Understanding Major and Mild Neurocognitive Disorders in HIV: Types, Symptoms, and Treatment
Infectious Neuropsychiatry • Cognitive Disorders • HIV Care
Understanding Major and Mild Neurocognitive Disorders in HIV
HIV-associated neurocognitive disorder (HAND) ranges from asymptomatic neurocognitive impairment to mild neurocognitive disorder and HIV-associated dementia. This Emocare guide summarises clinical features, assessment, antiretroviral (ART) considerations and multidisciplinary management.
What is HIV-associated neurocognitive disorder (HAND)?
HAND is a spectrum of cognitive impairment related to HIV infection. With effective ART, severe HIV dementia has become less common, but mild and moderate cognitive impairments persist and impact quality of life and adherence.
Classification (Frascati criteria)
- Asymptomatic neurocognitive impairment (ANI): neuropsychological impairment in ≥2 domains without detectable impact on daily functioning.
- Mild neurocognitive disorder (MND): mild-to-moderate cognitive impairment with mild interference in everyday functioning.
- HIV-associated dementia (HAD): marked cognitive impairment with significant functional dependence (now less common in ART era).
Core features & domains affected
- Slowed information processing and reduced psychomotor speed.
- Executive dysfunction — planning, multitasking, cognitive flexibility.
- Attention and working memory deficits.
- Learning and retrieval memory problems (subcortical pattern).
- Behavioural symptoms: apathy, mood disturbance, irritability.
Risk factors
- Advanced immunosuppression (low CD4 count), high plasma or CSF viral load.
- Poor ART adherence, treatment failure or neurotoxic ART regimens.
- Older age, cardiovascular risk factors, substance use, psychiatric comorbidity and CNS opportunistic infections.
Assessment — clinical and investigation priorities
- Detailed history including HIV duration, nadir and current CD4, ART history, adherence and opportunistic infections.
- Cognitive screening (MoCA recommended) and domain-specific neuropsychological testing to apply Frascati criteria.
- Functional assessment — ADLs, instrumental ADLs, occupational impact and adherence capacity.
- Investigations: HIV viral load (plasma and CSF if indicated), CD4 count, MRI brain (to exclude opportunistic lesions), basic labs (B12, TSH, glucose), syphilis, hepatitis C screening and toxicology as indicated.
- Consider CSF analysis when progressive decline, suspected meningitis/encephalitis or suspected CSF viral escape despite plasma suppression.
Treatment & management
Management focuses on optimising HIV control, addressing comorbidities, cognitive rehabilitation and supporting adherence and daily functioning.
Antiretroviral therapy (ART)
- Ensure effective ART with good CNS penetration when indicated; consider regimen review for neurotoxicity.
- Treat virological failure and consider CSF viral load in suspected CSF escape.
Address reversible contributors
- Correct metabolic, nutritional and substance use contributors; treat opportunistic infections and co-infections (e.g., syphilis).
Cognitive & rehabilitative interventions
- Neuropsychological rehabilitation, compensatory strategies and occupational therapy to support daily functioning.
- Adherence support: pill organizers, directly observed therapy in select cases, caregiver involvement.
Psychiatric management
- Treat depression, anxiety and substance use disorders — SSRIs and psychosocial interventions as needed.
- Monitor drug–drug interactions between ART and psychotropics.
Monitoring & follow-up
- Regular cognitive screening and functional assessment to detect progression or improvement after ART optimisation.
- Monitor ART adherence, plasma viral load and CD4 count; consider CSF testing if clinically indicated.
- Coordinate care between infectious disease, neurology, psychiatry and rehabilitation services.
Case vignette
Patient: N., 52, long-standing HIV on ART with intermittent adherence. Complaints of slowed thinking, forgetfulness and missed clinic appointments. Plasma viral load detectable. MoCA 22/30. Approach: review and optimise ART, adherence support, treat depressive symptoms, neuropsychological assessment and occupational therapy. Viral suppression achieved and cognitive complaints partially improved at 6 months.
Special considerations
- Stigma and confidentiality concerns — maintain privacy and provide sensitive counselling.
- Consider occupational implications and driving safety — assess case-by-case.
- Address social determinants of health (housing, food security) which impact adherence and cognition.
தமிழில் — சுருக்கம்
HIV தொடர்புடைய அறிவுப் புலமை பாதிப்புகள் (HAND) பல்வேறு அளவுகளில் வருகின்றன. முக்கியம்: ART ஐச் சரிசெய்து, மறுசீரமைப்புத் திட்டங்களை அமல்படுத்தி, மனநலம் மற்றும் பொருளாதார ஆதரவை உடனடியாக முகாமை செய்வது.
Key takeaways
- HAND is a spectrum—ANI, MND and HAD—requiring careful neuropsychological assessment using Frascati criteria.
- Optimise ART and address reversible causes (substance use, metabolic issues, co-infections).
- Multidisciplinary care, cognitive rehabilitation and adherence support improve outcomes.