ABSTRACT
Introduction
HIV associated dementia has been found to be the most devastating central nervous system consequence of HIV infection which invade the brain directly. Progression into HIV associated dementia (HAD) is associated with a number of bio-psychosocial factors. Despite the high prevalence of HIV infection, there are no adequate data on HIV associated dementia both internationally and locally especially. The aim of this study was to establish the prevalence of HAD, the associated socio-demographic factors, and the association between International HIV Dementia Scale Score and viral load among HIV/AIDS adult patients attending the Kapsabet Comprehensive Care Centre, Nandi County.
Methodology
The study design was descriptive cross-sectional study and the study population was 4,100 HIV positive adults who were drawn from various locations within the county. Sample size was 352 patients who came for their routine clinic appointment. Sampling method used was simple random sampling where the potential participants randomly picked numbers in a container at the triage nurse desk. Those who picked odd numbers from 1 to 31 and met inclusion /exclusion criteria participated in the study. International HIV dementia scale, Socio-demographic and HIV related designed questionnaire was used to collect the data.
Data Analysis
The data collected was analyzed using SPSS Version 20 and the results were presented in tables, graphs, Charts and narratives.
Study results
The prevalence of HIV associated dementia was 65.6% among HIV patient attending Kapsabet Comprehensive Care Centre, There was no association between viral load and International HIV dementia score with a chi-square of 3.96 and p-value of 0.267
Conclusion
The results indicated that HIV associated dementia is common among HIV patients attending Kapsabet comprehensive Care Centre.
Chapter one
Introduction and background
A study done by National Institute of Neurological Disorders and Stroke (2015) defined dementia as the loss of cognitive functioning that involve the ability to reason, memory, language skills, visual perception, ability to focus and pay attention, loss of behavioral abilities, inability to solve problems and presence of delusion. This occur as a result of HIV attacking the brain cells and is severe enough to hinder an individual from performing everyday tasks. This was supported by a study done by the Acquired Immunodeficiency Syndrome.Gov Mission team in 2010 which found that the Human Immune Virus (HIV) causes real problems in the human central nervous system because it crosses the blood brain barrier into the brain and spinal cord, causing HIV associated dementia (HAD). The National Institute of Health (2013) highlighted that HAD occurs in people who are positive for the human immunodeficiency virus because the virus damages the brain s white matter and leads to social withdrawal, and trouble concentrating. There is need to establish the magnitude of the problem described in order to plan for an intervention because it has the ability to interfere with daily functioning of an individual.
According to the AIDS Education & Training Centre (2014), the above effects have been categorized into three HIV associated neurocognitive disorders. These include; asymptomatic neurocognitive impairment or disorder (ANI), mild neurocognitive disorder (MND) and HIV associated dementia (HAD) which involves moderate to severe functional impairment. HAD in the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) has been associated with major neurocognitive disorders. The study will be narrowed to the third category which is severe.
In terms of severity, Sing (2013) commented that, without treatment HAD has a rapid progression of 3-6 months mean survival rate. Haddow, Floyd, Copas & Gilson (2013) in the Frascati criteria research classification system commented that, HIV associated dementia (HAD) is the most severe grade of HIV associated neurocognitive disorder (HAND) which involves impairment of at least two cognitive domains scoring at least 2 points below demographically-appropriate score of 12 in International HIV Dementia Scale. The above two writers agree on the severity of HAD. The researcher will use a cut-off of < 10 during the study.
There is limited data on the severity of HAD in most parts of the world including Kenya. Sacktor, Nakasujja, Robertson and Cliff (2007) commented that there is inadequate data on HIV dementia patients in many parts of the world, they had hopes that more studies will be carried out in order to shade more light on devastating effects of HIV associated dementia in resource limited, and poorer regions of the world. Studies on prevalence of HIV have been given more weight in Kenya but information on HAD is limited, results on few studies on prevalence HAD have been generalized to represent wider area, for example study done in Nigeria was generalized to represent West Africa and Uganda to represent Sub-Saharan Africa, but specific prevalence in some countries is wanting.
Globally, Huang (2016) found the prevalence of HAD to range between 7 to 27 %, majority affected are those in the late stages of HIV infection. The prevalence was inversely proportional to the CD4 count, the prevalence comprised of both those on ARVs and those without. The prevalence could be high if it is confined to those on ARVs due to the HIV stage and drug side effects. Kevin et al (2007) in his study on prevalence of HAD in United States of America found that it affects 10-15 % of the patients which is lower than the global prevalence. However, prior to the advent of highly active antiretroviral therapy (HAART), dementia was a common source of morbidity and mortality in HIV-infected patients, and it was usually observed in the late stages of the Acquired Immunodeficiency Syndrome (AIDS) when CD4 count fall below 200 cells/ml, this was seen in up to 50% of patients prior to their death. Comparison of the two previous studies in America shows that ARVs had brought about changes in prevalence. This can explain the reason as to why HIV positive patients on ARVs live longer compared to the life span prior to the advent of ARVs, this also increases the prevalence because patient with neurocognitive disorder live longer. WHO recommend that, any patient with dementia should be commenced on ARVs and issues concerning good adherence should be addressed this will slow progression of HAD.
The African continent has also been hit by the scourge of HIV associated dementia. In 2012, Howlette in his study found that, prevalence of HAD among HIV population was 10-20 %.This finding is higher than the prevalence in the United States of America. This could be attributed to disease pattern, poverty and poor health system.
A study done in South Africa by Joska et al (2011) showed that, prevalence of HAD among the under 40 years patients initiating ARVs was 25.4 % and the prevalence among individuals receiving HAART was 10%.This study gives no room for comparison of prevalence among the general HIV population in South Africa and other countries who are yet to commence medication. However it could be lower because of the established health care system compared to other African countries.
In 2013, a study done by Nakkhu et al in Uganda found that, the prevalence of HAD was 64.4 % which was high compared to studies in developed countries. However, previous studies done in Uganda to represent Sub Saharan Africa in 2003 and 2010 was 31% and 64.1% respectively. These show that there has been progressive increase of prevalence from the previously done studies. Uganda is among the countries with high population of patients with dementia, this can be explained by high prevalence of HIV and poor economy. There is need to carry out assessments periodically in order to monitor the trend of dementia and plan for possible intervention. This may include early commencement of ARVs on dementia patients as recommended by WHO even before CD4 count or viral load done.
A pilot study done in western part of Kenya in 2012 by Kwasa et al. to test the sensitivity and reliability of dementia assessment tools, found that the prevalence of HAD among general HIV positive patients was 20%. This finding was lower than the three the studies done in Uganda, the sample size was only 30 patients because its objective was to test the tool. Kenya that has been ranked the fourth country in world with high prevalence of HIV, this means that the prevalence of HAD can be high in relation to disease burden.
Many researchers in the previous studies have commented that there is in adequate data on HIV associated dementia. This may hinder planning for intervention because the magnitude of the problem is unknown. More researches will inform the general public on the magnitude of the problem and will aid in planning for intervention, it will also be used as a baseline for other subsequent researches.
Statement of the problem
According to Florian (2017) HIV associated dementia causes decline in cognitive functioning such as thinking of cognitive functioning, reasoning ,judgment, concentration, problem solving, may interfere with problem of daily living and may lead to a vegetative state, in which the person has minimal awareness of his or her surrounding and incapable of interacting. This poses an overwhelming responsibility on families including Child parenting because adult parents cannot meet the expected level of performance. Dementia affect production in all areas which in turn will affect the economy of the country, health care cost has gone up because of the care required in terms of support and medication of HIV patients who could be suffering from dementia. Magnitude of this problem has not been established in many countries despite more data on Prevalence of HIV. This poses a challenge because no intervention can be successful without data that will guide in planning. There is therefore need to carry out more studies on prevalence and plan for intervention in order to halt progression into HAD.