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HIV treatment and its penetration into brain/spinal fluids
Apr 22, 2012

Dear Doc,

Currently on Kivexa (Epzicom) and Stocrin following a change from Atripla due to presenting bone/kidneys issues. I have been doing very well on treatment and have nothing to complain about with most labs in the applicable ref ranges and normal CD4 and % and UD. Fit healthy and strong and HIV pos for 18 mths, commencing meds within 6 mths of infection.

As I am getting older (45yrs.....God help me!!!) I will be keeping an eyeout for potential side effects of HIV treatment and potential health issues as I gracefully age. Dementia is a disease that one would never wish upon one's loved ones.

I understand that different meds have different brain/spinal fluid penetration. I am aware that being UD in plasma does not necessarily indicate that HIV replication is absent from the brain, spine and in semen.

I am also aware that current medical thinking suggests that it is especially important for middle age/older HIV pos patients to be on meds that have proven to easily pass through to the brain and spinal fluids to prevent potential HIV replication in the brain and spinal fluids therefore preventing health issues such as HAND and other nasties at bay. Am I correct in my assumptions above and are you a believer of this current medical thinking?

Are you able to point out to me current research on the net or perhaps list here the ranking of current meds that have proven to have a stronger penetration into the brain and spine? I do recall being told that my current meds' treatment is superior to Atripla in this regard and has a stronger penetration ranking to prevent potential HIV replication in the brain and spinal fluids.

I fail to see anywhere (UK/EUROPE/US/Aust) where it is recommended as part of routine care for aging HIV pos patients to test for HIV replication in the brain and spine? Perhaps we may see future upcoming recommendations as medical providers change their treatment focus.

Would it be unreasonable for me to approach my medical provider to test for potential HIV copies in my brain and spinal fluid (and perhaps semen as i'm in a pos/neg relationship)? Are these difficult/painful tests to undertake?

I apologise for the long list of questions. Thank you sincerely for your help.

Response from Dr. Young

Hello and thanks for posting your important questions.

There is a growing awareness of the potential risks of HIV on cognitive function, particularly among older individuals. You're right to be mindful of potential health issues, and memory is part of that story.

First, I like to remind people that the first steps in the process are trying to recognize if there are any problem symptoms of memory. A simple screening tool that is recommended by the European AIDS Clinical Society is the International HIV Dementia Scale. It's a very simple and validated test to evaluate if there are problems. If one scores abnormally, then more detailed neurocognitive testing is recommended. The EACS recommends screening anyone complaining of disturbances in memory, or (importantly) asymptomatic persons with detectable plasma (blood) HIV, the use of medications with low CPE, low CD4 count nadir (<200) or depression. You can see that this recommendation extends to a very large segment of the HIV population.

Second, you're also right in pointing out that different HIV medications seem to cross into the cerebrospinal fluid with different efficiencies. This observation has led to the development of the CNS Penetration Effectiveness ranking scale for antiretroviral medications. Some medications cross into the CNS well, others less so. Increasingly, there seems to be a correlation between the CPE and risks of CNS problems (thought not universally agreed upon).

A Powerpoint presenation by Dr. Scott Letendre contains many details of the most recent science on this topic, including a updated CPE scale. Part of the issue is that the meds with the highest CPE ranks are not ones that we typically use (AZT, indinavir, nevirapine), while some of our most commonly prescribed medications (tenofovir) are below average. Medications that have above average CPE rank include abacavir, emtricitabine, efavirenz, maraviroc and raltegravir.

I generally don't recommend getting the somewhat painful spinal tap procedure needed to determine if HIV is circulating in the spinal fluid, unless there are concerns about cognitive function. Rather this test would be reserved for those with abnormal neurocognitive testing- then we'd be asking about spinal fluid viral load and perhaps running drug resistance testing, if positive. Further, for those people with abnormal cognitive function, some advocate, if possible and safe, to switch ARVs to a new regimen with a higher CPE score (those with above average CPE rank).

I hope that's helpful. Be well. BY



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