Is Cognitive Care the Next Blind Spot in HIV Clinical Practice? Exploring the Facilitators and Barriers to Integrating Cognitive Care into Routine HIV Care in Malaysia: A Mixed Method Study

Abstract

In the antiretroviral therapy era, as people living with HIV (PWH) age, the decline of HIV-associated dementia has been accompanied by a growing burden of earlier Alzheimer-type pathology and other milder, heterogeneous cognitive impairments, underscoring the need for proactive detection and multidisciplinary management within routine HIV care. Yet, cognitive care remains largely absent, particularly in low- and middle-income countries (LMIC). We evaluated readiness to integrate a multidomain cognitive-rehabilitation program into tertiary HIV clinic in Malaysia and identified implementation determinants. We used a sequential mixed-methods design. An online Knowledge–Attitude–Practice survey was distributed to all infectious-disease physicians nationwide (N = 94). Qualitative data were generated through focus-group discussions with health care providers (HCPs) and in-depth interviews with PWH aged >40 years. Transcripts were analyzed thematically using the Consolidated Framework for Implementation Research (CFIR 2.0). Forty-nine physicians responded (52.4% response), median age was 44 years (inter-quartile range (IQR) 38–51), and 71.4% were female. While 71–82% demonstrated satisfactory knowledge and attitudes toward cognitive health, 88% reported poor practice; only 20.5% routinely screened older PWH. Thirty-three HCPs from multidisciplinary backgrounds participated in five focus groups, alongside 19 in-depth interviews with PWH. Three interlinked domains emerged: (1) knowledge–practice gap related to uncertainty around screening tools, referral pathways, and evidence applicability; (2) systemic barriers including time constraints, high caseloads, lack of guidelines, and workforce limitations; and (3) stigma affecting acceptability. Facilitators included strong patient motivation for brain health, allied health upskilling, physician-initiated referrals, and dedicated care coordination. Integration of multidisciplinary cognitive rehabilitation is hindered by modifiable structural deficits in knowledge translation, workforce organization, and guideline support. HIV-adapted screening algorithms, formalized referral processes, and task-shared coordinator roles could enable earlier cognitive interventions for older adults living with HIV in Malaysia and similar LMIC settings.