New onset seizure etiologies and outcomes among adults with HIV in the era of broadly available antiretroviral therapies

Abstract

OBJECTIVES: In this era of widely available antiretroviral therapy (ART), information regarding new onset seizure, seizure recurrence and mortality is needed to guide clinical decision-making. METHODS: A rural, prospective, cohort study was conducted April 2016 to June 2019. Inclusion criteria were HIV positivity, age ≥ 18 years, and new onset seizure. Two-year seizure recurrence was the outcome. Risk factors for seizure recurrence were evaluated using a Fine-Gray model to account for the competing outcome of death. RESULTS: 258 people were screened, 95 were eligible and 89 were enrolled. 47 (53 %) were female, mean 39 years, and 64 (72 %) were on antiretroviral therapy (ART). Only 25/64 (39 %) of these were virally suppressed. At presentation, 12 (13 %) were in status epilepticus and 46 (52 %) had multiple or prolonged seizures. The commonest seizure etiology was cryptococcal meningitis, 18 (20%). At discharge, 6 (7 %) patients were prescribed antiseizure medications (ASM). Follow-up was exclusively directed to ART Clinics. After median 585 days, 24 % (21/89) developed epilepsy with multiple seizure recurrences. No one was consistently maintained on ASM. A history of prior central nervous system (CNS) injury was associated with seizure recurrence (HR 5.1;95 %CI1.9-13.2;p = 0.0001). Epilepsy development was less likely in individuals with a worse HIV disease stage (HR 0.2; 95 %CI 0.1-0.5;p = 0.002). Mortality was 37 % (n = 33). SIGNIFICANCE: Despite high and early mortality, among rural persons living with HIV who have new onset seizure, almost a quarter will go on to develop epilepsy. Prior CNS injury was a risk factor for epilepsy. Having more advanced HIV disease was protective against epilepsy suggesting that if conditions associated with advanced HIV disease are the underlying cause of new onset seizures, once HIV is treated, seizure recurrence risk is reduced. Better models of care are needed that include dedicated epilepsy care which was neglected in the HIV clinics.