The Changing Spectrum of Cognitive Impairment in People with HIV; Establishment and Updates of the International HIV-Cognition Working Group

Abstract

With the widespread availability of effective antiretroviral therapy, the spectrum of cognitive impairment in people with HIV has changed from a subcortical dementia to milder impairment. The 2007 criteria for HIV-associated neurocognitive disorders (HAND) provided a methodological approach to classify milder and asymptomatic forms. Research using these criteria found that around 45% of people with HIV had HAND. This does not align with clinical observations that people with HIV supressed on modern treatment generally have good clinical outcomes, including cognitively. HAND criteria have several limitations which may account for an overestimation of prevalence including a high false classification rate, inadequate mitigation of psychosocial confounds to testing of cognitive performance, and the attribution to HIV of multifactorial causes of brain injury. This overestimation can hinder neuro-HIV research, increase anxiety around health outcomes, and worsen stigma and discrimination towards people with HIV. In response an International HIV-Cognition Working Group was established. The group proposed six consensus recommendations towards a new approach, including that HIV-associated brain injury (HABI) - which can be active or legacy - is conceptually separated from other cases of brain injury in people with HIV. The recommendations are aimed at harmonising clinical and research terminology, destigmatising terminology, and providing more accurate information on prevalence and prognosis. Cognitive impairment remains an important complication of HIV, particularly as the population ages, requiring a nuanced approach to classification and management.