The grey matters

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14 Jun 2017

HIV has many hiding places — or “sanctuary sites” as the scientists like to call them. One of which is the brain. The virus enters the brain within the early stages of infection — just a matter of a few weeks. Usually, the blood-brain barrier (BBB) acts as a shield to protect against invasion. But HIV is not your usual virus : it employs a Trojan horse-like method to compromise the BBB and gain access to the brain. Once there, the virus can genetically mutate, meaning that treatment may not work as effectively in the central nervous system as it does in other parts of the body. Over time, HIV in the brain can affect movement, memory and concentration — a syndrome known as HIV-associated neurocognitive disorder, or HAND. Those who have lived with HIV for a long period of time and/or are ageing are at particular risk of HAND.

The brain damage seen in people with HIV is similar to the impairment experienced by people with early-stage Parkinson’s or Alzheimer’s disease. (However, no studies have shown that either of these conditions is occurring at greater rates in people with HIV than the general population.) HAND symptoms can range across the spectrum from mild (when they can often go unnoticed) to severe. Tell-tale signs can include: bumping into things, or dropping things; tripping or falling; a reduced ability to recall names or spell words; a lack of concentration; sudden mood swings and increased anxiety levels; becoming forgetful; losing track of a conversation or time. Of course, all of those symptoms could be just a matter of general ageing — so how does a positive individual know if they’re suffering from HAND as opposed to doddery-ness?

When diagnosing HAND, neurological specialists are keen to rule out the possibility that problems with memory or thinking are not symptomatic of other, more common causes. Similar symptoms could arise from cardiovascular disease, hepatitis C coinfection, anxiety and depression (both found at higher rates in people with HIV) and heavy use of alcohol or recreational drugs. HAND can also be caused by a number of prescription medications — including antiretroviral drugs, such as efavirenz found in Atripla.

If, however, HAND is suspected, a neurocognitive screening test (a simple Q&A) will be sought. Such a test will involve an individual being asked, for example, whether they’ve noticed changes in memory loss, whether they’ve experienced difficulties in paying attention, or if they’ve felt their reasoning has slowed. If further tests are needed, then an MRI (brain) scan will be carried out.

Detecting HAND — even if a person doesn’t notice any problems or symptoms (i.e. asymptomatic) — is important. People who are asymptomatic are more likely to develop increased neurocognitive impairment in the future. Also, asymptomatic neurocognitive impairment may interfere with treatment adherence and HIV management.

Since the advent of highly active antiretroviral treatment (HAART) in 1996, the number of people diagnosed with HIV-related cognitive impairment has decreased dramatically. In the past, without effective treatment people with HIV would develop a severe form of cognitive impairment called AIDS dementia complex (ADC). This was brought on by high viral loads and immune activation in the cerebrospinal fluid. These days, ADC is only seen in individuals who present extremely late for treatment.

Although antiretroviral treatment can help prevent HAND, people on HIV meds can still develop cognitive difficulties: a 2010 study found that 52 percent of people with HIV had registered some form of cognitive impairment. By contrast, according to the CNS HIV Antiretroviral Therapy Effects Research study, only 10 percent of people in the general population experience such problems.

Whether you have memory problems due to HAND, another co-existing condition, or the normal ageing process, there are things you can do that may help:

  • Take time to learn new information — avoid remembering new things when you’re tired or under pressure
  • Use the recorder on your phone or a pad and pen to keep notes of things
  • Use your phone as an alarm to remind you to take your pills and remember healthcare appointments
  • Remembering involves all five senses. Seeing a phone number, repeating it out loud, and writing it down increases the chance of remembering it
  • Break large, difficult tasks into small sections

By far the most important thing you can do is to ask for help. If you’re worried you may be experiencing symptoms of HAND start a conversation with your healthcare provider. Seeking medical help early on is very important.

There is still much to understand about HAND. It’s not known, for instance, how common the condition is, which people are most vulnerable to it, or how it can be prevented. It will likely take a few more years when older people with HIV can be studied in larger numbers until more is known about HIV-associated neurocognitive disorder. However, there are a number of factors that can significantly reduce the risk of developing symptoms such as:

  • Keeping HIV in check with treatment. A study found that people with suppressed viral loads were far less likely to develop HAND, and if they already had symptoms, HAND was less likely to progress
  • Treat other causes of cognitive impairment — high blood pressure, high cholesterol and gut fat accumulation can all place stress on the brain, as can hepatitis C and B, and kidney and liver disease
  • Get plenty of exercise — studies confirm that regular aerobic activity protects the brain
  • Stay socially engaged — social activity helps keep the brain nimble
  • Stimulate the mind by learning a new language or playing brain games