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  XVII International AIDS Conference
Mexico City
3-8 August 2008
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Cognitive Disorders Despite Undetectable Viremia: Low Scores in The HIV Dementia Scale (HDS)
  Reported by Jules Levin
IAC Mexico City Aug 3-8, 2008
Samanta Simioni1, Jean-Marie Annoni1,4, Matthias Cavassini3, Aline Rimbault Abraham4, VŽronique Schiffer6, Jean-Philippe Chave3, Ezio Giacobini7, A. Calmy5, Renaud A. Du Pasquier1,2,Bernard Hirschel*6
Our results show that 1) the prevalence of mild cognitive disorders is high in aviremic, immunocompetent HIV+ patients with subjective impression of cognitive dysfunction and 2) the HDS and IHDS are useful not only to detect full-blown HIV-related dementia but also milder cognitive disorders.
BACKGROUND : HAART has decreased mortality and morbidity, including HIV-associated dementia, whereas mild cognitive disorders remain frequent. The relevance of the HIV Dementia Scale (HDS) to diagnose HIV-associated minor cognitive disorders is unknown.
DESIGN / METHODS : We recruited patients (1) with plasma and CSF HIV < 50/ml, (2) cognitive complaints, (3) without major OI in the past two years, and (4) without active drug use or major depression. All completed the HDS, the IHDS, and a battery of neuropsychological tests assessing sub-cortical functions. Cognitive impairment was defined as >2 tasks below 2 Z-scores.
RESULTS : Median age 45, CD4 cells count 523, median duration of undetectable HIV viremia before testing 36 mos. 31/50 pts with evidence of cognitive deficits, mainly executive dysfunction and mental slowing. Cognitively impaired and not impaired patients were similar in age, CD4 count, duration of undetectable HIV viremia, hepatitis C co-infection, or mood disorders. A cut-off of <13 on the HDS had a sensitivity of 77.4% (p=0.01) for the dx of mild cognitive deficits (see Figure), as compared to the "gold standard" of neuropsychologic testing.
CONCLUSIONS / RELEVANCE : A majority of aviremic patients with subjective complaints of cognitive dysfunction show abnormalities in neuropsychiatric tests. The HDS is useful to detect mild cognitive disorders, and, in the future, to measure the effects of therapeutic interventions.
To quantitate cognitive disorders in a cohort of aviremic HIV+ patients.
To assess the accuracy of the HIV Dementia Scale (HDS) for the detection of mild cognitive deficits.
Despite HAART, the prevalence of d mild cognitive disorders seems not to have decreased. However, the relationship between HIV viremia, immune status and cognitive disorders remains unclear.
The performance of HDS to diagnose HIV-associated minor cognitive disorders is unknown.
Population: Fifty HIV+ patients with (1) undetectable HIV viral load (<50 copies/ml), and (2) subjective impression of cognitive dysfunction. Medians: Age 45, CD4 count 523, duration of undetectable HIV viremia 40 months.
Exclusions: (1) major opportunistic infection of the CNS in the past 3 years; (2) opportunistic infection not affecting the brain in the past 12 months; (3) active IVDU; (4) major depression according to DSM-IV criteria.
Use of antidepressant drugs or methadone, and co-infection with hepatitis C virus (HCV) were recorded.
Patients completed the HDS and a battery of neuropsychological tests assessing the sub-cortical functions (see Figure 1).
After the neuropsychological testing, patients were diagnosed as having:
Definite cognitive impairment if they had a performance £2 z-scores below the given mean for ≥2 tests measuring two different cognitive functions and sufficient functional decline to meet the diagnostic criteria for mild cognitive and motor disorder (MCMD) or HIV-related dementia (HIV-D) according to the American Academy of Neurology AIDS Task Force (AAN)
Possible cognitive impairment if they presented a performance £2 z-scores for only one test or £1.5 z-scores for >1 test; pts in this category had a 2nd session to clarify their cognitive status (fig 1) or
No cognitive impairment
Statistics: Non parametric tests were used.
1) Neuropsychological status and associations with demographics and clinical markers of HIV:
- Thirty-one HIV+ patients (62%) displayed definite cognitive impairment, showing mainly executive dysfunction and mental slowing (see Fig 1).
- Impaired patients were more likely to be taking antidepressives (p=0.02).
- No significant differences between impaired and not impaired pts in terms of age, CD4 count, duration of undetectable HIV viremia, HCV coinfection, or mood disorders.


2) HIV Dementia Scale: sensitivity and specificity to HIV-related mild cognitive deficits:
Using a Receiver Operating Characteristic (ROC) curve, a cut-off of £13 on the HDS was found to have a sensitivity of 77.4% (p=0.01) and 82.1% (p=0.03), respectively, for the diagnosis of mild cognitive deficits, with complete neuropsychiatric testing as the "gold standard".