Neurocognitive functioning of HIV positive children attending the comprehensive care clinic at Kenyatta national hospital: exploring neurocognitive deficits and psychosocial risk factors

Psychometric evaluation of the computerized battery for neuropsychological evaluation of children (BENCI) among school aged children in the context of HIV in an urban Kenyan setting

INTRODUCTION

Culturally validated neurocognitive measures for children in Low- and Middle-Income Countries are important in the timely and correct identification of neurocognitive impairments. Such measures can inform development of interventions for children exposed to additional vulnerabilities like HIV infection. The Battery for Neuropsychological Evaluation of Children (BENCI) is an openly available, computerized neuropsychological battery specifically developed to evaluate neurocognitive impairment. This study adapted the BENCI and evaluated its reliability and validity in Kenya.

METHODOLOGY

The BENCI was adapted using translation and back-translation from Spanish to English. The psychometric properties were evaluated in a case-control study of 328 children (aged 6 - 14 years) living with HIV and 260 children not living with HIV in Kenya. We assessed reliability, factor structure, and measurement invariance with respect to HIV. Additionally, we examined convergent validity of the BENCI using tests from the Kilifi Toolkit.

RESULTS

Internal consistencies (0.49 < α < 0.97) and test-retest reliabilities (-.34 to .81) were sufficient-to-good for most of the subtests. Convergent validity was supported by significant correlations between the BENCI's Verbal memory and Kilifi's Verbal List Learning (r = .41), the BENCI's Visual memory and Kilifi's Verbal List Learning (r = .32) and the BENCI's Planning total time test and Kilifi's Tower Test (r = -.21) and the BENCI's Abstract Reasoning test and Kilifi's Raven's Progressive Matrix (r = .21). The BENCI subtests highlighted meaningful differences between children living with HIV and those not living with HIV. After some minor adaptions, a confirmatory four-factor model consisting of flexibility, fluency, reasoning and working memory fitted well (χ² = 135.57, DF = 51, N = 604, p < .001, RMSEA = .052, CFI = .944, TLI = .914) and was partially scalar invariant between HIV positive and negative groups.

CONCLUSION

The English version of the BENCI formally translated for use in Kenya can be further adapted and integrated in clinical and research settings as a valid and reliable cognitive test battery.

Neurocognitive deficits and socioeconomic risk factors among children and adolescents living with HIV in sub-Saharan Africa: a systematic review

INTRODUCTION

Children and adolescents living with HIV (C/ALHIV) are at a risk for significant neurocognitive deficits. There is limited literature that addresses the role of socioeconomic factors in neurocognitive deficits among CALHIV in Sub Saharan Africa (SSA), as it is very difficult to establish this causal relationship. Our systematic review was guided by the biodevelopmental framework that assumes that foundations of health and adversity affect later development and life outcomes. This systematic review aims to assess available evidence on the relationship between neurocognitive deficits and socioeconomic factors among HIV children and adolescents in SSA region.

METHOD

Using a pre-determined search strategy, we searched electronic databases including PubMed, web of Science and EBSCOhost (CINAHL and MEDLINE). Peer-reviewed publications that address neurocognitive deficits, psychosocial and socioeconomic risk factors among children and adolescents living with HIV in SSA were included in review.

RESULTS

Out of 640 articles, 17 studies from SSA met the inclusion criteria. Four studies reported no significant differences in the neurocognitive measures comparing children and adolescents with HIV infection to those uninfected. However, 10 studies suggest that C/ALHIV scored significantly low in general intellectual functions as compared to their uninfected peers. C/ALHIV were found to have substantial deficits in specific cognitive domains such as sequential processing, simultaneous processing, and learning. In addition, deficits in visuo-spatial processing, visual memory and semantic fluency were mentioned. Socioeconomic factors such as lower socioeconomic status (income, education and occupation), child orphanhood status and under-nutrition were linked with neurocognitive deficits.

CONCLUSION

Our findings suggest that CALHIV presented with poorer neurocognitive outcomes when compared to other populations which were associated with specific socioeconomic factors.

Neurocognitive function among HIV-infected children on protease inhibitor -based versus non-protease inhibitor based antiretroviral therapy in Uganda: a pilot study

BACKGROUND

HIV infection is associated with significant neurocognitive deficits making maximization of cognitive function among children receiving antiretroviral therapy (ART) a public health imperative. Non-protease inhibitors (non-PIs) achieve higher drug levels in the cerebral spinal fluid (CSF) compared to PIs, potentially leading to better neurocognitive function by reducing CSF viral load and inflammation. ART that maximises children's neurodevelopment and school achievement could result in improved quality of life and productivity as adults, but little research to date has examined whether non-PI ART is associated with better neurocognitive outcomes. We compared the neurocognitive function between children living with HIV receiving PI-based and non PI-based ART.

METHODS

We recruited a consecutive sample of clinically stable Ugandan children living with HIV aged 5-12 years who received PI-based or non PI-based ART for ≥ 1 year (viral load < 1000 copies). Neurocognitive function was assessed using the Kaufman Assessment Battery for Children, the Test of Variables of Attention, and Bruininks-Oseretsky Test of Motor Proficiency. Age-adjusted neurocognitive z-scores for the two groups were compared using linear regression models in STATA version 13. The Hommel's method was used to adjust for multiple testing.

RESULTS

We enrolled 76 children living with HIV; 34 on PI ART and 42 on non-PI ART. Mean (±SD) age was greater in the non-PI vs. PI group (9.5 ± 1.9 vs. 8.5 ± 2.0) years (p = 0.03). Children in the non-PI group had lower socioeconomic scores (5.7 ± 3.3 vs. 7.4 ± 2.8, p = 0.02). There was no difference in neurocognitive function between the groups (adjusted p > 0.05) for KABC and TOVA. Children in the PI group had better total BOT scores than their counterparts (46.07 ± 1.40) vs. 40.51 (1.24), p = 0.03).

CONCLUSIONS

We detected no difference in neurocognitive function among children on PI and non PI-based ART therapy based on KABC and TOVA tests. Children on PI based ART had better motor function than their counterparts. We recommend a prospective study with a larger sample size.

Significant differences between verbal and non-verbal intellectual scales on a perinatally HIV-infected cohort: from pediatrics to young adults

Delayed neurodevelopment is a common outcome in perinatally HIV-infected children. Our aim was to assess the intellectual profile of our cohort, considering both the infection and socio-environmental related variables. A cross-sectional cohort study was undertaken at seven major hospitals in Spain belonging to the CoRISpeS cohort (n = 97). Patients were followed up according to a standard protocol. Intellectual measures, psychosocial profile and HIV infection-related data have been analysed. The average patient age was 15 years. The median CD4 cell percentage was 35% (1,59). Viral load was undetectable in 80% of the patients and 27% were on AIDS category; 38% of whom had encephalopathy. The average composite score of both crystallized intelligence (CI) and intelligence quotient (IQ) for the cohort was lower than that of the general population (p < 0.001). Results revealed a significant difference of 38% between crystallized and fluid intelligence. There was a clear association between IQ and age of diagnosis (p = 0.022); CI and CDC classification (p = 0.035), CD4 count (p = 0.011) and CD4 nadir (p = 0.001). Higher parental education was associated with better performance across all intelligence scales (p < 0.002). A regression model showed that CI was influenced by the academic level of caregivers (p = 0.002), age at start of cART (p = 0.050) and primary language (p = 0.058). Findings revealed significant differences in verbal and non-verbal intellectual scales resulting in a misleading IQ Composite score. Crystallized intelligence demonstrated the highest level of impairment despite adequate treatment and good immunovirological status, while fluid intelligence results were average. Caregiver level of education was the strongest factor across all intelligence measures.

Positive and Healthy Living Program Manual Development for Young People Living With HIV at the Comprehensive Care Center at the Kenyatta National Hospital: An Open Pilot Implementation Trial

Background: Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) remains a great challenge among young people in Kenya. Young people living with HIV are faced with a lot of challenges that are often overlooked and may have an impact on their treatment adherence and overall well-being. This calls for interventions that are age-appropriate and which tap into the psychosocial problems they experience. This is a protocol of a proposed study aimed at developing a facilitator-led peer support manual called the "Positive and Healthy Living Program" that will be the basis for running support groups with young people at the Comprehensive Care Center (CCC) at the Kenyatta National Hospital (KNH). Methods: We will carry out our study in two phases. The first phase will focus on the development of the manual and training of peer-facilitators. The second phase will make use of a pilot trial research design using both qualitative and quantitative approaches. It will be carried out among 10-24 year-olds attending CCC at KNH, and will consist of three groups: Tumaini Group (10-14 years), Amani Group (15-19 years), and Hodari Group (20-24 years). The groups will participate in an eight-session support group, whose activities will focus on four domains: social-recreation, psychotherapy, peer-modeling, and psychoeducation. Quantitative data will be collected using laboratory measures of Viral Load and CD4 as well as socio-psychological assessment tools. Qualitative data will be collected through interviews with the young people and peer facilitators. We will conduct a descriptive analysis which will describe the key features of the dataset and bivariate analyses will examine the association between variables. The change will be measured at baseline and post-treatment. The interviews will be coded into themes and we will generate experiential categories from the data around the effectiveness of the program, the peer facilitators' experience of providing support, how the young people respond to the program, and its influence on their overall well-being. Discussion: We expect that the peer facilitators will find this manualized treatment acceptable and the eight-sessions group intervention will be feasible for the three age groups. We hypothesize that there will be improvements detected with regards to reported adherence and viral load, self-esteem, depression, and psychological functioning.