Recognizing cognitive and psychiatric changes in the post-highly active antiretroviral therapy era

Abstract

Amid numerous complications that plague the health and quality of life of people living with HIV, neurocognitive and psychiatric illnesses pose unique challenges. While there remains uncertainty with respect to the pathophysiology surrounding these disorders, their adverse implications are increasingly recognized. Left undetected, they have the potential to significantly impact patient well being, adherence to antiretroviral treatment and overall health outcomes. As such, early identification of HIV-associated neurocognitive disorders (HAND) and psychiatric illnesses will be paramount in the proactive management of affected patients. The present review focuses on strategies to ensure optimal screening and detection of HAND, depression and substance abuse in routine practice. For each topic, currently available screening methods are discussed. These include identification of risk factors, recognition of relevant symptomatology and an update on validated screening tools that can be efficiently implemented in the clinical setting. Specifically addressed in the present review are the International HIV Dementia Scale, a novel screening equation and algorithm for HAND, as well as brief, validated, verbal questionnaires for detection of depression and substance abuse. Adequate understanding and usage of these screening mechanisms can ensure effective use of resources by distinguishing patients who require referral for more extensive diagnostic procedures from those who likely do not.

Keywords: Depression; HIV; HIV-associated neurocognitive disorders; Screening; Substance use disorders.

Figure 1)

HIV-associated neurocognitive disorders prevalence rates. Gray bars represent mild to moderate impairment; light gray bars represent severe impairment; white bars with dashed outline represent neurocognitive deficit in one domain only (significance unknown) and multistriped bars represent neurocognitive impairment (severity not described). *Severe neurocognitive impairment rates were not reported in this study.^†These studies reported the proportions of HIV-infected patients who were neurocognitively impaired versus normal; they did not differentiate the severities of impairment. Data adapted from references –. US United States; UK United Kingdom

Figure 2)

Suggested algorithm for the detection and management of HIV-associated neurocognitive disorder (HAND). cART Combination anti-retroviral therapy; CNS Central nervous system. Reproduced with permission from reference