Routine screening for cognitive and psychological impairment in <scp>HIV</scp>‐infected patients

This letter refers to the paper titled ‘Limitations to the identification of HIV-associated neurocognitive disorders in clinical practice’ by Morley et al. (2013) 1. The authors raised a very important point regarding the necessity for a quick and easy to use screening tool for HIV-associated neurocognitive disorder (HAND). Screening HIV-infected patients for cognitive decline and psychological well-being should be the impetus of the clinician rather than solely in response to cognitive or psychological complaints from the patient, and doctors should be proactive in ensuring this standard of care is achieved. The recent British HIV Association (BHIVA) ‘Standards of Care for People Living with HIV’ (2013) advises the initiation of routine screening for identification of cognitive and psychological impairment in HIV-infected patients. Patients who screen positive should be referred to appropriate neuropsychologists for accurate diagnosis via extensive neuropsychological testing 2. However, the screening tools currently available are difficult to implement into regular HIV care and there is a need for a new screening tool, which would be easy to use and patient friendly, and not impact on the overall duration of the consultation. Multiple screening tools have been utilized to help identify those who may require referral to neuropsychologists for diagnosis of HAND. Examples include the HIV Dementia Scale (HDS), the modified HIV Dementia Scale (mHDS), the international HIV Dementia Sclae (iHDS), the Mini Mental State Exam (MMSE), and the Montreal Cognitive Assessment (MoCA) as well as various computer assessments. These take more than 10 minutes to complete, and each has its own limitations narrowing its usefulness. The article discussed in this letter makes it clear that there is limited use for many of these screening tools in both genitourinary medicine and infectious disease out-patient clinics and in emergency department settings. This is because of time constraints, a lack of privacy, limited knowledge of the existence of HAND or the requirement for training. These issues are common hindrances to successful screening being achieved. A separate article not cited in the discussed paper by Simioni et al. (2011) reported a study that evaluated the efficacy of three very brief screening questions to identify patients who may be symptomatic for HAND, and yielded a specificity of 84% 3. This type of screening tool would fit the criteria of being quick and easy to use and readily available and, if presented as a questionnaire form, would have no requirements for training or impact patient privacy. Furthermore, this type of screening method could be highly adaptable for use in many hospital, out-patient or primary care settings. We developed and evaluated a method of screening for both depression and neurocognitive impairment in HIV-infected patients, the aim being to provide a new standard of care for our unit in line with national recommendations. A screening questionnaire of five questions was given to 100 patients during HIV out-patient clinic appointments. To assess the feasibility of implementing this tool in the clinic setting, all physicians who took part were asked to fill out a separate feedback questionnaire. Our results revealed that just over half of the patients screened positive for depression and approximately one-third for neurocognitive impairment. These rates are very similar to reported prevalence rates for these conditions in the HIV-infected population. Evaluation of the efficiency of implementing this questionnaire in the clinic revealed that it was highly suitable and met all the requirements set. Specifically, it was easy to complete, it acted as a prompt for clinicians to screen for mood and memory issues and it did not extend the overall duration of the clinic. This study was an evaluation of the service provided to HIV-infected patients, and on the basis of the results it was decided to set up a dedicated neurocognitive impairment service for HIV-infected patients, where neuropsychologists will be formally involved. All patients who screened positive were offered referral for assessment and appropriate diagnostic testing by the HIV-dedicated psychologists. Out of 33 patients who screened positive for neurocognitive impairment, 21 were referred for psychometric testing, of whom 16 have been seen over the 4 months since initial screening took place, four remain to be seen, and one sadly died prior to the appointment. Five of the patients who were not referred are under follow-up care by neuropsychology, and the remaining have not been referred either because they declined referral or the request for referral was not acted upon. From the list of 24 patients who screened positive for depression alone, one has been seen in the psychology out-patient department, one is booked for appointment, and the remaining 22 have not been seen: again, either as a result of failure in the pathway referral process or because they declined referral. Upon retrieval of the results from diagnostic testing, we will be able to more accurately determine the sensitivity and specificity rates of the proposed screening questionnaire. However, the apparent failure in the referral process underscores the need for a more efficient departmental system, which is now being realized with the introduction of a new database. Combining these five questions fulfils the level of screening recommended in the BHIVA Standards of Care and is a validated and effective method for identifying significant depression and neurocognitive dysfunction requiring further referral and specific management. In our hands, it has been easy to incorporate into everyday clinic use and has not been obtrusive to patient, physician, or overall consultation time.

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