NEUROPSYCHIATRY ASPECTS OF HIV (Detailed Overview).pptx

A detailed overview on the Neuropsychiatry Aspects of HIV for MD, MMed internal medicine, Msc neurology, MMed Psychiatry and diploma in clinical medicine

1. NEUROPSYCHIATRY ASPECTS OF HIV YASIN KHATRI (MD, MUHAS 2025) @med.tutor.tz/@health.gramm on Instagram 8/11/2024

2. Introduction HIV/AIDS can affect the CNS, presenting clinically in the form of either neurologic or psychiatric manifestations due to neurocognitive or neuropsychiatric disorders, respectively. These manifestations can be due to HIV itself , opportunistic infections, ARV medications or psychological perception of the illness. 8/11/2024

3. Pathophysiology HIV penetrates the CNS through infected macrophages  goes to infect glial cells  secretes neurotoxins through them  triggers cytokine and chemokine release  apoptosis  neuronal death (frontal lobe, subcortical white matter, and basal ganglia) 8/11/2024

4. Predisposing Factors Direct effects of virus Pre-existing psychiatric conditions Personality vulnerabilities Affective disorders Drug addictions Personal responses to the social isolation due to HIV 8/11/2024

5. Disorders Due to HIV 8/11/2024

6. HAND It is a spectrum consisting of 3 disorders based on severity and effect on functionality -Asymptomatic neurocognitive impairment -Mild neurocognitive disorder -HIV associated Dementia Due to Cortical and subcortical changes in brain function 8/11/2024

7. Risk Factors F>M Advanced age Low education level Anemia High Serum/CSF fluid viral load 8/11/2024

8. Risk Factors inadequate control of HIV in the central nervous system (CNS) Evolution of ARV-resistant viral strains Effects of chronic long-term systemic and brain inflammation, and the effects of comorbid factors such as aging, substance use disorder, hypertension, diabetes, past history of CNS trauma, and co-infections, such as with the hepatitis C virus 8/11/2024

9. Diagnostic Criteria A. The criteria are met for major or mild neurocognitive disorder. B. There is documented infection with human immunodeficiency virus (HIV). C. The neurocognitive disorder is not better explained by non-HIV conditions, including secondary brain diseases such as progressive multifocal leukoencephalopathy or cryptococcal meningitis. 8/11/2024

10. Diagnostic Criteria D. The neurocognitive disorder is not attributable to another medical condition and is not better explained by a mental disorder. Specifier: -With/without behavioral disturbance 8/11/2024

11. Clinical Features Features Mild HAND HAD Course Indolent Subacute, waxing and waning Symptoms Difficulty with attention Affective symptoms (apathy) Motor symptoms (unsteady gait, clumsy fine movements) Impaired working memory Impaired executive functioning and speed of information processing Concentration impairment Depressive symptoms Impaired psychomotor speed and precision 8/11/2024

12. Clinical Features Features Mild HAND HAD Functional status Affected in the form of difficulty reading, performing complex tasks, maintaining concentration in activities but may not be attributed to HAND Impaired 8/11/2024

13. Clinical Features The symptoms are due to subcortical changes so there is no effect on judgment, no aphasia, no agnosia, and no apraxia. Relative sparing of recognition memory, verbal abstraction, and naming as well. 8/11/2024

14. Investigations for HAND Brain MRI -Reduction in total brain volume + cerebral atrophy (basal ganglia + white matter + slightly cortical) ± T2 diffuse/patchy white matter hyperintensity CSF Analysis - >/= ratio of CSF viral load : plasma Plasma biomarkers e.g exosomes may serve as biomarkers of on ongoing viral activity in CNS and cognitive impairment. 8/11/2024

15. Approach to a HIV Patient With Cognitive Deficits Characterize degree of illness -Hx taking -Neuropsychological testing Time course Functional impact Establish stage of HIV disease and treatment status Look for other causes of cognitive symptoms 8/11/2024

16. Major Depression 4% to 22% for HIV-seropositive men and 2% to 18% for HIV-seropositive women Worsens ARV adherence A/c w HIV disease progression and death 8/11/2024

17. Major Depression ARV a/c w depression  NNRTI (efavirenz + rilpivrine ) and Intergrase inhibitors (dolutegravir)  CNS side effects e.g fatigue and cognitive impairment It is underdiagnosed because vegetative symptoms of depression are anyway present during the HIV course of illness (fatigue, anorexia, insomnia) 8/11/2024

18. Major Depression Clinical features: -Diminished mood in the morning -Anhedonia points more towards Treatment of depressive symptoms improves psychosocial functioning + quality of life Studies show TCA, SSRI and mirtazapine to be effective. Interpersonal psychotherapy and CBT are also used. 8/11/2024

19. Mania Around 1.5% experience it in early HIV but it goes up to 6% in AIDS Thought to be 2° to HIV CNS infection Closely a/c w cognitive changes• It is often characterized by Irritability rather than euphoria, cognitive impairment, no fam hx of bpd, more chronic, and doesn't remit if left untreated 8/11/2024

20. Mania Antidepressants have the same efficacy as in non-AIDS patients, but side effects need to be considered, for e.g: -Carbamazepine  decreases drug levels of PI and NNRTI and can reach toxic levels with ritonavir -Hypoalbuminemia/antibiotic use  elevates valproate 8/11/2024

21. Psychosis Uncommon, mostly found in pts with AIDS related neurocognitive impairment Could also be caused by ART (Ganciclovir/efavirenz) More sensitive to EPS  better use atypical antipsychotics (Risperidone/clozapine) 8/11/2024

22. Schizophrenia No evidence suggests that HIV causes schizophrenia, but data indicate that schizophrenia contributes to high-risk behavior associated with HIV infection. Treatment of schizophrenia in patients with HIV is similar to standard treatment of schizophrenia.  8/11/2024

23. DDx CNS infections CNS tumors Other Dementia syndromes Nutritional deficiencies Endocrine disorders SUD Delirium Polypharmacy 8/11/2024

24. General Management HAART that crosses the BBB to decrease the virus in CNS Neuroprotective agents ( Pentoxyfilline , Nimodipine, Peptide T, Memantine, Selegilline , Lexipafant ) Psychostimulants and dopamine agonists for apathy and cognitive slowing Mood stabilizers and antipsychotics for agitation and psychosis 8/11/2024

25. References Overview of the neuropsychiatric aspects of HIV infection and AIDS – UpToDate HIV-associated neurocognitive disorders: Epidemiology, clinical manifestations, and diagnosis – UpToDate Depression, mania, and schizophrenia in patients with HIV – UpToDate DSM-5 TR 8/11/2024