Is Cognitive Care the Next Blind Spot in HIV Clinical Practice? Exploring the Facilitators and Barriers to...

In the antiretroviral therapy era, as people living with HIV (PWH) age, the decline of HIV-associated dementia has been accompanied by a growing burden of earlier Alzheimer-type pathology and other milder, heterogeneous cognitive impairments, underscoring the need for proactive detection and multidisciplinary management within routine HIV care. Yet, cognitive care remains largely absent, particularly in low- and middle-income countries (LMIC). We evaluated readiness to integrate a multidomain cognitive-rehabilitation program into tertiary HIV clinic in Malaysia and identified implementation determinants. We used a sequential mixed-methods design. An online Knowledge-Attitude-Practice survey was distributed to all infectious-disease physicians nationwide (N = 94). Qualitative data were generated through focus-group discussions with health care providers (HCPs) and in-depth interviews with PWH aged >40 years. Transcripts were analyzed thematically using the Consolidated Framework for Implementation Research (CFIR 2.0). Forty-nine physicians responded (52.4% response), median age was 44 years (inter-quartile range (IQR) 38-51), and 71.4% were female. While 71-82% demonstrated satisfactory knowledge and attitudes toward cognitive health, 88% reported poor practice; only 20.5% routinely screened older PWH. Thirty-three HCPs from multidisciplinary backgrounds participated in five focus groups, alongside 19 in-depth interviews with PWH. Three interlinked domains emerged: (1) knowledge-practice gap related to uncertainty around screening tools, referral pathways, and evidence applicability; (2) systemic barriers including time constraints, high caseloads, lack of guidelines, and workforce limitations; and (3) stigma affecting acceptability. Facilitators included strong patient motivation for brain health, allied health upskilling, physician-initiated referrals, and dedicated care coordination. Integration of multidisciplinary cognitive rehabilitation is hindered by modifiable structural deficits in knowledge translation, workforce organization, and guideline support. HIV-adapted screening algorithms, formalized referral processes, and task-shared coordinator roles could enable earlier cognitive interventions for older adults living with HIV in Malaysia and similar LMIC settings.