Measuring neurocognitive impairment in virally suppressed HIV: HIV-associated neurocognitive disorders,...

To discuss neurocognition measurement in view of current controversies in HIV-associated neurocognitive disorders (HAND).

The HAND criteria have been criticised for several reasons with some proposing alternative criteria and terminology, HIV-associated brain injury (HABI). The following concerns have been raised: the legacy effect from past ineffective therapy is not included, the adoption of an asymptomatic neurocognitive impairment (ANI) stage, including liberal neuropsychological test cut-offs overestimate neurocognitive impairment (NCI), and that NCI with viral suppression is still related to HIV rather than the effect of either legacy and/or comorbidities. However, the legacy effect cannot be easily identified, the HAND criteria have been inappropriately used, and there is increasing evidence that low level HIV replication is important in virally suppressed HAND, though likely mitigated in some by resilience factors. Potential solutions to addressing these within the HAND framework will be proposed.

The HAND framework is still useful but it must be put in clinical context. ANI should be considered a research category pending further clarification of its clinical utility. Further work is needed to identify and quantify the legacy effect/ongoing NCI, as well as the nature of resilience.