Denise Cummins: Sydney District Nursing, Sydney Local Health District 

Summary  

This section explores key issues for nurses in relation to cognitive impairment and people living with HIV (PLHIV): 

• Background 
• Examples of dementia 
• HIV associated neurocognitive disorder (HAND) 
• Screening, diagnosis, and predictors of HAND 
• Signs and symptoms of HAND  
• Treatment of HAND 
• Strategies for support of cognitive changes 
• Advice for caregivers 

Introduction  

People living with HIV (PLHIV) may be susceptible to cognitive changes which could be related to HIV, vascular cognitive impairment or they may develop conditions such as Alzheimer’s disease as they age, all of which can have a profound effect on a person’s daily function and quality of life. Cognitive impairment for PLHIV is frequently multifactorial (1). 

This chapter briefly describes a range of dementias but will focus on HIV associated neurocognitive disorder, or HAND. More importantly for the PLHIV is recognition and validation of cognitive symptoms, to enable early intervention and treatment. 

Background 

The complexities around neurological health for PLHIV may be increasing. Ageing is seen as a factor in cognitive impairment for PLHIV because they may be more vulnerable to cognitive impairment than the general populations (2,3). However, the Charter Study (2023) noted there was little difference between age groups unless the person had significant co-morbidities and was not virally suppressed (4). Additionally, those with baseline cognitive decline showed significant deterioration which could be a predictor of future cognitive ability (5). Continued research is required in this space to provide guidance for clinicians to support PLHIV experiencing signs and symptoms (S&S) of cognitive change.  

The International HIV-Cognition Working Group (2023) (6) suggests a new approach to cognitive changes for PLHIV towards an emphasis on the clinical context, suggesting that HIV-associated brain injury may encompass any potential cause of brain injury caused by HIV which may represent changes to the clinical burden of disease.  Recommendations state that cognitive symptoms should refer to any change in cognition noticed by the person or others regardless of the impact on daily function. Cognitive symptoms are now generally milder in PLHIV due to improved HIV treatments which can affect quality of life but may not have a great impact on activities of daily living (4). 

Comorbidities which are more prevalent in PLHIV (7,8) can increase the risk of developing vascular impairment, such as cardiovascular disease (especially midlife), a recognised risk for vascular dementia, Alzheimer’s disease, and mixed dementia (9). Risk factors for vascular cognitive impairment include ageing, mild HAND, socioeconomic and ethnicity factors, mental health, alcohol, and substance use, smoking and antiretrovirals (10). 

Additionally, chronic viral infection in neurodegeneration and brain amyloid accumulation is a key neurodegenerative pathway (11). Studies have recognised that Stroke is becoming another complex health issue for long-term treated PLHIV (12). Cystique and Brew (2023) suggest that there may be a cumulative risk of dementia in ageing PLHIV from multimorbidity and disease burden perspectives (13). This is due to the effects of chronic immune activation, immune senescence, and cardiovascular disease, noting that PLHIV should be assessed for vascular S&S. Strategies should be developed to prevent or reduce risk of vascular disease (e.g. treating hypertension and diabetes), as mild vascular cognitive impairment contributes to neurodegeneration (13).