Academic journal article South African Journal of Psychiatry

HIV-Associated Neurocognitive Disorders

Academic journal article South African Journal of Psychiatry

HIV-Associated Neurocognitive Disorders

Article excerpt

South Africa continues to be home to the world's largest population of people living with HIV. (1) In developed countries such as the USA, the introduction of highly active antiretroviral therapy (HAART) as the mainstay of HIV treatment has resulted in impressive reductions in the incidence of severe HIV-associated neurocognitive disorders (HAND) and impacted favourably on survival rates in patients with HIV infection. (2) Neurocognitive impairments, however, do not present universally among all HIV-infected persons. Neuropsychological signs and symptoms of at least mild extent have been found in approximately 30% of persons with asymptomatic HIV infection and about 50% of individuals with AIDS. (3) Furthermore, despite the apparent reduction in the incidence of HIV-associated dementia (HAD), the incidences of milder forms of HAND appear relatively stable and may even have increased in individuals who are not immunosuppressed. (4) Therefore, despite the remarkable improvements in the USA, HAND will probably remain a public health concern of increasing severity in South Africa, given that the majority of adults and children in the region in need of antiretroviral therapy do not have access to it.

This article reviews the current diagnostic nosology for HAND and the neuropsychological domains typically affected by the HIV disease. The review concludes with a discussion of the commonly used neuropsychological screening tools for the detection and diagnosis of HAND.

Diagnostic nosology for HAND

The diagnostic nosology for HAND was revised and amended in 2007 using recommendations from the US National Institutes of Health working group.5 The revisions emphasised that documented neurocognitive disturbance was an essential feature in the diagnosis of HAND, and specified more precise criteria for three syndromes: (i) asymptomatic neurocognitive impairment (ANI); (ii) HIV-associated mild neurocognitive disorder (MND); and (iii) HAD. These syndromes are discussed in turn below.

Asymptomatic neurocognitive impairment (ANI)

This previously unclassified phenomenon is estimated to represent the majority of HAND cases (over 50% of diagnosed cases) and 21-30% of asymptomatic HIV-infected individuals. (6) ANI refers to mild slowing in mental acuity and loss of concentration, quantified as less than 1 standard deviation (SD) below the mean of demographically adjusted normative scores in the presence of intact everyday functioning. The fall-off is so subtle that it is best assessed with the use of neuropsychological assessment tools. This exercise of early assessment and diagnosis acts as way to pre-identify patients at further risk of later and more significant cognitive as well as functional decline. The rationale of early identification premises that as effective treatments for neurological complications are developed, intervention at this early stage of HAND might represent the best chance to achieve remission, or at least delay the rapid progression of this debilitating disease.

Mild neurocognitive disorder (MND)

A diagnosis of MND requires evidence of mild to moderate neurocognitive impairment that represents at least 1 SD below the mean of demographically adjusted normative scores. To satisfy the diagnostic criteria, such impairment should occur in at least 2 cognitive domains in the presence of mild functional fall-off. The requirement of mild functional impairment is satisfied when at least 2 of the following criteria are met: (i) patient or informant report of decline in at least 2 instrumental activities of daily living (bathing, dressing or financial management); (ii) unemployment or a significant reduction in job responsibilities secondary to reduced cognitive abilities; (iii) decline in vocational functioning (e.g. increased errors, decreased productivity, or greater effort required to achieve prior levels of productivity); (iv) patient or informant report of increased problems in at least 2 cognitive ability areas in day-to-day life (this criterion cannot be used if based only on the self-report of an individual with current depression, since depression may bias self-report); and (v) scores of 1 SD below the mean on a performance-based laboratory measure of everyday functioning (e. …

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