Treatment of HAND

More than 20% of people with HIV will develop cognitive impairment regardless of optimal therapy and virological suppression. Before combination antiretroviral therapy (ART) with diagnosis of AIDS, median survival after a dementia diagnosis was 6 months. Since antiretroviral therapy there has been a decrease in neuropsychiatric diagnosis, incidence of dementia has halved and survival time increased to 48 months’ survival with AIDS dementia complex (as it was known then).^[25] [26]

Medication adherence can be difficult for someone experiencing signs and symptoms of HAND.

Following initiation of treatment or changes in treatment, people with HIV should show improvements; however, for various reasons some people may be left with some form of deficit or their deficit may worsen. The reasons for this result are varied: some people with HIV will experience improvements.  Antiretroviral medication can cross the blood-brain barrier to varying degrees, and some drugs have increased anti-HIV activity in the CNS. Regardless of whether the person is treatment-naive or experienced with antiretroviral medications, the option of adding an antiretroviral medication that will have enhanced coverage in the CNS should be considered in the choice of medications.^[27]  Once diagnosed and treated, improvement in HAND may be seen within 12 weeks, continuing up to 18 months.^[28] 

Some people with HIV, however, may notice increased deficits. Reasons for this may include poor penetration across the blood-brain barrier; a legacy effect (damage before initiation of antiretroviral therapy) which may cause continuing neurocognitive decline; potential for resistance with reseeding of systematic compartment 10% escaped to cerebrospinal fluid (some people with HIV, although viral load is controlled in the plasma, will still have detectable virus in the CSF, and this, over time, may be linked to less effective control by antiretroviral therapy in CSF affecting the brain, and additionally affecting immune activation in the CSF with cognitive dysfunction); toxicity from antiretroviral therapy and inadequacy of antiretroviral agents with low level replication occurring (Table 7).^[29] 

The CNS penetration effectiveness (CPE) score was proposed in order to rank HIV drug penetration and efficacy in the CNS ^[30]. Although currently the CPE score is limited by its categorical scoring, unclear weighting of each criterion (pharmacokinetic, chemical properties, etc.), and lack of consideration of toxic effects or drug interactions, some clinicians continue to take the CPE score into consideration at least in patients that have symptomatic CNS disease as studies have shown regimes with higher CPE scores to be associated with lower cerebrospinal fluid viral loads ^[31].

TABLE 7: Central nervous system penetration effectiveness scores 2010 ( updated according to Letendre, 2014)

NNRTI – non-nucleoside reverse transcriptase inhibitors; NRTI – nucleoside reverse transcriptase inhibitors; PI – protease inhibitors; -r – boosted with ritonavir

Source: Letendre SL, Ellis RJ, Ances BM, et al.  Neurologic complications of HIV disease and their treatment. Top HIV Med 2010;18:45-55.

A value of 1, 2, 3or 4 is assigned to the different antiviral substances (first line). The CPE values of a cART regimen are summed up to arrive at the CPE score. A higher the score stands for better penetration into the CNS.

THE ONE SIGNIFICANT THING THAT PEOPLE LIVING WITH HIV CAN DO IS TO MAINTAIN ADHERENCE TO cART.

Changes in medication adherence may be one sign that a person is developing some cognitive changes. Additionally, decline in medication adherence can be difficult for someone experiencing signs and symptoms of HAND. Strategies should be developed with the person and a caregiver, if they have the support of a caregiver to improve medication adherence asHAND may fluctuate over months with some people improving, some deteriorating and the majority remaining stable ^[32]