Background:  HIV-1 can be detected in cerebrospinal fluid (CSF) and the brain early in the course of HIV-1 disease. We have shown improvement in neurocognitive function in patients treated with HAART. Adherence to ART is a predictor of successful treatment. Memory and attention are likely to be important cognitive components in adhering to treatment (e.g., memory dysfunction will lead to missed medication doses). We undertook a study to examine the relationship between initial cognitive impairment in those starting ART and later adherence to medication at 6 months.

Methods:  Eligibility criteria included starting a new HAART regimen and no confounding neurological disease. Subjects underwent standardized medical and neurologic history and examination, venipuncture, lumbar puncture, and a neuropsychological test battery prior to HAART initiation at study entry and at 24 weeks later.

Results:  We included 37 subjects who were starting or changing ART at study baseline, and had adherence data and follow-up at 6 months. The subjects’ characteristics were: mean age of 42.5 years, 69% male, 22% white, and 12.5 years of education. The subjects had a mean CD4 count of 293.1, a CSF HIV RNA of 2.53 log copies/mL, and plasma HIV RNA of 3.83 log. Poor adherence was found in 12 subjects, defined as less than 100% adherence in the last 4 days; 25 subjects were adherent. We found significant differences between those adherent and not adherent in the baseline neuropsychological domains of verbal memory (not adherent –1.46, (1.04), adherent –0.78 (0.81), attention (not adherent –0.83 (0.74), adherent –0.31 (0.63), and total battery score (not adherent –1.07 (0.81), adherent –0.52 (0.57)).

Conclusions:  We found that neurocognitive dysfunction is related to later ability to adhere to medications. It is likely that those with cognitive dysfunction may have more difficulty with adherence, creating a vicious cycle of lack of adherence, increased viral load, further immunosuppression, and increased cognitive dysfunction and neurological disease. Patients suspected of having cognitive dysfunction represent a group with special treatment needs, and efforts to enhance adherence should be maximized.