Should the Frascati criteria for HIV-associated neurocognitive disorders be used in children?

Cognitive impairment is likely common in children and adolescents with HIV infection in low-resource settings.¹ While early treatment with highly active antiretroviral therapy has greatly reduced the most severe form of cognitive impairment in children,² milder forms of cognitive impairment may be increasing in prevalence due to longer survival.^3–5 Before 2007, marked heterogeneity in definitions of HIV-associated neurocognitive disorders (HAND) made it challenging to interpret different rates of cognitive impairment among regions or populations. The Frascati criteria, developed in 2007, created a uniform approach to the diagnosis of HAND in adults and vastly improved the ability of researchers to understand these disorders and their consequences. Application of the Frascati criteria requires neuropsychological testing in at least 5 cognitive domains, assessment of impairment of activities of daily living, and exclusion of other causes of cognitive impairment.⁶ Recently, several analyses suggest that the Frascati criteria have a high false-positive rate for milder forms of HAND in adults, which may limit the utility of these criteria.^5,7,8 False-positive rates may be affected by incomplete exclusion of confounding disorders such as subclinical depression, drug use, educational deprivation, and effects of socioeconomic status.