Neurologic Complications of Human Immunodeficiency Virus Infection

Deanna Saylor, MD, MHS Neuroinfectious Disease p. 1397-1421 October 2018, Vol.24, No.5 doi: 10.1212/CON.0000000000000647
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PURPOSE OF REVIEW: Widespread use of antiretroviral therapy (ART) has led to near-normal life expectancy in people with human immunodeficiency virus (HIV) infection. However, neurologic complications of HIV remain common; can affect any part of the neuraxis; and are due to direct effects of the virus, immunosuppression because of untreated HIV infection, aberrant immune responses in the setting of ART initiation, and ART toxicities.

RECENT FINDINGS: HIV-associated neurocognitive disorder (HAND) remains one of the most common neurologic complications of HIV encountered today, but milder forms predominate in people on ART. No specific treatments for HAND exist, but small trials and epidemiologic evidence suggest paroxetine, intranasal insulin, and maraviroc may have utility in its treatment; further trials of these agents are ongoing. Widespread ART use has decreased the incidence of central nervous system opportunistic infections, but prognosis often remains poor in those who develop opportunistic infections. High-titer positive serum cryptococcal antigen is strongly predictive of cryptococcal meningitis and provides a tool to enhance diagnosis in areas with limited resources. HIV is an independent risk factor for stroke, and accelerated aging associated with HIV infection results in neurologic diseases of older age occurring at much younger ages in individuals infected with HIV. Ongoing HIV replication in the CSF despite peripheral virologic suppression may contribute to the development of HAND and may not improve despite adjusting the ART regimen to increase central nervous system penetrance.

SUMMARY: Neurologists are likely to encounter patients infected with HIV in clinical practice. This article reviews the presentation, diagnosis, and management of the most common neurologic conditions associated with HIV infection and ART.

Address correspondence to Dr Deanna Saylor, Department of Neurology, Johns Hopkins University School of Medicine, Meyer 6-113, 600 N Wolfe St, Baltimore, MD 21287, deanna@jhmi.edu.

RELATIONSHIP DISCLOSURE: Dr Saylor receives research/grant support from the National Institutes of Health (P30MH07565673-11A1, R01 MH099733, NS081196091, P30AI094189-01A1, L30 NS088658, R25 NS065729-05S2, R25 MH080661-08), Sara’s Wish Foundation, and the United States Department of State (Fulbright Scholar Award).

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Saylor discusses recent or ongoing clinical trials of intranasal insulin, maraviroc, and paroxetine for treatment of human immunodeficiency virus–associated neurocognitive disorder and the off-label use of interleukin-7, mirtazapine, and topotecan for the treatment of progressive multifocal leukoencephalopathy.

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© 2018 American Academy of Neurology