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Cognitive Impairment – Signs and Symptoms

Signs and Symptoms

HIV-associated neurocognitive disorders (HAND) may involve a range of symptoms with varying degrees of severity that can be represented by the 3Ms: memory, mood and motor.

  • Patients with HAND have an acquired impairment in at least 2 cognitive ability domains, including the following:1
    • attention/working memory
    • learning/recall memory
    • abstraction/executive functioning
    • speed of information processing
    • sensory-perceptual motor skills
    • language

HAND typically presents with milder symptoms in the highly active antiretroviral therapy (HAART) era than previously, and the condition may often be undiagnosed.2

  • The European AIDS Clinical Society (EACS) recommend that all patients without highly confounding conditions should be screened for cognitive impairment at HIV diagnosis, prior to initiation of antiretroviral therapy (ART), and every 2 years irrespective of ART.3
  • Approximately 30% of those diagnosed with HAND can be classified as having asymptomatic neurocognitive impairment (ANI)4 that does not interfere with daily functioning.1
  • In mild neurocognitive disorder (MND), the patient shows at least a mild interference in daily functioning that can be defined as a reduction in mental acuity, inefficiency in work, homemaking, or social functioning that is self-reported and/or reported by knowledgeable others.1

HIV-associated dementia (HAD)

HAD is a form of HAND with a more marked acquired impairment in cognitive functioning than ANI or MND. Common early symptoms of HAD include:5

  • difficulty in finding words
  • forgetfulness
  • psychomotor slowing
  • diminished writing or visual/motor skills
  • depressed mood
  • hypomania

Common clinical features of late-stage HAD include seizures, incontinence and severe confusion.

Misdiagnosis of HAD

The early stages of HAD are often difficult to recognize and may resemble primary psychiatric disorders.5

  • Early HAD can be differentiated from Alzheimer’s disease by its association with behavioral changes and its more rapid progression
  • Early HAD may be associated with abnormal cerebrospinal fluid findings, and is rarely associated with aphasia
  • In cognitively-impaired patients with HIV, levels of β-amyloid were similar to those in patients with mild dementia of the Alzheimer type, while CSF tau (a biomarker of Alzheimer Disease) levels were different between the groups6
  • Depression and dementia may present with similar symptoms, particularly in older people

Find out about diagnostic tools 


  1. Antinori A, Arendt G, Becker JT, et al. Updated research nosology for HIV-associated neurocognitive disorders. Neurology. 2007;69:1789–1799.
  2. Valcour V, Sithinamsuwan P, Letendre S, et al. Pathogenesis of HIV in the central nervous system. Curr HIV/AIDS Rep. 2011;8:54–61.
  3. European AIDS Clinical Society (EACS). Guidelines. Version 6.0. Accessed 4 July 2012.
  4. McArthur J, Steiner J, Sacktor N, Nath A. Human immunodeficiency virus-associated neurocognitive disorders: Mind the gap. Ann Neurol. 2010;67:699–714.
  5. Office of the Medical Director, New York State Department of Health AIDS Institute in collaboration with the Johns Hopkins University Division of Infectious Diseases. Clinical Guidelines: Cognitive Disorders and HIV/AIDS. Accessed 3 March 2011.
  6. Clifford DB, Fagan AM, Holtzman DM, et al. CSF biomarkers of Alzheimer disease in HIV-associated neurologic disease. Neurology. 2009;73:1982–1987.