 48 HIV-positive participants who were receiving stable cART and had undetectable viral loads (< 50 copies/mL) and 31 controls were included in the study.

Collins and colleagues evaluated the participants using eight standard tests recommended to assess HAND and used MRIs to measure each participant’s brain volume. Participants completed two testing and MRI sessions at least 1 1/2 years apart, with a mean time between visits of 2.1 years for the HIV group and 1.9 years for controls.

At baseline, patients with HIV had significantly poorer scores in six of eight neuropsychological tests and significantly smaller cortical thickness and subcortical volumes compared with controls, according to Collins and colleagues. But changes over the course of 2 years were similar between the two groups, they reported.

“These findings support the hypothesis that brain injury due to HIV could occur principally during untreated infection,” they concluded. “This finding suggests that early initiation of cART and full viral suppression may preserve long-term brain health. - by Gerard Gallagher

Disclosures: The authors report no relevant financial disclosures.

Patients with HIV may experience changes in cognition and brain structure soon after seroconversion, but effective treatment can prevent or minimize progressive brain injury, recent study findings suggest.

“The introduction of combination antiretroviral therapy (cART) has transformed HIV from a fatal disease to a chronic condition,” D. Louis Collins, PhD, professor of biomedical engineering and neurology and neurosurgery at McGill University in Montreal, and colleagues wrote in JAMA Neurology. “However, HIV-associated neurocognitive disorders (HAND) are still prevalent, affecting up to 40% of HIV-positive individuals despite effective viral suppression. The possible cause of this mild brain dysfunction that limits quality of life remains unclear.”

Collins and colleagues compared the brain function and structure of patients with HIV who were involved in an ongoing study at Washington University in St. Louis with demographically similar HIV-negative individuals they recruited from the St. Louis area. A total of 48 HIV-positive participants who were receiving stable cART and had undetectable viral loads (< 50 copies/mL) and 31 controls were included in the study.

Collins and colleagues evaluated the participants using eight standard tests recommended to assess HAND and used MRIs to measure each participant’s brain volume. Participants completed two testing and MRI sessions at least 1 1/2 years apart, with a mean time between visits of 2.1 years for the HIV group and 1.9 years for controls.

At baseline, patients with HIV had significantly poorer scores in six of eight neuropsychological tests and significantly smaller cortical thickness and subcortical volumes compared with controls, according to Collins and colleagues. But changes over the course of 2 years were similar between the two groups, they reported.

“These findings support the hypothesis that brain injury due to HIV could occur principally during untreated infection,” they concluded. “This finding suggests that early initiation of cART and full viral suppression may preserve long-term brain health. - by Gerard Gallagher

Disclosures: The authors report no relevant financial disclosures.

    Perspective


    This article provides some welcome support for the clinical experience that starting ART as soon as possible after infection is likely to forestall or at least slow the progression of HAND in many people who are infected. One finding that is important is the lack of correlation between imaging and performance on neuropsychological tests that serve to define the impact of HIV in the brain on various domains of function. 

    As the article notes, there are some limitations to the study. The clinical population is more complex than the study group in terms of other comorbid conditions, such as substance use and vascular changes that are common with hyperlipidemia, diabetes and smoking. These comorbid conditions may make the brain more vulnerable and less protected by ART, and this would need to be studied with a large study group comparing HIV-infected and noninfected patients with similar comorbid conditions. 

    Aside from the acknowledged absence of functional evaluation, the impact of HIV on affective stability, irritability and depression might alter some of the findings as well. Most importantly, perhaps, is the increasing age of the cohort of those who have been infected and on ART for 20-plus years. The increased vulnerability to HIV in the central nervous system (CNS) in the group of patients aged 60 years and older might yield differing information. In my clinical practice, I have seen changes in affect regulation, working memory, short-term memory and decreasing ability to process information among a subset of patients who have been extraordinarily adherent to HIV ART. 

    The article provides support for further investigation into the impact of HIV in the CNS in patients who better represent the real world of clinical practice.

    Marshall Forstein, MD

    Acting chair, department of psychiatry
    Cambridge Health Alliance
    Associate professor of psychiatry

    Harvard Medical School

    Disclosure: Forstein reports no relevant financial disclosures.