Screening Tool For HIV-associated Neurocognitive Disorders Research Articles

Assessment of neurocognitive disorders in HIV infected patients receiving combination of anti-retroviral therapy at a tertiary care hospital - An observational study

cARTTherapy (combination antiretroviral therapy) has improved the live expectancy of people living with HIV (PLHIV). But HIV associated neurocognitive disorders (HAND) are still prevalent. One of the factors associated could be the cARTtherapy itself. The study aims to calculate the prevalence of HAND and associated risk factors in PLHIV who are on Cart therapy and to compare the efficiency of MMSE and IHDS scales in the assessment of HAND. A case-control study involving 54 PLHIV on cART therapy and 27 HIV negative controls were screened for their neurocognition by two neuropsychological tests such as MMSE and IHDS, followed by staging into Asymptomatic Neurological Impairment (ANI), Mild Neurocognitive Impairment (MND), HIV Associated Dementia (HAD) in PLHIV. Statistical analysis was done using suitable software. The overall prevalence of HAND in our study was found to be 70.37%. Prevalence estimates for specific HAND diagnoses were 57.89% ANI, 28.9% MND, and 13.1 % HAD. IHDS demonstrated good screening ability for HAND with an optimal cut-off score of 10, high sensitivity of 70% and minimal specificity. Age, male gender, low literacy, presence of comorbidities, severity of the disease, cART regimen with low CPE (CNS penetration effectiveness) score were strongly correlated. Study findings suggest that IHDS serves as a better screening tool for HAND with greater sensitivity and can facilitate further cognitive evaluation. The overall prevalence was found to be equivalent to that of the recently reported studies.

Screening tools for HIV-associated neurocognitive disorders among adults living with HIV in sub-Saharan Africa: A scoping review.

Background: People living with HIV are at risk of developing HIV-associated neurocognitive disorders (HAND) which adversely affects their quality of life. Routine screening of HAND in HIV care is recommended to identify clinically important changes in cognitive functioning and allow for early interventions. However, HAND detection in routine clinical practice has never been reported in sub-Saharan Africa (SSA), partly due to a lack of adequately standardized screening tools. This review was conducted to identify the commonly used screening tools for HAND in SSA and document their psychometric properties and diagnostic accuracy. Methods: We searched Ovid Medline, PsycINFO and Web of Sciences databases for empirical studies published from 1/1/1980 to 31/8/2018 on HAND among adults living with HIV in SSA. Results: We identified 14 eligible studies, of which 9 were from South Africa. The International HIV Dementia Scale (IHDS) was the most frequently reported tool, being used in more than half of the studies. However most studies only reported the diagnostic accuracy of this and other tools, with specificity ranging from 37% to 81% and sensitivity ranging from 45% to 100%. Appropriate data on construct validity and reliability of tools was rarely documented. Although most tools performed well in screening for severe forms of HAND, they lacked sensitivity and specificity for mild forms of HAND. NeuroScreen, one of the newer tools, yielded good diagnostic accuracy in its initial evaluation in South Africa (81% to 93% sensitivity and 71% to 81% specificity). Conclusions: This review identified a lack of adequately standardized and contextually relevant HAND screening tools in SSA. Most screening tools for HAND used in SSA possess inadequate psychometric properties and diagnostic accuracy. There is a need for further validation of existing tools and development of new HAND screening tools in SSA.

Screening tools for HIV-associated neurocognitive disorders among adults living with HIV in sub-Saharan Africa: A scoping review

Background: People living with HIV are at risk of developing HIV-associated neurocognitive disorders (HAND) which adversely affects their quality of life. Routine screening of HAND in HIV care is recommended to identify subtle changes in cognitive functioning and allow for early interventions. However, HAND detection is rarely done in sub-Saharan Africa (SSA), partly due to a lack of adequately standardized screening tools. This review was conducted to identify the commonly used screening tools for HAND in SSA and document their psychometric properties and diagnostic accuracy.Methods:We searched Ovid Medline, PsycINFO and Web of Sciences databases for empirical studies published from 1/1/1980 to 31/8/2018 on HAND among adults living with HIV in SSA.Results:We identified 14 eligible studies, of which 9 were from South Africa. The International HIV Dementia Scale (IHDS) was the most frequently reported tool, being used in more than half of the studies. However most studies only reported the diagnostic accuracy of this and other tools, with specificity ranging from 37% to 81% and sensitivity ranging from 45% to 100%. Appropriate data on construct validity and reliability of tools was rarely documented. Although most tools performed well in screening for severe forms of HAND, they lacked sensitivity and specificity for moderate forms of HAND. NeuroScreen, one of the newer tools, yielded good diagnostic accuracy in its initial evaluation in South Africa (81% to 93% sensitivity and 71% to 81% specificity).Conclusions:This review identified a lack of adequately standardized and contextually relevant HAND screening tools in SSA. Most screening tools for HAND used in SSA possess inadequate psychometric properties and diagnostic accuracy. There is a need for further validation of existing tools and development of new tools to make them sensitive and specific enough to identify both severe and moderate forms of HAND in SSA.

MoCA Utility as a Quick Testing Tool for Neurocognitive Disorders in HIV Patients: Analysis of a Prospective Cohort

Background Since the introduction of highly active antiretroviral therapy, asymptomatic and mild neurocognitive impairment are the main clinical manifiestations of HIV associated neurocognitive disorders (HAND), compromising adherence to treatment, daily performance, quality of life, and even increasing the risk of mortality. We do not have validated screening tools for early detection of HAND applicable to the routine medical visit. The Montreal Cognitive Assessment test (MoCA) is a simple questionnaire used in Alzheimer’s disease, but its utility as a screening tool for HAND remains controversial.Methods We designed a prospective study to establish MoCA´s usefulness as a rapid and sensitive tool for the detection of HAND, compared with a gold-standard test (GST) that includes Mini-mental State Examination (MMSE) and a battery of assays that evaluate several neurological domains. Adult patients with HIV infection attending our institution were included. The MoCA test was performed by infectious diseases specialists, and the GST by neurologists. History of recent stroke, neurological disease, opportunistic central nervous system infection, major depression, schizophrenia, bipolar disorder, substance abuse or dependence on alcohol, were exclusion criteria. We analized demographic and clinical variables.ResultsFifty HIV-infected patients were enrolled, 94% males, with a mean age of 45.6 years (range 20–75), and an average of 14.8 years of education (range 3–26). The mean CD4 cell count was 596 cells/ml (range 65–1130), and 70% of the patients had undetectable viral load (≤20 copies/mL) at the time of the evaluation. Compared with GST, MoCA had a sensibility (S) of 94.12% (CI 71.3–99.8), specificity (E) 78.79% (CI 61.09–91.02), positive predictive value (PPV) 69.57% (CI 47–86.79) and negative predictive value (NPV) 96.3 (CI 81–99.9). In contrast, the MMSE presented S 11.76% (CI 1.46–36.44), E 100% (CI 89.4–100), PPV 100% (CI 15.8–100) and NPV 68.75% (CI 53.7–81.3). Cohen’s kappa coefficient between MoCA and GST was 0.67 (95% CI 0.46–0.87), reflecting an adequate agreement.Conclusion MoCA’s performance as a screening test was adequate compared with GST and far superior to MMSE for early detection of HAND. Although specifity could be optimized, MoCA test remains a valuable screening tool in the routine medical visit in our HIV population.Disclosures All authors: No reported disclosures.

Validation of the International HIV Dementia Scale as a Screening Tool for HIV-Associated Neurocognitive Disorders in a German-Speaking HIV Outpatient Clinic.

BackgroundHIV-associated neurocognitive disorders (HAND) are widely present among people living with HIV. Especially its milder forms, asymptomatic neurocognitive impairment (ANI) and mild neurocognitive disorder (MND), remain highly prevalent worldwide. Diagnosing these conditions is subject to a time and resource consuming neuropsychological assessment. Selecting patients at a higher risk of cognitive impairment by using a simple but effective screening tool helps to organise access to further neuropsychological diagnosis. The International HIV Dementia Scale (IHDS) has until now been a well-established screening tool in African and American countries, however these populations’ demographics defer significantly from ours, so using the same parameters could be ineffective.ObjectivesTo calculate the prevalence of this condition among people attending an HIV outpatient clinic in Berlin and to validate the use of the IHDS as a screening tool for HAND in a German-speaking population.MethodsWe screened 480 HIV-infected patients using the IHDS, 89% of them were on a stable antiretroviral treatment. Ninety of them completed a standardised neuropsychological battery of tests and a specific cognitive complaints questionnaire. The same procedure was applied to a control group of 30 HIV-negative participants. HAND diagnosis was established according to the Frascati criteria.ResultsThe overall prevalence of HAND in our cohort was 43% (20% ANI, 17% MND and 6% HIV-associated dementia). The optimal cut-off on the IHDS for detecting HAND cases was set at 11 and achieved both a sensitivity and a specificity of 80%. When specifically screening for the more severe form of HAND, HIV-associated dementia, a cut-off value of 10 offered an increase in both sensitivity (94%) and specificity (86%). The Youden Index for diagnostic accuracy was 0.6 and 0.8, respectively.ConclusionsThe prevalence of HAND was comparable to the reported by recent studies performed in countries with a similar economic development. The study confirms the IHDS to be a useful HAND screening tool in primary care settings and establishes new recommendations for its use in German-speaking countries.

A better screening tool for HIV-associated neurocognitive disorders

Objective:Existing screening tools for HIV-Associated Neurocognitive Disorders (HAND) may lack the accuracy required for clinical use. We hypothesized that the diagnostic accuracy of the Montreal Cognitive Assessment (MoCA) as a screening tool for HAND might be improved with a stronger scoring methodology.Design:Two hundred HIV-positive participants aged 18–65 years completed the MoCA and a battery of neuropsychological tests.Methods:HAND diagnosis was established according to the Frascati criteria, and an NPZ-8 score was also calculated. Rasch analysis was applied to the MoCA items to create a quantitative score.Results:The optimal cut-off on the quantitative MoCA for detecting impairment as per Frascati criteria yielded a sensitivity of 0.74 and a specificity of 0.68. Overall accuracy was 0.79 (95% CI: 0.73–0.85), an improvement over standard scoring methods. However, whether cognition was quantified with the quantitative MoCA or with NPZ-8, there was substantial overlap between diagnostic categories; several individuals categorized as impaired had better overall cognitive function as assessed by NPZ-8 or quantitative MoCA than those classified as normal using standard criteria.Conclusion:Quantifying performance on MoCA items through Rasch analysis improves its accuracy as a screening tool for HAND, and demonstrates that cognition can be measured as a unidimensional construct in HIV, at least at the level of precision of bedside testing. However, the current categorical diagnostic approach to HAND is poorly aligned with summary measures of cognitive ability. Measuring cognition as a quasi-continuous construct may be more relevant than conventional HAND diagnostic categories for many clinical purposes.

Performance of Community Screening Instrument for Dementia in Screening for HIV-Associated Neurocognitive Disorders in Nigeria

Background: Cognitive function of HIV-infected patients in Nigeria has been studied using the community screening instrument for dementia (CSI-D) battery. However, its ability to detect HIV-associated neurocognitive disorders (HAND) is unclear. The study assessed the CSI-D battery in detecting HAND. Methods: Age, sex and education matched 30 HIV-positive and 30 HIV-negative subjects were administered the CSI-D battery. An extensive multi-domain neuropsychological tests (MDNPT) battery was used as gold standard. Measures of functional status including personal assessment of own functioning inventory (PAOFI), instrumental activities of daily living (IADL) and Beck depression inventory (BDI) were also administered. Diagnostic accuracy indices of the CSI-D were determined from a receiver operator characteristic (ROC) curve. Linear associations were explored using correlation coefficient. Results: HIV-positive subjects performed significantly worse than HIV-negative subjects in several domains across the 2 batteries. Large effect sizes were found in verbal fluency (COWAT), verbal learning, memory recall and language comprehension. Significant correlations between the two batteries were seen in all the domains except motor function. Subjects with HAND but normal on CSI-D scored poorly on motor function test. The area under the ROC curve was 0.79; 95 % confidence interval (CI) of 0.68-0.90, p < 0.0001. At cut-off score of ≤ 63, the CSI-D had sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 77%, 63%, 55% and 61% respectively. Conclusion: CSI-D has good psychometric properties for use as a screening tool for HAND. The addition of test of motor function is advisable to complement it.

Evaluation of brief screening tools for neurocognitive impairment in HIV/AIDS

Objective(s):To systematically review literature on brief screening tools used to detect and differentiate between normal cognition and neurocognitive impairment and HIV-associated neurocognitive disorders (HANDs) in adult populations of persons with HIV.Design:A formal systematic review.Methods:We searched six electronic databases in 2011 and contacted experts to identify relevant studies published through May 2012. We selected empirical studies that focused on evaluating brief screening tools (<20 min) for neurocognitive impairment in persons with HIV. Two reviewers independently reviewed retrieved literature for potential relevance and methodological quality. Meta-analyses were completed on screening tools that had sufficient data.Results:Fifty-one studies met inclusion criteria; we focused on 31 studies that compared brief screening tools with reference tests. Within these 31 studies, 39 tools were evaluated and 67% used a comprehensive neuropsychological battery as a reference. The majority of these studies evaluated HIV-associated dementia (HAD). Meta-analyses demonstrated that the HIV Dementia Scale (HDS) has poor pooled sensitivity (0.48) and the International HIV Dementia Scale (IHDS) has moderate pooled sensitivity (0.62) in detecting a range of cognitive impairment. Five newer screening tools had relatively good sensitivities (>0.70); however, none of the tools differentiated HAND conditions well enough to suggest broader use. There were significant methodological shortcomings noted in most studies.Conclusion:HDS and IHDS perform well to screen for HAD but poorly for milder HAND conditions. Further investigation, with improved methodology, is required to understand the utility of newer screening tools for HAND; further tools may need to be developed for milder HAND conditions.

Neurologic manifestations of human immunodeficiency virus-2: dementia, myelopathy, and neuropathy in West Africa

While well documented in human immunodeficiency virus (HIV)-1, neurologic sequelae have not been systematically evaluated in HIV-2. After excluding for confounding comorbidities, 67 individuals from a rural cohort in Guinea-Bissau (22 HIV-2 participants, 45 seronegative controls) were evaluated. HIV + individuals were divided into CD4 < 350 and CD4 ≥ 350 for analysis. HIV-associated neurocognitive disorders (HAND), assessed by the International HIV Dementia Scale (IHDS), distal sensory polyneuropathy (DSPN), and myelopathy were the main outcome variables. In univariate analysis, there was no difference in IHDS scores among groups. When analyzed by primary education attainment, IHDS scores were nonsignificantly higher (p = 0.06) with more education. There was no significant difference in DSPN prevalence among groups; overall, 45% of participants had DSPN. There were no cases of myelopathy. In multivariate linear regression, higher IHDS scores were significantly correlated with older age (coefficient = -0.11, p < 0.001). Logistic regression analysis showed that older age (odds ratio (OR) 95% CI 1.04-1.20), lower CD4 count (OR 95% CI 0.996-0.999), and higher BMI (OR 95% CI 1.02-1.43) significantly predicted the presence of DSPN. While a significant increase in cognitive impairment was not observed in HIV-2-infected individuals, the study suggests the IHDS may be a less effective screening tool for HAND in settings of lower educational attainment as encountered in rural Guinea-Bissau. Similar to HIV-1, DSPN seems to occur with lower CD4 counts in HIV-2. Further study of the viral-host interactions in HIV-2 and its consequent neurological diseases may provide an avenue for understanding the epidemic problems of HIV-1.

Risk factors for HIV-associated neurocognitive disorders (HAND) in sub-Saharan Africa: The case of Yaoundé-Cameroon

Background The prevalence of HIV-associated neurocognitive disorders (HAND), especially HIV-associated dementia (HAD) is influenced by several risk factors. The prevalence as well as risk factors for HAD are not well known in sub-Saharan Africa (SSA). We have shown that the International HIV Dementia Scale (IHDS) is a useful screening tool for HAND in Yaoundé [Njamnshi AK, Djientcheu VdP, Fonsah JY, Yepnjio FN, Njamnshi DM, Muna WFT. The IHDS is a useful screening tool for HAD/Cognitive Impairment in HIV-infected adults in Yaoundé-Cameroon. Journal of Acquired Immune Deficiency Syndromes 2008;49(4):393–397], but no study in Cameroon has yet investigated the risk factors for HAND or HAD. Patients and methods A cross-sectional study was conducted in Yaoundé, the capital of Cameroon from September to December 2006. One hundred and eighty-five HIV-positive subjects were included. Diagnosis of HAND was done using the IHDS with a score ≤ 10 considered as abnormal. Age, sex, level of education, IV drug use, body mass index (BMI), CDC clinical stage, CD4 counts, hemoglobin levels, administration of highly active antiretroviral therapy (HAART) and type of regimen used, were considered in univariate analysis, with level of significance set at P ≤ 0.05. A binary logistic regression was used to determine independent risk factors. Results The following factors were independent predictors of HAND: advanced clinical stage (OR = 7.43, P = 0.001), low CD4 count especially CD4 ≤ 200 cells/µL (OR = 4.88, P = 0.045) and low hemoglobin concentration (OR = 1.16, P = 0.048). Conclusion This first study of the risk factors for HAND in Yaoundé-Cameroon shows findings similar to those described in other studies. These results call for rapid action by policy makers to include HAND prevention strategies such as providing early universal access to HAART based on these risk factors, in the management of HIV patients at risk of HAND in resource-limited settings of SSA like ours.