18 th Annual Conference of the British HIV Association (BHIVA) Dr Ria Daly Birmingham Heartlands Hospital 18-20 April 2012, The International Convention Centre, Birmingham
18 th Annual Conference of the British HIV Association (BHIVA) Dr Ria Daly Birmingham Heartlands Hospital COMPETING INTEREST OF FINANCIAL VALUE > 1,000: Speaker Name Statement Dr Ria Daly: None declared Date April 2012 18-20 April 2012, The International Convention Centre, Birmingham
I think I m going crazy Virtual Clinic BHIVA Annual Conference 2012 Ria Daly
History 36yr female Cameroon 2003 UK 2005 Diagnosed HIV in London CD4 263 cells/mm 3 (13%), VL 88,619 copies/ml 2007 Relocated to B ham Not on ARVs CD4 213 cells/mm 3 (9%), VL 29,914 copies/ml No major mutations Subtype CRF02-AG PMH: Ophthalmic zoster 2006 SH: Traumatic events in Cameroon Psychologist PTSD
2007 Feb Struggling with diagnosis Low mood Concern regarding likely adherence May MDT support Improved mood Commenced Truvada & Nevirapine CD4 461 cells/mm 3 (16%) VL <40copies/ml
Date CD4 cells/mm 3 (%) Viral Load copies/ml Dec 08 504 (30) <40 Starts college Red cross locate children in Cameroon Apr 09 613 (34) <40 New partner Aug 09 502 (34) <40 Nov 09 453 (35) <40 Maintains good mental state, adherent Mar 10 532 (32) 43 Granted leave to remain Jun 10 671 (34) <20 Oct 10 507 (30) <20 Feb 11 593 (34) <20 Discloses to children Jun 11 558 (32) <20 Continues at college Keen to start working
Sept 2011 Letter from GP Memory loss & poor concentration Mind switches off Functional impact Noted over last few months by college tutor No new stressors. No signs of depression No focal weakness, systemically well Vit B12, TFTs normal Maintaining adherence
What would you do next? A) Re-explore psychosocial circumstances B) Neurocognitive assessment C) MRI head + lumbar puncture D) All of the above E) Other
A) Re-explore psychosocial circumstances
Neurocognitive Assessments Name of test What does it assess? How did our patient score? International HIV dementia scale (ihds) Hopkins verbal learning test revised (HVLT-R) Grooved pegboard nondominant hand test (GP Nondom) Verbal memory recall Motor speed Psychomotor speed Verbal learning memory (recall & recognition) 6/12 Interpretation? Motor Psychomotor Total recall: 1.8 SD below predicted mean Delayed recall: 1.35 SD below predicted mean Recognition Discrimination Index: 5.6 SDs below predicted mean. 4.5 SD below predicted mean
Frascati Criteria Antinori A, Arendt G, Becker JT, Brew BJ, Byrd DA, Cherner M, et al. Updated research nosology for HIV-associated neurocognitive disorders. Neurology 2007; 69:1789 1799.
MRI Oct 2011 MRI & Lumbar Puncture CSF <1 WCC, no growth Glu 3 (plasma 4.5) Prot 0.24 Viral panel negative VDRL/TPPA negative Toxo PCR negative CSF VL <80 copies/ml Plasma VL 81 copies/ml
What would you do next? A) Continue current regimen B) Start antidepressants C) Change ARV regimen D) Other
BHIVA treatment guidelines (Draft 2012)
EACS Oct 2011
ARV modified What regimen would you use? A) TVD, DRV/r B) TVD, NVP, AZT C) TVD, NVP, MVC D) CBV, NVP, MVC E) Kivexa, Kaletra F) Kivexa, RAL G) Others?
ARV modified What regimen would you use? D) CBV, NVP, MVC
Did it make any difference? Subjectively - yes Started new college course Started work as a carer Making plans to travel to visit sons in Cameroon Objectively some improvement
Name of test Pre ARV change 6/52 post treatment change ihds 6/12 N/A Much less bradyphrenic Functionally improved HVLT-R Total recall: -1.8 SD Total recall: -2.3 SD Delayed recall: -1.35 SD Delayed recall: -1.35 SD Recognition Discrimination Index: - -5.6 SDs Recognition Discrimination Index: within 1 SD of predicted mean GP Nondom -4.5 SD -2 SD Colour trails 1 (speed of processing) Colour trails 2 (executive function) Within 1 SD of predicted mean -1.4 SD
Name of test Pre ARV change 6/52 post treatment change Now 6/12 post treatment change ihds 6/12 N/A Much less bradyphrenic Functionally improved HVLT-R Total recall: -1.8 SD Total recall: -2.3 SD N/A Social problems, low mood Still functionally improved Total recall: - 2.1 SD Delayed recall: -1.35 SD Delayed recall: -1.35 SD Delayed recall: -3.1 SD Recognition Discrimination Index: - -5.6 SDs Recognition Discrimination Index: within 1 SD of predicted mean Recognition Discrimination Index: within 1 SD of predicted mean GP Nondom -4.5 SD -2 SD -3.4 SD Colour trails 1 (speed of processing) Colour trails 2 (executive function) Within 1 SD of predicted mean -1.4 SD -2.5 SD -1.47 SD
With thanks to Elizabeth Stevens Claire Robertson Steve Taylor Next Case.