HIV NEUROPSYCHOLOGY

Understanding the HIV life cycle

 HIV (Human immunodeficiency virus) attacks the body’s immune system.
 It targets CD4 helper cells, weakening the immune system’s ability to fight
infections.
 Left untreated, even minor infections can become severe.
 HIV destroys CD4 cells by hijacking their replication machinery.
Progression of HIV and advances in treatment
 HIV replication damages or destroys infected CD4 cells, perpetuating the cycle.
 Untreated HIV can lead to a compromised immune system.
 A CD4 count below 200 indicates progression into AIDS. Nadir CD4 is the lowest-
ever CD4 count.
 Advancements in HIV treatment enable longer and healthier lives for individuals
with HIV.

Modes of HIV transmission

 Unprotected sex
 Drug addicts
 Blood transfusion
 Pregnancy
 Non-sterile instruments
NOT TRANSMITTED
 Through touching
 Through food
 With a kiss
  Insect bites
 In the pool
Mother to child transmission
 Mother-to-child transmission (MTCT) of HIV can occur during
o Pregnancy
o Childbirth
o Breastfeeding
 Most common mode of transmission in children
Strategies for HIV prevention
 To prevent HIV transmission, multiple strategies can be employed:
o ABSTINENCE: refraining from sexual activity is the most effect way to
prevent HIV transmission
o CONDOM USE: correct and consistent condom use during sexual activity
significantly reduces the risk of HIV transmission.
o NEVER SHARE NEEDLES: using clean needles and syringes and
refraining from sharing them with others is crucial to prevent HIV
transmission.
 Preventing HIV with PrEP
o Pre-exposure prophylaxis
o Antiretroviral medicine that prevents HIV transmission
o Individuals who are at risk, HIV-negative, sexually active, or drug users
should take this.
o It reduces risk of HIV infection 90%+ from sex and 70%+ from injection-
drug use.
HIV prevalence in South Africa
 South Africa has one of the highest prevalence rates globally for HIV.
 Of the estimated 7.5 million South Africans living with HIV, nearly 60% are
women over the age of 15.
 Nearly 4500 South Africans are newly infected every week, and 1/3 are
adolescent girls/young women ages 15-24.
Challenges and response in South Africa

Significance of understanding HIV in South African children

 High prevalence among children in South Africa
 HIV can directly and indirectly affect child development outcomes.
ANTIRETROVIRAL THERAPY (ART) FOR HIV
 Antiretroviral drugs are essential medications for treating HIV infection.
 They function by
o blocking various stages of the HIV replication cycle,
o inhibiting virus multiplication,
o reducing immune function,
o alleviating symptoms,
o prevent HIV transmission.
 ART involves taking a combination of these drugs, often referred to as an HIV
cocktail to suppress HIV replication.
 ART significantly reduces mortality and morbidity rates, improving the quality of
life for HIV-infected individuals.
 ART also plays a vital role in preventing HIV transmission by suppressing viral
replication in those living with the virus.
 ART combats HIV infection, and lowers the risk of cognitive decline including its
neurological impact.
 Mechanisms
o Suppresses virus.
o Reduces replication.
 Goals
o Viral suppression
o Immune preservation
o Neuroprotection
Achieving viral Suppression with ART
1. Viral suppression is attained when HIV levels in the blood drop to less than 50
copies/ mL.
2. Achieving and maintaining viral suppression is a primary goal of ART.
a. Reduces the risk of transmitting HIV to others.
b. Improves health outcomes for individuals living with HIV.
c. It reduces mortality and morbidity rates.
d. Enhances quality of life
e. Prevents transmission.
f. Prevents drug resistance.
g. Halts progression to AIDS.
Key aspects of ART in HIV neuropsychology
 Neuropsychological benefits
o Slows cognitive decline.
o May improve cognition in individuals with HIV associated neurocognitive
disorders (HAND)
 Adherence
o Importance of consistent dosing for effectiveness
 long term management
o lifelong treatment required for chronic HIV.

Classes of ARV drugs

 6 classes of antiretroviral drugs, each with unique mechanisms of action
o Entry inhibitors
o Nucleoside reverse transcriptase inhibitors (NRTIs) NINE-PC
o Non-Nucleoside reverse transcriptase inhibitors (NNRTIs)
o Integrase strand transfer inhibitors (INSTIs)
o Protease inhibitors (PIs)
o Capsid inhibitors

Latent HIV reservoirs

 Latent reservoirs
o Latent HIV reservoirs consist of immune system cells infected with HIV but
not actively producing the new virus.
o These reservoirs are established during early HIV infection and primarily
compromise resting memory CD4+T cells.
o ART can reduce blood HIV levels to undetectable, but latent reservoirs
persist.
o ART cannot eliminate latent HIV reservoirs, preventing a cure for HIV
infection.
Cognition and behavior problems in children living with HIV
 1.54Mill children living with HIV
 >80% of children living with HIV younger than age 15 reside in sub-saharan
Africa.
 Despite ARV therapy, many display impaired cognition and behavioral difficulties.
 Key domains of impairment
o Psychomotor functioning
o Language
o Attention
o Learning and memory
o Executive functions
o Behavior

Neuroinflammation
 Neuroinflammation in HIV refers to the brains immune response to the presence
of the virus.
o It is a key characteristic of HIV-Associated neurocognitive disorders.
 Mechanism
o HIV can breach the blood-brain barrier, leading to activation of microglia
and astrocytes, the brains immune cells.
o This activation results in a state of chronic, low-grade inflammation in the
brain.
o Implications for neuropsychology
 Cognitive impact
 Neuroinflammation can affect cognitive functions, including
Memory and problem-solving abilities.
 Behavioral changes
 It may lead to alterations in behavior and mood.
Challenges and barriers to HIV care and neuropsychological assessment in SSA
 Limited healthcare infrastructure.
 Stigma surrounding HIV.
 Socioeconomic disparities
 Limited access to neuropsychological expertise and resources.
Assessment of HIV-Associated Cognitive impairment
 History taking
o Determine the progression and severity of the disease.
o Duration of HIV infection, previous CD4 and viral load counts
 ART history
 o Is the patient on ART? Previous regimens? How long?
o Adherence to treatment
 TB treatment history
o Stage and duration of TB
o Current TB treatment status.
 Biomarkers to determine CNS involvement.
o HIV
 Current CD4 count and Viral load data.
o Neuroimaging
 MRI, FMRI or CT scan
o Biomarkers of inflammation
 Levels of inflammatory cytokines or cerebrospinal fluid (CSF)
analysis.
 testing and assessment
o neuropsychological assessment
 comprehensive assessment
 should include psychomotor.
 Learning and memory
 Attention
 Executive function
 Processing speed
 Emotional and behavioral well-being
 Age-appropriate assessment
 Considering the development age
 Culturally sensitive assessment
 Take into account cultural background.
 Beliefs
 Norms
 Child-friendly
o Functional assessment
 Daily functioning and activities of daily living – adults
 Children – vinelands
o Mental health assessment
 Screening for mood disorders (e.g., depression and anxiety)
o Social and environmental factors
 Understanding living situation
 Social support network
 Potential sources of stress
o Medication review
 Review current medication and potential side effects.
 Discuss the role of
 o Early intervention cultural factors, healthcare infrastructure, access to
neuropsychological assessment, caregiver involvement and ethical
considerations in addressing challenges of pediatric HIV.
 Significance of early detection and intervention
o Timely intervention can improve cognitive outcomes and prevent long-term
academic and psychosocial difficulties.
o Identify cognitive impairments to provide appropriate support, tailored
interventions and enhanced quality of life for children.
 Impact of cultural factors and stigma
o Culture and stigma influence healthcare-seeking behaviors therefore
navigate these sensitively.
o Address stigma through community engagement and education – may
reduce barriers to assessment and intervention.
 Challenges related to limited access.
 Pediatric neuropsychologists and assessments are limited in
LAMICs
 To address we may need innovative approaches.
 Telehealth
 Task-shifting to community health workers
 Training local professionals in neuropsychological
assessment techniques
 Collaboration with local and governmental organizations to
expand and mobilize resources.
 potential interventions and strategies
o interventions for HIV-associated neurocognitive disorders
 cognitive rehabilitation
 psychoeducation for caregivers and teachers
 adherence support for ART.
 Community based interventions
 Peer support
 School-based programmes
o A holistic approach that includes both cognitive and psychosocial aspects
is essential for optimal outcomes.