Important note: Information in this article was accurate in 2005. The state of the art may have changed since the publication date.What is the life span/prognosis for an ADC [AIDS Dementia Complex] patient?
Rodger MacArthur, M.D.
Wayne State University
Division of Infectious Diseases
The clinical condition known as AIDS Dementia Complex, or HIV encephalopathy, is caused by the neurotoxic effects of HIV on the substance (parenchyma) of the brain. ADC typically is seen late in the course of infection with HIV, usually when the CD4+ cell count is less than 50 cells/mm3. Earlier cognitive deficits, due to ongoing HIV replication in the brain, can be detected in many HIV- infected individuals during formal neuropsychiatric testing. These deficits typically take the form of decreased memory and/or computational difficulty (with math problems, for example).
In the typical presentation of the ADC, the HIV-infected person is diagnosed clinically with a passive dementia. CT or MR scanning of the brain typically shows a somewhat shrunken brain and other non-specific findings. The findings are considered non-specific because other conditions, such as aging, can be associated with the same radiologic appearance. In addition, other infectious and non-infectious causes of dementia (such as syphilis or Alzheimer's disease) need to be considered and ruled-out prior to making the diagnosis of ADC.
The treatment of ADC is straightforward, and involves the use of combination antiretroviral therapy. Not all antiretroviral agents penetrate the brain as well as others; in particular, the protease inhibitor class has the least penetration into the brain, whereas the non-nucleoside reverse transcriptase inhibitor class gets into the brain the best. Nevertheless, the goal of treatment is to maximally suppress HIV replication, as evidenced by an HIV RNA level in the blood of less than 400 copies/ml, regardless of which specific drugs are used in combination. Shutting down viral replication allows the brain to recover. Clinical changes are usually apparent within 2 weeks, and radiologic improvement or stabilization can be seen within several months.
An individual typically does not die because of the ADC. Rather, the individual's profoundly weakened immune system results in substantially increased risk of infection with a variety of organisms which are usually the immediate cause of death. While suppression of HIV replication is sufficient to reverse the clinical manifestations of the ADC, the life expectancy of an individual with ADC depends on whether the CD4+ cell count increases sufficiently (typically above 200 cells/mm3) to reduce the risk of opportunistic infections. If the CD4+ cell count can be sustained above 200 cells/mm3 or better, an individual with the previous diagnosis of ADC can live 5-10 years or more with a relatively normal life. If the CD4+ cell count can increase above 350 cells/mm3, life expectancy is likely to be 10-20 years or longer with currently available therapy.
In summary, the ADC is seen in many HIV-infected persons with CD4+ cell counts less than 50 cells/mm3. It can be treated with the use of combination antiretroviral therapy, and resolves quickly after initiation of these drugs. Life expectancy is dependent on restoration of adequate immune function, rather than anything specific to ADC.
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