How is HIV-associated neurocognitive disorder (HAND) diagnosed and treated?

Updated: Apr 12, 2018
  • Author: Regina Krel, MD; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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HAND is a group of neurocognitive disorders consisting of HIV-associated dementia (HAD), previously referred to as "AIDS dementia complex," and mild neurocognitive disorder (MND). HAD, the more severe form of HAND encompasses changes in personality, memory deficits, and motor dysfunction. Before ART, 20% of infected patients died with HAD. [19, 26]  At autopsy, most persons with AIDS had findings consistent with HIV encephalitis. After the introduction of ART, fewer than 5% of patients have HAD, and almost none have HIV encephalitis at autopsy. However, based on the CHARTER study, MND, a milder form of neurocognitive disorder, occurs in as many as 45% of infected individuals. [25]

The continued presence of HAND despite aggressive treatment with ART and decrease in viral load suggests that there is a continued immune response, oxidative dress and inflammation within the brain. To date, the lowest CD4+ count at any point during infection, or the CD4+ nadir, is the best marker for the risk of HAND, although other potential biomarkers are being investigated. [19]

The diagnosis of HAND is a clinical one. The Frascati criteria, developed in 2007, allowed for uniformity in the diagnosis of HAND. It involves neuropsychological testing across various cognitive domains. Activities of daily living and ruling out other potential factors/causes for cognitive decline are also part of the diagnostic criteria. [27]

Currently, there is no specific treatment for HAND and management is geared toward preventing HIV replication in the CNS. Choosing an antiretroviral then becomes paramount in patients with HAND or those at a high risk. CNS penetration of the drug is of utmost importance for the reduction of CNS viral replication. A CNS penetration effectiveness index (CPE) can aid clinicians in choosing the correct medication. [20]  Maraviroc was found to lead to cognitive improvement over a 12-month period. [28]  While higher CPE index ART regimens result in a lower CNS viral load, some regimens have resulted in worsening neuropsychological performance suggesting drug neurotoxicity. Efavirenz is one such medication. [20]

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