Major or Mild Neurocognitive Disorder Due to HIV Infection DSM-­5 294.11 (F02.81)

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DSM-5 Category: Neurocognitive Disorders

Introduction

HIV has been a global threat for decades to health care, as a result of its many and overwhelming effects. In addition to suppression the immune system, the HIV virus has extensive effects on the central nervous system, a condition known as HIV-associated neurocognitive disorder (The Lancet Infectious Diseases, 2013). The creation of combined antiretroviral therapy (cART) has transformed HIV into a chronic disease where patients who undergo treatment have life spans similar to the normal population (The Lancet Infectious Diseases, 2013).

cART treatment has resulted in a decline seen with HIV-dementia but does not eliminate the virus (Clifford & Ances, 2013). Unfortunately, despite receiving treatment, HIV-associated neurocognitive disorders (HAND), particularly milder forms, is still seen, with approximately thirty to sixty percent of HIV-positive persons experiencing at least mild neurocognitive disturbance (Clifford & Ances, 2013). HAND affects cognitive activity, as well as memory, learning, attention, problem solving, and decision making (The Lancet Infectious Diseases, 2013).

The advent of modern treatment has decreased rates of major neurocognitive disorders due to HIV infection, yet milder ones still remain. The main goal is still to determine the causes, prognosis and best form of treatment for patients with major or mild neurocognitive disorder due to HIV infection (Clifford & Ances, 2013).

Prevalence of Major or Mild Neurocognitive Disorder Due to HIV Infection

A large amount of individuals with HIV disease end up being diagnosed with NCD. While up to one half may partially fit the criteria for mild NCD, only an estimated twenty five percent may meet the complete criteria for NCD (American Psychiatric Association, 2013). About five percent of these individuals may fit the criteria for major NCD (American Psychiatric Association, 2013).

With higher rates of HIV infection in developing countries compared to developed countries, means higher rates of neurocognitive disorders due to HIV infection. In developing countries, this results in NCD being seen in children and adolescence, where it can present in neurodevelopmental delay. In developed countries, NCD is mostly seen with adults, engaging in risky behaviors (American Psychiatric Association, 2013).

Symptoms of Major or Mild Neurocognitive Disorder Due to HIV Infection

According to DSM-5, the following criteria must be met in order for an individual to be diagnosed with major or mild NCD due to HIV infection (American Psychiatric Association, 2013).

In addition to the fulfilling the requirements for mild or major neurocognitive disorder, the individual should have a confirmed case of human immunodeficiency virus (HIV) infection. The reason for the neurocognitive disorder is not as a result of other brain conditions such as cryptococcal meningitis or progressive multifocal leukoencephalopathy. Furthermore, the neurocognitive disorder should not be due to another medical condition or mental disorder.

The following neurocognitive disturbances are noted: attention impairments, processing speed, working memory, deficits in executive functioning, expressive language, visuospatial skills, and decline in motor functioning (Dennis, Houff, Yan, & Schmitt, 2011).

Diagnosis of Major or Mild Neurocognitive Disorder Due to HIV Infection

HIV infection occurs as a result of exposure to the HIV virus. This transmission occurs with intravenous drug use, unprotected sexual intercourse, or accidental transmission through a tainted needle or blood donation. Over time, HIV infected individuals experience a relentless reduction in the CD-4 lymphocytes cells. This results in excessive immunocompromise, and increases the risk of contracting opportunistic infections. An advanced HIV infection is known as acquired immune deficiency syndrome (AIDS).

HIV screening is done using an ELISA test, and confirmed through the use of a Western blot test or a polymerase chain reaction-based (PCR) assay.

Neurocognitive disorders sometimes develop in individuals with HIV infections. This presents largely with significantly damaged executive function, decreasing of processing speed, challenges with more difficult tasks which require advanced concentration, and complexity in learning new information, but not as much issues with remembering learned information (American Psychiatric Association, 2013). A difference between major and minor NCD is that with major NCD, notable slowing takes place. While individuals may experience difficulty with fluency, language issues such as aphasia are not typically seen.

An increased number of NCD cases are seen in individuals who have a history of incidents of severe immunosuppression, elevated viral load seen in the cerebrospinal fluid (CSF), and other features seen with advanced HIV disease such as decreased hemoglobin (anemia) (American Psychiatric Association, 2013). In some cases, severe issues are seen with coordination, motor, balance, and ataxia. Some individuals may have challenges controlling emotions, and express inappropriate apathy (American Psychiatric Association, 2013).

Testing for NCD in HIV infected individuals can be done using several methods. Neuropsychometric performace testing can be used to figure out more subtle cases, though it is not ideal as it is not sensitive and specific for NCD due to HIV infection (Clifford & Ances, 2013). Another possibility is that of systemic and plasma markers which have been associated with individuals with NCD due to HIV Infection (Clifford & Ances, 2013). An example of this is plasma soluble CD-14, which has been associated with learning and attention in HIV patients with NCDs. Some other tests with the possibility of clinical usefulness include CSF markers and neuroimaging such as MRI and PET imaging.

Treatment of Major or Mild Neurocognitive Disorder Due to HIV Infection

The present form of treatment for HIV infection is administering antiretroviral therapy which inhibits the action of the viral reverse transcriptase, protease, and integrase enzymes which allow duplication of the viral DNA (Dennis, Houff, Yan, & Schmitt, 2011). Since HIV duplicates very fast and the process is prone to errors allowing the virus to fast become resistant to solitary agents or complete drug classes, the most successful method to stop the virus from spreading means using multiple drugs in different classes. The present standard is called HAART, and involves using at least three drugs, consisting two nucleoside reverse transcriptase inhibitors (NRTIs) and a PI or two NRTIs and a non-NRTI (Dennis, Houff, Yan, & Schmitt, 2011).

There is substantial heterogeneity with ARV drugs with how successful they penetrate into the central nervous system (CNS). Research has shown that higher viral control as a result of CNS penetration may sway survival and has been associated with better neurocognitive improvement (Dennis, Houff, Yan, & Schmitt, 2011). Other research has shown that medication regimens consisting of efavirenz could result in better normalization of the infected nervous system, but ultimately result in worsening neurocognitive performance (Winston, Duncombe, Li, & al., 2010). Like other causes of dementia, treating cognitive and emotional issues lies largely with treating symptoms and aimed at extending average cognitive performance and maintaining an individual’s quality of life. Memory loss challenges may best be treated with acetylcholinesterase inhibitor, which is used in treating Alzheimer’s Disease. A drug like memantine can help NCD patients by doing two things, helping with memory and cognitive functioning, and helping against cytokine injury in the central nervous system (CNS).

In the case of NCD that involves emotional and psychiatric disturbances, the treatment may consist of traditional psychotherapy or the use of antidepressant medications or using a combined form of pharmacotherapy (Dennis, Houff, Yan, & Schmitt, 2011).

Living with Major or Mild Neurocognitive Disorder Due to HIV Infection

Individuals with NCD due to HIV infection have many challenges that come from living with a lifelong ailment such as HIV/AIDS. Family support is beneficial in ensuring that the individuals have access to ARVs and treatment. While the use of ARVs helps with keeping viral load low, there is the stigma that comes from having the disease. Additionally, HAART has without a doubt enhanced the position for the HIV-infected individual by reducing the occurrence of HIV dementia and escalating the survival rate. In spite of the success of decreasing viral loads, research shows that at least fifty percent of HIV infected individuals will go through neurocognitive dysfunction. It is especially important to look at other factors that can complicate NCD like substance abuse, psychiatric illness, coinfection, and aging (Dennis, Houff, Yan, & Schmitt, 2011). All of which means encouraging healthy living and up to date comprehensive health care that treats associated psychiatric, neurological, and neuropsychological dysfunctions, as well as mood disorders.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Clifford, D., & Ances, B. (2013). HIV-associated neurocognitive disorder. The Lancet Infectious Diseases, 13, 976-86.

Dennis, B., Houff, S., Yan, D., & Schmitt, F. (2011). Development of neurocognitive disorders. Neurobehavioral HIV Medicine, 3, 9-18.

The Lancet Infectious Diseases. (2013). The challenge of HIV associated neurocognitive disorder. The Lancet Infectious Diseases, 13(11), 907.

Winston, Duncombe, Li, & al., e. (2010). Altair Study Group: Does choice of combination antiretroviral therapy (cART) alter changes in cerebral function testing after 48 weeks in treatment-naive, HIV-1-infected individuals commencing cART? A randomized, controlled study. Clin Infect Dis, 50(6), 920-929.


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