In this issue of Neurology, Rubin and colleagues report disconcerting data from their analysis of the Women’s Interagency HIV Study database. In longitudinal assessments of cognitive and motor function in women with and without HIV infection, even among women with continuous viral suppression HIV-associated differences were evident. Perhaps even more disturbingly, in some domains women with continuous suppression performed more poorly than those with HIV who were not suppressed.
This cohort data is from 2009-2013 so many of the participants would have an antiretroviral therapy initiated only after some significant period of viral suppression and possibly with a very low CD4 nadir—both recognized as underlying risk factors for adverse neurologic outcomes in HIV. One can hope that with earlier treatment initiation long term cognitive outcomes in women with HIV will cease to differ from their HIV uninfected counterparts. Nonetheless, the women with continuous viral suppression had longer antiretroviral therapy duration and greater use of efavirenz and this report may offer some fuel to the fire of concerns regarding the neurotoxicity of antiretrovirals, particularly efavirenz.1 The strongest HIV-related predictor of neurocognitive performance remains the proportion of time with undetectable viral load. Within the context of HIV as a chronic condition, balancing the toxicity and neurologic protective aspects of antiretroviral use appears to be one of the bigger challenges that lies ahead.
- Ma Q, Vaida F, Wong J, et al. Long-term efavirenz use is associated with worse neurocognitive functioning in HIV-infected patients. J Neurovirol 2016;22:170-178.