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Perhaps no area of neurology has experienced the transforming changes of improved therapeutics more than neuroAIDS. From the inception of the AIDS epidemic in the 1980s through 1996, patients regularly presented with dreadful opportunistic complications due to severe immunodeficiency, as well as disabling cognitive impairment closely associated with advanced HIV disease involving the brain.1 Combination antiretroviral therapy (cART) was transforming, resulting in precipitous reduction in lethal opportunistic complications. At the same time, the AIDS dementia complex became a rare entity.2
The euphoria induced by this advance in therapeutics has been muted by emerging observations. For several years, multiple groups performing careful examination of patients receiving cART have noted that nearly half of the population remains mildly cognitively impaired when carefully evaluated and compared with normative populations.3–5 The etiology of this impairment is incompletely understood. That HIV continues to drive cognitive impairment remains plausible, perhaps enabled by the challenges of treatment of this virus beyond the blood–brain barrier …
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