NEUROLOGICAL COMPLICATIONS OF HIV

INFECTION : ZIMBABWE 2005

Jens Mielke

Department of MedicineCollege of Health Sciences,

Harare

Epidemiology of HIV in Zimbabwe

• 2/3 of the people in the world living with HIV live in sub-Saharan Africa,

• 2 million people in Zimbabwe HIV+• 24.6% of adults 15-49 are HIV+• life expectancy in Zimbabwe:

– 52 years in 1990 / 34 years in 2005. • In 2003, 170 000 people in Zimbabwe died

of AIDS. • 66.6% of HIV-1-infected women were

infected with subtype C, 48.3% with subtype A, and 33.3% with subtype B

Healthcare resources

• the world’s slowest growing economy (-3.1% growth in 2004)

• little public funding available for HIV care.• For political reasons excluded from many

US – based funding programmes for roll-out

• antiretroviral drug ‘rollout’ programmes are not yet treating significant numbers of patients

Healthcare resources

• However: urban and rural health care infrastructures in place

• Active collaborative HIV research; prevention, treatment and complications

• High awareness at government and medical school of priorities

• 90% of hospital admissions in internal medical and paediatric services are HIV infected

Status of Antiretrovirals

• In 2004 ARVs first offered in the public sector, in dedicated opportunistic disease clinics

• but the majority of recipients of ARVs are purchasing them privately and are receiving treatment from private sector

• In 2005, 6000 of the 290 000 people who need to be on treatment are receiving treatment

Status of AntiretroviralsStatus of Antiretrovirals combination generic

antiretroviral medications at lower cost have accelerated the use of ARVs considerably

There are published national ARV use guidelines,

the mainstay of therapy is a combination drug (stavudine, lamivudine and nevirapine).

Protease inhibitors are included in second line therapy

Epidemiology of HIV Epidemiology of HIV opportunistic diseasesopportunistic diseases

Little systematic review tuberculosis the commonest

opportunistic disease by far 90% of tuberculosis cases are

pulmonary, but extrapulmonary (pleural, lymph node, peritoneal, pericardial, ileal and meningeal) do occur more commonly than in non-HIV infected individuals

Epidemiology of HIV Epidemiology of HIV opportunistic diseasesopportunistic diseases

Other opportunistic diseases probably present with roughly the same frequency as elsewhere,

important exceptions : Kaposi’s sarcoma (which is possibly

commoner), cryptococcal meningitis (which is the

commonest CNS opportunistic infection) and

toxoplasmosis encephalitis (which is relatively uncommon).

Epidemiology of Epidemiology of Neurological Opportunistic Neurological Opportunistic

InfectionsInfectionsMeningitis increased dramatically since the

onset of the HIV pandemic outcome of meningitis is seriously

altered by the presence of HIV infection, with in-hospital mortality exceeding 60% for patients with bacterial and tuberculous meningitis in Zimbabwe

Epidemiology of Epidemiology of Neurological Opportunistic Neurological Opportunistic

InfectionsInfections Cryptococcal meningitis remains the

commonest cause of adult meningitis

45% cryptococcus neoformans, 16% pyogenic (mainly streptococcus pneumoniae), 12% tuberculous, the remainder an unidentified mixed bag of ‘mononuclear’ meningitis – presumably viral and partially treated bacterial meningitis).

Epidemiology of Epidemiology of Neurological Opportunistic Neurological Opportunistic

InfectionsInfections since 2003 fluconazole has been available

in the public sector, 960 patients treated at one referral centre

– but very poor follow-up and re-prescription rate (<10% more than three prescriptions) – most not on ARVs.

Immune reconstitution syndromes are a serious complication of antiretroviral therapy.

Epidemiology of Epidemiology of Neurological Opportunistic Neurological Opportunistic

InfectionsInfections Cryptoccocoma presenting as an intracranial

mass lesion, cryptococcal myelitis presenting as an acute

spinal cord syndrome cryptococcal meningitis in children – all routinely

seen Complications of cryptococcal meningitis seen

include optic neuritis and other cranial mononeuropathies, cerebrovascular accident and hydrocephalus

Intracranial mass lesionsIntracranial mass lesions MRI scan since 1995 stereotactic biopsy (and therefore frequently histological

diagnosis) remains unavailable Polymerase chain reaction diagnosis for viral agents is

not available. likely that toxoplasma encephalitis and tuberculoma are

similar to published results from South Africa , (toxoplasmosis less common than tuberculoma as compared to opposite findings in the northern hemisphere).

Bacterial abscesses and as a distant fourth primary CNS lymphoma make up the remainder

Spinal cord diseaseSpinal cord disease

acute presentation: vertebral tuberculosis transverse myelitis (sometimes zoster) Spinal meningitis (TB, cryptococcal) Intraspinal (intramedullary or extradural) lymphoma

Chronic / subacute progressive radiculopathy vacuolar myelopathy Syphilis not common (widespread penicillin use)

Peripheral NeuropathyPeripheral Neuropathy

Distal symmetrical peripheral neuropathy drug induced neuropathy has become an

important differential diagnosis Acute demyelinating (postinfectious) and chronic

inflammatory demyelinating polyneuropathy Cranial neuropathies, (facial nerve palsy,

isolated third or sixth nerve palsy, mononeuritis multiplex syndrome, peripheral mononeuropathies.)

AIDS DementiaAIDS Dementia

not systematically studied in Zimbabwe Anecdotal cases of AIDS dementia

definitely exist Do patients survive long enough to

become overtly demented ?

ConclusionConclusion adverse economic and political circumstances in

Zimbabwe seriously hamper efforts to counter the effects of the HIV pandemic

opportunities for learning about the neurological manifestations of HIV and associated opportunistic diseases continue.

co-existence of AIDS victims naïve to ARVs and treated groups,

late presentations of opportunistic diseases, high prevalences of fungal and bacterial

diseases