Use of WHO clinical stage for assessing patient eligibility to antiretroviral therapy in a routine health service setting in Jinja, Uganda

Insufficient declines in new HIV infection rates amidst high scores in HIV testing and awareness: ‘a game theory simulation’

Aim

Substantial progress has been made towards the 90–90–90 global targets; however, the pace at which new infections are declining remains undesirable to meet the UNAIDS 2020 global targets of below 500,000 new infections annually. We discussed the possibility of continued HIV incidence amidst remarkable scores in the 90–90–90 global targets.

Subject and methods

A game theory simulation was used to explain micro-level sexual interactions in situations of imperfect information on each partner’s HIV status. A non-cooperative sex game tree was constructed following the Harsanyi transformation in two scenarios; scenario one: a player assigns higher subjective probability that the partner is HIV negative; and in scenario two: a player assigns higher subjective probability that the partner is HIV positive. Subjective expected utilities were computed using hypothetical payoffs.

Results

Accepting unprotected sex is a pure strategy for both players in scenario 1. Player2 is likely to acquire HIV/AIDS. Accepting protected sex is a mixed strategy equilibrium for both players in scenario 2. Player2 is likely to avoid HIV infection.

Conclusion

Choice for safe or risky sex is a function of subjective probabilities individuals attach to their partners being infected or uninfected. More efforts towards addressing factors affecting individual probability distributions on riskiness of their sexual partners is required, especially for young women in Sub-Saharan Africa.

Prediction of CD4 T-Lymphocyte Count Using WHO Clinical Staging among ART-Naïve HIV-Infected Adolescents and Adults in Northern Ethiopia: A Retrospective Study

BACKGROUND

WHO clinical staging has long been used to assess the immunological status of HIV-infected patients at initiation of antiretroviral therapy and during treatment follow-up. In setups where CD4 count determination is not readily available, WHO clinical staging is a viable option. However, correlation between CD4 count and WHO clinical staging is not known in an Ethiopian setting, and hence, the main aim of this study was to assess predictability of CD4 T-lymphocyte count using WHO clinical staging among ART-naïve HIV-infected adolescents and adults in northern Ethiopia.

METHODS

A retrospective cross-sectional study was done in the Tigray Region, Ethiopia, from April 2015 to January 2019 from a secondary database of 19525 HIV-infected patients on antiretroviral treatment. Analysis was done using STATA-14.0 to estimate the frequencies, mean, and median of CD4 T-cell count in each WHO stages. Sensitivity, specificity, positive predictive value, negative predictive value, kappa test, and correlations were calculated to show the relationships between WHO stages and CD T-cell count.

RESULTS

The sensitivity of WHO clinical staging to predict CD4 T-cell counts of <200 cells/μl was 94.17% with a specificity of 3.62%. The PPV was 49.03%, and the NPV was 3.62%. The sensitivity of WHO clinical staging to predict CD4 T-cell counts of <350 cells/μl was 94.75% with a specificity of 3.00%. The PPV was 75.81%, and the NPV was 15.09%. Similarly, the sensitivity of WHO clinical staging to predict CD4 T-cell counts of <500 cells/μl was 95.03% with a specificity of 2.73% and the PPV and NPV were 88.32% and 6.62%, respectively. The kappa agreement of WHO clinical stages was also insignificant when compared with the disaggregated CD4 counts in different categories. The correlation of WHO clinical staging was inversely associated with the CD4 count, and the magnitude of the correlation was 5.22%.

CONCLUSIONS

The WHO clinical staging had high sensitivity but low specificity in predicting patients with CD4 count <200 cells/μl, <350 cells/μl, and <500 cells/μl. There was poor correlation and agreement between CD4 T-lymphocyte count and WHO clinical staging. Therefore, WHO clinical staging alone may not provide accurate information on the immunological status of patients, and hence, it is better to use the CDC definition rather than the WHO clinical definition.

Evaluation of PIMATM CD4 System for Decentralization of Immunological Monitoring of HIV-Infected Patients in Senegal

BACKGROUND

HIV infection is a concern in the army troupes because of the risk behaviour of the military population. In order to allow regular access to CD4+ T cell enumeration of military personnel as well as their dependents and civilians living with HIV, the Senegalese Army AIDS program is implementing PIMATM Alere technology in urban and semi-urban military medical centres. Validation such device is therefore required prior their wide implementation. The purpose of this study was to compare CD4+ T cell count measurements between the PIMATM Alere to the BD FACSCountTM.

METHODOLOGY

We selected a total of 200 subjects including 50 patients with CD4+ T-cells below 200/mm3, 50 between 200 and 350/mm3, 50 between 351 and 500/mm3, and 50 above 500/mm3. CD4+ T-cell count was performed on venous blood using the BD FASCountTM as reference method and the PIMATM Point of Care technology. The mean biases and limits of agreement between the PIMATM Alere and BD FACSCountTM were assessed with the Bland-Altman analysis, the linear regression performed using the Passing-Bablok regression analysis, and the percent similarity calculated using the Scott method.

RESULTS

Our data have shown a mean difference of 22.3 cells/mm3 [95%CI:9.1-35.5] between the BD FACSCountTM and PIMATM Alere CD4 measurements. However, the mean differences of the two methods was not significantly different to zero when CD4+ T-cell count was below 350/mm3 (P = 0.76). The Passing-Bablok regression in categorized CD4 counts has also showed concordance correlation coefficient of 0.89 for CD4+ T cell counts below 350/mm3 whilst it was 0.5 when CD4 was above 350/mm3.

CONCLUSION

Overall, our data have shown that for low CD4 counts, the results from the PIMATM Alere provided accurate CD4+ T cell counts with a good agreement compared to the FACSCountTM.

Diagnostic accuracy of the WHO clinical staging system for defining eligibility for ART in sub-Saharan Africa: a systematic review and meta-analysis

INTRODUCTION

The World Health Organization (WHO) recommends that HIV-positive adults with CD4 count ≤500 cells/mm(3) initiate antiretroviral therapy (ART). In many countries of sub-Saharan Africa, CD4 count is not widely available or consistently used and instead the WHO clinical staging system is used to determine ART eligibility. However, concerns have been raised regarding its discriminatory ability to identify patients eligible to start ART. We therefore reviewed the accuracy of WHO stage 3 or 4 assessment in identifying ART eligibility according to CD4 count thresholds for ART initiation.

METHODS

We systematically searched PubMed and Global Health databases and conference abstracts using a comprehensive strategy for studies that compared the results of WHO clinical staging with CD4 count thresholds. Studies performed in sub-Saharan Africa and published in English between 1998 and 2013 were eligible for inclusion according to our predefined study protocol. Two authors independently extracted data and assessed methodological quality and risk of bias using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) tool. Summary estimates of sensitivity and specificity were derived for each CD4 count threshold and hierarchical summary receiver operator characteristic curves were plotted.

RESULTS

Fifteen studies met the inclusion criteria, including 25,032 participants from 14 countries. Most studies assessed individuals attending ART clinics prior to treatment initiation. WHO clinical stage 3 or 4 disease had a sensitivity of 60% (95% CI: 45-73%, Q=914.26, p<0.001) and specificity of 73% (95% CI: 60-83%, Q=1439.43, p<0.001) for a CD4 threshold of ≤200 cells/mm(3) (11 studies); sensitivity and specificity for a threshold of CD4 count ≤350 cells/mm(3) were 45% (95% CI: 26-66%, Q=1607.31, p<0.001) and 85% (95% CI: 69-93%, Q=896.70, p<0.001), respectively (six studies). For the threshold of CD4 count ≤500 cells/mm(3) sensitivity was 14% (95% CI: 13-15%) and specificity was 95% (95% CI: 94-96%) (one study).

CONCLUSIONS

When used for individual treatment decisions, WHO clinical staging misses a high proportion of individuals who are ART eligible by CD4 count, with sensitivity falling as CD4 count criteria rises. Access to accurate, accessible, robust and affordable CD4 count testing methods will be a pressing need for as long as ART initiation decisions are based on criteria other than seropositivity.

Measures of viral load using Abbott RealTime HIV-1 Assay on venous and fingerstick dried blood spots from provider-collected specimens in Malawian District Hospitals

BACKGROUND

Viral suppression is a key indicator of antiretroviral therapy (ART) response among HIV-infected patients. Dried blood spots (DBS) are an appealing alternative to conventional plasma-based virologic testing, improving access to monitoring in resource-limited settings. However, validity of DBS obtained from fingerstick in field settings remains unknown.

OBJECTIVES

Investigate feasibility and accuracy of DBS vs plasma collected by healthcare workers in real-world settings of remote hospitals in Malawi. Compare venous DBS to fingerstick DBS for identifying treatment failure.

STUDY DESIGN

We recruited patients from ART clinics at two district hospitals in Malawi, collecting plasma, venous DBS (vDBS), and fingerstick DBS (fsDBS) cards for the first 149 patients, and vDBS and fsDBS only for the subsequent 398 patients. Specimens were tested using Abbott RealTime HIV-1 Assay (lower detection limit 40 copies/ml (plasma) and 550 copies/ml (DBS)).

RESULTS

21/149 (14.1%) had detectable viremia (>1.6 log copies/ml), 13 of which were detectable for plasma, vDBS, and fsDBS. Linear regression demonstrated high correlation for plasma vs. DBS (vDBS: β=1.19, R(2)=0.93 (p<0.0001); fsDBS β=1.20, R(2)=0.90 (p<0.0001)) and vDBS vs. fsDBS (β=0.88, R(2)=0.73, (p<0.0001)). Mean difference between plasma and vDBS was 1.1 log copies/ml [SD: 0.27] and plasma and fsDBS 1.1 log copies/ml [SD: 0.31]. At 5000 copies/ml, sensitivity was 100%, and specificity was 98.6% and 97.8% for vDBS and fsDBS, respectively, compared to plasma.

CONCLUSIONS

DBS from venipuncture and fingerstick perform well at the failure threshold of 5000 copies/ml. Fingerstick specimen source may improve access to virologic treatment monitoring in resource-limited settings given task-shifting in high-volume, low-resource facilities.

A novel community health worker tool outperforms WHO clinical staging for assessment of antiretroviral therapy eligibility in a resource-limited setting

The accuracy of a novel community health worker antiretroviral therapy eligibility assessment tool was examined in community members in Blantyre, Malawi. Nurses independently performed World Health Organization (WHO) staging and CD4 counts. One hundred ten (55.6%) of 198 HIV-positive participants had a CD4 count of <350 cells per cubic millimeter. The community health worker tool significantly outperformed WHO clinical staging in identifying CD4 count of <350 cells per cubic millimeter in terms of sensitivity (41% vs. 19%), positive predictive value (75% vs. 68%), negative predictive values (53% vs. 47%), and area under the receiver-operator curve (0.62 vs. 0.54; P = 0.017). Reliance on WHO staging is likely to result in missed and delayed antiretroviral therapy initiation.

Field evaluation of PIMA point-of-care CD4 testing in Rakai, Uganda

Objective

To assess the accuracy of PIMA Point-of-Care (POC) CD4 testing in rural Rakai, Uganda.

Methods

903 HIV positive persons attending field clinics provided a venous blood sample assessed on site using PIMA analyzers per manufacturer's specifications. The venous samples were then run on FACSCalibur flow cytometry at a central facility. The Bland–Altman method was used to estimate mean bias and 95% limits of agreement (LOA). Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated for a CD4 threshold of <350 and <500 cells/uL for antiretroviral eligibility.

Results

There was a high correlation between PIMA and FACSCalibur CD4 counts (r = 0.943, p<0.001). Relative to FACSCalibur, the PIMA POC CD4 had negative mean bias of −34.6 cells/uL (95% LOA: −219.8 to 150.6) overall. The dispersion at CD4<350 cells/uL was 5.1 cells/uL (95% LOA: −126.6 to 136.8). For a threshold of CD4<350 cells/uL, PIMA venous blood had a sensitivity of 88.6% (95%CI 84.8–92.4%), specificity of 87.5% (95%CI 84.9–90.1%), NPV of 94.9% (95%CI 93.1–96.7%), and PPV of 74.4% (95%CI 69.6–79.2%). PIMA sensitivity and PPV significantly increased to 96.1% and 88.3% respectively with increased threshold of 500 cells/uL.

Conclusions

Overall, PIMA POC CD4 counts demonstrated negative bias compared to FACSCalibur. PIMA POC sensitivity improved significantly at a higher CD4 threshold of 500 than a 350 cells/uL threshold.

Frequency and predictors for late start of antiretroviral therapy in primary care clinics, Kampala, Uganda

BACKGROUND

Access to antiretroviral treatment (ART) has improved greatly in many parts of the world, including Uganda, yet, many patients delay to start ART even when registered within the HIV services. We assessed, in a routine ambulatory care setting, what proportion of patients start ART late and the associated factors.

METHODS

We conducted a cross-sectional study from a cohort of adult, HIV-infected, ART-naive patients seeking care at 3 primary care centers in Kampala, Uganda. ART eligibility at the time was World Health Organization clinical stage 4 or CD4 <200 cells/μL. We defined late start of ART as starting ART at CD4 count <100 cells/μL and analyzed associated factors using multivariable logistic regression.

RESULTS

Between May 2008 and August 2009, 326 adults were studied. Two hundred eighteen (67%) were women; the median age was 34 years (range, 18-71). The median CD4 count was 132 cells/μL (range, 1-505). Thirty-one patients (10%) were in World Health Organization stage 4. One hundred twenty-three patients (37.7%) were initiated on ART with CD4 cells <100 cells/μL. Being male [adjusted OR (aOR): 2.4; 95% confidence interval: 1.3 to 4.2, P = 0.002] and having no employment (aOR: 1.9; 95% confidence interval: 1.2 to 3.3, P = 0.012) were associated with late start of ART. Being older, being married, and showing signs of alcohol dependence were associated with an earlier start of ART.

CONCLUSIONS

A considerable proportion of patients started ART at very low CD4 counts. Male and unemployed patients were more likely and married people and those aged 40 years or older were less likely to start ART late.

CD4, viral load response, and adherence among antiretroviral-naive breast-feeding women receiving triple antiretroviral prophylaxis for prevention of mother-to-child transmission of HIV in Kisumu, Kenya

BACKGROUND

Health benefits and survival of an exclusively breast-fed infant is dependent on the mother's health; thus, the need for antiretroviral (ARV) intervention for prevention of mother-to-child transmission (PMTCT). Achieving maternal health benefits from these regimens requires adherence to the treatments and close monitoring. We evaluated virologic, immunologic responses, and adherence among women receiving maternal triple ARV prophylaxis consisting of lamivudine/zidovudine and nevirapine or nelfinavir in the Kisumu Breastfeeding Study.

METHODS

We analyzed baseline demographic data, trends in CD4 count, and viral load (VL) at enrollment (32-34 weeks gestation), delivery, 14 and 24 weeks postpartum among 434 women who remained in the study at 24 weeks postpartum. Adherence rates were determined using pill counts reinforced by self-report and drug calendar. We dichotomized adherence as ≥95% versus <95%.

RESULTS

Among the 434 women, 84% (n = 366) had adherence ≥95%. The proportion of women with undetectable VL (<400 copies/mL) increased from 6% at baseline to 79%, and that of those with CD4 count <250 cells per microliter decreased from 23% (100) at baseline to 5% (22) at 24 weeks postpartum. In discrete-survival model, time to achieving VL suppression was associated with baseline VL <5.0 log copies per milliliter, parity ≥2, and use of nelfinavir- versus nevirapine-based ARV. Association between undetectable VL with duration of therapy (P < 0.0001) and adherence with suppression of VL (P = 0.001) was observed.

CONCLUSIONS

High baseline VL and short exposure to ARVs for PMTCT are risk factors for failing to achieve undetectable VL. These findings support the new WHO guidelines for early initiation of ARV prophylaxis for PMTCT for maximal reduction of maternal VL.

Evaluation of portable point-of-care CD4 counter with high sensitivity for detecting patients eligible for antiretroviral therapy

Background

Accurate, inexpensive point-of-care CD4+ T cell testing technologies are needed that can deliver CD4+ T cell results at lower level health centers or community outreach voluntary counseling and testing. We sought to evaluate a point-of-care CD4+ T cell counter, the Pima CD4 Test System, a portable, battery-operated bench-top instrument that is designed to use finger stick blood samples suitable for field use in conjunction with rapid HIV testing.

Methods

Duplicate measurements were performed on both capillary and venous samples using Pima CD4 analyzers, compared to the BD FACSCalibur (reference method). The mean bias was estimated by paired Student's t-test. Bland Altman plots were used to assess agreement.

Results

206 participants were enrolled with a median CD4 count of 396 (range; 18–1500). The finger stick PIMA had a mean bias of −66.3 cells/µL (95%CI −83.4−49.2, P<0.001) compared to the FACSCalibur; the bias was smaller at lower CD4 counts (0–250 cells/µL) with a mean bias of −10.8 (95%CI −27.3−+5.6, P = 0.198), and much greater at higher CD4 cell counts (>500 cells/µL) with a mean bias of −120.6 (95%CI −162.8, −78.4, P<0.001). The sensitivity (95%CI) of the Pima CD4 analyzer was 96.3% (79.1–99.8%) for a <250 cells/ul cut-off with a negative predictive value of 99.2% (95.1–99.9%).

Conclusions

The Pima CD4 finger stick test is an easy-to-use, portable, relatively fast device to test CD4+ T cell counts in the field. Issues of negatively-biased CD4 cell counts especially at higher absolute numbers will limit its utility for longitudinal immunologic response to ART. The high sensitivity and negative predictive value of the test makes it an attractive option for field use to identify patients eligible for ART, thus potentially reducing delays in linkage to care and ART initiation.

Suboptimal patterns of provider initiated HIV testing and counselling, antiretroviral therapy eligibility assessment and referral in primary health clinic attendees in Blantyre, Malawi

Objective

To understand reasons for suboptimal and delayed uptake of antiretroviral therapy (ART) by describing the patterns of HIV testing and counselling (HTC) and outcomes of ART eligibility assessments in primary clinic attendees.

Methods

All clinic attendances and episodes of HTC were recorded at two clinics in Blantyre. A cohort of newly diagnosed HIV-positive adults (>15 years) was recruited and exit interviews undertaken. Logistic regression models were constructed to investigate factors associated with referral to start ART. Qualitative interviews were conducted with providers and patients.

Results

There were 2398 episodes of HTC during 18 021 clinic attendances (13.3%) between January and April 2011. The proportion of clinic attendees undergoing HTC was lowest in non-pregnant women (6.3%) and men (8.5%), compared with pregnant women (47.2%). Men had more advanced HIV infection than women (79.7% WHO stage 3 or 4 vs. 56.4%). Problems with WHO staging and access to CD4 counts affected ART eligibility assessments; only 48% completed ART eligibility assessment, and 54% of those reporting WHO stage 3/4 illnesses were not referred to start ART promptly. On multivariate analysis, HIV-positive pregnant women were significantly less likely to be referred directly for ART initiation (adjusted OR: 0.29, 95% CI: 0.13–0.63).

Conclusions

These data show that provider-initiated testing and counselling (PITC) has not yet been fully implemented at primary care clinics. Suboptimal ART eligibility assessments and referral (reflecting the difficulties of WHO staging in primary care) mean that simplified eligibility assessment tools are required to reduce unnecessary delay and attrition in the pre-ART period. Simplified initiation criteria for pregnant women, as being introduced in Malawi, should improve linkage to ART.

Economics of switching to second-line antiretroviral therapy with lopinavir/ritonavir in Africa: estimates based on DART trial results and costs for Uganda and Kenya

BACKGROUND

Substantial immunological improvement has been reported for HIV-infected patients who switch from a failing regimen to a protease inhibitor regimen with Lopinavir/ritonavir (LPV/r). We use decision analysis modeling to estimate health and economic consequences expected from this switch.

METHODS

A Markov model combined best evidence for CD4(+) T-cell response, infectious disease events, death rates, and quality of life for African populations with Kenyan and Ugandan data on drug and medical care costs. We estimate the incremental cost-effectiveness ratio of switching to an LPV/r-based regimen versus remaining on a failed first antiretroviral (ARV) regimen or discontinuing all ARV drugs. The model assumes concurrent use of cotrimoxazole, and 4% annual loss to follow-up. Local effects due to prevalence of malaria and tuberculosis are included in the model. Sensitivity analysis examines the effects of varying disease, ARV therapy and CD4(+) T-cell cost, and ART discontinuation assumptions.

RESULTS

The base model estimates an improvement of 20 months in average survival for the LPV/r group. The respective LPV/r ICER for Kenya is $1483 per quality-adjusted life year (QALY) compared to $1673/QALY for Uganda. The ICERs increase to $1517 and $1707, respectively, if CD4(+) T-cell tests cost $25. The model comparing switching to LPV/r to discontinuing all ARV drugs decreases both costs and benefits proportionally for the treatment groups.

CONCLUSION

The estimates are clearly below the most stringent World Health Organization benchmark for cost-effectiveness for Kenya and within the acceptable range of cost-effectiveness for Uganda. Thus, the switch to second-line therapy with LPV/r in these countries appears to be a cost-effective use of resources.

Barriers to starting ART and how they can be overcome: individual and operational factors associated with early and late start of treatment

OBJECTIVE

Despite expanding access to antiretroviral therapy (ART) in Sub-Saharan Africa, there are few data on patients' perceptions about starting ART to explore issues affecting decisions to start ART in eligible individuals during the ART roll out.

METHODS

We studied patterns of ART uptake for 957 participants in a trial of cryptococcal disease prevention and performed a qualitative cross-sectional study about issues affecting decisions to start ART in this cohort. In-depth interviews (IDIs) were conducted with 48 participants who started ART after variable time on the trial.

RESULTS

Time to starting ART from trial enrolment decreased during the ART roll out (Median 83 days to 68 days). Multiple factors causing delay to ART were reported; awaiting home visit by service provider (P=0.025), domestic issues (P=0.028), moving from area (P≤0.001) and fear of side effects (P=0.013) were statistically significant. In the IDIs, fear of side effects was the strongest factor for delay and observation of health improvement in others on ART was the strongest inducement to start. Information from patients already taking ART was the most valued source of information.

CONCLUSIONS

This study provided novel information about factors encouraging people to start ART early; positive beliefs about ART were the most important. Whilst side effects of ART must not be downplayed, programmes should provide information in a balanced way to prevent unnecessary fear of starting ART. Those already receiving ART were found to be good advocates and should be utilised by ART programmes to educate others.

Pre-treatment mortality and loss-to-follow-up in HIV-1, HIV-2 and HIV-1/HIV-2 dually infected patients eligible for antiretroviral therapy in The Gambia, West Africa

BACKGROUND

High early mortality rate among HIV infected patients following initiation of antiretroviral therapy (ART) in resource limited settings may indicate high pre-treatment mortality among ART-eligible patients. There is dearth of data on pre-treatment mortality in ART programmes in sub-Sahara Africa. This study aims to determine pre-treatment mortality rate and predictors of pre-treatment mortality among ART-eligible adult patients in a West Africa clinic-based cohort.

METHODS

All HIV-infected patients aged 15 years or older eligible for ART between June 2004 and September 2009 were included in the analysis. Assessment for eligibility was based on the Gambia ART guideline. Survival following ART-eligibility was determined by Kaplan-Meier estimates and predictors of pre-treatment mortality determined by Cox proportional hazard models.

RESULT

Overall, 790 patients were assessed as eligible for ART based on their clinical and/or immunological status among whom 510 (64.6%) started treatment, 26 (3.3%) requested transfer to another health facility, 136 (17.2%) and 118 (14.9%) were lost to follow-up and died respectively without starting ART. ART-eligible patients who died or were lost to follow-up were more likely to be male or to have a CD4 T-cell count < 100 cells/μL, while patients in WHO clinical stage 3 or 4 were more likely to die without starting treatment. The overall pre-treatment mortality rate was 21.9 deaths per 100 person-years (95% CI 18.3 - 26.2) and the rate for the composite end point of death or loss to follow-up was 47.1 per 100 person-years (95% CI 41.6 - 53.2). Independent predictors of pre-treatment mortality were CD4 T-cell count <100 cells/μL (adjusted Hazard ratio [AHR] 3.71; 95%CI 2.54 - 5.41) and WHO stage 3 or 4 disease (AHR 1.91; 95% CI 1.12 - 3.23). Forty percent of ART-eligible patients lost to follow-up seen alive at field visit cited difficulty with the requirement of disclosing their HIV status as reason for not starting ART.

CONCLUSION

Approximately one third of ART-eligible patients did not start ART and pre-treatment mortality rate was found high among HIV infected patients in our cohort. CD4 T-cell count <100 cells/μL is the strongest independent predictor of pre-treatment mortality. The requirement to disclose HIV status as part of ART preparation counselling constitutes a huge barrier for eligible patients to access treatment.

Validation of World Health Organisation HIV/AIDS clinical staging in predicting initiation of antiretroviral therapy and clinical predictors of low CD4 cell count in Uganda

Introduction

The WHO clinical guidelines for HIV/AIDS are widely used in resource limited settings to represent the gold standard of CD4 counts for antiviral therapy initiation. The utility of the WHO-defined stage 1 and 2 clinical factors used in WHO HIV/AIDS clinical staging in predicting low CD4 cell count has not been established in Uganda. Although the WHO staging has shown low sensitivity for predicting CD4<200cells/mm³, it has not been evaluated at for CD4 cut-offs of <250cells/mm³ or <350 cells/mm³.

Objective

To validate the World Health Organisation HIV/AIDS clinical staging in predicting initiation of antiretroviral therapy in a low-resource setting and to determine the clinical predictors of low CD4 cell count in Uganda.

Results

Data was collected on 395 participants from the Joint Clinical Research Centre, of whom 242 (61.3%) were classified as in stages 1 and 2 and 262 (68%) were females. Participants had a mean age of 36.8 years (SD 8.5). We found a significant inverse correlation between the CD4 lymphocyte count and WHO clinical stages. The sensitivity the WHO clinical staging at CD4 cell count of 250 cells/mm³ and 350cells/mm³ was 53.5% and 49.1% respectively. Angular cheilitis, papular pruritic eruptions and recurrent upper respiratory tract infections were found to be significant predictors of low CD4 cell count among participants in WHO stage 1 and 2.

Conclusion

The WHO HIV/AIDS clinical staging guidelines have a low sensitivity and about half of the participants in stages 1 and 2 would be eligible for ART initiation if they had been tested for CD4 count. Angular cheilitis and papular pruritic eruptions and recurrent upper respiratory tract infections may be used, in addition to the WHO staging, to improve sensitivity in the interim, as access to CD4 machines increases in Uganda.

Commentary: Early antiretroviral therapy for HIV infection in sub-Saharan Africa, a challenging new step

Recent changes in guidelines (World Health Organization (WHO), USA, and likely Europe soon) all move towards earlier initiation of antiretroviral therapy in asymptomatic patients infected with human immunodeficiency virus (HIV). Sonia Menon appropriately questions the feasibility and consequences at both individual and community levels of the early initiation of antiretroviral therapy in sub-Saharan Africa as likely effects will be both positive and negative. Local context should drive the uptake process in every country. Money, national and international, will be essential for the successful implementation of the new WHO recommendation. Leaders at both levels must take their responsibilities and mobilize the necessary resources, for example, doubling those for the Global Fund to Fight AIDS, Tuberculosis and Malaria from $10 billion to $20 billion USD for 2011-2013.

HIV/AIDS Clinical Manifestations and their Implication for Patient Clinical Staging in Resource Limited Settings in Tanzania

BACKGROUND

Tanzania HIV/AIDS management follows WHO clinical staging which requires CD4 counts as complement. Lacking CD4 counts facilities in rural health facilities remains a challenge. Simplified and sensitive clinical staging based on local clinical patterns is useful to ensure effective care without CD4 counts.

OBJECTIVES

To assess whether local HIV clinical manifestations can be used to guide HIV management in settings with limited access to CD4 counts in Tanzania.

METHODS

A Cross-sectional study conducted at Tumbi and Chalinze health facilities documented clinical manifestations and CD4 counts in 360 HIV/AIDS patients. Simplified management groups comprised of severe and moderate disease were formed based on clinical manifestations and CD4 counts results. Symptoms with high frequency were used to predict severe disease.

RESULTS

A Weight loss (48.3%) and chronic cough (40.8 %) were the most reported manifestations in the study population. More than 50% of patients presented with CD4≤200. Most symptoms were found to be highly sensitive (71% to 93%) in predicting severe immunosuppression using CD4<200 cut-off point as a 'Gold standard'. Chronic diarrhoea presented in 10.6%, and predicted well severe immunosuppression either alone (OR 1.95, 95%CI, 0.95-4.22) or in combination (OR 4.21, 95%CI 0.92-19.33) with other symptoms. Basing strictly on WHO clinical staging 30.8% of patients were detected to be severely immunosuppressed (Stage 4). While using our proposed management categories of severe and moderate immunosuppression 70% of patients were put into the severe immunosuppression group, consistent with CD4 cut-off count of≤350.

CONCLUSIONS

HIV/AIDS clinics managing large cohorts should develop validated site specific guidelines based on local experiences. Simplified guidelines are useful for resource constrained settings without CD4 counting facilities.

Use of nail and oral pigmentation to determine ART eligibility among HIV-infected Ugandan adults

OBJECTIVES

To evaluate the use of grey/distal banded nails as an indicator of advanced immunosuppression, and thus eligibility for ART, in resource poor settings.

METHODS

We tested whether grey/distal banded nails and/or oral pigmentation could be used to identify patients with low CD4 cell counts at two cut-offs: <200 and <350 cells/microl in ART naive adults.

RESULTS

Four hundred and three nail and oral cavities were photographed and assessed. Grey/distal banded nails and/or oral pigmentation were significantly associated with a CD4 cell count <200 cells/microl (P < 0.001), with a sensitivity of 66%, a specificity of 50% and a negative predictive value of 77%. However, there was no association when a CD4 cell count cut-off of <350 cells/microl was used. Inter-observer agreement (k 0.46) was fair/moderate.

CONCLUSIONS

While grey/distal banded nails and/or oral pigmentation are associated with low CD4 counts, the sensitivity and kappa score are too low for this method to be recommended as a tool to guide ART initiation; large number of individuals eligible for ART would be missed.

WHO clinical criteria-based initiation of antiretroviral therapy: lessons from rural district hospitals in Cameroon with regard to 2009 revised WHO recommendations

OBJECTIVE

To assess the proportion of patients infected with HIV with a CD4 count above 350 cells/mm(3) among those classified at WHO clinical stage 3 or 4 who initiated antiretroviral therapy in rural district hospitals in Cameroon to assess the 2009 revised WHO recommendations.

METHODS

Cross-sectional study in nine rural district hospitals where the treatment initiation is based on the WHO clinical criteria. The proportion of patients who were classified at stage 3 or 4 and who had a CD4 count >350 cells/mm(3) was assessed.

RESULTS

Of 458 patients included in 2006-2008 (women 70.5%; median age 37.0 years), 337 (73.6%) were classified at WHO clinical stage 3 and 121 (26.4%) at stage 4. Overall, 108 patients (23.6%) had a CD4 count >350 cells/mm(3). Of them, 94 patients (20.5%) were classified at WHO clinical stage 3, and 14 (3.1%) were classified at WHO clinical stage 4.

CONCLUSION

The WHO clinical stages 3 and 4 were poorly correlated with the 'gold standard' of CD4 cell count. This study highlights the need to promote CD4 testing for assessing the patient eligibility.

Evaluation of affordable screening markers to detect CD4+ T-cell counts below 200 cells/mul among HIV-1-infected Ugandan adults

OBJECTIVE

To evaluate validity of WHO staging, low body mass index (BMI) and anaemia in detecting HIV-infected adults with CD4+ T-cell counts < 200 cells/microl.

METHODS

Between October 1995 and April 2006, we screened Ugandans aged 16 or older at enrollment into an open cohort. We analysed highly active anti-retroviral therapy (HAART)-naïve HIV-infected patients with WHO stages 1-3 and complete data in a secondary cross-sectional study. Low BMI was a BMI < 18.5 kg/m(2). Anaemia was a haemoglobin level < 11 or 12 g/dl among women and men respectively.

RESULTS

Among 2892 HAART-naïve patients, the median age was 32 years. 71% were women, 54% had WHO stage 3 AIDS, 34% had anaemia, 16% had a low BMI and 43% had CD4+ T-cell counts < 200 cells/microl. WHO stage 3 compared to combined WHO stages 1 and 2 had a sensitivity (95% CI) of 70% (67, 72) and a specificity of 57% (55, 60) respectively to detect CD4+ T-cell counts < 200 cells/microl. Anaemia compared to normal haemoglobin had sensitivity (95% CI) of 47% (44, 50) and a specificity of 76% (74, 78). Low BMI compared to normal BMI had sensitivity (95% CI) of 23% (20, 25) and a specificity of 89% (87, 90) against CD4+ T-cell counts < 200 cells/microl.

CONCLUSION

Only WHO stage 3 had reasonably high sensitivity in detecting CD4+ T-cell counts below 200 cells/microl in this setting. Targeted low-cost CD4 testing strategies are urgently needed to detect patients eligible for HAART in rural Africa and other resource-limited settings.

Mortality and loss-to-follow-up during the pre-treatment period in an antiretroviral therapy programme under normal health service conditions in Uganda

Background

In many HIV programmes in Africa, patients are assessed clinically and prepared for antiretroviral treatment over a period of 4–12 weeks. Mortality rates following initiation of ART are very high largely because patients present late with advanced disease. The rates of mortality and retention during the pre-treatment period are not well understood. We conducted an observational study to determine these rates.

Methods

HIV-infected subjects presenting at The AIDS Support Clinic in Jinja, SE Uganda, were assessed for antiretroviral therapy (ART). Eligible subjects were given information and counselling in 3 visits done over 4–6 weeks in preparation for treatment. Those who did not complete screening were followed-up at home. Survival analysis was done using poisson regression.

Results

4321 HIV-infected subjects were screened of whom 2483 were eligible for ART on clinical or immunological grounds. Of these, 637 (26%) did not complete screening and did not start ART. Male sex and low CD4 count were associated independently with not completing screening. At follow-up at a median 351 days, 181 (28%) had died, 189 (30%) reported that they were on ART with a different provider, 158 (25%) were alive but said they were not on ART and 109 (17%) were lost to follow-up. Death rates (95% CI) per 100 person-years were 34 (22, 55) (n.18) within one month and 37 (29, 48) (n.33) within 3 months. 70/158 (44%) subjects seen at follow-up said they had not started ART because they could not afford transport.

Conclusion

About a quarter of subjects eligible for ART did not complete screening and pre-treatment mortality was very high even though patients in this setting were well informed. For many families, the high cost of transport is a major barrier preventing access to ART.