Dementia risk higher among adults with HIV in Malawi

Adults living with HIV in Malawi are more than twice as likely to also have dementia compared to those without HIV, according to a new study by a team of US and Malawian researchers. 

Their findings, published in the journal Alzheimer's and Dementia, shed light on the significant burden of dementia among people living with HIV in Malawi and the importance of studying dementia in resource-poor settings with limited access to health care.

Thanks to advances in the treatment of HIV with antiretroviral therapy, people with HIV are living longer lives. Yet aging with HIV comes with challenges, as the virus increases the chances of prematurely developing other age-related diseases, including diabetes, heart disease, and cancer. Due to inflammation and other changes in the brain, HIV also raises the risk for dementia.

In the southeastern African country of Malawi, 8 to 12 percent of adults are living with HIV and it remains the leading cause of death. However, life expectancy has dramatically improved in recent decades: according to the World Health Organization, a child born in 2000 is expected to live only to 45, while a child born in 2021 is likely to live to 63. With sub-Saharan Africa's aging population, experts are predicting a surge of dementia cases in the coming decades. 

Most of what we know about dementia and Alzheimer's disease comes from research studies in high-income countries, but less is known about dementia prevalence and risk in low- and middle-income countries."

Haeok Lee, professor at NYU Rory Meyers College of Nursing and study's lead author

To better understand the prevalence of dementia among people in Malawi with and without HIV, the researchers reviewed medical records from 400 adult patients 30 years and older seen at an outpatient clinic in Lilongwe, the capital city of Malawi. Half of the participants were living with HIV and taking antiretroviral therapy, while the other half did not have HIV. 

The researchers found that 22 percent of people with HIV had dementia, compared with 10 percent of those without HIV. Although the prevalence of dementia increased with age in both groups, the increase was more rapid in those with HIV, who also tended to be diagnosed with dementia at a younger age.

In addition to older age, depression was a significant risk factor for dementia for both people with and without HIV. For people living with HIV, unstable employment also increased the chances of developing dementia. 

The researchers caution that there are limitations to using medical records to understand dementia prevalence and risk in Malawi, including the challenges of analyzing paper charts (not electronic records), a lack of standardized diagnostic codes, and no records on alcohol and substance use. In addition, because of the shortage of healthcare professionals in the country-there is only one neurologist in the entire adult population-it's likely that dementia is underdiagnosed due to a lack of screening.

"We need to do more in order for us to look after patients with dementia in low- and middle-income countries," said study author Jonathan Ngoma of the Kamuzu Central Hospital and Malawi Ministry of Health. "We have embarked on a journey to bring out a lot of information to the world."

"Our findings highlight an urgent need to develop infrastructure for the management of dementia for both people living with HIV and the general population in Malawi, including culturally tested cognitive assessment tools and treatment guidelines that are tailored to Malawians and the local health care system," added Lee. 

The study will appear in a special issue of Alzheimer's and Dementia focusing on dementia research in Africa. In addition to Lee and Ngoma, study authors include Yohannie Mlombe of Kamuzu University of Health Sciences; Yeunjoo Song of Case Western Reserve University School of Medicine; Hyun-Sik Yang of Brigham and Women's Hospital and Harvard Medical School; Tiwonge Phiri of the Malawi Ministry of Health and Queen Elizabeth Central Hospital; Joseph Maseke and Esther Bauleni of Daeyang University in Malawi; Gyungah Jun of Boston University; and Yun-Beom Choi of Rutgers Medical School.