Neurocognitive Impairment in a Chronically Well-Suppressed HIV-Infected Population: The Dutch TREVI Cohort Study.

We assessed the value of screening for cognitive abnormalities in a chronically infected HIV population (N = 388) and investigated the association with clinical correlates. The mean age was 48 years (±11), the majority of the patients were male (89%), the median duration of infection was 6 years [interquartile range (IQR) = 2-12], the median CD count was 600 (IQR = 450-780), and 326 (84%) had a viral load below 200 copies/mL. Screening for cognitive complaints was applied using the three Simioni questions and the international HIV dementia scale (iHDS). Neuropsychological assessment (NPA) included 13 well-validated tests assessing motor speed, concentration, and memory. A total of 69 patients completed the NPA. CD4 (nadir), viral load, combination antiretroviral therapy (cART) duration, and the presence of comorbidities were evaluated for associations with NPA result. A total of 127 (33%) reported cognitive complaints during screening. The sensitivity and specificity of the Simioni questions were 82% and 24%, respectively. Adding the iHDS resulted in a sensitivity of 50% and a specificity of 73%. A CD4 nadir count <50 cells/m3 was associated with an abnormal NPA (p = 0.01). Comorbidities were more prevalent in patients with an abnormal NPA, although not statistically significant (p = 0.276). Age, current CD4, viral load, and cART duration were not associated with abnormal NPA. The authors conclude that current screening strategies are insufficient in detecting HIV-associated neurocognitive disorder. A low CD4 nadir is associated with poor neurocognitive outcome in HIV.

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

BACKGROUND: HIV-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. OBJECTIVES: To 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. METHODS: We 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. RESULTS: The 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. CONCLUSIONS: The 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.

Cognitive disorders in HIV-infected and AIDS patients in Guangxi, China.

The purposes of this study were to assess cognitive disorders in HIV/AIDS patients, identify the prevalence of HIV-associated neurocognitive disorders (HAND), provide evidence that may be used for early diagnosis and treatment, and establish a baseline for follow-up studies. The setting for this study was Guangxi, a culturally and economically underdeveloped province located in southwestern China with a large minority community. Due to the specific geographic and cultural environment, Guangxi has the second highest HIV incidence in China. There have been no research or large epidemiologic studies exploring cognitive disorders in HIV/AIDS patients in Guangxi; therefore, the prevalence of HAND in patients is unknown. Thirteen tests from 12 reliable and valid neuropsychological instruments (the digit symbol test, trail making test, arithmetic scores, digit span, wood puzzle, immediate visual memory, visual memory, Stroop test, vocabulary fluency, conceptual fluency, and the Wisconsin Card Sorting Test) were used to test and compare the cognitive functions and prevalence of HAND in 99 healthy individuals and 230 HIV/AIDS patients. Within the patient group, 114 were HIV-positive without cognitive impairment and 86 (37.39%) had HAND. Among them, 42 (18.27%) had HIV-related neurocognitive impairment (ANI), 25 (18.87%) had HIV-related mild neurocognitive disorder (MND), and 19 (8.26%) had HIV-associated dementia (HAD). These results may be used for future research, such as neuroimaging studies and risk factor analysis of HAND, and in the development of early diagnosis and treatment options for HAND patients.

Screening for HIV-associated dementia in South Africa: potentials and pitfalls of task-shifting.

There is an urgent need for valid, reliable, and simple-to-use screening tools for HIV-associated dementia (HAD) in South Africa, as little is known about its impact on South Africa's 5.5 million people living with HIV (PLWH). Screening for HAD in South Africa involves several challenges, including few culturally appropriate and validated screening tools, and a shortage of trained personnel to conduct screening. This study examined rates of positive HAD screens as determined by the cutoff score on the International HIV Dementia Scale (IHDS) administered by nonspecialist community health workers (CHWs) in South Africa and examined associations between positive HAD screens and common risk factors for HAD. Sixty-five Xhosa-speaking HIV-positive individuals on antiretroviral therapy (ART) with low CD4 counts and documented ART adherence problems were administered a battery of demographic, psychiatric and neurocognitive screening measures. Positive HAD screens were present in 80% of the sample. Presence of a current alcohol dependence disorder and CD4 counts of 200 or lower were significantly associated with positive HAD screens. HIV-positive South Africans on ART with low CD4 counts and ART adherence problems may be at a very high risk for HAD, highlighting the need for more routine screening and monitoring of neurocognitive functions among South Africa's millions of PLWH on ART. Future research is needed to: (1) validate IHDS performance against a gold standard neurocognitive battery for the detection of HAD among larger samples of Xhosa-speaking South Africans with ART adherence difficulties and (2) compare performance of CHW to expert health care personnel in administering the IHDS.

[An exploratory study on the diagnostic cutoff value of International HIV-associated Dementia Scale in minority ethnic groups with different educational levels, in Guangxi].

OBJECTIVE: Using Intelligence Scale of Mini Mental State Estimated (MMSE) as the gold standard to determine the relevance of International HIV-associated Dementia Scale (IHDS) in minority ethnic areas in Guangxi populations with different cultural values. Corresponding boundary value related to the authenticity and reliability on IHDS were also evaluated. METHODS: 200 patients with HIV infection were randomly selected from the minority ethnic groups in Guangxi. For each infected person, MMSE and IHDS blind scale were tested at the same period. Using the results from MMSE scale test as the gold standard, ROC curve and IHDS scale in Guangxi minority populations with different education levels which related to the diagnosis of dementia-HIV values were determined. The value of a specific sector under the IHDS sensitivity, specificity, and internal consistency coefficients was also evaluated. RESULTS: When considering the infected person did not differ on their educational level, the IHDS scale diagnostic cutoff appeared as 8.25, while IHDS sensitivity as 0.925, specificity as 0.731 and Kappa as 0.477 (P < 0.001). When considering the extent of cultural differences did influence the prevalence of infection, the different education groups showed different IHDS diagnostic cutoff values. People with high school, secondary school or higher education levels, the IHDS diagnosis appeared to be 8.25, when sensitivity was 0.917, specificity was 0.895 and Kappa was 0.722 (P < 0.001). People with only primary education level, the IHDS appeared to be 7.25. When sensitivity was 0.875, specificity was 0.661 and Kappa was 0.372 (P < 0.001). CONCLUSION: The IHDS diagnostic sector in Guangxi minority groups was lower than the internationally recommended level of diagnostic cutoff value (IHDS ≤ 10 points). When using IHDS to perform the HIV related dementia screening program, in the minority areas of Guangxi, culture context, the degree and difference of HIV infection should be considered, especially in using IHDS diagnostic cutoff values.

Lost the feel for the game: meanings of onset and diagnosis of AIDS dementia for significant others.

The onset and diagnosis of AIDS dementia marks a new dimension to living with HIV, an aspect few imagine or are equipped for. As a result of the profound changes that AIDS dementia makes to the ways the person with HIV acts, the life of significant others is similarly altered. Drawing on the metaphor of "the game" from Bourdieu's work on habitus, I explore how the onset and subsequent diagnosis of AIDS dementia comes to signify for significant others a moment in which life is permanently altered, whereby they no longer have the feel for the game. With AIDS dementia, life ("the game") is altered. Significant others feel that AIDS dementia is not a normal or acceptable AIDS illness: fears are contested, secrets managed and disclosed, and relations strained. This change in play further marginalizes significant others, and increases their sense of alterity from others living with and affected by HIV alone, because dementia is not the socially acceptable way of being ill with HIV.

Cliniconeuropathologic correlates of human immunodeficiency virus in the era of antiretroviral therapy.

The objective of this study was to examine the spectrum of human immunodeficiency virus (HIV) brain pathology and its clinical correlates in the antiretroviral era. We carried out a cross-sectional survey, analyzing prospective clinical and neuropathological data collected by the National NeuroAIDS Tissue Consortium (NNTC), comprising 589 brain samples from individuals with advanced HIV disease collected from 1999 onwards. We assessed gender, ethnicity/race, mode of transmission, age, year of death, nadir CD4, plasma viral load, last antiretroviral regimen, presence of parenchymal HIV brain pathology, HIV-associated neurocognitive disorder, and major depressive disorder. We compared cohort demographic variables with Centers for Disease Control and Prevention US HIV/AIDS statistics and examined associations of parenchymal HIV brain pathology with demographic, clinical, and HIV disease factors. With regard to Centers for Disease Control and Prevention US data, the NNTC was similar in age distribution, but had fewer females and African Americans and more Hispanics and men who have sex with men. Only 22% of the brains examined were neuropathologically normal. Opportunistic infections occurred in 1% to 5% of the cohort. Parenchymal HIV brain pathology was observed in 17.5% of the cohort and was associated with nadir CD4 and plasma viral load. Brains without parenchymal HIV brain pathology often had other noninfectious findings or minimal nondiagnostic abnormalities that were associated with HIV-associated neurocognitive disorder. Clinically, 60% of the cohort reported a lifetime episode of major depressive disorder and 88% had a HIV-associated neurocognitive disorder. No pathological finding correlated with major depressive disorder. Both antiretroviral treatment regimen and elevated plasma HIV viral load were associated with presence of parenchymal HIV brain pathology; however, multivariate analyses suggest a stronger association with plasma viral load. The frequency of HIV brain pathology was lower than previous pre-antiretroviral reports, and was predicted by lower nadir CD4 and higher plasma viral load. Noninfectious pathologies and minimal changes correlated with HIV-associated neurocognitive disorder, suggesting a shift in pathogenesis from florid HIV replication to other, diverse mechanisms.

The frequency and profile of neurology in black South African HIV infected (clade C) patients - a hospital-based prospective audit.

AIM: To determine the frequency and spectrum of neurological illnesses in Black South African hospital-based HIV infected (clade C) patients. METHOD: A prospective audit of 506 consecutive HIV infected medical inpatients at the Helen Joseph Hospital, Johannesburg, South Africa. RESULTS: The patients had a mean age of 37 years; a male:female ratio of 1.2:1; a mean CD4 count of 107 cells/ml. Eighty four percent of patients had AIDS defining CD4 counts (less than 200 cells/ml). Seventy five percent of patients had a neurological illness. In 64% the neurological illness occurred in association with a non-neurological (systemic) illness. Eleven percent of patients had an isolated neurological illness. The predominant systemic illness was tuberculosis (TB), occurring with a frequency of 46%. The neurological spectrum in our patients was similar to that described in the literature, (clade B virus data) other than for a greater frequency of infectious illnesses. CONCLUSION: The neurological profile of HIV infection is a function of the environment and the immunological state of the patient (CD4 count) rather than an influence of the clade.

Risk of opportunistic infection in the HAART era among HIV-infected Latinos born in the United States compared to Latinos born in Mexico and Central America.

There are few studies that compare opportunistic infection (OI) rates for U.S.-born, Mexican-born, and Central American-born Latinos in the pre- or post-highly active antiretroviral therapy (HAART) era. Data on 803 Latino persons in treatment for HIV infection in Los Angeles, California, were examined to evaluate differences in risk for specific and total OIs by country of origin. In a Cox proportional hazards regression analysis that controlled for HAART use, CD4 counts, and age, U.S.-born Latino women were more likely than Central American-born Latino women to develop an OI from 1996 to 2000 (hazard ratio [HR] = 2.9, 95% confidence intervals [CIs]: 1.3, 6.5). In a Poisson regression analysis, U.S.-born Latino men and women combined were at greater risk for HIV encephalopathy (RR = 3.4, 95% CIs: 1.2, 10.0) and Kaposi's sarcoma (RR = 2.9, 95% CIs: 1.1, 7.6). In addition to underreporting that may result from the use of English-based criteria for diagnosing HIV encephalopathy among Spanish-speaking patients, these HAART era data suggest that variation in OI risk among Latinos may also be explained by acculturation factors, such as loss of social support systems and negative lifestyle changes.