The role of HAART in mitigating neurocognitive decline among HIV-positive Africans: Systematic review and...

HIV-associated neurocognitive disorders (HAND) remain a significant public health concern among people living with HIV (PWH) in Africa, despite the widespread implementation of highly active antiretroviral therapy (HAART). While HAART has been effective in reducing the incidence of severe neurocognitive disorder, milder forms of neurocognitive impairment continue to be observed even among individuals receiving active antiretroviral therapy. These subtle deficits, particularly prevalent in low-resource and low-literacy contexts, are associated with adverse outcomes such as diminished functional capacity, poor adherence to antiretroviral therapy, and reduced quality of life. This systematic review and meta-analysis aims to synthesize the current evidence on the effectiveness of HAART on neurocognitive outcomes among HIV-positive individuals in Africa.

A comprehensive systematic search was conducted across multiple electronic databases-including PubMed/MEDLINE, Scopus, African Journals Online, PsycINFO, EMBASE, CINAHL, and the Cochrane Library-to identify primary research studies that examined the prevalence and clinical impact of HIV-associated neurocognitive disorders (HAND) among HIV-infected populations in Africa. Study selection and data extraction were performed independently by two reviewers using predefined standardized protocols to ensure methodological rigor and minimize the risk of bias. The review protocol was prospectively registered with PROSPERO (CRD420251017353).

This meta-analysis, which included 62 primary studies with a combined sample of 19,831 individuals living with HIV, estimated a pooled prevalence of HIV-associated neurocognitive disorders was 47.18% (95% CI: 39.94%-54.42%). In contrast, among 2,176 HIV-negative individuals in the control group, the prevalence of neurocognitive disorder was 13.48% (95% CI: 10.9%-15.32%). Sub-regional stratification revealed the highest HAND prevalence in Eastern Africa (50.85%), followed by Southern Africa (48.12%) and Western Africa (43.67%), while Central Africa reported the lowest prevalence at 34.68%. Among individuals receiving antiretroviral therapy (ART), the prevalence of HAND was 46.96%, compared to 50.22% in ART-naïve participants, indicating only a modest reduction in neurocognitive impairment associated with ART exposure. Meta-regression analyses identified several independent predictors significantly associated with increased odds of HAND, including advanced HIV disease stage (odds ratio [OR] 3.59; 95% CI: 2.81-4.59), lower educational attainment (3.13, 2.19-4.48), older age (2.05, 1.51-2.78), being female (2.18, 1.79-2.64), history of substance use (2.70, 2.65-2.75), reduced CD4+ T-cell counts (2.49, 1.42-4.36) and comorbid medical illness (2.05, 1.57-2.67).

HIV-associated neurocognitive disorders affect nearly half of people living with HIV in Africa, despite the widespread availability of HAART, highlighting a critical unmet need in HIV care. While HAART reduces severe cognitive impairment, it offers limited protection against milder yet disabling forms, especially in socioeconomically disadvantaged and low-literacy populations. Contributing factors include advanced disease, low education, aging, being female, substance use, immune suppression and additional chronic medical illness. Integrating regular cognitive assessments, timely interventions, and culturally appropriate rehabilitation into HIV care is vital for enhancing clinical outcomes and quality of life.