What HIV does to your brain — and how ARVs halt that

When free antiretrovirals (ARVs) were introduced to South Africa’s public health system in 2004, the medicines transformed an HIV infection from a death sentence to a chronic disease. Millions of lives have been saved by the treatment, which pushes down the amount of HIV in someone’s body to often undetectable levels because it blocks the virus from making copies of itself. (This is called being virally suppressed and means that someone can’t infect others through sex.)

But, to get there, someone needs to take their ARVs daily, at about the same time each day, for the rest of their life. Many government patients have been on treatment for almost two decades and, although many patients in South Africa stick to taking their pills the right way — health department figures show that 92% of people on ARVs are virally suppressed — taking lifelong treatment can be tough. 

But the health department’s figures also show that the country still struggles to get people who know they’re HIV positive on ARVs — about a quarter of diagnosed HIV-positive people have not started treatment. 

Starting treatment late can be bad for your health because it gives the virus time to permanently harm an infected person’s cells. ARVs can stop it from happening, but they can’t reverse any damage that was done before treatment was started, John Joska from the University of Cape Town’s HIV Mental Health Research Unit told Mia Malan on Bhekisisa’s monthly television show Health Beat. 

Without treatment, an HIV infection can, for instance, lead to someone gradually losing brain tissue because of inflammation caused by the virus. Infection can also lead to depression and anxiety and a sudden state of confusion. 

If someone stops taking their pills (sometimes called a treatment holiday), HIV can again start causing harm like this.

That’s why psychologist Marnie Vujovic says it’s important to make sure someone on ARVs has a plan to help them stick to taking their drugs. Reminders, she says, are helpful and she encourages her patients to think what a suitable reminder would look like for them.

“Would it be a cellphone reminder? A TV programme? A sticker on the [bathroom] mirror, so that when you go to brush your teeth, you see it there? Would it help to have a treatment buddy?” 

Malan asked Joska how HIV affects someone’s brain and how ARVs can halt any damage. 

Mia Malan (MM): How does HIV affect your brain or central nervous system?

John Joska (JJ): The brains of people with HIV may be affected by the virus [itself] or through psychological and social effects of living with HIV. HIV infects mainly the white blood cells known as CD-4 lymphocytes [and] these cells may enter the brain quite early after someone gets infected. A chain of events driven by infection and slow inflammation of the brain tissue may then happen. In the days before ARVs, people with HIV would develop Aids, as well as a syndrome known as HIV encephalopathy, which is an acute confusional state. But these days, this is quite rare. What more often happens is a slow and gradual loss of brain tissue, due to the inflammation before the person starts their ARVs. 

MM: Does taking ARVs make it harder for HIV to get to your brain and so lead to less inflammation?

JJ: [Taking] ARVs is crucial to [maintaining] brain health in HIV infection. When taken regularly, they will help to clear and suppress HIV in all body compartments, even the brain. When the brain tissue is clear of HIV, then the cycle of events leading to inflammation and brain tissue damage is halted, and [the] brain returns to normal, apart from any damage that might have occurred before the ARVs were started.

MM: Are there any side-effects [of ARVs] that could impact on your mental health or affect your brain?

JJ: Some [ARVs] cause side-effects to the brain and the nervous system. For example, the drug efavirenz, which until recently was a common component of our national triple therapy regimen [in the form of a three-in-one pill], may cause sleep changes, nightmares, depression and anxiety, especially in the first few months of treatment. There’s also been a question mark around whether efavirenz may impact cognitive functions. Our [research] group has done some research on efavirenz and we think that people who take it are more likely to perform poorly on cognitive testing than people who don’t have HIV. The [treatment] programme nationally has switched from efavirenz to dolutegravir and we think this is a major advantage for brain health.

MM: Is there any psychiatric medication that can be taken to counter the effect of HIV on the brain?

JJ: People [with HIV] may experience a change in their mood, have high levels of anxiety or have poor memory, and they should report this to their clinician. The first step would be to ensure that they are [virally] suppressed. The second might be to consider switching ARVs, for example, from efavirenz to dolutegravir. If symptoms of depression or anxiety persist, then one might consider using medications such as antidepressants or refer the person to a psychotherapist or counsellor for care. 

MM: Do ARVs and psychiatric medicine work together or do they sometimes work against each other?

JJ: It’s quite possible to take ARVs and psychotropics [drugs that affect mood, perception or behaviour] together, [although] there might be a few occasions where one would need to be cautious. Examples of [such] ARVs would be protease inhibitors [which block the mechanism HIV uses to make copies of itself]. [These] are fortunately far less commonly needed in regimens now but [they are] sometimes [used for] people who are on second– or third-line [treatment] [pill courses which patients who don’t respond to the initial combination of medicines switch to], and there might be drug interactions with these medications. But, in general, most psychotropics are fairly safe.

Watch the full interview.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.