How GPs can screen for depression or a decrease in cognition in their HIV+ patients
December 1 is World AIDS day. 37 million are living with this treatable and preventable disease. Dr Lucette Cysique researches the chronic effects of HIV on brain functions.
In Australia, general physicians (GPs) with high HIV-patient caseloads have played a crucial role in curbing the HIV epidemic. They continue to play a key role in maintaining HIV patients’ health with one of the highest rate of successful viral control in the world (>92% HIV patients treated are virally undetectable). GPs also have a unique role in managing the now-chronic complications of HIV. One such complication has, however, remained outside their capacities: screening for cognitive health.
This issue was recently addressed in a study published in collaboration between Dr. Mark Bloch, director of the Holdworth House GP and myself, head of the NeuroHIV research group.
We devised a cognitive health screening tool that could be implemented in busy GP practices, requires no neuropsychology training from the examiner, but an ongoing supervision by a senior neuropsychologist, assesses cognitive, mental health and everyday activities to yield a prediction of how much need there is for a neurology review and within which timeline. The procedure is not diagnostic, but streamlines patients in an efficient fashion.
The screening procedure combines CogState cognitive NeuroHIV computerised screen, standard depression and everyday questionnaires in 20 minutes. The patient can complete the screen in a quiet space supervised by an examiner. The screen’s scoring is semi-automated optimising the GPs’ results interpretation in each patient’s clinical context, thus hastening the clinical decision process.
This new screening procedure addresses increasing worries about cognitive health in the ageing HIV community. The cognitive health screens reassure those with normal cognitive functioning and plan for monitoring in a timely fashion. It also better directs patients with mental health issues towards the appropriate service – in particular for depression, which remains common in persons with HIV infection (life time estimate is 40%).
It also targets HIV+ persons who may be developing mild to moderate levels of cognitive deficits – level of deficits that cannot be detected without testing and can happen with comorbid depression or not. Between 20%-30% of persons with chronic HIV infection may experience cognitive problems despite HIV viral control. Those difficulties are rarely severe, unless the HIV+ person is off treatment, or does not know about their HIV status. Mild to moderate cognitive difficulties still impacts on the most demanding aspects of everyday life such as gaining and retaining employment; efficiency at work, learning new skills.
Since the study publication, HIV community members and the study investigators are working on a plan to transform the screening procedure from a research-validated tool to a clinically validated tool.
The study has been published in the journal Clinical Infectious Diseases as a major article.