4.3.
Résultats
Les caractéristiques générales des 137
patients traités par combinaisons thérapeutiques sont
montrés dans les annexes $8 et $9. Sur les 81 patients qui survivaient,
47 % étaient autonomes dans la vie quotidienne, 28% étaient
à leur domicile mais nécessitaient une aide médicale ou
paramédicale et 25 % étaient institutionnalisés.
La survie et le handicap fonctionnel n'étaient
liés ni à l'âge, ni au taux de lymphocytes CD4, ni à
la charge virale. La survie était en revanche liée à
l'index nutritionnel (NRI), au score de Karnowsky et au score EAVQ. Les
variables qui contribuaient le plus à un risque de décès
étaient l'encéphalite du VIH, la toxoplasmose
cérébrale, la LEMP et la cachexie. Les variables qui
contribuaient le plus à une dépendance étaient la
toxoplasmose cérébrale, la LEMP et les « autres
atteintes neurologiques ». Les résultats étaient
similaires dans le sous-groupe de patients ayant répondu au
questionnaire de Lawton et Brody. Le score EAVQ chez les patients
traités par combinaisons thérapeutiques n'était lié
ni à l'âge, ni au taux de lymphocytes CD4, à la charge
virale ou au NRI. Il était, en revanche, lié au score de
Karnowsky, et inversement lié à la durée de suivi.
4.4.
Conclusions
Dans cette étude, nous avons confirmé les
résultats de la littérature sur l'augmentation du taux de survie
chez les patients ayant des affections neurologiques liées au SIDA
(24.7% des patients hospitalisés dans le service ont survécu
avant l'introduction des combinaisons thérapeutiques et 57.9%
après leur instauration). L'encéphalite du VIH, la LEMP, la
toxoplasmose cérébrale, l'infection neurologique par le CMV, la
cachexie et les infections opportunistes étaient associés
à un plus mauvais pronostique. Le facteur nutritionnel apparaissait plus
important dans la survie des patients traités par combinaisons
thérapeutiques que ne l'étaient le taux de lymphocytes CD4 ou la
charge virale.
Cependant, seuls 47% des patients n'avaient pas de handicap
dans leur vie quotidienne. 28% nécessitaient une aide à domicile
et étaient institutionnalisés. Les facteurs intervenant le plus
dans le handicap étaient la LEMP, la toxoplasmose
cérébrale, le score NRI et le score de Karnowsky. Le score EAVQ
étaient inversement liés à la durée de suivi. Deux
hypothèses pourraient l'expliquer: soit une amélioration
progressive ultérieure à la sortie des patients, soit un
meilleure pronostic chez les patients dont la complication neurologique
était récente, en raison de l'amélioration de la
qualité des soins. Seul un suivi longitudinal permettrait de
trancher.
En conclusion, dans cette étude de patients atteint des
principales affections neurologiques liées à l'infection par le
VIH, la moitié des patients survivent avec un handicap quotidien. Ces
résultats montrent clairement la nécessité d'anticiper sur
les besoins de ces patients en termes médicaux et paramédicaux (
de rééducation notamment) et de prévoir d'important
efforts pour améliorer leur vie quotidienne.
VI.
CONCLUSION
Nous avons étudié les troubles cognitifs des
patients infectés par le VIH, leur évolution depuis l'apparition
des combinaisons thérapeutiques modernes et les paramètres
neurobiologiques qui interviennent dans ces troubles. Nous nous sommes ensuite
interrogés sur l'avenir de ces patients, en terme de dépendance
quotidienne et sur les nouveaux enjeux thérapeutiques qu'ils doivent
faire prévoir.
Phénomène très rare dans l'histoire des
neurosciences, la démence du SIDA, qui est devenue dans certains cas, au
moins partiellement, réversible. La définition d'une
démence doit-elle prendre en compte l'irréversibilité des
troubles ? Ce point a été longtemps discuté Quoiqu'il
en soit la « démence du SIDA » doit être,
aujourd'hui, classée parmi les démences potentiellement
curables.
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VIII. ANNEXES
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