HIV and the brain

Lecture 1
Immune System
●​ A system that defends the body against infection, whilst protecting the body’s own
cells
●​ HIV affects the white blood cells

White blood cells (Leukocytes)

●​ Type of blood cell that helps fight infection and other diseases.
●​ HIV attacks lymphocytes and monocytes

Lymphocytes
●​ Type of white blood cell that helps fight viruses, bacteria and cancer
●​ T Cells = kill infected cells and control immune response to foreign substances
●​ B Cells = Create antibodies
●​ HIV affects t-cells

T Lymphocytes
●​ Type of blood cell that helps fight infection and other diseases.
●​ Helper T Cells: Trigger the immune system to destroy viruses (LOOK AT THIS
SPECIFICALLY FOR HIV ATTACK)
●​ Regulatory (suppressor) T Cells: make substances that help end your immune
system response
●​ Cytotoxic (killer) T Cells: kill the infected cells
Monocytes
●​ Type of white blood cell that differentiate into macrophages, which engulf pathogens
●​ Macrophages in the brain are known as microglia, which play a primary role in the
immune system of the brain
●​ Dendritic cells also part of the immune system

What is HIV?
●​ HIV = Human Immunodeficiency Virus
●​ HIV is a virus that attacks the body’s immune system, primarily the CD4 cells.
●​ If not treated, can lead to AIDS (Acquired Immunodeficiency Syndrome), the most
advanced stage of HIV infection
●​ Transmission: blood, semen, vaginal or rectal fluid, breast milk
●​ Unlike other viruses, the body cannot completely get rid of HIV (i.e. for life)
●​ HOWEVER, it can be fully controlled through medication

How it attacks the immune system

●​ HIV primarily attacks and destroys the CD4 cells (CD4 T lymphocyte)
●​ It does this by attacking/infecting the CD4 cell and using its machinery to replicate
and spread around the body
●​ This process of how HIV attacks the immune system is called the HIV Life Cycle
●​ There are 7 stages of the Life Cycle (but we are learning the simplified version)

Stages
●​ Stage 1: Attachment and Entry
-​ HIV attaches and enters the CD4 cell
●​ Stage 2: Genetic material released
-​ HIV releases its genetic material into the CD4 cell
●​ Stage 3: Integration
-​ HIV DNA is integrated into CD4’s DNA
●​ Stage 4: Replication
-​ HIV uses machinery of infected CD4 cell to replicate itself
-​ When infected CD4 is replicated so is HIV
●​ Stage 5: Viral Budding
-​ New HIV leaves CD4 cell by “budding” off the cell membrane
How HIV destroys the immune system
●​ In the process of multiplying and spreading through the body, CD4 cells are
destroyed.
1.​ Burden of Viral Replication:
-​ Viral replication puts a significant burden on cell resources, leading to cell
stress and damage
-​ After HIV enters the CD4 cell and integrates its genetic material into the host's
DNA, the cell is used to produce new copies of the virus. The replication
process puts a significant burden on the cell’s resources, leading to cell stress
and damage.
2.​ Viral Budding damage:
-​ The viral budding process damages the cell membrane, weakening the cell
over time
-​ When new HIV particles are formed, they leave the CD4 cell by "budding" off
the cell membrane. This process damages the cell membrane, weakening the
cell over time and contributing to its death.
3.​ Apoptosis (programmed cell death):
-​ The immune system can recognize that the CD4 cell is compromised and
signal it to self-destruct
-​ HIV-infected CD4 cells can also undergo apoptosis, a form of programmed
cell death. The immune system recognizes that the cell is compromised and
signals it to self-destruct, further reducing the number of CD4 cells.
HIV
●​ What we are left with is:
-​ Fewer CD4 cells (↓ CD4 count)
-​ More HIV cells (↑ viral load)
●​ Assessing the severity of HIV involves measuring CD4 count and viral load
●​ CD4 count:
-​ Normal range = 500 - 1,500 cells/mm3
-​ AIDs: < 200 per mm3
●​ Viral load:
-​ Virally suppressed = <50 copies/mml
-​ Severe = >1000 copies/ml
●​ Nadir CD4 count = lowest level of CD4 count ever

Latent HIV Reservoir

●​ Not all HIV infected CD4 cells are destroyed, some go into a resting or latent stage
(i.e., CD4 cells are infected, but no new HIV is produced)
●​ HIV can hide inside these cells for years, forming a latent HIV reservoir
●​ At any time, cells in the latent HIV reservoir can become active again

HIV infection of monocytes

●​ While HIV predominantly affects CD4 T cells, it also infects monocytes, particularly
when they differentiate into macrophages
●​ HIV enters monocyte through same receptor as CD4 (this receptor is present in
smaller amounts on monocytes compared to CD4 cells)
●​ Once infected, monocytes can act as “reservoir” for HIV
●​ Results in infected macrophages (microglia)
Management and Treatment of HIV
●​ HIV treatment is called antiretroviral therapy (ART)
●​ It involves taking antiretrovirals (ARVs)
●​ ART cannot cure HIV, but can help PLWH live longer, healthier lives and reduces the
risk of HIV transmission
●​ Begin ART as soon as possible after diagnosis
●​ ART = Treatment
●​ ARV = Drug
●​ HIV drugs are called antiretrovirals (ARVs)
●​ It is important to take a combination of ARVs:
-​ Each ARV acts at a different stage of the HIV lifecycle. This is called
combination antiretroviral treatment (cART)
-​ Can be put into a single pill or can take multiple different pills
●​ Goal of ART is to achieve viral suppression

Viral Suppression
●​ Viral suppression:
-​ Stopped HIV from multiplying, which reduces viral load
-​ Having less HIV, gives the immune system a chance to recover and produce
more CD4 cells
-​ Even though there is still HIV in the body, the immune system is strong
enough to fight off infections.
-​ In SA, viral suppression is defined as having a viral load <50 copies/mL
-​ Viral suppression can only be achieved if someone is adherent to ART
●​ Undetectable viral load:
-​ Viral load is so low that a test can’t detect it

Adherence
●​ Taking ART as prescribed, i.e. every day but also attending health care appointments
to monitor viral load and collect ARVs.
●​ If achieved:
-​ HIV cannot be transmitted
-​ HIV is no longer life-limiting infection
-​ Opportunistic infections and malignancies rare
●​ Possible issue:
-​ ART Resistance: HIV mutates and ARVs become less effective

South Africa
●​ 7.7 million (±12.6% of the population) living with HIV in SA
Barriers and Treatment Adherence
●​ Structural-level:
-​ Poverty-related barriers (e.g., lack of transport, competing demands, food
insecurity)
-​ Institutional barriers (e.g., overburdened healthcare facilities)
-​ Poor health literacy
●​ Individual-level:
-​ Concerns around stigma
-​ Cognitive impairment/forgetfulness
-​ Suspicions of treatment
-​ Work and family responsibilities
-​ Treatment complexity (e.g., number of pills)
Statistics (according to UNAIDS)
●​ 12.6% of people would not buy fresh veggies from HIV+ shopkeepers.
●​ 7.5% of people said they don’t think HIV+ children should attend school with HIV-
children
●​ 45.8% of young people aged 15-24 know about HIV prevention

Immune System in the Brain

●​ Blood-brain-barrier (BBB)
●​ Microglia (brain’s immune cells)
●​ Astrocytes (support cells with immune functions)
●​ Limited role of peripheral immune cells (T cells + B cells)

Blood Brain Barrier

●​ Semi-permeable barrier that separates the brain from the circulating blood
●​ Gatekeeper, only allowing essential nutrients to pass through while keeping out most
pathogens and immune cells
●​ When infection is in the body, it becomes more permeable

Microglia
●​ Primary immune cells of the CNS
●​ Originate from monocytes (a type of white blood cell), already in brain from early
development
●​ They constantly survey brain for signs of infection, injury, or damage
●​ When threat is detected (e.g., pathogens, damaged neurons), they become
activated and start defense response:
-​ Engulfing/digesting foreign invaders
-​ Removing dead or damaged cells (process called phagocytosis)
-​ Releasing pro-inflammatory cytokines to recruit other immune cells and signal
that there is a problem
-​
Astrocytes
●​ Plays role in maintaining health of brain’s immune environment
●​ Support neurons, maintain BBB, secrete immune-modulating factors that influence
inflammation and immune responses
●​ During infection:
-​ Release inflammatory molecules that aid in the immune response
Limited role of peripheral immune cells
●​ Under normal circumstances, T cells and B cells do not enter the brain due to the
BBB
●​ However, in certain situations like inflammation or infection, the BBB can become
more permeable, allowing CD4+ T cells and monocytes to enter the CNS.
●​ Once inside, they can assist in fighting infections (but can also contribute to chronic
inflammation)
●​ Peripheral immune cells = immune cells that are part of the body’s immune system
(i.e. not the CNS immune system)
Lecture 2
HIV Associated Cognitive Impairment
●​ HIV infection can cause cognitive impairment
●​ Occurs when HIV is uncontrolled resulting in HIV infection in the CNS
●​ Prevalence:
-​ 15-55%
-​ Range hugely due to challenges related to diagnosing HIV cognitive
impairment
●​ There are different types of cognitive impairments due to HIV

●​ HIV encephalitis – inflammation/infection of the brain

●​ Cognitive impairments – varies in levels from mild to extreme (dementia is the
extreme)

HIV Entry into CNS

●​ While HIV is known to mainly attack the immune system, it also invades the CNS,
leading to neurocognitive impairment in some individuals
●​ The process of how it enters is complex and widely known as the “Trojan Horse”
mechanism (involves white blood cells crossing BBB)

Stages
●​ Stage 1: Peripheral Infection and Early Immune Response
-​ HIV infects CD4+ T cells and monocytes circulating in blood
-​ HIV infection can cause blood-brain-barrier to be more permeable
●​ Stage 2: Monocytes as the Trojan Horse
-​ Infected monocytes can cross the BBB due increased permeability
-​ Infected monocytes carry HIV into the brain
-​ Resulting in infected microglia
●​ Stage 3: Viral Replication
-​ Infected microglia release HIV allowing the virus to replicate
-​ Unlike CD4 cells, microglia are more resistant to HIV-induced cell death,
which means they can harbour the virus for long periods, contributing to a
chronic infection

Ways HIV Causes Cognitive Impairment

●​ Direct effects:
-​ Neuroinflammation
-​ Legacy effects – damage done before art was started
-​ CSF HIV escape (rare) – in cerebrospinal fluid, ARVS aren’t stopping hiv
replication in the csf
 ●​ Indirect effects:
-​ Chronic immune activation – in the body
-​ Compromised BBB
-​ ART side effects

Neuroinflamation
●​ HIV-infected microglia serve as reservoirs for the HIV virus
●​ When immune system is activated in brain, inflammatory signals can trigger latent
HIV microglia to become active again.
●​ Once infected, microglia release pro-inflammatory cytokines (signaling molecules to
come to site of infection) neuroinflammation
●​ Infected microglia also release viral proteins neurotoxic (i.e. damage neurons) +
neuroinflammation

Effects of Neuroinflammation
●​ Chronic inflammation:
-​ Damages neurons over time
●​ Synaptic dysfunction:
-​ Weakens synapses between neurons (disrupts communication between
neurons)
-​ Excitotoxicity: neurons are overstimulated, leading to cellular damage and
even neuronal death
●​ Inflammation produces reactive O2 species oxidative stress:
-​ Damages neuronal membranes, proteins, and DNA.

Legacy of effects
●​ Lasting damage that occurs before an individual begins ART (irreversible damage)
●​ Pre-ART Damage:
-​ Uncontrolled HIV spreads to the brain, causing inflammation, and leaving
“scars” on cognitive functions
●​ Cognitive Reserve:
-​ Cognitive Reserve = brain’s ability to find alternative ways of getting a job
done. People with higher cognitive reserve (built through education, mental
engagement, brain health) can withstand damage before cognitive
impairments become apparent
-​ HIV reduces cognitive reserve through early neuronal damage before ART is
initiated = individuals more vulnerable to effects of future damage

CSF HIV escape

●​ Rare
●​ HIV continues to replicate in CSF despite being virally suppressed in blood
●​ This occurs because ARVs often have varying levels of penetration into the CNS
leading to insufficient suppression of HIV in the brain and CSF
●​ CSF escape can be detected by comparing viral load in the blood and CSF, if HIV is
undetectable in blood but elevated in CSF, indicates virus has escaped suppression
in the CNS
●​ Exacerbates risk of HIV-associated cognitive impairment
Can cognitive impairment directly occur with ART?
●​ Legacy effects:
-​ Longer the delay in starting ART, more significant legacy effects
-​ Effects persist despite viral suppression
●​ Chronic neuroinflammation:​
-​ ART may not eradicate HIV reservoirs, microglia can release
pro-inflammatory viral proteins if activated
-​ Prolonged activation of microglia can maintain inflammatory state (chronic
neuro-inflammation

Chronic inflammation
●​ Even before HIV enters brain, chronic immune activation and chronic inflammation
release cytokines that affect the brain indirectly

Compromised BBB
●​ HIV weakens BBB through systemic inflammation, allowing HIV-infected monocytes
to enter CNS

ART side effects

●​ Some medications have neurotoxic side effects (especially older ones)
●​ Prolonged use can be linked to cognitive side effects

Opportunistic infections can indirectly cause cognitive impairment

Lecture 3
Areas of Brain HIV Targets
Brain areas affected in HIV
●​ Subcortical Structures:
-​ Basal Ganglia
-​ Thalamus
-​ Diffuse white matter damage
●​ Cortical structures:
-​ Frontal lobe (especially prefrontal cortex)
-​ Temporal lobes (including hippocampus)
●​ Cerebellum (in advanced cases)

Cortical-subcortical Loop in HIV

●​ The cortical-subcortical loop is most susceptible to damage in the context of HIV

●​ Prefrontal cortex → Basal Ganglia

-​ Cerebral cortex (esp. prefrontal cortex) sends signals to the basal ganglia
-​ Basal ganglia processes these cortical inputs to ensure appropriate executive
functions are executed
●​ Basal ganglia → Thalamus:
-​ Basal ganglia sends processed signals to thalamus
-​ Thalamus acts as relay station and forwards the signals to appropriate
centers to execute functions
●​ Thalamus → Prefrontal cortex
-​ Thalamus sends processed signals back to prefrontal cortex
-​ Prefrontal cortex

Cognitive Presentation
●​ Subcortical loop damage subcortical presentation → dysexecutive impairment
-​ Attention
-​ Working memory
-​ Planning
-​ Problem-solving
-​ Complexity
-​ Abstraction
●​ Slower information processing speed
●​ Generativity problems
●​ Learning and memory problems
Assessment of HIV cognitive impairement
●​ HIV-associated cognitive impairment implies it is caused by the effect of HIV on the
brain (i.e. no other reasons)
●​ The widely used term is HIV-related Neurocognitive Disorder (HAND)
-​ HAND is a spectrum of cognitive impairments
●​ In practice, many people with cognitive impairment have a combination of factors
contributing to their cognitive complaint (i.e. difficult if it is due solely to HIV)

Cognitive Performance in PWH

Diagnosing HAND
●​ Comprehensive approach
-​ Integrating clinical evaluations, neurocognitive testing, neuroimaging
techniques
●​ Various screening tools have been developed to aid early identification and
monitoring of HAND
●​ Different criteria have been developed to diagnose HAND
●​ The most widely used is the Frascati Criteria (not universally adopted)

Frascati Criteria to diagnose HAND

●​ Guideline developed to standardize the diagnosis of HAND and classify into three
levels of severity
●​ Diagnosis is based on performance on cognitive tests compared to matched controls
●​ Need to have deficits in at least 2 cognitive domains for HAND

Frascati Criteria Classification

1.​ Asymptomatic Neurocognitive Impairment (ANI):
-​ Impairment in ≥2 cognitive domains (≥1 SD)
-​ Does not interfere with daily functioning
2.​ Mild Neurocognitive Disorder (MND)
-​ Impairment in ≥2 cognitive domains (≥1 SD)
-​ Mild to moderate interferes with daily functioning (e.g. subtle difficulties with
work or social functioning)
3.​ HIV-associated Dementia (HAD)
-​ Marked (≥2 SD) impairment in ≥2 cognitive domains
-​ Marked interference in daily functioning (affects ADLs)

Other Suggested Criteria

●​ Gisslén criteria
●​ Global deficit score (GDS)
●​ Multivariate normative comparison (MNC)
●​ Novel multivariate method (NMM)
What should we do?
●​ Clinical history (medical folders, collateral)
-​ HIV History: time of diagnosis, time of ART initiation, adherence, nadir CD4
count
-​ Medical history: e.g. co-morbid conditions, vascular risk factors
-​ Cognitive history: cognitive problems reported, onset of difficulties and how
they coincide with HIV history
●​ Biomarkers (if available):
-​ Brain scan: evidence of HIV brain pathology
-​ CSF biomarkers: amount of HIV in CSF
-​ Blood tests: current viral load, CD4 count, level of ARVs
●​ Neuropsychology Testing:
-​ Evidence of cognitive impairment
-​ Does pattern of impairment on testing fit with the cognitive presentation of
HIV?