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. Author manuscript; available in PMC: 2022 Apr 1.
Published in final edited form as: AIDS Care. 2020 Mar 5;33(4):468–472. doi: 10.1080/09540121.2020.1736256

Assessing HIV provider knowledge, screening practices, and training needs for HIV-associated neurocognitive disorders. A short report.

Hetta Gouse 1,§,*, Catherine J Masson 2, Michelle Henry 3, Thomas D Marcotte 4, Leslie London 5, Greg Kew 6, Sean Rourke 7, Reuben N Robbins 8,*
PMCID: PMC7483165  NIHMSID: NIHMS1570436  PMID: 32138523

Abstract

Management of HIV-associated neurocognitive disorders (HAND) is becoming increasingly important with HIV-positive people living normal life spans. We aimed to establish the level of HAND awareness among doctor and nurse occupational health practitioners, screening used to detect impairment, factors limiting screening for HAND, and training needs. One-hundred-and-five members of the nursing and physician professional societies for occupational health practitioners in South Africa and Occupational Health Departments at five South African universities responded to an email invitation to complete an online survey addressing demographics, HAND knowledge, screeners being used to screen for HAND and related training needs. While 80% had heard of HAND, few (13.3%) were aware of the Frascati criteria. Only 2% had received training addressing HAND; 11.4% screened for HAND; 45.7% did not know what screening tool to us; 80% preferred spending < 15 minutes on screening. The largest obstacle to screening was lack of expertise (77.1%) but 77.3% thought it important to screen for HAND. 94.3% wanted screening training. Health providers are poorly informed about HAND and lack expertise and tools to screen for HAND in their treatment programs. While few had relevant training, they recognise the importance of screening for HAND in the workplace and desire training.

Keywords: HIV, HIV-associated neurocognitive disorders (HAND), workplace management, neurocognitive impairment, screening, mental health

Introduction

HIV prevalence is highest in sub-Saharan Africa (SSA; 20 million HIV-infected), particularly in South Africa (Shisana et al., 2014; UNAIDS, 2018). An estimated 12.6% (7.06 million, 18% adults) of the South African population has HIV (Statistics SA, 2017). Most people living with HIV (PLWH) on ART with well-controlled viremia are expected to have a normal lifespan (Croxford et al., 2017). Many will remain healthy enough to participate, with varying degrees, in the general workforce (McGoldrick, 2012).

HIV-associated neurocognitive disorder (HAND) (Antinori et al., 2007) is a common HIV-related condition that negatively impacts morbidity, activities of daily living, employment, and ART adherence (Ettenhofer et al., 2009; Gorman, Foley, Ettenhofer, Hinkin, & van Gorp, 2009; Heaton et al., 2004; Hinkin et al., 2002). HAND prevalence rates (PR) range from 22%−84% globally (Bonnet et al., 2013; Habib et al., 2013; Heaton et al., 2011) and can be present even among PLWH with well-controlled viremia (Heaton et al., 2011). The HAND spectrum covers three levels of severity: Asymptomatic neurocognitive impairment (ANI; PR=58%), Mild Neurocognitive Disorder (MND; PR=40%) and HIV-associated Dementia (HAD; PR=2%) (Sacktor et al., 2016).

Workplace HIV prevalence in South Africa reflects the national HIV prevalence rate, and HAND prevalance in one occupational setting had been reported as 32% (Van Wijk & Meintjies, 2015). Employed PLWH frequently receive healthcare via employers’ occupational health services (Arenas-Pinto et al., 2014). Here, workplace health providers are tasked with managing employees’ HIV in confidence, so as to prevent discrimination from employers. Employed PLWH in high risk safety-sensitive tasks may be particularly vulnerable for critical risks that can endanger themselves and others. While treatment options for HAND are limited, benefits are the potential for improvement of neurocognitive functioning through medication regimen changes, attention to comorbidities, and cognitive remediation (Vance, Fazeli, Ross, Wadley, & Ball, 2012; Vance, McDougall, Wilson, Debiasi, & Cody, 2014), in particular for people who are not on ART or those non-adherent.

Best clinical practice for healthcare providers working with PLWH include routinely screening for HAND, and appropriately refering patients (The Mind Exchange Working Group et al., 2013). Early detection is important for adequate treatment and HAND management (Cummins et al., 2018; Saylor et al., 2016). Unlike in public settings, health providers in occupational settings have resources for cognitive screening, and can provide this service to patients without prejudicing them in the workplace. They furthermore have health and safety responsibilities toward their patient and their work environment, necessitating active screening for risk conditins.

It is not clear how knowledgeable HIV care providers are of HAND, especially in high HIV burden low- and middle-income countries (LMICs), like South Africa. No study to date has examined what steps, if any, HIV care providers take in South Africa to screen for HAND. In this first study of HAND knowledge and practices among HIV health providers in South Africa, we examined: 1) level of awareness of HAND, 2) current HAND screening practices, 3) barriers to HAND screening, and 4) needs for training programmes addressing HAND among occupational care providers.

Methods

This cross-sectional study used a self-completed online RedCap (Harris et al., 2009) based questionnaire to assess healthcare provider knowledge of and attitudes towards screening for HAND, and training needs. One-thousand-and-seventy-eight health providers were emailed an invitation during 22 February 2018 to 5 April 2018 to participate in the study by two professional occupational health societies and five South African universities providing occupational health training.

Participants

Inclusion criteria were providers actively delivering occupational health services in the private or public sector, or active in academia. The Human Research Ethics Committee of the Faculty of Health Sciences, University of Cape Town, approved the study.

Materials

Survey

The questionnaire took approximately 10 minutes to complete. All questions within each section, i) demographics, ii) HAND knowledge, iii) HAND screening practices, and iv) training needs, consisted of checklists of pre-identified options or likert-type rating scales, with a free-comment section at the end of the questionnaire.

Statistical analysis

Descriptive and inferential analyses:

Using Statistical Package for Social Sciences 25 we report descriptive statistics (means and standard deviations for continuous variables, and proportions for categorical variables).

Results

Socio- and occupational-demographics

One-hundred-and-five surveys (approximately 10% response rate) were completed by 45 (43%) doctors, 52 (50%) nurses and 8 (8%) academics. Half (50.5%) of the providers reported encountering HIV-infected patients on a weekly basis, 20.9% on a monthly basis, and less than one-third (28.6%) a few times per year; 73.3% reported all users of their clinical services are offered HIV testing. On average, 58% of patients consent to HIV testing. Seventeen (16.2%) reported they had patients who expressed concerns about neurocognitive problems.

Level of awareness of HAND

Knowledge of HAND

Most providers (76.2%, n = 80) had heard of HAND, though most were only aware of HAD (75.2%, n=79), the most severe and least common form; 37.1% (n=39) and 25.7% (n=27) had heard of milder forms, MND and ANI, respectively.

Knowledge of prevalence of HAND in HIV populations

Most providers (76.2%, n = 80) estimated the prevalence of HAND among the overall HIV population at 40% or less, with HAND prevalence being lower among those on ART vs. not on ART (Figure 1).

Figure 1.

Figure 1.

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The percent of responders estimating various HAND prevalence rates in 1) the overall HIV population, 2) patients who are not on ART and 3) patients on ART.

Knowledge of risk factors associated with HAND

Table 1 lists most likely risk factors for HAND reported by providers.

Table 1.

Occupational health providers’ estimated risk factors for HAND.

Health Providers
Variable (n = 97)
Risk factors for HAND (% who said yes)
 Medication non-compliance 81 (83.5)
 Low CD4 count 78 (80.4)
 Substance misuse 78 (80.4)
 Depression 77 (79.4)
 Opportunistic infection 73 (75.3)
 High viral load 73 (75.3)
 Older age 65 (67.0)
 Sociodemographic factors 61 (62.9)
 Environmental factors 57 (58.8)
 Metabolic syndrome 53 (54.6)
 Hepatitis C 47 (48.5)
 Level education 43 (44.3)
 Ethnicity 23 (23.7)
 Female gender 15 (15.5)
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Note. Number of participants are presented with proportion in parentheses.

HAND screening practices and preferences

Only 12 (11.4%) providers reported screening for HAND in their practice. Of those, Orientation to Person, Place and Time (OPPT) and the Mini Mental State Examination (MMSE) were the most commonly used screening tools (n=5 and 9 respectively). Fewer than five used the Montreal Cognitive Assessment (MoCA), HIV Dementia Scale (HDS) and Brief Neurocognitive Screen (BNCS). Twelve (11.4%) and 15 (14.3%) providers deemed the OPPT and International HIV Dementia Scale (IHDS), respectively, adequate screening tools for HAND.

Most providers (80%) reported preferring spending under 15 minutes on screening for HAND, with one-third (28.2%) only willing to spend 5 minutes, and only 4 (3.8%) willing to spend more than 30 minutes. Regarding screening tools, approximately one-third of providers indicated they would consider using OPPT (29.5%) and MMSE (28.6%); 22.9% the HDS, and 15.2% the IHDS and BNCS. Almost half (45.7%) of all providers did not know what screening tool to use.

Barriers to screening for HAND

Table 2 lists the barriers to screening for HAND.

Table 2.

Factors limiting screening for HAND.

%
Variable (n = 97)
Factors limiting screening for HAND
 Lack of expertise 74 (72.1)
 Lack of screening tool 66 (68.0)
 Lack of time 51 (52.5)
 Communication difficulty 31 (31.9)
 Poor patient cooperation 14 (14.4)
 Environment/lack privacy 3 (3.0)
 Noisy environment** 4 (4.1)
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Note. Number of participants who answered yes are presented with proportion in parentheses.

Importance of screening for HAND

Table 3 describes provider attitudes towards the importance of screening for HAND and concerns that HAND has safety implications.

Table 3.

Views on the importance of screening for HAND; and Screening for HAND

Health Providers
Variable (n = 97)
Important to screen for HAND 77.30 (17.88)
Concerned HAND has safety implications 81.72 (17.96)
Recommend screening for HAND to patients 77.89 (20.31)
Recommend screening for HAND to employers 74.76 (21.37)
Likely to screen for HAND if limiting factors removed 83.70 (16.66)
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Note. Means are presented with standard deviations in parentheses. Means represent percentages with higher scores indicating greater importance/concern/recommendation/likelihood to screen.

Needs for training programs addressing HAND

Prioritising training in HAND screening, nearly all providers (94.3%) wanted training on HAND and how to manage it in a workplace setting.

Discussion

Detecting and managing HAND are overlooked priorities in LMIC, where the burden of HIV resides and healthcare resources are very limited. Among providers who worked regualry with PLWH in the workplace, less than a quarter were aware of the milder forms of HAND, MND and ANI. Importantly, about a quarter of providers had no awareness that HIV can lead to HAND. Providers underestimated HAND prevalence among patients on ART. More providers reported depression and substance use as risk factors for HAND than biological factors (e.g. low nadir CD4 count, high viral load), yet depression and substance use problems are not considered major risk factors for HAND (Byrd et al., 2011; Pinheiro et al., 2016; The Mind Exchange Working Group et al., 2013; Tymchuk et al., 2018). The misconception that patients on ART are less likely to be affected, as opposed to presenting with milder impairment, and the lack of regular screening for HAND increases the risk of providers overlooking milder neurocognitive symptoms. The lack of awareness of the more endemic milder forms of HAND and poor understanding of the risk factors for HAND may impede successful treatment as early intervention is key to improved long-term health and cognitive outcomes (Heaton et al., 2010; Saylor et al., 2016).

The majority of respondents recognised the importance of screening for HAND but used largely inadequate tools for early detection, especially for the milder forms (Janssen, Bosch, Koopmans, & Kessels, 2015; Kamminga, Cysique, Lu, Batchelor, & Brew, 2013; Oshinaike et al., 2012). Repondents’ high concern that HAND may have safety implications in the workplace suggests awareness of the need to address HAND in occupational health settings, but also inaction due to lack of support structures around managing HAND.

There is an urgent need for training workplace HIV care providers in best practice for managing HAND. Providers should also be empowered with knowledge of how to best assist their patients, how to discuss HAND with their patients, and their role in supporting their patients (Liboro et al., 2017).

Because HAND affects work ability and fitness, screening for HAND should feature in workplace based caregivers’ service to patients, a service unlikely to be available in primary care. Guidelines for HAND screening and patient referral are urgently needed. Potential benefits to worker patients are better informed medical care, improved long term health, and retention in the work place.

Funding:

Fogarty Institute, 1K43TW010361-01

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