Literature Commentary by Dr. John G. Bartlett: Improved Cognitive Function With HAART, January 2008

John G. Bartlett, MD


January 11, 2008

McCutchan JA, Wu JW, Robertson K, et al. HIV suppression by HAART preserves cognitive function in advanced, immune-reconstituted AIDS patients. AIDS. 2007;21:1109-1117. The authors address the very important issue of improvement in cognitive impairment among patients with HIV infection treated with HAART.

Methods: ACTG 362 was a randomized study of azithromycin prophylaxis for Mycobacterium avium complex after immune reconstitution with HAART. Patients had CD4+ counts < 50 cells/microliter (mcL) at enrollment and >100 cells/mcL on HAART. Participants in this component of the study had neuropsychological assessments and no concurrent central nervous system disease (history of meningitis, encephalitis, tumors, or stroke). At baseline, the cognition was assessed using Trailmaking A/B and Digit Symbol Tests. In this substudy, the median CD4+ count at enrollment had increased to 230 cells/mcL, and viral suppression < 500 HIV RNA copies/mL was achieved in 65% of patients.

Results: There were 284 participants, with a baseline prevalence of neuropsychiatric impairment (NPI) of 27%. Sequential analysis showed NPI decreased significantly to 16% at week 48 and 14% at week 96 (P < .001). NPI improvement correlated with virologic suppression, but not with immune recovery as indicated by CD4+ cell count.

Conclusions: The authors conclude that patients who respond to HAART for prolonged periods have stable or improving cognition, although continuing neurologic recovery is incomplete on HAART.

Comment: Prior studies have sometimes had differing results. Dore and colleagues[1] indicated that HAART is not effective in treating or reversing HIV-associated neuropsychologic impairment. Koletar and coinvestigators[2] showed variable results with neuropsychological recovery over 5 years on HAART that correlated with CD4+ cell count recovery. This study provides strong support that patients given HAART for prolonged periods usually have stable or improving cognitive function, although they remain more likely than the general population to be cognitively impaired.


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