HIV Dementia cases in Africa: How many Who cares And where to from here

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HIV Dementia cases in AfricaHow many? Who
cares? And where to from here?

• Gretchen L. Birbeck, MD MPH
• Chikankata Health Services
• Director-Epilepsy Care Team Research Consultant
  
• Michigan State University
• Associate Professor Director-International
  Neurologic Psychiatric Epidemiology Program

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HIV-D in US pre-HAART

• 7 incidence annually among HIV
• 20 risk after developing AIDS
• Rates have decreased with HAART, but among people
  with HIV-D at the time of ART initiation, full
  recovery is not the norm

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Consider possible factors impacting HIV-D rates
in Africa

• Competing causes of death
• Different HIV subtypes (and HIV-2)
• Different life course of CNS development/injury/
  toxic exposures
• Limited ART regimens, even where available

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HIV-D Epidemiology in Africa

• ?

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Lack of expertise
Havent seen a thing all day
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Cognitive Impairment Among African PLWA
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Problems with studies to date

• Unclear terminology
• Vague diagnostic criteria
• Lack of ecologically valid measures
• Lack of normative data
• No population-based assessments
• Assessment not feasible for pop-based screening
  or routine clinical applications

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HIV-D Epidemiology-Who cares?

• Warrants treatment, where available
• Impact on ART adherence
• Impact on health services utilization and social
  support for PLWAs

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HIV-D as an AIDS-defining illness

• HIV-D represents the first AIDS-defining illness
  in 5-6 of cases
• African non-physician healthcare workers are not
  trained in cognitive assessments
• Especially relevant since ARTs are being launched
  in settings without CD4 counts available

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Impact on Health Services Utilization Social
Support

• PLWAs in Africa are cared through home-based care
  (HBC)
• HBC places an extreme burden on care givers
  (primarily women)
• Already under great stress. Patient abandonment
  rates increasing?
• ARTs could improve survival outcomes, but with
  associated cognitive disability

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HIV-D and ART Resistance

• There are many existing concerns regarding ART
  adherence in Africa since non-adherence will
  promote ART resistance
• People with HIV-D will struggle with adherence
• Worsened by stigma and lack of disclosure even to
  immediate family
• DOTs or other interventions could help if we
  recognize the problem

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Zambia

• Assess the prevalence of CI among in-patient
  admissions at a hospice in Lusaka, Zambia
• Assess the usefulness of simple screening
  instruments that can be used by non-physician
  healthcare providers to detect HIV-related CI

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Population

• Kalingalinga, Lusaka
• Illegal, non-permanent settlement with extreme
  poverty, poor sanitation, limited access to
  healthcare
• Estimated 26.6 HIV prevalence (antenatal clinic
  attendees)2

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Interview Procedure

• PLWAs (WHO CCD) and normative pop.
• Cognitive Tests including
• Locally adapted Mini-Mental State Exam (MMSE)
• Modified HIV dementia scale (mHDS)
• Color Trails 1

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Defining Cognitive Impairment

• Significant Cognitive Impairment defined as
• gt 2.5 standard deviations below the mean on any
  one test
• Or gt 1 standard deviation below the mean on any 2
  tests

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Study Group
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Results

• Overall, 33 (69) of PLWAs met study definition
  for significant CI
• 24 patients scored gt2.5 SD below the healthy
  group mean on at least one test
• 9 patients scored lt2.5, but gt1 SD below the mean
  on at least two tests

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Where to from here?

• Consensus on terminology and criteria applicable
  in resource-poor settings
• Develop ecologically valid screening instruments
• Conduct population-based studies
• Screening followed by more detailed studies (WHO
  model)
• Incorporate into routine care?

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Developing Screening Instrument

• Ideally, one that can be adapted for use across
  the broad range of African settings
• Must be validated within each population
• Proper translations critical for patient-reported
  data
• Normative data should also be acquired in each
  population

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A starting point?

• Uganda (Sacktor et al)
• Psychomotor slowing plus balance or memory
  problems
• 80 sensitivity 73 specificity
• Zambia (Powell et al)
• Patient response to Have you experienced any
  problems with your memory?
• 49 sensitivity 67 specificity
• PPV 80 NPV 32

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Where to from here?

• Consensus on terminology and criteria applicable
  in resource-poor settings
• Develop ecologically valid screening instruments
• Conduct population-based studies
• Screening followed by more detailed studies (WHO
  model)
• Incorporate into routine care?

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• Thank you

UNZA- Elwyn Chomba CCHS-Alan Haworth MSU- Michell
e Powell Dan Murman Ellen Velie