Neurocognitive impairment is an independent risk factor for death in HIV infection. San Diego HIV Neurobehavioral Research Center Group
R. J. Ellis, R. Deutsch, R. K. Heaton, T. D. Marcotte, J. A. McCutchan, J. A. Nelson, I. Abramson, L. J. Thal, J. H. Atkinson, M. R. Wallace and I. Grant
Department of Neurosciences, University of California, Department of Medicine, San Diego, USA. roellis@ucsd.edu
OBJECTIVE: To determine if mortality is increased in individuals with human
immunodeficiency virus type 1 (HIV-1)-associated neurocognitive disorders
less severe than frank dementia. DESIGN: A prospective cohort study; median
duration of follow-up was 2.4 years. Kaplan-Meier analysis and Cox
proportional hazards models were used to compare survival times according
to neurocognitive classification. SETTING: University-based research unit.
PARTICIPANTS: A volunteer sample of 414 individuals seropositive for HIV-1.
Subjects were classified at their baseline evaluation as
neuropsychologically (NP) normal or abnormal (impaired in > or = 2 NP
test domains). A subgroup of NP abnormal subjects met operational criteria
for HIV-associated minor cognitive motor disorder; the remaining subjects
were designated NP impaired. Subjects with frank dementia were excluded.
MAIN OUTCOME MEASURE: Mortality. RESULTS: At the baseline evaluation, 256
(62%) of 414 subjects were designated normal; 109 (26%). NP impaired; and
49 (12%), minor cognitive motor disorder. One hundred six participants
(26%) died during follow-up. Compared with the NP normal group, the
unadjusted relative risk (RR) of death for all NP abnormal subjects (minor
cognitive motor disorder and NP impaired) was significantly increased (RR,
1.7; 95% confidence interval [CI], 1.2-2.6; P < .005). After adjusting
for concurrently measured predictors of survival (CD4 lymphocyte counts,
Centers for Disease Control and Prevention HIV disease classification,
hemoglobin concentration, and serum beta 2-microglobulin) in proportional
hazards models, mortality for all NP abnormal subjects remained elevated
(RR, 1.8; 95% CI, 1.2-2.8; P < .01). The elevation in mortality risk for
subjects with minor cognitive motor disorder was statistically significant
(RR, 2.2; 95% CI, 1.2-3.8; P < .01); for NP impaired subjects it was
marginally significant (RR, 1.6; 95% CI, 1.0-2.8; P = .06). CONCLUSIONS:
The HIV-infected individuals with NP impairment had a higher risk of dying
than those without impairment. This was particularly true for those meeting
syndromic diagnostic criteria.
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