AIDS

Seizures that signal HIV create treatment Catch-22

Physicians in sub-Saharan Africa must often choose between treating an HIV infection and controlling seizures, which can occur if the disease goes undiagnosed for too long.

While the study, which appears in the journal Neurology, initially had the purpose of identifying risk factors for seizures in HIV-positive patients and thereby providing physicians with a blueprint for care, it has instead highlighted the difficult decisions that providers and patients must confront.

Seizures are a common symptom in individuals with advanced stage HIV. At least 11 percent of people with the infection will have a seizure at some point if the disease is undiagnosed and not treated.

In many parts of Africa there are still significant social and economic barriers that prevent people from being tested for HIV. Consequently, some people are diagnosed with HIV only after going to the hospital after a seizure.

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Once this occurs, caregivers face no-win situation. Because the HIV infection is often advanced, the appropriate course of action is to aggressively start a treatment of combined antiretroviral therapy (cART). However, there is also a sense of pressure and urgency to treat the seizures, which represent a significant health risk if left unaddressed.

The dilemma exists due to limited treatment options. Most African regions with high rates of HIV infection continue to rely largely on older, enzyme-inducing antiepileptic drugs (AED) for seizure management. Unlike newer anti-seizure treatments, these AEDs are known to interfere with cART, which makes the HIV treatment less effective. This interaction not only places the patients at greater risk from death from the disease—a third of the patients were dead within a year of their first visit to the hospital—but also could give rise to drug-resistant strains of HIV.

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While the long-term solution is to increase access to newer anti-seizure drugs, the study’s authors believe that the priority should be to reconstitute the immune system by getting patients on cART as soon as possible. They acknowledge that a treatment approach that omits AEDs leaves patients vulnerable to a reoccurrence of seizures, but believe that the HIV infection poses the far greater health risk in the long term.

Gretchen Birbeck, professor in neurology at University of Rochester Medical Center, led the study. Birbeck also serves as director of the Epilepsy Care Team at Chikankata Hospital in rural Zambia and is an honorary lecturer at the University of Zambia.

Additional coauthors are from Beth Israel Deaconess Medical Center, Michigan State University, the Greater Lawrence Family Health Center, the National Institutes of Health, the San Antonio Military Medical Center, the University of Zambia, the Centre for Infectious Disease Research in Zambia, and the University of Rochester. Grants from the Fogarty International Center and the National Institute of Neurological Disorders and Stroke supported the work.

Source: University of Rochester

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