1. Post Haart, HIV dementia is seen at higher CD4 counts and the nadir CD4 count is more important than present count.
2. Host genetic factors are important in the development, including genetic mutations in the promoter region of monocyte chemoattractant factor 1 or its receptor CCR2 and TNF alpha.
3. Cognitive slowing and apathy are well known signs. Gait disturbance, bradykinesia, falls, loss of dexterity, and frontal release signs are also well known. Less well known is mania in 5 %, or accompanying myelopathy and symmetric peripheral sensory neuropathy.
4. Distinguishing HIV dementia from effects of drug abuse is important since the latter is unlikely to respond to HAART. Differentiating from effects of HCV is also a challenge especially as HAART drugs are metabolized hepatically.
5. There is increased incidence in older patients and apo E4 alleles and thus an interaction with Alzheimer's disease which can also present in older patients, albeit faster in some cases than it would have otherwise.
6. IRIS patients may have features similar to JC virus and PML but without JC virus detectable in brain or CSF, and IRIS patients may respond partially to steroids.
7. Potent antiretrovirals with 3 or more highly penetrant drugs are the standard of care for most cases of HIV dementia. Highly penetrant drugs include D4T, AZT, ABV, EFV, NVP, IDV.
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