Low performance on cognitive tests may not always mean that a PLWH has an HIV-associated neurocognitive disorder, researchers argued in Clinical Infectious Diseases. Instead, they proposed a new assessment framework that incorporates a number of variables beyond cognitive testing.
Most of the 20%-60% of PLWH around the globe who meet current HAND criteria are diagnosed with asymptomatic neurocognitive impairment. While HAND is a real problem for PLWH, especially in areas without universal ART, cognitive abilities run on a continuum and are influenced by a variety of factors beyond test performance, the authors noted.
The authors’ novel proposed framework thus incorporates HIV brain pathology, comorbidities, and lifestyle and social/educational factors to account for the multifactorial nature of neurocognition. They called for combining a clinical history of cognitive symptoms and the trajectory of a possible decline, performance on cognitive tests, and brain pathology. Brain pathology should be defined separately from test performance, they urged, and a low performance on such tests should not be called cognitive impairment if there are no symptoms.
To overcome the limitations of relying on self-reported symptoms, study authors recommended asking for observer accounts, but conceded that this may be difficult if PLWH did not disclose their status to family and friends.
The authors also noted that in low-resource settings, neuroimaging for brain pathology may not be available, requiring a possible/probable/definite diagnostic hierarchy based on symptoms and the exclusion of other illnesses.
“We hope this framework will lead to the development of new consensus criteria to classify cognitive impairment in [PLWH], appropriate for the modern era of widespread effective ART,” study authors concluded.