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The Changing Spectrum of Cognitive Impairment in People with HIV; Establishment and Updates of the International HIV-Cognition Working Group
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Sam Nightingale1
Received: 2 March 2026 / Accepted: 4 March 2026
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Cognitive impairment remains an important complication of HIV, with devastating consequences for those affected. It is a particularly important area given the ageing population of people with HIV globally.
Together we established 6 consensus recommendations towards a new approach [40]. The first recommendation coined the term ‘HIV-associated brain injury’ (HABI) to represent the direct effect of HIV on the brain. We suggested that HABI should be conceptually separated from brain injury due to other causes (such as cerebrovascular disease or traumatic brain injury), although multiple mechanisms may coexist. The second was that HABI should be further differentiated into legacy (i.e. due to pre-ART CNS damage which is non-progressive), or active (leading to clinical or radiological progression).
Importantly, it is not clear whether active HABI occurs in the presence of sustained HIV suppression in plasma and CSF, and defining active HABI as a distinct entity is intended to facilitate research into that important question. The third recommendation was that those with cognitive performance occurring below a certain threshold should be termed as having ‘low cognitive performance’, rather than diagnosed with ANI or HAND. This recognises that, although there may be benefit defining a group at the lower end of the cognitive spectrum in research studies, the language should be destigmatised such that they are not labelled with a disease. The forth recommendation is that rates of low cognitive performance should be interpreted in the context of the false classification rate underlying whichever statistical methodology was applied. For example a low cognitive performance prevalence of 30% is interpreted very differently in the knowledge that the false classification rate is 26%. Fifth we propose that a classification of cognitive impairment be made if at least two of the following are present: low cognitive performance, cognitive symptoms, and objective evidence of brain injury (i.e. abnormality on neurological investigations). And lastly that cognitive symptoms should refer to any change in cognition that has been noticed by the individual or an observer, whether or not this change has an impact on daily functioning (as was the case in HAND criteria), recognising the importance of milder symptoms in the modern era.
Our approach is intended as a pragmatic reframing of the issue to harmonise research terminology with clinical diagnosis. In contrast HAND was a research criteria never intended for clinical use. Our approach was adopted by the European AIDS Clinical Society in 2023 [41], and it is hoped that further discussion and refinement will lead to a broader consensus and agreement on new criteria going forward.
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