Neurologic and psychiatric complications of antiretroviral agents

Dramatic advances over the last decade have transformed HIV infection from a short-term, inevitably fatal disease to a chronic condition amenable to medical management, similar to diabetes or congestive heart failure. The ability to monitor treatment and disease status by quantifying plasma viral load and CD4 T-lymphocyte counts has contributed to this transformation, but the most important contribution to this transformation has been the development of HAART. However, experience has shown that both HIV infection and its treatment have neurologic and psychiatric consequences. In addition, a major challenge currently is the dramatic difference between predicted and actual percentages of patients whose HIV levels can be brought under control. Although research predicts that most patients should be able to attain persistent undetectable viral loads with HAART, only a minority actually do so. Among barriers to successful treatment are psychiatric disorders that may place patients at risk for infection in the first place, contribute to the spread of infection by influencing high-risk behaviors, and compromise adherence to antiretroviral treatment. Patients with HIV and comorbid psychiatric disorders tend to require more time, effort, and resources than do other HIV-infected patients, at a time when the health care system is already beleaguered by cost containment measures. For the indigent HIV-infected population, mental health resources and illicit drug treatment resources are scarce. People with psychiatric illness respond to medication and adhere to HIV treatment regimens better after treatment. Furthermore, it is possible that effective treatment of psychiatric disorders may curb risky behaviors that may contribute to transmission of HIV. Thus, it is important to recognize neurologic and psychiatric symptoms, to distinguish, when possible, between HIV-associated and HAART-related symptoms, and to implement appropriate treatment for comorbid neurologic or psychiatric disorders. Despite the complexity of the patient population in the USA, we find that effective treatment for psychiatric disorders, when delivered in collaboration with effective HIV care, dramatically improves outcomes and quality of life. Successful treatment may also allow patients to achieve levels of function they may never have considered to be within their reach subsequent to their diagnosis of HIV. As new developments become available to help patients live more normal lives, it is essential for clinicians to have the skills and resources to assess and manage the disorders that hinder treatment of patients with HIV. This is critical not only in terms of cost containment and outcome measures, but as a matter of doing what is right for the vulnerable, underserved, and disenfranchised patients who currently get and transmit HIV at epidemic rates.