Cognitive dysfunction among HIV positive and HIV negative patients with psychosis in Uganda

Clinical presentation of first episode psychosis in people with and without HIV in KwaZulu-Natal, South Africa

AIM

Mental disorders and HIV are the main contributors to the increase in years lived with disability rates per person in sub-Saharan Africa. A complex inter-relationship exists between HIV and mental illness, especially in a region with a high HIV prevalence. We examined the duration of untreated psychosis (DUP), and the nature of psychotic and cognitive symptoms in people with first episode psychosis (FEP) living with and without HIV.

METHODS

Adults aged between 18 and 45 years were assessed using a clinical interview, physical examination and several psychiatric tools. These included the Mini International Neuro-psychiatric Interview to confirm psychosis, Positive and Negative Syndrome Scale, International HIV Dementia Scale and other scales to measure symptom variables. HIV ELISA was used for HIV serology testing, with measures being carried out within 6 weeks of the first presentation.

RESULTS

Of the 172 people presenting with FEP, 36 (21%) had comorbid HIV, those with both being older and more likely to be female (p < .001). Clinically, participants with FEP and HIV scored lower on the positive subscale (p = .008). There were no statistically significant differences for DUP or cognitive screening. Of those living with HIV and FEP (n = 36) comorbidity, nine were newly diagnosed with HIV at the time of the study.

CONCLUSION

Individuals presenting with FEP and comorbid HIV were older, female and reported more mood symptoms. The identification of nine new HIV infections also reflects the ongoing need to test for HIV in people presenting with severe mental illness.

Neurocognitive Impairment and Associated Factors Among People Living with HIV: A Systematic Review and Meta-Analysis of African Studies

Background

Neurocognitive impairment (NCI) is one of the most common neurological complications in HIV-positive individuals, particularly in resource-limited countries. Neurocognitive impairments can occur at any stage of HIV infection, although the risk increases as the infection progresses. However, in Africa, there are few studies with highly variable and inconsistent results. Therefore, this study aimed to determine the prevalence and factors associated with NCI among HIV-positive people in Africa.

Methods

For this systematic review and meta-analysis, we used PubMed/Medline, Scopus, Web of Science, the Cochrane Library, Embase, and PsycINFO to comprehensively search a number of papers. Studies reporting the prevalence of NCI and its factors were included in the estimation of the pooled prevalence. A consistent data extraction format was created in Microsoft Excel to extract the data, which was then imported into STATA 11 statistical software for analysis. The heterogeneity was evaluated using the I2 test, and a random effect meta-analysis model was employed to calculate the pooled prevalence of NCI because the included studies showed significant heterogeneity.

Results

In all, Africa had a pooled prevalence of NCI of 45.15% (95% CI: 36.86, 53.43). According to the subgroup analysis of this study, West Africa had the lowest frequency, at 42.40% (95% CI: 22.03, 62.77), whereas Central and South Africa had the highest prevalence, at 49.33% (95% CI: 10.72-87.95).

Conclusion

In Africa, the cumulative prevalence of NCI was high. Being a woman, not having a formal education, those with only an elementary education, being older, having late-stage HIV, and abusing drugs were all often associated with NCI. The average burden of NCI in Africa is high and that would be a significant figure for interventional actions in the area.

Factors associated with verbal fluency in older adults living with HIV in West Africa: A longitudinal study

OBJECTIVE

Verbal fluency decline, observed both in aging and HIV infection, has been related to lower quality of life. This study aimed to evaluate the factors associated with categorical fluency in people living with HIV (PLHIV) aged ≥60 years living in West Africa.

METHODS

In this longitudinal study, PLHIV aged ≥60 years, on antiretroviral therapy (ART) for ≥6 months were included in three clinics (two in Côte d'Ivoire, one in Senegal) participating in the West Africa International epidemiological Databases to Evaluate AIDS (IeDEA) collaboration. Categorical fluency was evaluated with the Isaacs Set Test at 60 s at baseline and 2 years later. Factors associated with verbal fluency baseline performance and annual rates of changes were evaluated using multivariate linear regression models.

RESULTS

Ninety-seven PLHIV were included with 41 of them (42%) having a 2-year follow-up visit. The median age was 64 (62-67), 45.4% were female, and 89.7% had an undetectable viral load. The median annual change in categorical fluency scores was -0.9 (IQR: -2.7 to 1.8). Low baseline categorical fluency performance and its decline were associated with older age and being a female. Low educational level was associated with low baseline categorical fluency performance but not with its decline. Categorical fluency decline was also associated with marital status and hypertension.

CONCLUSIONS

Among older West African PLHIV, usual socio-demographic variables and hypertension were the main factors associated with low categorical fluency performance and/or its decline. Interventions that focus on supporting cardiometabolic health are highly recommended to prevent cognitive disorders in PLHIV.

Evaluating construct and criterion validity of NeuroScreen in assessing neurocognition among hospitalized Ugandan first-episode psychosis patients

Introduction

Neurocognitive impairment (NCI) is commonly exhibited among patients experiencing their first episode of psychosis. However, there are few resources in many low-income countries, such as Uganda, that allow for the administration of extensive neurocognitive test batteries for the detection of NCI. NeuroScreen is a brief tablet-based neurocognitive assessment battery that can be administered by all levels of healthcare staff. We examined the validity of NeuroScreen to assess neurocognition and detect NCI in first-episode psychosis (FEP) patients in Uganda.

Methods

We enrolled 112 participants FEP patients and matched controls at Butabika Mental Referral Hospital. Each participant completed NeuroScreen and a traditionally administered neurocognitive battery: the MATRIC Consensus Cognitive Battery (MCCB). We examined correlations between participant performance on NeuroScreen and the MCCB. A ROC curve determined sensitivity and specificity of NeuroScreen to detect NCI as determined by MCCB criterion.

Results

There was a large, statistically significant correlation between overall performance on NeuroScreen and the MCCB [r(112) = 0.64, p < .001]. Small to large correlations were found between tests in the MCCB and NeuroScreen batteries. The ROC curve of NeuroScreen performance to detect MCCB-defined NCI had an area under curve of 0.80 and optimal sensitivity and specificity of 83 % and 60 %, respectively.

Conclusion

There was a moderate positive correlation between overall performance on both batteries. NeuroScreen shows promise as a valid assessment battery to assess neurocognition and detect NCI in FEP patients in Uganda. Further studies of NeuroScreen in healthy individuals and in a range of mental disorders are recommended.

Prevalence, profile and associations of cognitive impairment in Ugandan first-episode psychosis patients

Introduction

The MATRICS consensus cognitive battery (MCCB) is the gold standard for neuropsychological assessment in psychotic disorders but is rarely used in low resource settings. This study used the MCCB to determine the prevalence, profile and associations of various exposures with cognitive impairment in Ugandan first-episode psychosis patients.

Methods

Patients and matched healthy controls were recruited at Butabika Hospital in Uganda. Clinical variables were first collated, and after the resolution of psychotic symptoms, a neuropsychological assessment of seven cognitive domains was performed using the MCCB. Cognitive impairment was defined as two standard deviations (SD) below the mean in one domain or 1SD below the mean in two domains. Descriptive statistics determined the prevalence and profile of impairment while regression models determined the association between various exposures with cognitive scores while controlling for age, sex and education.

Results

Neuropsychological assessment with the MCCB found the burden of cognitive impairment in first-episode psychosis patients five times that of healthy controls. The visual learning and memory domain was most impaired in first-episode psychosis patients, while it was the working memory domain for the healthy controls. Increased age was associated with impairment in the domains of the speed of processing (p < 0.001) and visual learning and memory (p = 0.001). Cassava-rich diets and previous alternative and complementary therapy use were negatively associated with impairment in the visual learning (p = 0.04) and attention/vigilance domains (p = 0.012), respectively. There were no significant associations between sex, history of childhood trauma, or illness severity with any cognitive domain.

Conclusion

A significant burden of cognitive impairment in Ugandan first-episode psychosis patients is consistent with prior data from other contexts. However, the profile of and risk factors for impairment differ from that described in such work. Therefore, interventions to reduce cognitive impairment in FEP patients specific to this setting, including dietary modifications, are required.

Psychometrics of the Patient Health Questionnaire (PHQ-9) in Uganda: A Systematic Review

BACKGROUND

Depression is screened by many psychological tools, whereas the Patient Health Questionnaire-9 (PHQ-9) is one of the most commonly used self-administered tools. Uganda is a culturally diverse country with a wide variety of tribes, ethnic groups, languages, and disease conditions; it is urgent to know the psychometrics of the used PHQ-9 across different cohorts. However, there is no prior review to assess its reliability in this culturally diverse country, where this review fulfills the knowledge gap.

METHODS

Adhering to the PRISMA guideline, a systematic search was performed in several databases (i.e., PubMed, Africa-Wide Information, AJOL, and PsycINFO, among others), and a total of 51 articles were included in this review, confirming the study inclusion criteria (e.g., using the PHQ-9).

RESULTS

The PHQ-9 has been used among individuals above 10 years and both genders, and the tool has been used most among the HIV patient group (n = 28). The tool is frequently administered by interviews and has been translated into several languages (mostly Luganda, n = 31). A cutoff of 10 was commonly used to identify clinical or major depression (n = 23), and its prevalence ranged from 8 to 67%. It has been validated for use in two populations, (i) HIV-positive participants and (ii) the general population attending a health facility. The sensitivity and specificity were 92 and 89%, respectively, at a cutoff score of 10, whereas 67 and 78%, respectively, at a cutoff score of 5. The Cronbach alpha ranged between 0.68 and 0.94.

CONCLUSION

The PHQ-9 has been used in several studies in Uganda but validated in only two populations and is commonly used in one language. Thus, validation of the tool in various populations and languages is warranted to improve the tool's acceptance in Uganda.

Worldwide Occurrence of HIV-Associated Neurocognitive Disorders and Its Associated Factors: A Systematic Review and Meta-Analysis

BACKGROUND

HIV-associated neurocognitive disorders are common in people living with HIV/AIDS and affect the adherence of patients to prescriptions, activities of daily living, and quality of life of patients. However, there is a lack of summative evidence in the area. The present meta-analysis was therefore addressing this gap.

METHODS

We did our electronic search in Psych-Info, EMBASE, Scopus, and PubMed. The retrieved articles were stored with the endnote reference manager and data was extracted using Meta-XL version 5.3. The quality of studies was evaluated with the modified Newcastle-Ottawa Scale (NOS). A random-effect model and STATA-16 were used to compute the average estimate of HAND. Heterogeneity was weighed with I² statistics. A sensitivity analysis and subgroup analysis were employed. The existence/nonexistence of a publication bias was checked with the Eggers test of publication bias.

RESULTS

The average prevalence of HAND was 50.41% (95% CI: 45.56, 55.26). The average estimate of HAND in Europe was found to be 50.015% whereas in Africa, Asia, and the United States of America (USA) it was 49.566, 52.032, and 50.407% respectively. The prevalence of HAND in studies that used the HIV Dementia Scale (IHDS) was 36.883% and 59.956% at cutoff points of IHDS <9.5 and IHDS <10 respectively. Besides, the estimated average of HAND with the global dementia scale (GDS) was 40.766%. The prevalence of HAND in cross-sectional, cohort, and case-control studies was 49.52, 54.087, and 44.45% in that order. Socio-demographic variables; low level of education and older age, clinical and HIV related variables; the advanced stage of the illness and CD4 count of 500 cells/dl or less and psychological variables such as comorbidity of depression increases the risk of HAND.

CONCLUSION

The prevalence of HIV-associated neurocognitive disorders was about 50.41%. Low level of education and older age, clinical and HIV related variables such as the advanced stage of the illness and CD4 count of 500 cells/dl or less, and comorbidity of depression were associated with HIV associated neurocognitive disorders. Public health interventions for HIV patients should target these essential problems.

The Dual Burden of HIV Infection and First-Episode Psychosis in Africa: A Systematic Review and Meta-Analysis

ABSTRACT

A systematic review and meta-analysis was conducted to synthesize data on HIV prevalence in individuals with first-episode psychosis (FEP) and to provide an overview of the association of HIV with clinical variables of FEP. Electronic databases were searched for quantitative studies published from January 1986 to November 2019. Meta-analyses were undertaken to calculate the pooled HIV/FEP proportion based on random effects modeling with inverse variance method. Seven HIV/FEP studies from sub-Sahara Africa (SSA) met inclusion criteria. The prevalence of HIV in FEP ranged from 24% to 40%, and FEP in people living with HIV (PLWHIV) ranged from 17% to 29%. The pooled proportion of HIV in FEP was 26% (95% confidence interval [CI], 10%-43%), with significant heterogeneity (n = 3, I2 = 89%, p < 0.01), and of FEP in PLWHIV was 23% (95% CI, 15%-32%), without significant heterogeneity (n = 3, I2 = 0%, p = 0.43). There are concerning levels of HIV and FEP comorbidity in SSA, necessitating an integrated health care service.

Investigating the impact of HIV on patients with first episode psychosis: a study protocol for a longitudinal cohort study

INTRODUCTION

South Africa (SA) has a high HIV prevalence and limited mental healthcare resources. Neuropsychiatric complications such as psychosis onset in people living with HIV (PLWHIV) remains poorly understood. The study aims to compare the socio-demographic, clinical, substance use, cognitive and trauma profile of PLWHIV presenting with first episode psychosis (FEP) to those with the condition but without HIV.

METHODS AND ANALYSIS

This study will compare presentation, course, and outcome of a cohort of PLWHIV and FEP with a control group recruited over a 3-year period. We will prospectively test the hypothesis that the 2 groups are socio-demographically, clinically and cognitively distinct at illness presentation, with higher trauma burden and poorer outcomes in those with the dual burden of HIV and FEP. FEP participants, confirmed by a structured neuropsychiatric interview, will have their socio-demographic, psychosis, mood, motor, trauma and substance use variables assessed. A neuropsychological battery will be completed to assess cognition, while quality of life, psychotic symptoms and HIV markers will be measured at 3, 6 and 12 months.

ETHICS AND DISSEMINATION

The study protocol has been reviewed and ethics approval obtained from the Biomedical Research Ethics Committee (BC 571/18) of the University of KwaZulu-Natal. The results from this investigation will be actively disseminated through peer-reviewed journal publications and conference presentations.

A systematic review of research on neuropsychological measures in psychotic disorders from low and middle-income countries: The question of clinical utility

INTRODUCTION

Several studies of neuropsychological measures have been undertaken in patients with psychotic disorders from low- and middle-income countries (LMICs). It is, however, unclear if the measures used in these studies are appropriate for cognitive screening in clinical settings. We undertook a systematic review to determine if measures investigated in research on psychotic disorders in LMICs meet the clinical utility criteria proposed by The Working Group on Screening and Assessment.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses were employed. We determined if tests had been validated against a comprehensive test battery, the duration and scope of the tests, the personnel administering the tests, and the means of administration.

RESULTS

A total of 31 articles were included in the review, of which 11 were from Africa. The studies included 3254 participants with psychosis and 1331 controls. 3 studies reported on the validation of the test against a comprehensive cognitive battery. Assessments took 1 h or less to administer in 6/31 studies. The average number of cognitive domains assessed was four. Nonspecialized staff were used in only 3/31 studies, and most studies used pen and paper tests (17/31).

CONCLUSION

Neuropsychological measures used in research on psychotic disorders in LMICs typically do not meet the Working Group on Screening and Assessment clinical utility criteria for cognitive screening. Measures that have been validated in high-income countries but not in LMICs that do meet these criteria, such as the Brief Assessment of Cognition in Schizophrenia, therefore deserve further study in LMIC settings.

Cognitive differences associated with HIV serostatus and antiretroviral therapy use in a population-based sample of older adults in South Africa

Previous clinical studies have reported adverse cognitive outcomes for people living with HIV (PLWH), but there are no population-based studies comparing cognitive function between older PLWH and comparators without HIV in sub-Saharan Africa. We analyzed baseline data of 40 + years-old participants in "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI) cohort. We measured cognition using a battery of conventional instruments assessing orientation, immediate- and delayed-recall, and numeracy (N = 4560), and the Oxford Cognitive Screen [OCS]-Plus, a novel instrument for low-literacy populations, assessing memory, language, visual-spatial ability, and executive functioning (N = 1997). Linear regression models comparing cognitive scores between participants with and without HIV were adjusted for sex, education, age, country of birth, father's occupation, ever-consumed alcohol, and asset index. PLWH scored on average 0.06 (95% CI 0.01-0.12) standard deviation (SD) units higher on the conventional cognitive function measure and 0.02 (95% CI - 0.07 to 0.04) SD units lower on the OCS-Plus measure than HIV-negative participants. We found higher cognitive function scores for PLWH compared to people without HIV when using a conventional measure of cognitive function but not when using a novel instrument for low-literacy settings.

One year prevalence of psychotic disorders among first treatment contact patients at the National Psychiatric Referral and Teaching Hospital in Uganda

Introduction

Hospital based studies for psychotic disorders are scarce in low and middle income countries. This may impact on development of intervention programs.

Objective

We aimed to determine the burden of psychotic disorders among first treatment contact patients at the national psychiatric referral hospital in Uganda.

Methods

A retrospective patient chart-file review was carried out in March 2019 for all patients presenting to the hospital for the first time in the previous year. Patients were categorised into those with and without psychotic disorders. We collected sociodemographic data on age, gender, occupation, level of education, ethnicity, religion and home district. We determined the one year prevalence of psychotic disorders among first treatment contact patients. Using logistic regression models, we also determined the association between psychotic disorders and various exposure variables among first treatment contact patients.

Results

In 2018, 63% (95% CI: 60.2–65.1) of all first time contact patients had a psychosis related diagnosis. Among the patients with psychotic disorders, the median age was 29 years (IQR 24–36). Most of the patients were male (62.8%) and unemployed (63.1%). After adjusting for patients’ residence, psychotic disorders were found to be more prevalent among the female gender [OR 1.58 (CI1.46–1.72)] and those of Pentecostal faith [OR 1.25 (CI 1.10–1.42)].

Conclusion

Among first treatment contact patients in Uganda, there is a large burden of psychotic disorders. The burden was more prevalent among females as well as people of Pentecostal faith who seemed to use their church for faith-based healing. Incidence studies are warranted to determine if this phenomenon is replicated at illness onset.

Symptomatic cerebrospinal fluid HIV-1 escape in two patients on second-line antiretroviral therapy in Uganda

Two HIV-infected individuals on second-line atazanavir-based antiretroviral therapy presented with neuropsychiatric symptoms. Cerebrospinal fluid HIV RNA was higher than plasma HIV RNA and antiretroviral regimens' optimization led to prompt resolution of symptoms in one. Patients on second-line atazanavir-based antiretroviral therapy with documented previous treatment failure may be at risk of symptomatic cerebrospinal fluid escape.

Effects of HIV on executive function and verbal fluency in Cameroon

HIV-associated neurocognitive disorders (HAND) are frequently associated with impaired executive function and verbal fluency. Given limited knowledge concerning HAND in Sub-Saharan-Africa and lack of Cameroonian adult neuropsychological (NP) test norms, we administered four executive function [Halstead Category Test (HCT), Wisconsin Card Sorting Test (WCST), Color Trails-II (CTT2), and Stroop Color-Word-Interference (SCWT)] and three verbal fluency (Category, Action, and Letter Fluency) tests to 742 adult Cameroonians (395 HIV-, 347 HIV+). We developed demographically-corrected NP test norms and examined the effects of HIV and related variables on subjects' executive function and verbal fluency. HIV+ subjects had significantly lower T-scores on CTT2 (P = 0.005), HCT (P = 0.032), WCST (P < 0.001); lower executive function composite (P = 0.002) and Action Fluency (P = 0.03) T-scores. ART, viremia, and CD4 counts did not affect T-scores. Compared to cases harboring other viral subtypes, subjects harboring HIV-1 CRF02_AG had marginally higher CTT2 T-scores, significantly higher SCWT (P = 0.015) and executive function (P = 0.018) T-scores. Thus, HIV-1 infection in Cameroon is associated with impaired executive function and some aspects of verbal fluency, and viral genotype influenced executive function. We report the first normative data for assessing executive function and verbal fluency in adult Cameroonians and provide regression-based formulas for computing demographically-adjusted T-scores. These norms will be useful for investigating HIV/AIDS and other diseases affecting cognitive functioning in Cameroon.

The Impact of co-morbid severe mental illness and HIV upon mental and physical health and social outcomes: a systematic review

Our aim was to review the evidence related to the impact of co-morbid severe mental illness SMI (schizophrenia, schizoaffective and bipolar disorder) and HIV upon mental health, physical health and social outcomes. We carried out a systematic review of scientific evidence, searching online databases (MEDLINE, PsychInfo, EMBASE, Global Health and Scopus) for studies between 1983 and 2017 using search terms for SMI and HIV. Studies were included if they compared health or social outcomes between people living with co-morbid SMI and HIV and people living with either: a) HIV only; or b) SMI only. Outcomes of interest were: mortality, health service use, HIV/SMI-related, co-morbidities, and social outcomes. We identified 20 studies which met our inclusion criteria. Although studies were generally high quality, there was heterogeneity in both selection of outcomes and choice of measure. It was therefore difficult to draw strong conclusions regarding the impact of co-morbid SMI and HIV across any outcome. We found little evidence that co-morbid SMI and HIV were associated with lower levels of treatment, care or poorer clinical outcomes compared to people living with SMI or HIV alone. However, mortality appeared to be higher among the co-morbid group in three out of four analyses identified. Physical and mental co-morbidities and social outcomes were rarely measured. Limited data mean that the impact of co-morbid SMI and HIV is uncertain. In order to develop evidence-based guidelines, there is an urgent need for further research. This may be realized by exploring opportunities for using data from existing cohort studies, routinely collected data and data linkage to investigate important questions relating to this neglected but potentially important area.

HIV and mental illness in Malawi and the neuropsychiatric sequelae of efavirenz

Introduction

Little is published about mental disorders in Malawi, specifically in relation to Human Immunodeficiency Virus (HIV) and it's treatment. Efavirenz is a medication commonly used as part of triple therapy for HIV treatment. Indeed, in 2013, Malawi introduced 5A with Efavirenz as part of it's 1st line treatment for HIV. There exists some literature documenting known psychiatric side effects of Efavirenz, which include anxiety, mood changes, nightmares, psychosis and suicidal ideation. Little is known about what features are most common in the presentation and what factors in the patient and drug which may make this reaction more likely.

Aim

The aim of this commentary is to review the association between HIV and psychiatric disorder, and consider the neuropsychiatric side-effects of Efavirenz.

Method

An evaluative literature review was completed by means of multiple electronic database search as well as an additional manual search to obtain published works identified through the electronic search. Search terms used were: Efavirenz, Acquired Immunodeficiency Syndrome, Africa, Antiretroviral Therapy, Developing Countries, Malawi, Mental Disorders, Public Health, and Psychiatry.

Conclusion

This is an important area of study, as potentially large numbers of individuals with HIV are being placed on Efavirenz as first line treatment, yet 60% may experience some form of neuropsychiatric side effects.

The Chronicity of HIV Infection Should Drive the Research Strategy of NeuroHIV Treatment Studies: A Critical Review

HIV infection has become a chronic illness when successfully treated with combined antiretroviral therapy (cART). The long-term health prognosis of aging with controlled HIV infection and HIV-associated neurocognitive disorder (HAND) remains unclear. In this review, we propose that, almost 20 years after the introduction of cART, a change in research focus is needed, with a greater emphasis on chronicity effects driving our research strategy. We argue that pre-emptive documentation of episodes of mild neurocognitive dysfunction is needed to determine their long-term prognosis. This strategy would also seek to optimally represent the entire HAND spectrum in therapeutic trials to assess positive and/or negative treatment effects on brain functions. In the first part of the paper, to improve the standard implementation of the Frascati HAND diagnostic criteria, we provide a brief review of relevant quantitative neuropsychology concepts to clarify their appropriate application for a non-neuropsychological audience working in HIV research and wanting to conduct randomized clinical trials on brain functions. The second part comprises a review of various antiretroviral drug classes and individual agents with respect to their effects on HAND, while also addressing the question of when cART should be initiated to potentially reduce HAND incidence. In each section, we use recent observational studies and randomized controlled trials to illustrate our perspective while also providing relevant statistical comments. We conclude with a discussion of the neuroimaging methods that could be combined with neuropsychological approaches to enhance the validity of HIV neurology (neuroHIV) treatment effect studies.

Disability and Living with HIV: Baseline from a Cohort of People on Long Term ART in South Africa

BACKGROUND

Through access to life saving antiretroviral treatment (ART) in southern Africa, HIV has been reconceptualised as a chronic disease. This comes with new challenges of HIV-related co-morbidities and disabilities. We still lack an understanding of the types and scope of disabilities experienced by people on long term ART and how this impacts health, adherence, and livelihood. This paper describes the results of a cohort study examining the new health- and disability-related needs of the millions of people on ART in the region.

METHODS

Data was collected from a cohort of people who had been on ART for six months or longer in a semi-urban public health care setting in South Africa. 1042 adults (18 and older) participated in the cross-sectional study which investigated disabilities/activity limitations, health, ART adherence, depression symptoms, and livelihood. We analysed the associations between these constructs using descriptive statistics, and bivariate and multivariate analyses.

RESULTS

A large number of participants (35.5%) obtained a weighted score of two or more on the WHODAS 2.0 indicating possible activity limitations. A positive relationship was found between activity limitations and depression symptoms, adherence, and worse health outcomes, while none was found for BMI or CD4 count. These associations varied by type of activity limitations and, in some cases, by gender.

CONCLUSION

Activity limitations are potentially experienced by a large portion of people on ART in southern Africa which impacts health and ART adherence negatively. These results highlight the importance of better understanding the new health-related needs of people who are on long term ART, as well as the nuances of the disability they experience. This is urgently needed in order to enable HIV-endemic countries to better prepare for the new health-related needs of the millions of people on ART in southern Africa.

The relationship between HIV and prevalence of disabilities in sub-Saharan Africa: systematic review (FA)

OBJECTIVE

To systematically review evidence on the prevalence and risk of disabilities among children and adults living with HIV in sub-Saharan Africa.

METHODS

Articles were identified from 1980 to June 2013 through searching seven electronic databases. Epidemiological studies conducted in sub-Saharan Africa that explored the association between HIV status and general disability or specific impairments, with or without an HIV-uninfected comparison group, were eligible for inclusion.

RESULTS

Of 12 867 records initially identified, 61 papers were deemed eligible for inclusion. The prevalence of disability was high across age groups, impairment types and study locations. Furthermore, 73% of studies using an HIV- comparator found significantly lower levels of functioning in people living with HIV (PLHIV). By disability type, the results were as follows: (i) for studies measuring physical impairments (n = 14), median prevalence of limitations in mobility and motor function among PLHIV was 25.0% (95% CI: 21.8-28.2%). Five of eight comparator studies found significantly reduced functioning among PLHIV; for arthritis, two of three studies which used an HIV- comparison group found significantly increased prevalence among PLHIV; (ii) for sensory impairment studies (n = 17), median prevalence of visual impairment was 11.2% (95%CI: 9.5-13.1%) and hearing impairment was 24.1% (95%CI: 19.2-29.0%) in PLHIV. Significantly increased prevalence among PLHIV was found in one of four (vision) and three of three studies (hearing) with comparators; (iii) for cognitive impairment in adults (n = 30), median prevalence for dementia was 25.3% (95% CI: 22.0-28.6%) and 40.9% (95% CI: 37.7-44.1%) for general cognitive impairment. Across all types of cognitive impairment, twelve of fourteen studies found a significant detrimental effect of HIV infection; (iv) for developmental delay in children with HIV (n = 20), median prevalence of motor delay was 67.7% (95% CI: 62.2-73.2%). All nine studies that included a comparator found a significant difference between PLHIV and controls; for cognitive development and global delay, a significant detrimental effect of HIV was found in five of six and one of two studies, respectively. In the nine cohort studies comparing vertically infected and uninfected children, eight showed a significant gap in development over time in children with HIV. Finally, fifteen of thirty-one (48%) studies found a statistically significant dose-response relationship between indicators of disease progression (CD4 or WHO stage) and disability.

CONCLUSIONS

HIV is widespread in sub-Saharan Africa and the evidence suggests that it is linked to disabilities, affecting a range of body structures and functions. More research is needed to better understand the implications of HIV-related disability for individuals, their families as well as those working in the fields of disability and HIV so that appropriate interventions can be developed.

HIV prevalence in persons with severe mental illness in Uganda: a cross-sectional hospital-based study

Background

In Uganda, a previous study reported high HIV prevalence in persons with severe mental illness (SMI) compared to the general population, suggesting that persons with SMI might constitute a high-risk group for HIV. However, the study included first-time psychiatric admissions only, a group whose HIV prevalence may not reflect the prevalence in persons with SMI in general. We determined prevalence and correlates of HIV in both first-time and previous psychiatric admissions, in a psychiatric hospital in Uganda.

Methods

Cross-sectional study of HIV status in persons consecutively discharged from psychiatric admission wards in Butabika hospital, Uganda. Inclusion criteria: age 18–49 years; schizophrenia, bipolar disorder, depression, or other non-substance-use-related psychosis; Luganda or English proficiency. Exclusion criterion: Mental incapacity to give informed consent. Participants were HIV-tested, and interviewed using a structured questionnaire. Data were analysed using logistic regression.

Results

HIV prevalence was 11.3% (CI 8.8-13.8) overall, 7.3% (CI 4.1-10.5) in men and 14.3% (CI 10.6-18.0) in women. Females had higher risk of HIV infection than males (OR 2.10; CI 1.20-3.67), after adjustment for age. Older patients had higher risk of HIV infection than younger patients (40–49 vs. 18–29 years: OR 2.34; CI 1.27-4.32), after adjustment for sex. Place of residence, marital status, income, education, occupation, psychiatric diagnosis and history of previous admission were not associated with HIV infection, after adjustment for sex and age. The above associations did not significantly differ between men and women.

Conclusions

Persons admitted for SMI in Uganda have higher HIV prevalence than persons in the general population, irrespective of previous admissions. The excess HIV prevalence is mainly confined to women. The findings call for the integration of HIV prevention, testing and care with mental health services in settings with generalized HIV epidemics. Moreover, further research is needed to clarify the mechanisms underlying the increased HIV prevalence in women with SMI in Uganda, and to identify effective community-based interventions for this vulnerable group.