A Systematic Review of the Screening Accuracy of the HIV Dementia Scale and International HIV Dementia Scale

Shanghai Medical College, Fudan University, China
PLoS ONE (Impact Factor: 3.23). 04/2013; 8(4):e61826. DOI: 10.1371/journal.pone.0061826
Source: PubMed


The HIV Dementia Scale (HDS) and International HIV Dementia Scale (IHDS) are brief tools that have been developed to screen for and aid diagnosis of HIV-associated dementia (HAD). They are increasingly being used in clinical practice for minor neurocognitive disorder (MND) as well as HAD, despite uncertainty about their accuracy.
A systematic review of the accuracy of the HDS and IHDS was conducted. Studies were assessed on Standards for Reporting Diagnostic Accuracy criteria. Pooled sensitivity, specificity, likelihood ratios (LR) and diagnostic odds ratios (DOR) were calculated for each scale as a test for HAD or MND. We retrieved 15 studies of the HDS, 10 of the IHDS, and 1 of both scales. Thirteen studies of the HDS were conducted in North America, and 7 of the IHDS studies were conducted in sub-Saharan Africa. Estimates of accuracy were highly heterogeneous between studies for the HDS but less so for the IHDS. Pooled DOR for the HDS was 7.52 (95% confidence interval 3.75-15.11), sensitivity and specificity for HAD were estimated at 68.1% and 77.9%, and sensitivity and specificity for MND were estimated at 42.0% and 91.2%. Pooled DOR for the IHDS was 3.49 (2.12-5.73), sensitivity and specificity for HAD were 74.3% and 54.7%, and sensitivity and specificity for MND were 64.3% and 66.0%.
Both scales were low in accuracy. The literature is limited by the lack of a gold standard, and variation in estimates of accuracy is likely to be due to differences in reference standard. There is a lack of studies comparing both scales, and they have been studied in different populations, but the IHDS may be less specific than the HDS. These rapid tests are not recommended for diagnostic use, and further research is required to inform their use in asymptomatic screening.

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Available from: Lewis J Haddow
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    • "While these tests are well developed, many of them are neither sensitive nor specific to HAND (Haddow et al., 2013; Hasbun et al., 2012; Sakamoto et al., 2013; Skinner et al., 2009; Valcour et al., 2011), or are too time-consuming to be used in routine clinical assessment (Spudich and Ances, 2012). In addition to the development of new neuropsychological testing that is more specific and more sensitive to HAND, biomarkers that correlate with disease progression could be extremely helpful in assisting clinical diagnosis and evaluating therapeutic effects as they provide a more objective measurement and avoid the practice effects associated with repetitive behavioral testing (Ciborowski, 2009; Fox, 2013; Marcotte et al., 2013). "
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    ABSTRACT: In the post combination antiretroviral therapy (cART) era, the prevalence of mild forms of HIV-associated neurocognitive disorders (HAND) in individuals with HIV-infection remains high. There is a pressing need to find biomarkers that can aid clinical assessment of HAND, especially in those with mild or no neurocognitive symptoms. Here we hypothesized that a reduction in neural specificity, or the specificity of neuronal tuning, could serve as a potential biomarker of asymptomatic HAND. To directly test this hypothesis, we applied two advanced fMRI techniques to examine the difference in neural specificity between middle-aged HIV+ women and age-matched negative controls, with a focus on the fusiform face area (FFA), a critical region in face processing. Face discrimination performance was assessed outside of the scanner. While the behavioral performance of face discrimination was comparable between the two groups, a reduced neural specificity in the FFA of HIV-positive women was revealed by a novel fMRI analysis technique, local regional heterogeneity analysis, or Hcorr , as well as an established technique, fMRI-rapid adaptation. In contrast, conventional fMRI techniques were insensitive to these early changes. These results suggest that, prior to the onset of detectable behavioral deficits, significant neuronal dysfunctions are already present in HIV+ individuals, and these early neuronal dysfunctions can be detected and assessed via neural specificity, which, in combining with the novel Hcorr technique, has a strong potential to serve as a biomarker of asymptomatic HAND and other neurodegenerative diseases.
    Full-text · Article · Dec 2014 · Clinical neuroimaging
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    • "In sub-Saharan Africa the diagnosis has thus far been based largely on the International HIV Dementia Scale (IHDS) [10], which was designed to quickly identify patients at risk of HAD but not to diagnose HAND. It has not performed consistently in patients on cART [7], [8], [28]. Neurocognitive test batteries are considered the ‘gold standard’ for diagnosing HIV related neurocognitive impairment in Western settings, but only two cohorts from sub-Saharan Africa have reported prevalence of HAND based on formal neurocognitive testing [5], [29]. "
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    ABSTRACT: Background Little is known about the prevalence and burden of HIV associated neurocognitive disorder (HAND) among patients on combination antiretroviral therapy (cART) in sub-Saharan Africa. We estimated the prevalence of HAND in adult Malawians on cART and investigated the relationship between HAND and adherence to cART. Methods HIV positive adults in Blantyre, Malawi underwent a full medical history, neurocognitive test battery, depression score, Karnofsky Performance Score and adherence assessment. The Frascati criteria were used to diagnose HAND and the Global Deficit Score (GDS) was also assessed. Blood was drawn for CD4 count and plasma nevirapine and efavirenz concentrations. HIV negative adults were recruited from the HIV testing clinic to provide normative scores for the neurocognitive battery. Results One hundred and six HIV positive patients, with median (range) age 39 (18–71) years, 73% female and median (range) CD4 count 323.5 (68–1039) cells/µl were studied. Symptomatic neurocognitive impairment was present in 15% (12% mild neurocognitive disorder [MND], 3% HIV associated dementia [HAD]). A further 55% fulfilled Frascati criteria for asymptomatic neurocognitive impairment (ANI); however factors other than neurocognitive impairment could have confounded this estimate. Neither the symptomatic (MND and HAD) nor asymptomatic (ANI) forms of HAND were associated with subtherapeutic nevirapine/efavirenz concentrations, adjusted odds ratio 1.44 (CI. 0.234, 8.798; p = 0.696) and aOR 0.577 (CI. 0.09, 3.605; p = 0.556) respectively. All patients with subtherapeutic nevirapine/efavirenz levels had a GDS of less than 0.6, consistent with normal neurocognition. Discussion/Conclusion Fifteen percent of adult Malawians on cART had a diagnosis of MND or HAD. Subtherapeutic drug concentrations were found exclusively in patients with normal neurocognitive function suggesting HAND did not affect cART adherence. Further study of HAND requires more robust locally derived normative neurocognitive values and determination of the clinical relevance of ANI.
    Full-text · Article · Jun 2014 · PLoS ONE
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    • "Valcour and colleagues [17••] recently summarised existing HAND screens, however their review was not exhaustive and did not differentiate between those validated in pre-cART versus cART samples or against a gold standard neuropsychological assessment. More recently, a systematic review [18••] was conducted, although it was limited to the screening accuracy of the HDS and International HDS, and calculation excluded those with ANI, the most common form of HAND. To our knowledge, no study to date has systematically reviewed the criterion and construct validity of all existing cART era HAND cognitive screening studies under comprehensive methodological constraints. "
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    ABSTRACT: Various screening tools have been proposed to identify HIV-Associated Neurocognitive Disorder (HAND). However, there has been no systematic review of their strengths and weaknesses in detecting HAND when compared to gold standard neuropsychological testing. Thirty-five studies assessing HAND screens that were conducted in the era of combination antiretroviral therapy were retrieved using standard search procedures. Of those, 19 (54 %) compared their screen to standard neuropsychological testing. Studies were characterised by a wide variation in criterion validity primarily due to non-standard definition of neurocognitive impairment, and to the demographic and clinical heterogeneity of samples. Assessment of construct validity was lacking, and longitudinal useability was not established. To address these limitations, the current review proposed a summary of the most sensitive and specific studies (>70 %), as well as providing explicit caution regarding their weaknesses, and recommendations for their use in HIV primary care settings. Electronic supplementary material The online version of this article (doi:10.1007/s11904-013-0176-6) contains supplementary material, which is available to authorized users.
    Full-text · Article · Sep 2013 · Current HIV/AIDS Reports
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