CROI summary shows decrease in neurocognitive deficit in PLHIV

An abstract presented at this year’s Conference on Retroviruses and Opportunistic Infections (CROI) confirmed the results of an Italian investigation into a potential link between people living with HIV (PLHIV) taking new antiretroviral therapies and the prevalence of neurocognitive disorders.

A comparison of HIV-associated neurocognitive disorder (HAND) outcomes among people living with HIV who complain or do not complain of having HAND symptoms shows that there has been a marked decrease in the overall prevalence of disease.

The results of 1365 study participants, attending the National Institute of Infectious Diseases Lazzaro Spallanzani (in Rome, Italy, and 2383 Neuropsychological Assessment Tests (NPA) from 2009-2011, 2012-2014, 2015-2017 and 2018 -2020 were presented during the oral abstract session, “Is There a Role of Novel ART Regimens in the Declining Prevalence of HAND?” at this year’s conference on retroviruses and opportunistic infections.1

The Frascati criteria were used to classify HAND, of which there are 3 progressive stages: asymptomatic neurocognitive impairment (ANI), mild HIV-associated neurocognitive disorder (MND) and HIV-associated dementia (HAD). Individuals are categorized into a stage following an assessment of 13 function tests that include attention and working memory, mental processing speed, memory and fine motor skills, as well as whether it is determined that their impairment does not stem from another condition (eg, head trauma or substance abuse).2

“HAND is still prevalent among PLHIV,” the investigators wrote. “The aim of the study was to assess the prevalence and predictors of HAND, including treatment-related factors, in a large cohort of PLHIV over the past decade.”

Cognitive impairment was reported in 33% of 2383 NPA tests, with the remainder not reporting complaints, and the overall prevalence of HAND was 22%. Breaking down the hand prevalence further, most had ANI, followed by MND and HAD.

Eighty-two percent of participants were male, 22% of the entire cohort had comorbid hepatitis C, 85% had HIV RNA below 40 copies/mL, the median ( interquartile range) years of infection was 10 (4-20), median CD4 count was 600 (419-790) cells/mm3nadir CD4 count was less than 200 cells/mm3 in 35%, and the median number of years of schooling was 13 (8-14).

Antiretroviral treatment regimens included combination nucleoside reverse transcriptase inhibitor (NRTI)/non-nucleoside reverse transcriptase inhibitor in 42% of cases, boosted protease inhibitor/NRTI in 19% of cases, and integrase strand transfer (INSTI)/INTI in 18%; dual regimens in 8% of cases (4% of which were INSTI-based); and dolutegravir in 8%.

Analyzing the NPA test results in more detail, HAND was more than 3 times more common in tests with a cognitive complaint compared to those without a complaint: 40% versus 13%. Additionally, key differences were observed between the complaining and non-complaining cohorts, respectively:

  • 78% versus 84% ​​men
  • 40% versus 48% gay/bisexual men
  • 78% vs 89% with a viral load below 40 copies/mL
  • 51% versus 26% with a CD4 count below 200 cells/mm3

A higher risk of HAND was associated with older age, lower education, lower CD4 count and comorbid HCV. Lower risk was associated with an additional year of schooling, higher CD4 count, recent NPA, and antiretroviral therapy (ART) with integrase inhibitors or a dual regimen.

Overall, there was a downward trend in HAND between the first NPA (2009-2011) and the last NPA (2018-2020): 38% for all, 52% among those with cognitive disorders, and 23% among those without neurocognitive disorders.

Although the strengths of these results are that they highlight how HAND has multifactorial pathogenesis and that newer ART regimens have superior efficacy and tolerability, the possibility that the results overestimate HAND, due to the use of the Frascati criteria remains a possible limitation.2

The references

1. Mastrorosa I, Brita AC, Mondi A, et al. Is there a role for new ART regimens in the decreasing prevalence of HAND? Presented at: Conference on Retroviruses and Opportunistic Infections; February 12-16, 2022; Virtual. Oral-11.

2. Volny-Anne A. Have neurological disorders associated with HIV decreased in people living with HIV thanks to recent antiretrovirals? Map of NAM aids. Published February 22, 2022. Accessed February 24, 2022.

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