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

This project addresses a critical gap in detecting neurocognitive impairment (NCI) among children with HIV (CWH) in resource-limited settings, with the proposed study taking place in Uganda. There are approximately 2.1 million CWH under 15 years globally, most with perinatally-acquired HIV living in LMICs and surviving into adolescence and young adulthood. In Uganda alone there are over 130,000 CWH under 15. Lifelong viral infection, chronic inflammation, impacts on neurodevelopment, mental health challenges, and the demands of lifelong antiretroviral therapy place these children at heightened risk for failing to achieve key developmental milestones. NCI commonly affects working memory, executive functions, and processing speed, undermining school performance, social functioning, medication adherence, and increasing risk behaviors that can perpetuate HIV transmission in older youth. Detecting NCI is the essential first step for research, clinical care, and intervention, yet Uganda currently lacks appropriate, brief, culturally valid tools for children aged 5–12.

Existing neurocognitive tests for Ugandan children are few, often require highly trained personnel, are time-consuming, and may carry cultural biases from being developed and normed in high-income countries. Without accurate, clinically useful, and relatively brief assessments that can be administered by staff at all levels, clinicians and researchers are limited in their capacity to identify NCI, study its correlates and consequences, and implement interventions. The BRAIN Child study centers on NeuroScreen, an Android-based app comprising twelve neurocognitive tests that assess processing speed, executive functions, working memory, verbal memory, and motor speed. NeuroScreen is standardized, highly automated, requires minimal training, and eliminates record-keeping and manual scoring burdens. While it has been used successfully with adults and adolescents, it has not been evaluated for children under 13.

The proposed work has three primary aims: first, to determine the adaptations necessary to make NeuroScreen usable, understandable, and acceptable for CWH under 13 and for the HIV care providers likely to administer it; second, to generate preliminary validity estimates for the adapted tests among CWH and matched controls aged 5–12; and third, to explore associations between NeuroScreen performance and behavioral health. By assessing usability and acceptability, adapting content and administration for developmental and cultural relevance, and producing initial validity indicators and behavioral correlates, the project will establish foundational data for future larger-scale studies. These data will support subsequent validation, implementation, and scale-up of an mHealth tool that could enable routine screening for NCI in Uganda and other LMICs, expand research on neurocognitive outcomes in CWH, and inform interventions to mitigate NCI’s long-term impacts on education, mental health, adherence, and transmission risk.

Funded through awards recorded under the Fogarty International Center/NIH, the project leverages mHealth innovation to confront practical, cultural, and clinical barriers to NCI detection in pediatric HIV, aiming to create a feasible, scalable approach to identify and ultimately address neurocognitive needs among children in resource-limited settings.