Background:  Children perinatally infected with HIV are at risk for impairment in higher cognitive functions, including language. This study evaluated the prevalence of primary and secondary language impairment for perinatally infected children, and examined associations with markers of HIV disease severity.

Methods:  Perinatally infected children enrolled in PHACS were evaluated for language impairment (LI) using a comprehensive standardized language test (CELF-4). LI was defined as scoring >1 SD below the reference mean (CELF <85). The children were classified as having primary LI (LI with monolingual English exposure and no cognitive or hearing impairment), secondary LI (LI with cognitive or hearing impairment or bi- or multi-lingual exposure), or no LI. Non-verbal cognitive abilities were evaluated with the Weschler Intelligence Scale for Children (WISC-IV). Hearing status was determined by audiological exam or parental report. Association of HIV disease markers with LI category was evaluated using chi-square tests and multinomial logit analysis.

Results:  Of 141 children (48% male, 70% black, 20% Hispanic) with language assessments, 50 (35%) had either primary LI (19, 13%) or secondary LI (31, 22%), compared to an overall expected 16%. Of those with secondary LI, 65% had accompanying low cognitive performance, 23% had abnormal hearing, and 39% reported bi- or multi-lingual exposure. Children with secondary LI were more likely to have CDC Class C diagnosis at entry than those with primary LI or no LI (45% vs 11% and 29%, respectively, χ² p = 0.04), and were more likely to initiate ART in the first 6 months of life than those with primary or no LI (61% vs 26% and 40%, respectively, χ² p = 0.03). Other markers of increased HIV disease severity were also higher in those with secondary LI, but not significantly (see table). After adjustment for age and other co-variates, those enrolling as US Centers for Disease Control and Prevention (CDC) class C were marginally more likely to present with secondary LI and marginally less likely to have primary LI.

Conclusions:  Language impairments in perinatally infected children appear as part of the risk for higher cognitive abilities and are more common than expected. Secondary LI co-exists with cognitive and hearing impairment and is more likely with more advanced HIV disease, while primary LI is less likely to be associated with advanced HIV disease. Thus, such children may escape detection as higher risk of cognitive impairment. This study reveals that HIV disease is one of the multiple factors that can contribute to LI.