HIV-associated Neurocognitive Disorders (HAND)

• HIV-associated dementia (HAD): Occurs in advanced stages of HIV and is characterised by difficulties in attention, memory loss, and apathy. Early signs include jerky eye movements, hyperreflexia, and cerebellar dysfunction.

• Vascular myelopathy (VM): Typically co-occurs with HIV dementia, presenting as spastic paraparesis (weakness in both legs) without a distinct sensory level. Resembles nerve damage seen in vitamin B12 deficiency. 

• Distal sensory peripheral neuropathy (DSPN): Appears in late-stage AIDS in approximately 25% of patients, with paraesthesia, burning pain, and dysesthesia. Weakness is minimal, ankle reflexes are diminished or absent, and pain and temperature sensations are impaired.

• Other peripheral nerve syndromes:

  • Mononeuritis multiplex: damage to multiple nerves due to inflammation or infection such as HIV and CMV
  • Demyelinating polyneuropathy: damage to the protective covering of nerves
  • Diffuse inflammatory lymphocytosis syndrome (DILS): mimics Sjögren’s syndrome (with dry eyes/mouth), occurs during immunocompetent stages, and is linked to elevated CD8+ cell counts
  • Polyradiculopathy: inflammation of nerve roots, causing pain and weakness
• Myopathy
  • Polymyositis: muscle inflammation, causing weakness in early HIV stages.
  • Zidovudine-Induced Myopathy: drug-related, due to mitochondrial dysfunction. 

• Opportunistic infections affecting the brain/nerves:

  • Toxoplasmosis: Results in multiple ring-enhancing brain lesions, leading to increased intracranial pressure and headaches.

  • Cryptococcal meningitis: causes headache, altered mental status, and meningism. MRI reveals meningeal enhancement and hydrocephalus.

  • Progressive multifocal leukoencephalopathy (PML): caused by JC virus reactivation. Symptoms include headache and focal signs. MRI presents white matter abnormalities.

  • CMV infection: causes meningoencephalitis and polyradiculopathy (brain and nerve inflammation).

HAND develops because HIV directly damages the brain and nervous system, or due to secondary infections, inflammation, and drug side effects. The risk is higher in advanced HIV/AIDS when immunity is severely weakened.

Doctors may recommend:

• MRI brain: to detect shrinkage (atrophy), white matter changes, or lesions
• CSF (spinal fluid) test: may show non-specific signs of infection or detect viruses (like CMV, JC virus)
• Blood tests: to rule out vitamin B12 deficiency, diabetes, or co-infections (like HTLV-1)
• Neuropsychological testing: to assess memory, attention, and processing speed
• Nerve conduction studies/biopsy: in suspected neuropathy cases

There is no single cure, but treatment aims at controlling infection and symptoms:

• Antiretroviral therapy (ART): crucial to control HIV and prevent progression of HAND
• Treatment of opportunistic infections: e.g., antifungals for cryptococcal meningitis, antivirals for CMV, antibiotics for toxoplasmosis
• Symptomatic treatment: pain management, physiotherapy, counselling, and memory support
• Supportive care: maintaining nutrition, treating depression/anxiety, and avoiding substances that worsen nerve/brain damage

You should seek medical advice if you notice:

• New or worsening memory problems
• Difficulty concentrating, planning, or performing daily tasks
• Burning pain, tingling, or numbness in hands/feet
• Sudden weakness, balance issues, or seizures
• Persistent headache with fever or confusion

While HAND cannot always be fully prevented, risks can be reduced by:

• Starting and continuing ART early to control HIV infection
• Regular monitoring of cognitive and neurological health
• Managing other health conditions (blood pressure, diabetes, cholesterol)

For diagnosis and management of HAND, consult a Neurologist (for diagnosis and management) or an Infectious disease specialist (for HIV treatment and managing associated infections)