Pre-clinical atherosclerosis is found at post-mortem, in the brains of men with HIV

Neurocognition and the Aging Brain in People With HIV: Implications for Screening

The introduction of effective antiretroviral therapy (ART) has converted HIV infection from a lethal disease to a manageable chronic condition for most people. The drastic improvement in life expectancy of people with HIV has led to an expansion of the aging population of people with HIV globally. Recent research indicates that people with HIV on suppressive ART still sustain persistent, albeit alleviated, systemic and cerebral immune activation that can facilitate age-related causes of cognitive impairment (CI), including neurodegenerative and cerebrovascular diseases. Although HIV-associated neurocognitive disorder remains prevalent in older people with HIV on suppressive ART, the co-occurrence of other age-related causes of CI makes the investigation and management of CI more challenging. More importantly, it remains unknown if the neuropsychiatric manifestations of HIV-associated neurocognitive disorder are modified by the presence of age-related causes of CI, such as Alzheimer disease, and vice versa. This article will review findings regarding the interaction between HIV-1 infection and age-related comorbidities, namely atherosclerosis and neurodegenerative diseases, followed by cognitive outcomes of people with HIV in longitudinal studies. Cognitive symptoms of people with HIV on stable ART will be discussed. The review will go through the latest recommendations for cognitive screening in different HIV management guidelines, as well as the usefulness of various screening tools in the setting of stable viral suppression.

Prevalence and Characteristics of HIV-Associated Stroke in a Tertiary Hospital Setting in South Africa

BACKGROUND AND OBJECTIVES

Antiretroviral treatment (ART) era HIV-associated stroke data from sub-Saharan Africa are limited. We determined the prevalence of HIV in patients presenting with acute symptomatic stroke and compared risk factors, clinical characteristics, and brain imaging with age-matched stroke patients without HIV.

METHODS

We conducted a retrospective study of adults presenting with any type of stroke to Tygerberg Hospital in a 12-month period. Patients living with HIV (PLWH) and HIV-uninfected (HIV-) patients were matched based on age group (1:2 ratio). Patients were identified by keyword search, while HIV status was ascertained from laboratory data. Clinical and imaging data were extracted from medical records.

RESULTS

Among 884 patients presenting with acute strokes, the minimum prevalence of HIV infection was 9.3% (95% CI: 7.4%-11.2%), with 496 patients (56.1%) with negative HIV status and 306 patients with unknown HIV status (34.6%). The mean age at presentation in PLWH was 46 (±11) years compared with 55 (±14) years in HIV- patients (p < 0.001). Smoking was less prevalent in PLWH with an adjusted relative risk ratio of RR = 0.58 (95% CI: 0.39-0.86). Concurrent infection was more prevalent in PLWH (25.6% vs 4.9%, p ≤ 0.001) with an adjusted relative risk ratio of RR = 2.07 (95% CI: 1.49-2.84), largely in patients with a CD4 count <200 cells/μL. PLWH with higher CD4 counts (≥200 cells/μL, 51.3%) had more traditional risk factors and less concurrent infection. Among PLWH, 68.3% were on ART, and 39.3% of them had been started or restarted on ART within the past 6 months. Basal ganglia infarcts (35.6% vs 18.3%, p = 0.014) and multiple vascular territory involvement (25.4% vs 7.7%, p = 0.002) were more common in PLWH. Clinical presentation, ischemic stroke type, and in-hospital outcomes did not differ between the groups.

DISCUSSION

Stroke patients with HIV were younger, had less traditional cardiovascular risk factors, and more concurrent infections than patients without HIV, especially those with a lower CD4 count. Recent ART initiation or reinitiation rates were high. Significant differences in CT brain imaging findings were seen. Understanding the multifactorial mechanisms underlying increased stroke risk, including associated infections and potential ART-associated immune reconstitution, is crucial and needs further study.