Utility of the International HIV Dementia Scale for HIV-Associated Neurocognitive Disorder

Background: We assessed the utility of the International HIV Dementia Scale (IHDS) in detecting HIV-associated neurocognitive disorder (HAND) in Uganda in antiretroviral (ART)-naive and ART-experienced adults. Setting: A longitudinal observational cohort study in Rakai, Uganda. Methods: Three hundred ninety-nine HIV+ ART-naive adults underwent neurological, functional status, and neuropsychological assessments including the IHDS. Three hundred twelve participants who initiated ART were re-evaluated after 2 years. HAND stages [asymptomatic neurocognitive impairment, mild neurocognitive disorder, and HIV-associated dementia (HAD)] were determined based on Frascati criteria using local normative data. Sensitivity, specificity, and area under the ROC curve were determined for various IHDS thresholds (<= 9, <= 9.5, and <= 10). Results: At baseline, the participants' mean age was 35 years (SD +/- 8), 53% were men, and 84% had less than a high school education. At baseline, sensitivity for detecting any HAND stage, symptomatic HAND [mild neurocognitive disorder, HAD], and HAD alone were maximized at IHDS <= 10 (81%, 83%, 92%, respectively). Among 312 individuals who returned for the 2-year follow-up and had initiated ART, a score of <= 10 provided a lower or equal sensitivity for detecting different stages of HAND (all HAND: 70%; symptomatic HAND: 75%; HAD: 94%). The area under the ROC curve was higher for ART-experienced versus ART-naive individuals. Conclusions: The IHDS is a potentially useful screening tool for neurocognitive impairment in rural Uganda for both ART-naive and ART-experienced adults. A cutoff <= 10 demonstrates higher sensitivity for more severe HAND stages compared with less severe HAND. Future studies should focus on potential modifications to the IHDS to improve its specificity.