Evolving clinical phenotypes in HIV-associated neurocognitive disorders

Purpose of review To describe the changes in the presentation of HIV-associated neurocognitive disorders (HAND) comparing the current combination antiretroviral therapy (cART) treatment era to the pre-cART era. Recent findings The frequency of the most severe stage of HAND, HIV-associated dementia (HAD), has decreased, but the frequencies of milder stages of HAND, asymptomatic neurocognitive impairment (ANI) and mild neurocognitive disorder, have increased. In the pre-cART era, HAD was a progressive disorder leading to death within months. With cART, HIV+ individuals with HAND frequently remain stable over many years, though they may still show signs of the ongoing central nervous system (CNS) injury. On neuropsychological testing, there may be a shift from the prominent slowed motor and speed of processing deficits in the pre-cART era to a greater impact on learning, memory, and executive functioning deficits in the cART era. Importantly, ANI has recently been shown to lead to a two-fold to five-fold increased progression to symptomatic HAND. Thus, early recognition and treatment of those with ANI is important to protect the CNS over the long term. Summary HAND continues to be an important neurological manifestation in both HIV_ individuals naive to cART and on cART.