The human immunodeficiency virus (HIV) exhibits a notable affinity for neural tissue, entering the nervous system within weeks of infection and potentially leading to various neurological complications. In children, the neurological manifestations of HIV infection are varied and include HIV encephalopathy (HIVE), HIV-associated neurological disorder (HAND), opportunistic infections, cerebrovascular disease, epilepsy, central nervous system (CNS) tumors, cognitive and psychiatric disorders, and peripheral neuropathies. These are collectively known as neuro AIDS.1 These complications may result from the direct impact of the virus on nervous system tissues, immune responses to the infection, or the effects of antiretroviral therapy (ART).2

Before the advent of combination antiretroviral therapy (cART), it was estimated that 50-90 % of children infected with HIV experienced CNS involvement, typically presenting as HIVE.3,4 With the introduction of cART, the incidence of HIVE in children has decreased to approximately 13-23 %.1,5

In children with HIV (CWH), opportunistic neuro-infections are seen in up to 34 % of cases, mostly in those with advanced disease (WHO stages 3 and 4).6 These include recurrent bacterial meningitis, tuberculous meningitis, cytomegalovirus (CMV) infection, cerebral toxoplasmosis, and cryptococcal meningitis.7 The risk of acquiring opportunistic neuro-infections is determined by the severity of the immunodeficiency, adherence to cART administration, antimicrobial preventive therapy, and the efficacy of routinely administered childhood vaccines. In low- and middle-income countries (LMICs), especially sub-Saharan Africa, where the majority of HIV-infected children live, prevalent social factors such as overcrowding and poor nutritional status also impact the risk of acquiring opportunistic neuro-infections .8

Cerebrovascular diseases and seizures occur at higher rates in CWH compared with non-infected children.9,10 Cognitive and neuropsychiatric diseases also result from direct viral invasion of neural tissue or from the effects of treatment.11

In this review, we describe the neurological effects of HIV in children, highlighting virus characteristics, transmission, manifestations and treatments, with a focus on LMICs.