Majority of the respondents were females who accounted for 69.3 %, this shows that disease burden was high among women compared to men. Avert (2017) found that women account for more than a half the number of people living with HIV worldwide because of vulnerabilities created by unequal cultural practices, social and economic status. This scenario is replicated in HIV clinics where patients visit to seek medical help which was observed during the study.
The finding of this study revealed that 17.3 % of the respondents were not adhering to ARVs and this pose a danger of incomplete suppression of the virus creating resistance which will result into HIV associated dementia. Asmare et al. (2014) in Journal of antiretroviral and antiviral emphasized 95% adherence to ARVs in order to be fully effective.
The overall prevalence of HIV associated dementia was (65.6%) with a cut off score of < 10, only 34.4 % of the patients who participated in this study scored above the cut-off. This prevalence could be lower if done in a different facility within county because Comprehensive Care Centre receives patients across the county including referrals who need further consultation because of medical problems, and they could be suffering from neurocognitive disorders that leads to poor progress.
Varied prevalence have been reported in different countries both developed and developing. Tanzania has the highest prevalence in Africa though it was confined to National hospital. Nyundo et al. (2015) on a study on neurocognitive correlates of the use of combined Antiretroviral Therapy at Muhimbili National Hospital Dar salaam-Tanzania, revealed that the prevalence of Neurocognitive disorder was 68.4 %. With the cut-off of < 10 on IHDS. Another study by Asekomeh et al. (2013) done earlier in the same country but in different location showed that the prevalence of dementia in Tanzania was 56%. The difference was brought about by the study site, Muhimbili is a national hospital and could have received more patient as referrals with already existing challenges. This can be compared with the study site at Kapsabet because it receives referrals together with general HIV clients though it is lower than Muhimbili National Hospital.
The second highest prevalence of HIV associated dementia was from the country of Nigeria.
Asekomoth et all.(2013) found that prevalence of HIV dementia was 66.2% and it was done to represent west African countries, the prevalence could have been high because it was done on patients with advanced level of disease progression. Advance level of disease progression is as a result of high level of virus which increase the chance of brain injury, these are a group of patients who already have medical challenges by the fact that they had advanced infection. If the study is replicated in general HIV population the prevalence could be lower.
Uganda has also reported high prevalence of HIV associated dementia. In 2013, Nakku, Kinyanda, & Hoskins did a study at Entebbe District Hospital-Uganda, the researchers found that probable HIV dementia in ambulatory HIV adult population was 64.4%. The prevalence could have gone high because of the study site. District hospital serve a big population and is acting like a referral hospital. District Hospital in Uganda could be equated to county hospital in Kenya though the difference could be the population and the prevalence of HIV within the location of the hospital or town.
Africa countries have something in common, they are low economically, unestablished health care system, low education and nutritional challenges, this affect the health of the individuals. The three East African countries are in Sub-Sahara Africa where disease burden and poverty is high, this increase the prevalence of HIV associated dementia.
Developed countries have also experienced HIV associated dementia. Heathon (2010) found that prevalence of HAD in Europe was 2%. Robin et al. (2007) found that United Nations had 10-15 %. The difference in prevalence can be explained by the disease burden in Africa countries, low economic level, cultural practices, low education and poor health care system.
The study found that there was significant association between income of the patient and the score on International HIV dementia scale with p value of 0.029. Rai, Y.et al. (2011) found that, low socio-economic state, substance abuse, low educational level and greater psychiatric morbidity were associated with the Neurocognitive impairment. However there were no figures that gives association. During the study it was revealed that 47% of the respondents were earning below 5,000 Kenya shillings per month, this denied them access to education, proper health care and nutrition. Generally their living standards was low, this hasten the development of neurocognitive disorder resulting into HAD.
Sub-Sahara Africa is known to be the poorest region in the world, this state of poverty is associated with many challenges, this has also impacted negatively in Education, nutrition and health as mentioned above. Mbirimtengerenji (2007) commented that Sab-Saharan Africa is a home to 60% of people who live bellow UN poverty line of US$ 1 per day, also commented on the studies that found that HIV and poverty are correlated, the study also revealed that sub-Saharan Africa is home to 62% of worlds HIV cases. This state of poverty and HIV burden explains why it has high prevalence of HAD. Sahn (2009) in his study showed that, poverty level hinders individuals from accessing health care and weaken the immunity during infection, the intervention is delayed due to late diagnosis and ARVs initiation, this result into HAD. The distribution of earning among the patients who participated in the study showed that 78.7% earn 10,000 Ksh and bellow, this shows clearly the level of poverty that exist among the participants.
There was an ssociation between use of protective and HIV dementia with p=0.020. 28.4 % of those who were active sexually were not using any protective, this increases the chance of cross infection and multiplication of HIV virus which injures the brain, this also predispose the development of resistant strain that continues to attack brain cells. Those who were not using protective during sexual intercourse had wider margin standard deviation compared to the users.
Females patients living in rural areas, uneducated groups, and new ART users in Ethiopia were less likely to use condoms consistently (Shewamene, 2015).The above scenario in Ethiopia depict the state of respondent in the study, the study interviewed and assessed respondents from across the county, from rural setting and town, majority had primary level of education (60.2%), some had no formal education, and this means that they fall under the group of those who are likely to engage in sexual relationship without condom use.
Wilton (2013) fount that consistent use of condom is important in prevention of the virus during sexual relationship, both female and male condoms are equally effective and there is no reason to think they are not protective at all. This prevent cross transmission between people who are HIV positive and reduce the rate of multiplication and development of resistance virus. The two studies emphasize on the importance of use of protective in order to prevent more harm, continuous exposure increases the chance of brain injury leading to HAD.
The researcher determined that there exist significant association between stigma/discrimination with International dementia score with a p value of 0.038.This was calculated from the mean and standard deviation. (AVERT, 2017) in the study pointed out that there is cyclical relationship between stigma and HIV, people who experience sigma and discrimination are marginalized, this result into poor care within health sector and also they are not likely to access health care, loss of hope and feelings of worthless, loss of reputation, poverty and being reluctant to take antiretroviral therapy, this makes treatment less effective and may cause early death, Stigma has a damaging effect on the mental wellbeing of people living with HIV, this lower the score on HIV dementia scale.
Santoso et al, (2016) in a study done in Dominican republic found that stigma is associated with HAD because it prevents individual from disclosing her status and seeking proper treatment and support, when patient s HIV is unmanaged it will result in severe sequelae, namely HAD. This supports the previous researcher on the effects of stigma. The study found a small number of respondents who had not disclosed their HIV status to any one, this makes it difficult for them to access services and get support. This will affect their mental wellbeing leading to poor performance and low HIV Dementia score.
The researcher noted that there was no association between the viral load and the IHDS score of < 10 with (p-value of 0.267). There were respondents who had low detectable level of virus who scored as low as 4 points and others had over 1,001 virus per cubic milliliters and scored higher. The respondents with low detectable level of virus were 80.7 % yet 65.6% of all respondents had dementia, 4% with LDL scored 4 in IHDS, this shows that there is no association,
Reger et al. (2005) found that, equivocal results have been reported on the association between plasma viral load and cognitive functioning, the mechanism of cognitive impairment in HIV remains unclear, although dementia appears to be related to neuronal dysfunction and death. Continues to say that, Plasma HIV RNA levels may not predict the degree of neuropsychological disturbance in HIV infection among patients receiving antiretroviral treatment and that there were no difference between groups with undetectable, low or moderate plasma HIV RNA levels. The findings support what this study found because there were those who had LDL but scored high on dementia scale.
Kaul, 2009 found that though HAART maintains a significant effect on the incidence of HAD, it cannot prevent the progression of neurocognitive impairment because infected and activated macrophages and microglia in the blood seems to be a major factor promoting the development of HAD. He also found that, regardless of Viral load an individual will develop HAD in the long run even when taking ARVs though the onset is delayed and severity reduced. He also found that there are other factors that may contribute to Cognitive impairment other than viral load. Certain genetic factors can influence the risk of neurological side effects from HIV medicines.
AETC. (2014) in a recent research found that neuro-inflammation rather than the HIV viral load in Central nervous system is primarily responsible for cognitive impairment in HIV-Infected individuals. This also means that the viral load could be low as it was shown in this study but individual has neurological impairment. The study supported the finding of this research that there is no significant association between viral load and International HIV dementia score, cognitive impairment can be caused by injury of ARVs drugs, this explain why some patients had Low level of detectable virus but still scored low in IHDS.
Generally, the findings shows that majority (80.7 %) of the respondents had low detectable levels (LDL) yet they performed poorly in International HIV scale, this confirms that there is no association
According to Nam aidsmap, 2007 the more the HIV in the blood the greater the risk of becoming ill, this include HIV associated dementia among other complications. Steinbrink (2013) supported the association between the viral load and dementia score he found that, during the course of HIV infection different changes in the cerebrospinal fluid (CSF) of HIV infected patients have been observed as the infection progresses, when there is high viral load there is destruction of the brain cells, the researcher concluded that CD4 count and the viral load represent a strong predictors of the development of HAD and associated it with the severity of cognitive impairment. From the above studies it is evident that two observation have been made concerning association, this study supported the finding of those who found that there is no association between viral load and IHDS score. However there is need to study more in order to arrive into conclusion.
Further analysis using logistic regression revealed that those who had used ARVs for over 9 years and above had 0.07 times higher in developing dementia compare to those who had used it for a short time. This is explained by John Hopkins hospital (n.d) found that, neurological complications may result not only from damage caused by the virus itself, but also from other side effects of HIV and AIDS drugs used to treat HIV and AIDS while attempting to control the rapid spread of the virus, this means that the person who has used for long may experience more effects. Kaul (2009) found that infected and activated Microphages and microglia is a factor in developing HAD, they injure the brain and the longer they are in the body the higher the destruction of the brain cells. The risk of HIV associated dementia was about 4 times more among the participants who reported to have psychosocial problems (Stigma /discrimination). AVERT (2017) found that found that Stigma and discrimination has a damaging effect on the mental wellbeing of people living with HIV, also found that 50% of the people reports having discriminatory attitudes towards People living with HIV, this lowers the score because of disease progression. In Support of the finding a study by Santoso et al. (2016) in Dominican Republic determined that stigma is associated with HAD because it prevents individual from disclosing her status and seeking proper treatment and support. This explains why they are 4 times more likely to develop HAD than those without stigma.
Limitation of the study
1. The study lacked neurocognitive diagnostic battery to confirm the diagnosis of HIV associated because IHDS is a screening tool.
2. The study was not able to establish the previous state of an individual prior to HIV infection, if she or he already had dementia.
3. Issues of mental disability that require assessment was not ruled out during the study, this may affect the results.
4. The sample size was small to be generalized to give the country or county prevalence
Recommendations of the Study
1. Screening patients after every 2 months using IHDS.
2. Health messages should to emphasize on HIV, importance of drug compliance and the use of protective.
3. Availability of counselling services for those in need
4. Psychoeducation on alcohol and its effects on ARVs drugs interaction
5. Psycho-educate religious leaders on ARVs action and include them on the care of HIV positive patients.
6. Screen patient for depression and alcohol before IHDS assessment
Conclusion
There is a high prevalence of HIV associated dementia mong HIV patient attending Kapsabet comprehensive Care centre. This however is not associated with viral load.