Computed CD4 percentage as a low-cost method for determining pediatric antiretroviral treatment eligibility

Steven Fj Callens,Annelies Van Rie,Samuel Edidi,Jean Lusiama,Robert Colebunders,Nicole Shabani,Faustin Kitetele,Frieda Behets

doi:10.1186/1471-2334-8-31

Abstract

BackgroundThe performance of the WHO recommendations for pediatric antiretroviral treatment (ART) in resource poor settings is insufficiently documented in routine care.MethodsWe compared clinical and immunological criteria in 366 children aged 0 to 12 years in Kinshasa and evaluated a simple computation to estimate CD4 percent, based on CD4 count, total white blood cell count and percentage lymphocytes. Kappa (κ) statistic was used to evaluate eligibility criteria and linear regression to determine trends of CD4 percent, count and total lymphocyte count (TLC).ResultsAgreement between clinical and immunological eligibility criteria was poor (κ = 0.26). One third of children clinically eligible for ART were ineligible using immunological criteria; one third of children immunologically eligible were ineligible using clinical criteria. Among children presenting in WHO stage I or II, 54 (32%) were eligible according to immunological criteria. Agreement with CD4 percent was poor for TLC (κ = 0.04), fair for total CD4 count (κ = 0.39) and substantial for CD4 percent computational estimate (κ = 0.71). Among 5 to 12 years old children, total CD4 count was higher in younger age groups (-32 cells/mm3 per year older), CD4 percent was similar across age groups.ConclusionAge-specific thresholds for CD4 percent optimally determine pediatric ART eligibility. The use of CD4 percent computational estimate may increase ART access in settings with limited access to CD4 percent assays.

Highlights

The performance of the World Health Organization (WHO) recommendations for pediatric antiretroviral treatment (ART) in resource poor settings is insufficiently documented in routine care
We evaluated the impact of the 2006 WHO pediatric ART eligibility criteria on ART initiation decision making in a pediatric HIV care program in Kinshasa, Democratic Republic of Congo (DRC) and propose a lower cost alternative for the expensive CD4 percent assays
Data Analysis For the purpose of this analysis, we evaluated pediatric ART eligibility using clinical criteria and age-specific immunological criteria recommended in the 2006 WHO guidelines for pediatric ART in resource poor settings (Table 1) [1]

Summary

Introduction

The performance of the WHO recommendations for pediatric antiretroviral treatment (ART) in resource poor settings is insufficiently documented in routine care. WHO immunological thresholds for total CD4+ T lymphocyte count (CD4 count) and CD4 percent (Table 1) are associated with prognosis, and correspond to a 5% annual mortality risk in US and European children aged one year or older [3]. CD4 percent and CD4 count in healthy Kenyan children was markedly lower compared to children from Europe, USA and West Africa [6]. It is uncertain whether the use of thresholds established through longitudinal studies in the US and Europe can be extrapolated to other regions in the world

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Discussion

Conclusion