title: Lessons learned developing a diagnostic tool for HIV-associated dementia feasible to implement in resource-limited settings: pilot testing in Kenya.
abstract: OBJECTIVE
  To conduct a preliminary evaluation of the utility and reliability of a diagnostic tool for HIV-associated dementia (HAD) for use by primary health care workers (HCW) which would be feasible to implement in resource-limited settings.
  
  
  BACKGROUND
  In resource-limited settings, HAD is an indication for anti-retroviral therapy regardless of CD4 T-cell count. Anti-retroviral therapy, the treatment for HAD, is now increasingly available in resource-limited settings. Nonetheless, HAD remains under-diagnosed likely because of limited clinical expertise and availability of diagnostic tests. Thus, a simple diagnostic tool which is practical to implement in resource-limited settings is an urgent need.
  
  
  METHODS
  A convenience sample of 30 HIV-infected outpatients was enrolled in Western Kenya. We assessed the sensitivity and specificity of a diagnostic tool for HAD as administered by a primary HCW. This was compared to an expert clinical assessment which included examination by a physician, neuropsychological testing, and in selected cases, brain imaging. Agreement between HCW and an expert examiner on certain tool components was measured using Kappa statistic.
  
  
  RESULTS
  The sample was 57% male, mean age was 38.6 years, mean CD4 T-cell count was 323 cells/µL, and 54% had less than a secondary school education. Six (20%) of the subjects were diagnosed with HAD by expert clinical assessment. The diagnostic tool was 63% sensitive and 67% specific for HAD. Agreement between HCW and expert examiners was poor for many individual items of the diagnostic tool (K = .03-.65). This diagnostic tool had moderate sensitivity and specificity for HAD. However, reliability was poor, suggesting that substantial training and formal evaluations of training adequacy will be critical to enable HCW to reliably administer a brief diagnostic tool for HAD.
authors.affiliation: Center for Microbiology Research Kenya Medical Research Institute, Nairobi, Kenya.
authors.forename: Judith
authors.initials: J
authors.lastname: Kwasa
authors.forename: Deanna
authors.initials: D
authors.lastname: Cettomai
authors.forename: Edwin
authors.initials: E
authors.lastname: Lwanya
authors.forename: Dennis
authors.initials: D
authors.lastname: Osiemo
authors.forename: Patrick
authors.initials: P
authors.lastname: Oyaro
authors.forename: Gretchen L
authors.initials: GL
authors.lastname: Birbeck
authors.forename: Richard W
authors.initials: RW
authors.lastname: Price
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bukusi
authors.forename: Craig R
authors.initials: CR
authors.lastname: Cohen
authors.forename: Ana-Claire L
authors.initials: AC
authors.lastname: Meyer
mesh_terms: D015526:AIDS Dementia Complex / Q000175:diagnosis*; D000328:Adult; D005260:Female; D006282:Health Personnel; D006295:Health Resources; D006801:Humans; D007630:Kenya; D008297:Male; D008875:Middle Aged; D009483:Neuropsychological Tests; D010865:Pilot Projects; D055815:Young Adult