Question
How does HIV and HIV meds affect the brain?
17 April 2012. Related: All topics, Living with HIV long-term, Opportunistic infections.
Answer
The best way to answer this complicated question is to look at HIV and HIV drugs separately in terms of the brain.
HIV and the brain
HIV gets into the brain within the first few weeks of infection. However, most people luckily do not seem to experience any direct symptoms from this. Most people are able to continue with day to day life so long as their CD4 count stays high.
If your CD4 count drops below 200, the risk increases for infections that can affect how you feel and think. If the CD4 count drops to below 100 and especially below 50, this includes HIV-related dementia.
If ARV treatment is when the CD4 count is above 350, these problems are very unlikely. Even if started late, HIV drugs can often reverse problems related to brain function.
So for people on effective and stable treatment, HIV does not seem to progress to damage the brain or cause symptoms. Most people continue to be able to lead a normal life.
Ongoing research is now looking at long term complications of HIV. Some researchers think that there may be small changes that we haven;t know about before. Just as getting older increases the risk of symptoms like memory loss, this risk may be higher if you are HIV positive, or it might occur at an earlier age.
The medical name for changes in brain function is neuro-cognitive impairment (NCI for short).
HIV meds and the brain
How HIV drugs affect the brain is difficult to study but it is the focus of a lot of research.
The brain is physically difficult to research because it is encased in the skull and surrounded by a fluid that is also difficult to test. This fluid is called cerebral spinal fluid – or CSF for short. There is a filter between the blood and the CSF called the blood-brain barrier (BBB).
In practice, the BBB only lets the smallest HIV drug molecules get in to the CSF and the larger compounds are blocked. One group of researchers has summarised which drugs are likely to cross the BBB using CSF penetrating effectiveness (CPE) score.
Table 1: Estimated CSF penetration of individual HIV meds (CPE score)
| Drug class | 4 | 3 | 2 | 1 |
| Nukes | AZT | abacavir, FTC | ddI, 3TC, d4T | tenofovir, ddC |
| NNRTIs | nevirapine | efavirenz,
delavirdine |
etravirine | |
| PIs | indinavir/r | darunavir/r,
fosamprenavir/r, indinavir, lopinavir/r (Kaletra) |
atazanaivr/r,
atazanavir, fosamprenavir |
nelfinavir,
ritonavir, saquinavir, saquinavir/r, tipranavir/r |
| Entry inhibitors | maraviroc | T-20 (enfuvirtde) | ||
| Integrase inhibitors | raltegravir |
4=good CSF penetration; 1=little or no CSF penetration
This table is based on limited data though and sometimes the position of individual drugs changes as new research develops.
Some drugs can find another route into the brain and CSF that gets around the BBB, so this may not be the full story.
How important is it to use drugs that get into the CSF?
The answer to this question is not known. People using drugs that have low CSF penetration do not seem to be at higher risk of HIV brain-related illnesses compared to people using drigs that we think do get to the brain. However, in someone with NCI symptoms, guidelines recommended adding or switching to drugs that are more likely to get into the CSF.
Two other aspects of this research are important.
One is that drug levels in the CSF are only an indirect measure of whether drugs reach brain tissue. Measuring CSF is difficult enough. It involves a lumbar puncture (spinal tap) but is used because we cannot biopsy brain tissue directly. Really we need to know about whether drugs get into brain tissue (cells).
Another is that a few studies have suggested that drugs getting into the CSF also has the potential to cause side effects. There is even less data on whether this might be a long term concern. So far, again luckily, the balance of risk vs benefit seems to support getting in mat be better than not getting in, especially in someone with NCI symptoms.
Assessment and monitoring
Part of the difficulties about anything related to the brain is that changes in brian function can be difficult to measure and monitor. Extensive tests that take several hours or use difficult and expensive scanning techniques that are not practical for testing everyone in a clinic.
How you think and feel, including memory, can be affected by other things in your life. Brain function also changes over time in most people as we age.
The following three areas are used in the European EACS guidelines for assessing whether further testing might be needed.
- If you have changes in memory loss (e.g. do you forget the occurrence of special events even the more recent ones, appointments, etc. ?)
- If you feel that you are slower when reasoning, planning activities, or solving problems?
- If you have difficulties paying attention (e.g. to a conversation, a book, or a movie)?
Your doctor should also ask about these aspects of your health as part of routine monitoring, especially in older patients or in people with a low CD4 count.
Further reading
CHARTER study for details of 2010 CPE penetration score. 17th CROI, abstract 430.
http://www.retroconference.org/2010/Abstracts/39373.htm
PDF link
http://www.retroconference.org/2010/PDFs/430.pdf
EACS guidelines includes a section for assessing neurocognitive impairment (NCI) – see page 48.
http://www.europeanaidsclinicalsociety.org/images/stories/EACS-Pdf/eacsguidelines-v6_english.pdf
IADL (daily Living Score – used in EACS guidelines)
http://www.europeanaidsclinicalsociety.org/guid/index.html?b=annex&p=10
Hi,
If you’re having issues with your medication, you’ll need to discuss this with a doctor. If you can tell them that you need to be on a combination thta doesn’t contain efavirenz.
I was on efavirenz and I was moved to Alluvia and I defaulted and went to another clinic and told them I defaulted on efavirenz and they restarted me on efavirenz I haven’t slept in day’s and I feel crazy
Hi Zoh,
Please can you give us more info? What ARVs are you taking? And do you have access to your CD4 count and viral load?
Please let us know.
Are ever the side effects permanent especially if you have defaulted before
Hi Zothani,
What medication have you been taking, this is since you started medication. What medication have you know been given?
Hey I was on ARV treatment like two years back I was taking regiment 2. I was scared to go back to my clinic so I went to another and they put me on regiment 1 I have been taking it for 1 week now what are my risks will I go crazy
Hi Nkanyiso,
You can find out more about Atroiza at this link. As you can see,
side effects are mainly related to the efavirenz, the main drug in Atroiza. These include sleep disturbance, and if you’re tired from bad sleep this can make concentrating hard.
However, many people have mild side effects when they first start HIV treatment, or PEP. And this usually goes away in the first week or two.
But you can talk to the doctor and ask if there are different PEP meds you can switch to for the rest of PEP.
hy am taking atroiza as pep my third my week hard to concentrate feeling is it normal
Hi Nash,
If the ARVs that your mother is taking contain efavirenz this could be the reason why she is behaving like this. However, it could also be due to other reasons. The best thing to do is for your mother to talk to her doctor about this. She may need to change her combination.
Hi my mom is HIV positive she’s 55 this year, she’s been on meds for a couple of years I’m not sure about the meds she’s taking. she takes her meds at 8 at night the problem is after taking the meds maybe 30 minutes later she would go to bed and sleep around 11,12 or 01 at night she would act strange she would wake up act like she’s losing her mind maybe cry and say someone is beating her or chasing her, and later she would come back to her senses and go to sleep again. At 1st I thought maybe she was dreaming but but this happens more often maybe once after a month. This has been happening for maybe like 3years.