Diagnostic Accuracy of New and Old Cognitive Screening Tools for HIV–Associated Neurocognitive Disorders

M Trunfio; D Vai; C Montrucchio; C Alcantarini; A Livelli; MC Tettoni; G Orofino; S Audagnotto; D Imperiale; S Bonora; G Di Perri; A Calcagno


HIV Medicine. 2018;19(7):455-464. 

In This Article

Abstract and Introduction


Objectives: Considering the similarities between HIV–associated neurocognitive disorders (HAND) and neurodegenerative dementias and the frequency of executive dysfunctions among HIV–positive patients, we evaluated the accuracy of the Frontal Assessment Battery and Clock–Drawing Test together with the Three Questions Test and International HIV Dementia Scale to screen for HAND.

Methods: A cross–sectional monocentric study was conducted from 2010 to 2017. The index tests were represented by the four screening tools; the reference standard was represented by a comprehensive neurocognitive battery used to investigate 10 cognitive domains. Patients were screened by a trained infectious diseases physician and those showing International HIV Dementia Scale scores ≤ 10 and/or complaining of neurocognitive symptoms were then evaluated by a trained neuropsychologist.

Results: A total of 650 patients were screened and 281 received the full neurocognitive evaluation. HAND was diagnosed in 140 individuals. The sensitivity, specificity, correct classification rate and area under the receiver operating characteristic curve (AUROC) were, respectively, as follows: Frontal Assessment Battery, 40.7%, 95.1%, 68.3% and 0.81; International HIV Dementia Scale, 74.4%, 56.8%, 65.4% and 0.73; Clock–Drawing Test, 30.9%, 73.4%, 53.8% and 0.56; and Three Questions Test, 37.3%, 54.1% and 45.7%. Raising the Frontal Assessment Battery's cut–off to ≤ 16 improved its sensitivity, specificity and correct classification rate to 78.0%, 63.9% and 70.8%, respectively.

Conclusions: We observed poor screening performances of the Three Questions and Clock–Drawing Tests. While the International HIV Dementia Scale showed a poor specificity, the Frontal Assessment Battery showed the highest correct classification rate and a promising performance at different exploratory cut–offs.


The widespread availability of highly active antiretroviral treatment (HAART) has increased the life expectancy of HIV–positive patients, reducing the most serious complications; however, new comorbidities have emerged, including a wide range of mild cognitive and motor impairments, collectively called HIV–associated neurocognitive disorders (HAND).[1] Among the disorders on the HAND spectrum, there has been a significant decrease in the incidence of HIV–associated dementia (HAD) and a concurrent increase in the incidences of asymptomatic neurocognitive impairment (ANI) and mild neurocognitive disorders (MNDs).[2] Currently, up to 55% of people living with HIV develop HAND, which are the most common form of neurocognitive impairment in young adults worldwide.[3] Nevertheless, even these milder forms of impairment negatively affect patients' quality of life, employment, treatment adherence and overall mortality.[2] In addition, they may be a risk factor for further cognitive decline.[4] Considering the HAND burden and the fact that diagnosis of HAND relies on a comprehensive neurocognitive assessment which is time– and resource–consuming, there is a growing demand for reliable, brief and easy to administer screening tools.[5] Various attempts to develop such tools have been made, with conflicting results.[5–10] Among the most commonly used screening tests, the International HIV Dementia Scale (IHDS) demonstrated variable sensitivity (SE) and specificity (SP) for milder cases,[7–9] the Three Questions Test (3QT) did not have its previous promise confirmed[11] and the Montreal Cognitive Assessment still needs to be effectively assessed for HIV–positive patients.[12–14] Their pooled SE and SP range widely as a consequence of significant discrepancies across the studies in terms of HAND classification, enrolled populations and gold standard references.[5,7–9] Moreover, HAND presentation seems to be heterogeneous, with a mixed pattern of cortical and subcortical impairment;[15,16] furthermore, the physiopathology of HAND is still not completely clear and probably includes distinct aetiologies.[3,16] However, among the multiple cognitive domains affected by HIV, executive functioning has been found to be one of the most commonly and severely impaired.[17] The Frontal Assessment Battery (FAB) is a short battery that is widely used to screen for dysexecutive syndrome in non–HIV–infected populations with neurodegenerative diseases,[18,19] while the Clock–Drawing Test (CDT) is employed as stand–alone screening for cognitive impairment and dementias;[20,21] it has been previously tested once in HIV–positive subjects, showing promising preliminary results.[22] Considering the evidence in support of similar cognitive profiles between HAND and neurodegenerative dementias and the underlying mixed pattern of cortical and subcortical deficits,[16] we aimed to investigate FAB and CDT as new screening tools for HAND.