Human immunodeficiency virus dementia patients in Africa: How many? Who cares? And where to from here?

Dementia was a frequent consequence of human immunodeficiency virus (HIV) in developed countries before antiretroviral therapy (ART) became available and remains a common neurologic complication of acquired immunodeficiency syndrome (AIDS) among patients receiving appropriate therapy. The epidemiology of HIV dementia (HIV-D) in Africa remains unclear 20+ years into the AIDS epidemic. Early studies of cognitive impairment in HIV-positive populations in Africa were limited by vaguely defined criteria for cognitive impairment, inadequate assessment tools lacking ecologic validation, and the absence of normative population data. More recent studies have clarified definitions of impairment, utilized more sophisticated measures, and included normative comparisons. Unfortunately, these detailed neuropsychiatric assessments are not feasible for population-based studies or routine clinical implementation. Therefore, the prevalence data available for HIV-D in Africa represents rates found in people presenting to tertiary care centers and are unlikely to reflect HIV-D rates in the general population. As ART becomes available in Africa, future research efforts must provide a better understanding of the epidemiology of HIV-D, the effects of available ART regimens on HIV-D in this population, and the impact of HIV-D on ART adherence. Universally accepted terminology and criteria for HIV-D are needed. Population-based studies will require the development of neuropsychiatric batteries that can be adapted across a range of African environments. Ideally, these measures will be viable for nonphysician care providers to use as screening tools in the first stage of epidemiologic studies. Such screening tools could also serve as clinical indicators of possible HIV-related cognitive impairment facilitate implementation of ART adherence.