HIV CENTER for Clinical and Behavioral Studies at NY State Psychiatric Institute and Detecting HIV-Associated Neurocognitive Disorder in South Africa: The need for culturally valid screening tools Reuben N. Robbins, Ph.D. June 30 th , 2011 HIV Center Grand Rounds
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HIV CENTER for Clinical and Behavioral Studies at NY State Psychiatric Institute and Columbia University Detecting HIV-Associated Neurocognitive Disorder.
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HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
Detecting HIV-Associated Neurocognitive Disorder in South
Africa: The need for culturally valid screening tools
Reuben N. Robbins, Ph.D.
June 30th, 2011HIV Center Grand Rounds
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
What is HAND?(HIV-Associated Neurocognitive Disorder)
HIV has affinity for CNS and crosses blood brain barrier Cortical and subcortical brain regions affected1,2
Neurotoxic effects and inflammatory response
Disrupts neurocognitive functions3,4: Attention and concentration Motor speed and coordination Learning/Memory Planning and organization
Neurocognitive impairment disrupts activities of daily living5-9
Adherence Finance management Employment Driving
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
HAND highly prevalent among PLWH in developed countries11-13
Up to 60% have some form (typically milder form) HAD 1% - 10%
Milder HAND associated with mortality and progression to HAD14,15
Becoming more important as PLWH live longer
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
HAND in South Africa
Little known about prevalence and impact of HAND in South Africa
Yet, SA hardest hit by HIV with 5.5 million PLWH
Recent study by Joska et al. (2010)16
70% of younger adults with later stage HIV commencing ART had HAND (N=283)
25% HAD; 45% MND
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
How is HAND detected/diagnosed?
Neuropsychological tests that assess deficits in neurocognitive function
Do not detect disease, but rather pattern of impairment typical of the disease
Require stimulus books, forms, stopwatches, etc Numerous tests and batteries available Administration must be exact Performance compared to normative sample
Current gold-standard diagnosis requires multi-hour neuropsychological and neurological exam
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
How is HAND detected/diagnosed?
Screening for HAND not routine,17,18 but could help: Track and monitor Make most appropriate referrals Determine when to start ART
Current screening tools just for HAD HIV Dementia Scale (HDS)19
International HIV Dementia Scale (IHDS)20
Recent study used Montreal Cognitive Assessment (MoCA)21 to screen for less severe HAND22
Need for easy-to-use screening tools in South Africa: Few neurologists and neuropsychologists, and other experts Many undetected with HAND Shift screening demands to lay personnel
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
How is HAND Detected?
From International HIV Dementia Scale
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
IHDS, MoCA, and Grooved Pegboard Slight modifications to MoCA, cut-off score ≤23 (not 25) All assessments available in Xhosa and English Compare performance on MoCA (total, domain, and item) Compare HIV- group to MoCA published norms
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
Demographics
N= 78 39 HIV+ and 39 demographically matched HIV-
All Xhosa- and/or English-speaking Black South Africans from townships
Age: 29.62 (SD=5.75)
Education: 10.81 (SD=1.38)
Gender: 70% (n=55)
Some Employment: 22% (n=17)
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
ResultsMoCA Domain Score Comparisons
Table 2. Between groups Comparison on the MoCA
HIV- (n=39) HIV+ (n=39)
Mean SD Mean SD t p
Total Score (unadjusted for education) 21.67 2.00 18.62 4.39 3.95 .000
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
Acknowledgements
Robert Remien, PhD – Scientific Mentor The Masivukeni Team
Mount Sinai Institute of NeuroAIDS Disparities Scholar Grant (PI: Susan Morgello, MD)
John Joska, MD – University of Cape Town Corne Robertson Teboho Linda
HIV Center T32 Postdoctoral Training Fellowship (PI: Theo Sandfort, PhD)
International Elective
HIV Center (PI: Anke Ehrhardt, PhD)
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
References
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HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
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HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
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19. Power, C., Selnes, O. A., Grim, J. A., & McArthur, J. C. (1995). HIV Dementia Scale: A Rapid Screening Test. JAIDS Journal of Acquired Immune Deficiency Syndromes, 8(3), 273-278.
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HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
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HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
References
27. Joska, J. A., Westgarth-Taylor, J., Hoare, J., Thomas, K. G. F., Paul, R., Myer, L., et al. (2011). Validity of the International HIV Dementia Scale in South Africa. AIDS Patient Care and STDs, 25(2), 95-101. doi: doi:10.1089/apc.2010.0292
28. Singh, D., Sunpath, H., John, S., Eastham, L., & Gouden, R. (2008). The utility of a rapid screening tool for depression and HIV dementia amongst patients with low CD4 counts- a preliminary report. African Journal of Psychiatry, 11(4), 282-286.
29. Ganasen, K. A., Fincham, D., Smit, J., Seedat, S., & Stein, D. (2008). Utility of the HIV Dementia Scale (HDS) in identifying HIV dementia in a South African sample. Journal of the Neurological Sciences, 269(1-2), 62-64.
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University
HIV CENTER for Clinical and Behavioral Studiesat NY State Psychiatric Institute and Columbia University