Building Resources to Assess Impaired Neurocognition in Children with HIV in Low- and Middle-Income Countries (BRAIN Child in LMICs)

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There are 2.1 million children with HIV (CWH) under 15 years of age worldwide; the vast majority have perinatally-acquired HIV, reside in resource limited Low-and-Middle Income Countries (LMICs), and are surviving into adolescence and young adulthood. In Uganda, where the proposed study will take place, there are over 130,000 CWH under 15 years. CWH must contend with the negative effects of life-long viral infection and chronic inflammation on their neurodevelopment, medical status, mental health, and, for many, the demands of lifelong ART adherence – placing them at risk for not achieving crucial developmental milestones. Neurocognitive impairment (NCI) is chief among these negative effects. NCI in CWH most commonly affects the neurocognitive domains of working memory, executive functions, and processing speed. NCI can affect children’s ability to perform in and complete school, interact successfully with peers and adults, initiate and maintain long-term relationships, and develop independence. NCI can also interfere with adherence to medication, which is critical in HIV, and increase poor decision-making and greater HIV transmission risk behaviors (e.g., unprotected sex) for older children and adolescents. The first step in addressing NCI in CWH is detecting it but doing so in Uganda faces numerous challenges. Few neurocognitive tests exist for Ugandan children 5-12 years of age. The tests that do exist require highly trained personnel to administer and score, take several hours to administer, and many suffer from cultural biases because they were developed for and normed on youth in the US or Europe. Without accurate, clinically useful, and relatively brief NCI assessments that can be administered accurately by all levels of staff, researchers and clinicians will remain severely limited in their capacity to assess CWH in Uganda, missing opportunities to study and detect NCI, as well as intervene. NeuroScreen is a brief, easy-to-use app for Android devices to assess for NCI that is designed to be administered by all levels of clinical staff. The app contains twelve neurocognitive tests assessing processing speed, executive functions, working memory, verbal memory, and motor speed. It is standardized and highly automated, requires minimal training to administer, and does not require record-keeping or scoring. It has been used successfully with adults and adolescents but has not been evaluated for use with children under 13 years. The proposed study will: (1) determine the necessary adaptations needed to make NeuroScreen usable, understandable, and acceptable to CWH under 13 years, and for HIV providers likely to administer it; (2) generate preliminary estimates of the adapted tests’ validity indicators among CHW and matched controls 5-12 years of age; and (3) explore associations between NeuroScreen performance and behavioral health. These data will be the basis for future larger-scale research studies on NCI, as well as validation, implementation and scale-up of this mHealth tool for use in Uganda and other LMICs.