HAND

HAND stands for HIV-associated Neurocognitive Disorder. It affects as many as 50% of HIV patients even including those who are well controlled on cARV treatment with undetectable viral loads. Symptoms of HAND include behavioral changes; difficulty in making decisions; and learning, attention, concentration, and memory difficulties. Some patients develop tremors or loss of coordination.

Another form of HAND has been described in research studies: Asymptomatic Neurocognitive Impairment (ANI). Study participants with ANI have impaired performance on neuropsychological tests yet don't recognize having any symptoms. Early studies suggest that these participants do poorly on tests that evaluate their daily function, suggesting they have real impairment that goes unrecognized. Others note that participants with ANI are more likely to develop symptomatic impairment with time.

Managing HAND is sometimes difficult because side effects from medications, other HIV infections, nutritional imbalances, depression, and anxiety, as well as the effects of comorbid diseases (e.g. vascular disease and liver impairment) can all contribute to cognitive, behavioral, and mood disturbances.

Because neurological changes often develop gradually, it can be a challenge to determine exactly when isolated incidents or symptoms should be given a diagnosis of HAND. In the era of HIV where most people are on treatment, it is becoming clearer that cognitive impairment is often due to more than one cause.

The symptoms of HAND fall into three broad categories :

• Cognitiveproblems in concentration (difficulty following the thread of a conversation, short attention span, inability to complete routine tasks, trouble finishing a sentence); memory loss (trouble recalling phone numbers, appointments, medication schedules, agreements, or previous conversations); and a generalized slowdown in mental functions (difficulty understanding and responding to questions, loss of sense of humor or wit).
• Motorpoor coordination, weakness in legs, difficulty maintaining balance, tendency to drop things, decline in clarity of handwriting, loss of bladder or bowel control.
• Behavioral personality changes (increased irritability, apathy toward loved ones or life in general, loss of initiative, withdrawal from social contact); mood swings (depression, excitability, emotional outbursts); impaired judgment (impulsive decision-making, loss of inhibitions); and, on occasion, symptoms of psychosis (hallucinations, paranoia, disorientation, sudden rages).

An accurate diagnosis of HAND requires a comprehensive examination that generally includes a mental status test, a brain scan, and sometimes lab tests on the cerebrospinal fluid (the fluid that bathes the brain and spinal cord), which are obtained through a procedure known as a spinal tap or lumbar puncture. A mental status exam can help identify whether a person is suffering from memory loss, difficulties with concentration and other thinking processes, mood swings, and other symptoms. The best diagnosis requires a third party (e.g. friend, partner, or other family member) to corroborate the behavior/memory changes.

Because no single test definitively answers the question of whether someone has HAND, the final diagnosis is made by weighing all the evidence together. Time and repeated measures are helpful in confirming a diagnosis.

There is currently no definitive treatment for HAND other than reinforcing the need to remain on cART. Psychopharmacology to treat depression, anxiety and psychosis are prescribed but they only provide symptomatic relief. Neuropharmacology also provides only symptomatic treatment of movement disorders. Other approaches include aggressive treatment of comorbidities such a hypertension, lipodystrophy, liver and kidney impairments and proper nutrition.

Immgenuity believes that its IMTV014 therapeutic vaccine used in structured therapeutic interruptions would be beneficial by stimulating CD8 bearing T-lymphocytes in the brain to arrest progression of HAND.