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Need exists for specialist HIV cognitive impairment services

Prevalence of cognitive impairment (CI) has increased among the HIV population while services for diagnosing and treating afflicted individuals remains scarce, according to a study by researchers at Brighton and Sussex Medical School, the Sussex Partnership NHS Foundation Trust and Brighton and Sussex University Hospitals NHS Trust, which explored the development and management of neurological disorders in 52 patients living with HIV (PLWH).

A UK-based clinic performed a memory assessment service and found that 79% of patients had impartial CI: 31% met conditions for HIV-associated neuro-cognitive disorder (HAND), 4% were diagnosed with dementia, 27% showed CI related to mental illness or substance abuse, 13% had CI believed to be caused by factors other than HIV, and 4% had CI due to unknown reasons. The researchers found 62% of patients displayed at least partial abnormality on magnetic resonance imaging brain scans and that all patients scored significantly below average on tests of global cognition and executive functioning. The authors advocated that specialist HIV memory services should be included in future patient care.

HAND serves as an umbrella term to cover a wide spectrum of neurological disorders, including asymptomatic neuro-cognitive impairment, mild neuro-cognitive disorder, and HIV-associated dementia. The prevalence of HAND has been frequently determined by the Frascati criteria, a neuro-cognitive rating scale developed in 2007 that involves neuro-psychological testing across multiple cognitive domains. However, the Frascati criteria has been criticized to lack specificity and sensitivity, resulting in an uncommon amount of false-positive diagnoses.

“Based on Frascati criteria, 81% of patients attending the clinic would be diagnosed with HAND,” the authors explained. “Using our diagnostic processes, we found 79% had objective CI, however of these, 61% had a reason for this that was not HIV-related and only 39% had ‘true’ HAND.”

The clinic’s team consisted of a physician specializing in HIV, a geriatric psychiatrist skilled in dementia diagnosis and treatment, a neuro-psychologist with an assistant, a clinical psychologist, a nurse clinically skilled in HIV treatment, and virtual support provided by neurology and neuro-imaging services. The clinic conducted 2 monthly sessions with an additional monthly follow-up. The goal of the clinic was to diagnose CI in patients and establish a treatment and management plan. PLWH who had unexplained cognitive disorders or mentioned cognitive complaints were referred to the clinic.

Convincing evidence suggests a strong and complex relationship between mental illness, CI, and HIV. Overall, 27% of patients were determined to have a mental health condition, derived from either sleeplessness, obsessive compulsive disorder, or substance abuse, which was inferred to be responsible for their CI. HIV diagnosis can cause patients to develop depression and anxiety due to psychological distress and social stigmas associated with the condition. It was also significant that 44% of patients were taking antidepressant medication.

“In our clinic it has been vital to be able to address the mental health issues of patients,” the authors wrote. “This has involved either referrals to HIV-specialist mental health services or to general mental health services.”

CI has reportedly become more common in PLWH and is predicted to become a growing issue as survival rates rise and the population grows older. Mild to moderate CI has increasingly been reported and is associated with non-adherence to medication, higher likelihood of unemployment, shorter life expectancy, and lower overall quality of life.

Following the study, 23 of the original 52 patients were discharged – 9 were found to have no objective CI, 8 had CI due to mental health issues, 1 had CI due to previous HIV-related encephalitis, 1 had CI due to a previous traumatic brain injury, 3 were diagnosed with mild HAND, and 1 patient with Alzheimer’s disease died.

“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,” the authors concluded. “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.”

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.

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

[link url="https://www.ajmc.com/newsroom/diagnosis-and-treatment-of-cognitive-impairment-in-hiv-patients"]AJMC material[/link]
[link url="https://www.mdpi.com/2076-3425/9/2/37"]Brain Sciences abstract[/link]

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