Assessment and Management of HIV-Associated Cognitive Impairment: Experience from a Multidisciplinary Memory Service for People Living with HIV.

Kate Alford,Claire Elphick,Jaime H Vera,Sube Banerjee,Clara O’Brien,Olivia Pounds,Andrew Butler,Phillip Henshaw,Eileen Nixon,Stuart Anderson

doi:10.3390/brainsci9020037

Abstract

As the HIV population ages, the prevalence of cognitive impairment (CI) is increasing, yet few services exist for the assessment and management of these individuals. Here we provide an initial description of a memory assessment service for people living with HIV and present data from a service evaluation undertaken in the clinic. We conducted an evaluation of the first 52 patients seen by the clinic. We present patient demographic data, assessment outcomes, diagnoses given and interventions delivered to those seen in the clinic. 41 patients (79%) of those seen in the clinic had objective CI: 16 (31%) met criteria for HIV-associated Neurocognitive Disorder (HAND), 2 (4%) were diagnosed with dementia, 14 (27%) showed CI associated with mental illness and/or drugs/alcohol, 7 (13%) had CI which was attributed to factors other than HIV and in 2 (4%) patients the cause remains unclear. 32 (62%) patients showed some abnormality on Magnetic Resonance Imaging (MRI) brain scans. Patients attending the clinic performed significantly worse than normative scores on all tests of global cognition and executive function. Interventions offered to patients included combination antiretroviral therapy modification, signposting to other services, case management, further health investigations and in-clinic advice. Our experience suggests that the need exists for specialist HIV memory services and that such a model of working can be successfully implemented into HIV patient care. Further work is needed on referral criteria and pathways. Diagnostic processes and treatment offered needs to consider and address the multifactorial aetiology of CI in HIV and this is essential for effective assessment and management.

Highlights

In the UK over 100,000 people are chronically infected with HIV, with over 6000 new cases reported each year [1]
The main method used to define HIV-Associated Neurocognitive Disorder (HAND) are the Frascati criteria [7]. These involve neuropsychological testing across multiple cognitive domains, HAND is diagnosed when two or more domains are more than one standard deviation below normative scores and for Mild Neurocognitive Disorder (MND) and HIV-associated Dementia (HAD) when daily functions are affected
Recent studies have suggested that the Frascati criteria have poor sensitivity and specificity, and do not take into account the complexity of pathogenic mechanisms likely to contribute to cognitive impairment (CI) in patients living with HIV (PLWH) [7,8,9]

Summary

Introduction

In the UK over 100,000 people are chronically infected with HIV, with over 6000 new cases reported each year [1]. Recent studies have suggested that the Frascati criteria have poor sensitivity and specificity, and do not take into account the complexity of pathogenic mechanisms likely to contribute to CI in PLWH [7,8,9]. This lack of clarity in definition and diagnosis is a significant issue which affects the management of PLWH with CI. The pathogenic mechanisms causing CI are often multifactorial, including complex immunopathological processes controlled by HIV factors, the direct effects of cART, and host factors (e.g., co-infections, cardiovascular and cerebrovascular diseases, psychiatric illnesses, the effect of age and age-related illnesses on the brain and lifestyle factors, including social isolation [10])

Methods

Discussion

Conclusion