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Distinguishing cognitive impairment from HIV-associated neurocognitive disorder versus substance use?

HIV-associated neurocognitive disorders (HANDs) remain common despite combined antiretroviral therapy (cART). Estimates of the prevalence in virologically suppressed people living with HIV range from 25% to 40% [1,2] and asymptomatic neurocognitive impairment accounts for up to 70% of all forms of HAND [3]. Diagnosis is becoming more difficult as people living with HIV have an increasing burden of comorbidities, including aging-related disorders [4,5] cardiovascular and cerebrovascular diseases [6], metabolic disorder, insulin resistance and diabetes mellitus [7], polypharmacy, and coinfections. Particularly important in certain countries are substance use disorders (SUDs). It is clear from both basic science and epidemiological studies that SUDs may increase the risk of HAND [8,9]. It is also clear that there is substantial overlap in the neuropsychological profiles of cognitive impairment attributable to HIV and SUDs. However, the extent to which the neuropsychological profiles overlap requires further evaluation. A common clinical problem is whether a patient has cognitive impairment related to HAND or SUD or some complex interaction of both, be it additive or synergistic. A means of distinguishing between the two would help clinicians immeasurably, and potentially guide therapies,