Abstract
ObjectiveTo conduct a preliminary evaluation of the utility and reliability of a diagnostic tool for HIV-associated dementia (HAD) for use by primary health care workers (HCW) which would be feasible to implement in resource-limited settings.BackgroundIn resource-limited settings, HAD is an indication for anti-retroviral therapy regardless of CD4 T-cell count. Anti-retroviral therapy, the treatment for HAD, is now increasingly available in resource-limited settings. Nonetheless, HAD remains under-diagnosed likely because of limited clinical expertise and availability of diagnostic tests. Thus, a simple diagnostic tool which is practical to implement in resource-limited settings is an urgent need.MethodsA convenience sample of 30 HIV-infected outpatients was enrolled in Western Kenya. We assessed the sensitivity and specificity of a diagnostic tool for HAD as administered by a primary HCW. This was compared to an expert clinical assessment which included examination by a physician, neuropsychological testing, and in selected cases, brain imaging. Agreement between HCW and an expert examiner on certain tool components was measured using Kappa statistic.ResultsThe sample was 57% male, mean age was 38.6 years, mean CD4 T-cell count was 323 cells/µL, and 54% had less than a secondary school education. Six (20%) of the subjects were diagnosed with HAD by expert clinical assessment. The diagnostic tool was 63% sensitive and 67% specific for HAD. Agreement between HCW and expert examiners was poor for many individual items of the diagnostic tool (K = .03–.65). This diagnostic tool had moderate sensitivity and specificity for HAD. However, reliability was poor, suggesting that substantial training and formal evaluations of training adequacy will be critical to enable HCW to reliably administer a brief diagnostic tool for HAD.
Highlights
HIV-associated dementia (HAD) is an indication for initiating antiretroviral therapy regardless of CD4 T-cell count according to World Health Organization (WHO) guidelines
Six (20%) of the subjects were diagnosed with HAD by expert clinical assessment
Agreement between health care workers (HCW) and expert examiners was poor for many individual items of the diagnostic tool (K = .03–.65)
Summary
HIV-associated dementia (HAD) is an indication for initiating antiretroviral therapy regardless of CD4 T-cell count according to World Health Organization (WHO) guidelines Focusing on the diagnosis of HAD as opposed to milder forms of HIV-associated neurocognitive disorders (HAND) is critical in settings where decisions about whether to initiate ART are frequently made based on WHO criteria alone and where ART treatment is available only to those with the greatest need— individuals with very low CD4 T-cell counts and/or WHO Stage III and IV diagnoses. The diagnosis of HAD remains a challenge in HIV outpatient primary care settings in resource-limited regions [2]. Potential reasons for this include: a lack of specialized personnel and diagnostic tests, and the inherent difficulties in making a clinical diagnosis of a complex disorder. A simple diagnostic tool which is practical to implement in resource-limited settings is an urgent need
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