Parkinsonism in people with virally suppressed HIV

Parkinsonism is increasingly recognised in people who are ageing with virally suppressed HIV, with bradykinesia emerging earlier and more frequently than in idiopathic Parkinson's disease. Despite effective antiretroviral therapy (ART), studies report persistent motor symptoms-such as motor slowing, postural instability, and symmetric postural tremor-and non-motor features, including sleep disturbance, cognitive decline, and autonomic dysfunction. Neuroimaging reveals basal ganglia atrophy, white matter hyperintensities, and reduced dopamine transporter activity, underscoring a pathophysiology distinct from idiopathic Parkinson's disease. Proposed mechanisms include chronic neuroinflammation, cerebrovascular dysfunction, mitochondrial injury, disturbed iron metabolism, and possible ART-induced neurotoxicity, all contributing to basal ganglia dysfunction. Diagnosis is made complex by under-recognition, non-specific assessment tools, and comorbidities. Standardised rating scales, such as the Unified Parkinson's Disease Rating Scale and the HIV Dementia Motor Scale, can support clinical evaluation, but evidence-based management strategies are scarce. Although dopamine replacement therapy and deep brain stimulation show promise in case reports, no established guidelines exist for parkinsonism in people with virally suppressed HIV. As the global population of older adults with HIV grows, parkinsonism is expected to become an increasingly prevalent and underdiagnosed cause of frailty, highlighting the urgent need for targeted epidemiological, mechanistic, and interventional research, particularly in low-income and middle-income settings.