Clinical issues in HIV - 2017

Those of us who looked after patients in the early years of the HIV epidemic, prior to the introduction of highly active antiretroviral therapy (ART), were used to seeing unusual and severe neurological disorders and florid skin lesions, which were due to HIV directly or associated opportunistic infections. These clinical issues were extremely distressing for patients, and although both have now become less common in wealthy healthcare systems, where earlier diagnosis of HIV and access to treatment are available, they do still occur. It is therefore timely to consider these issues for those who have started to deliver HIV care more recently and who may not have the experience of those who practiced HIV care in the pre-ART era.

Neurological involvement in patients with HIV is often associated with cognitive impairment. HIV-associated neurocognitive disorder (HAND) occurs as a result of neural damage caused by HIV replication and subsequent immune activation in the central nervous system. Although the incidence of severe HAND and HIV-associated dementia (HAD) has decreased since the introduction of antiretroviral medication, up to 40% of HIV-infected individuals are estimated to develop mild to moderate cognitive impairment

A world increasingly accessible by cheap airline travel now provides a previously unlikely opportunity for tropical infections to be imported to countries in which they are not commonly seen. Returning travellers or new migrants who are HIV-positive and have lived in, or travelled to, an area endemic for an opportunist infection may either present with the disease or harbour the pathogen as a quiescent infection until, at a more advanced stage, the disease manifests. This is compounded by the fact that new migrants who are HIV-positive are more likely to present with advanced immunodeficiency, reflecting their arrival from a lowor middle-income country with limited access to antiretroviral therapy (ART). It is vital that a travel history is taken at presentation and that diseases found in the country of residence or travel are considered as part of the differential diagnosis, as not considering potential opportunistic infections relating to travel may result in a delay in diagnosis.