Epidemiology of neuropathy in HIV

Studies in people with symptomatic HIV infection have reported that about a third develop peripheral neuropathy. A recent study has shown that 51% of untreated HIV-positive patients in Uganda have peripheral neuropathy,1 while another study found that each year 8% of people with a CD4 count below 100 cells/mm3 developed peripheral neuropathy. About a third of adults and children with AIDS experience peripheral neuropathy at some point, although children may experience less severe symptoms.

Peripheral neuropathy is more common among injecting drug users (IDUs) than in the general population. Consequently HIV-infected IDUs may be more likely to experience neuropathy, particularly if they are taking nucleoside analogue reverse transcriptase inhibitor (NRTI), since these drugs can cause peripheral neuropathy as a side-effect.2

In the era of antiretroviral therapy, people with certain risk factors who are taking anti-HIV therapy may be at greater risk of peripheral neuropathy. Risk factors include:

  • Having a CD4 cell count below 100 cells/mm3.
  • A history of an AIDS-defining condition.
  • A history of peripheral neuropathy.
  • High alcohol consumption.
  • Use of other neurotoxic drugs.
  • Nutritional deficiencies.

Despite the abandonment of the antiretroviral drugs known to cause neuropathy in developed countries, there is some evidence that neuropathy remains highly prevalent among older people with HIV, and may in part be a consequence of ageing with HIV infection. The CHARTER study of people taking antiretroviral drugs in the US found that while 20% of 20 to 29 year olds had at least one symptom of neuropathy, this proportion climbed to 60% in 40 to 49 year olds and 75% in 50 to 59 year olds.3

Another US study, following 2155 participants on antiretroviral treatment, has found that the prevalence of neuropathy is increasing over time, despite a decline in the use of drugs that cause neuropathy. The prevalence among those with undetectable viral load and a CD4 count (n=1253) rose from 29.5% at week 48 to 44% after seven years, with 15% of those with neuropathy reporting moderate to severe pain.4

Taller people (>170cm) also have a higher risk of developing neuropathy. d4T appears to exacerbate this risk further in older, taller people. A study in the Asia-Pacific region found that patients who were younger (>40 years) and shorter had a sensory neuropathy risk of 20%. A third of those who were younger but taller developed neuropathy, compared to 38% of older but shorter patients. Two-thirds of patients who were older than 40 and taller than 170cm developed neuropathy if they received d4T.5

Age and height may prove to be useful screening tools for determining whether patients should avoid d4T altogether.

References

  1. Nakasujja N et al. Human immunodeficiency virus neurological complications: an overview of the Ugandan experience. J Neurovirol 11 Suppl 3:26-9, 2005
  2. Berger AR et al. Prevalence of peripheral neuropathy in injection drug users. Neurology 53: 592, 1999
  3. Ellis RJ et al. Persisting high prevalence of HIV distal sensory peripheral neuropathy in the era of combination ART: correlates in the CHARTER study. 16th Conference on Retroviruses and Opportunistic Infections, Montréal, abstract 461, 2009
  4. Evans SR et al. HIV-Associated peripheral neuropathy in the HAART era: results from AIDS Clinical Trials Group (ACTG) Longitudinal Linked Randomized Trials (ALLRT) Protocol A5001. 16th Conference on Retroviruses and Opportunistic Infections, Montréal, abstract 462, 2009
  5. Cherry C et al. Predicting neuropathy risk before stavudine prescription: an algorithm for minimizing neurotoxicity in resource-limited settings. 16th Conference on Retroviruses and Opportunistic Infections, Montréal, abstract 161, 2009
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