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Year : 2014  |  Volume : 4  |  Issue : 4  |  Page : 252-255

Assessment of neurocognitive functions in HIV/AIDS patients on HAART using the international HIV dementia scale

Department of Pharmacology, Sardar Patel Medical College, Bikaner, Rajasthan, India

Date of Submission04-May-2014
Date of Acceptance10-Jun-2014
Date of Web Publication22-Aug-2014

Correspondence Address:
Savita Saini
Type 2/114, Anudeep Colony, Rawatbhata, Chittorgarh 323 307, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2231-0738.139408

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Background: Human immunodeficiency virus (HIV)-infected individuals on National AIDS Control Organization's (NACO)-India-Based-highly active antiretroviral therapy (HAART) regimen often continue experiencing neurological complications, referred to as HIV-associated neurocognitive disorders (HAND). Objectives: The prime objective is to assess the status of neurocognitive functions among HIV-infected individuals on HAART, using the International HIV Dementia Scale (IHDS). Materials and Methods: This prospective cohort study was carried out between October 2011 and September 2012, on 80 HIV-positive individuals, randomly selected from the ART Centre of PBM and AG Hospital, Bikaner, India. The patients were clinically examined and tested using IHDS. Results: All the subjects on HAART were found to have HAND-prevalence at 32.50%. Asymptomatic Neurocognitive Impairment (ANI) and HIV-associated Mild Neurocognitive Disorder (MND) were observed in 30 and 2.5% of the patients, respectively, and HIV-associated Dementia (HAD) was absent. Conclusion: In our study the IHDS Score was abnormal, that is, ≤10, in 32.50% of the patients, which shows probable neurocognitive impairment in the study subjects. This suggests the need to routinely screen HIV-positive patients, to recognize the neurocognitive deficits at an early stage and the IHDS may have great value as a screening test for HAND.

Keywords: Asymptomatic neurocognitive impairment, highly active antiretroviral therapy, HIV-associated dementia, HIV-associated neurocognitive disorders, international HIV dementia scale, mild neurocognitive disorder

How to cite this article:
Saini S, Barar KV. Assessment of neurocognitive functions in HIV/AIDS patients on HAART using the international HIV dementia scale. Int J Nutr Pharmacol Neurol Dis 2014;4:252-5

How to cite this URL:
Saini S, Barar KV. Assessment of neurocognitive functions in HIV/AIDS patients on HAART using the international HIV dementia scale. Int J Nutr Pharmacol Neurol Dis [serial online] 2014 [cited 2023 Feb 4];4:252-5. Available from:

   Introduction Top

Changes in memory, mood, attention, and motor skills are common in HIV-infected patients and present a diagnostic challenge to the clinician. HIV enters the brain shortly after infection and has a predilection for the subcortical brain areas. The cognitive impairment is attributed to HIV replication in the brain and liberation of inflammatory neurotoxins leading to neuronal dysfunction. [1]

The American Academy of Neurology Task force on the acquired immunodeficiency syndrome (AIDS) defined two levels of neurological impairment in HIV patients: HIV-associated dementia (HAD) and minor cognitive motor disorder (MCMD). [2] A core difference between the two is the degree of functional impairment present; patients with HAD have more impairment than those with MCMD. The HIV Neurobehavioral Research Center (HNRC), San Diego, has proposed inclusion of an Asymptomatic Neurocognitive Impairment (ANI) category in addition to the above two categories described. [3]

In recent years, the HIV-related neurological disease has been increasingly recognized in resource-limited settings. We therefore, conducted this prospective cohort study to find out the neurocognitive impairment in HIV/AIDS patients on HAART in Bikaner city.

   Materials and methods Top

This prospective cohort study was conducted among '80' HIV-positive patients receiving the HAART regimen between October 2011 and September 2012 in ART Center of PBM and AG Hospital, Bikaner, Rajasthan (India).

The inclusion criteria were as follows: (1) HIV-positive patients on stabilized HAART for more than six weeks, (2) HIV-infected individuals between the ages of 21 and 50 years, (3) Ambulatory patients with a CD4 count above 200 cells/mm 3 , and (4) Ability to comprehend the study procedures.

The exclusion criteria were as follows: (1) Seriously ill/moribund patients, (2) Addiction or any substance abuse, (3) Severe psychiatric disorder or any other illness (TB, epilepsy, cancer, etc.), and (4) Pregnancy.

The patients were administered the International HIV Dementia Scale (IHDS) [4] It is a bedside screening tool, especially developed for detecting HIV dementia. The IHDS consists of three subtests:- (i) Timed finger tapping, (ii) Timed alternating hand sequence test, and (iii) Recall of four items in two minutes.

International 'Hiv' Dementia Scale

(A) Memory Registration and Recall of four common objects

Score = ____________4 (one point for each word spontaneously recalled and 0.5 point if correct answer after prompting)

(B) Motor Speed - Rapid tapping of thumb with first digit of non-dominant hand

Score = _____________

4 = 15 in 5 seconds

3 = 11 - 14 in 5 seconds

2 = 7 - 10 in 5 seconds

1 = 3 - 6 in 5 seconds

0 = 0 - 2 in 5 seconds

(C) Psychomotor Speed - Repetition of three positions alternating hand sequence-

(1) Clench hand in fist on flat surface

(2) Put hand flat on surface with palm down

(3) Put hand perpendicular to the flat surface on the side of the fifth digit.

4 = 4 sequences in 10 seconds

3 = 3 sequences in 10 seconds

2 = 2 sequences in 10 seconds

1 = 1 sequence in 10 seconds

0 = unable to perform

Score = ______________

Total Score = ___________ Maximum Score = 12

If the score is 10, the patient should be evaluated further for DEMENTIA.

Statistical analysis

Means and Standard Deviations (SD) were calculated for continuous variables. To analyze the association between the various factors and the cognitive dysfunction, the chi square test was employed. A P value of less than 0.05 (P < 0.05) was considered as statistically significant. All statistical analysis was done by using the INDOSTAT software.

   Results Top

A total of '80' HIV-positive patients were followed up monthly for six months.

Of the patients, 32.50% (n = 26) scored below 10, while 67.50% (n = 54) of the patients scored above 10 [Table 1] and [Figure 1].

There were significant differences between those with normal cognition and those with cognitive dysfunction for the IHDS total score and for the IHDS Luria test score (P < 0.05) [Table 2] and [Figure 2].
Figure 1: Distribution of patients according to the IHDS score

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Figure 2: IHDS scores stratified by cognitive diagnosis

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Table 1: Distribution of patients according to the IHDS score

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Table 2: IHDS scores stratified by cognitive diagnosis

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In our study, the patients were classified as having cognitive dysfunction and normal cognitive function on the basis of impaired performance in at least two domains of delayed recall, motor speed, psychomotor speed, attention, orientation, executive function, language function, abstract thought, and visuospatial function, as mentioned in the IHDS [4] [Table 3] and [Figure 3].
Table 3: Prevalence of cognitive dysfunction/ impairment

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Figure 3: Prevalence of cognitive dysfunction

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   Discussion Top

Dementia in AIDS indicates an increased risk of mortality. The presence of dementia may interfere with the ART treatment, which is the bed rock of AIDS management. Hence, it is imperative that cognitive impairment be recognized early in HIV-positive patients, to enhance drug compliance to ART.

The results of the present study showed a high prevalence of cognitive dysfunction (32.50%). Our study was supported by Lawler et al., [5] who also reported a high prevalence of HIV-associated neurocognitive impairment (38%) in HIV-positive individuals in Botswana. Similarly, in another study done in Uganda, the prevalence ranged from 11 to 31%. [4]

Asymptomatic Neurocognitive Impairment (ANI) is very common in AIDS patients and it has been observed in 30% of our study subjects. This finding is in agreement with the finding of Lawler et al., wherein a majority of the patients having cognitive dysfunction had been asymptomatic.

HIV-associated Mild Neurocognitive Disorder (MND) constituted 2.5% of our study population. A similar finding was observed in a previous study by Muniyandi et al. [6]

Prevalence of HIV-Associated Dementia (HAD) was less in our study. None of the patients had HAD, which was in concordance with two prospective studies from India which also reported a low incidence of HAD (1 to 2%). [7],[8]

In support of the previous study by Riedel et al., [9] the present study found an abnormal score (≤10) in 32.50% of the patients in IHDS. In concordance with the study by Smith et al., [10] a significant difference was observed for the IHDS total and IHDS Luria test score (P < 0.05) between those with normal cognition and those with cognitive dysfunction.

Limitation of the study: As our study was done in a small group it was difficult to apply the results on the general population.

   Conclusions Top

To conclude, the prevalence of neurocognitive impairment was higher in our study population. Early and periodic neuropsychological screening of HIV-positive asymptomatic individuals is a must in future, to spot the cognitive deficits at an early stage. The IHDS may be of great value as a screening test for HIV-associated neurocognitive disorders.

   Acknowledgments Top

The authors are thankful to the entire faculty of the ART Center and Medicine Department, PBM and AG Hospital, Bikaner, Rajasthan (India), for their cooperation and support during this study.

   References Top

1.Tyor WR, Wesselingh SL, Griffin JW, McArthur JC, Griffin DE. Unifying hypothesis for the pathogenesis of HIV-associated dementia complex, vacuolar myelopathy, and sensory neuropathy. J Acquir Immune Defic Syndr Hum Retrovirol 1995;9:379-88.  Back to cited text no. 1
2.Nomenclature and research case definitions for neurologic manifestations of human immunodeficiency virus-type 1 (HIV-1) infection. Report of a Working Group of the American Academy of Neurology AIDS Task Force. Neurology 1991;41:778-85.  Back to cited text no. 2
3.Cherner M, Cysique L, Heaton RK, Marcotte TD, Ellis RJ, Masliah E, et al. Neuropathologic confirmation of definitional criteria for human immunodeficiency virus-associated neurocognitive disorders. J Neurovirol 2007;13:23-8.  Back to cited text no. 3
4.Sacktor NC, Wong M, Nakasujja N, Skolasky RL, Selnes OA, Musisi S, et al. The international HIV dementia scale: A new rapid screening test for HIV dementia. AIDS 2005;19:1367-74.  Back to cited text no. 4
5.Lawler K, Mosepele M, Ratcliffe S, Seloilwe E, Steele K, Nthobatsang R, et al. Neurocognitive impairment among HIV-positive individuals in Botswana: A pilot study. J Int AIDS Soc 2010;13:15.  Back to cited text no. 5
6.Muniyandi K, Venkatesan J, Arutselvi T, Jayaseelan V. Study to assess the prevalence, nature and extent of cognitive impairment in people living with AIDS. Indian J Psychiatry 2012;54:149-53.  Back to cited text no. 6
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7.Satishchandra P, Nalini A, Gourie-Devi M, Khanna N, Santosh V, et al. Profile of neurologic disorders associated with HIV/AIDS from Bangalore, south India (1989-96). Indian J Med Res2000;111:14-23.  Back to cited text no. 7
8.Wadia RS, Pujari SN, Kothari S, Udhar M, Kulkarni S, Bhagat S, et al.Neurological manifestations of HIV disease. J Assoc Physicians India 2001;49:343-8.  Back to cited text no. 8
9.Riedel D, Ghate M, Nene M, Paranjape R, Mehendale S, Bollinger R, et al. Screening for human immunodeficiency virus (HIV) dementia in an HIV clade C-infected population in India. J Neurovirol 2006;12:34-8.  Back to cited text no. 9
10.Smith B, Skolasky R, Roosa H, Moxley R, Selnes O, McArthur J, et al. The international HIV dementia scale as a screening tool for all forms of HIV-associated neurocognitive disorder. CROI 2012.Poster 595.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]

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