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

Steven Baveewo,Peter Mugyenyi,Judith A Hahn,Joan N Kalyango,Elly Katabira,Francis Ssali,Charles Karamagi,Kenneth Ekoru,Malcolm Gracie Semple

doi:10.1371/journal.pone.0019089

Abstract

IntroductionThe 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.ObjectiveTo 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.ResultsData 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.ConclusionThe 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.

Highlights

The World Health Organisation (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
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
We found a significant inverse correlation between the CD4 lymphocyte count and WHO clinical stages

Summary

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 CD4 cell counts testing is critical in the determination of eligibility for ART, many HIV treatment centres in resource limited settings lack CD4 testing facilities. Some previous studies have explored the utility of using other predictors of low CD4 cell count to guide initiation of antiretroviral therapy. Other clinical factors, such as anaemia and body mass index have low sensitivities in detecting eligibility for HAART initiation [4] while other studies have shown that clinical factors such as anaemia could double sensitivity if used together with the WHO clinical staging guidelines [5]. Total lymphocyte counts ,1200 cells/microl used with WHO staging showed good specificity (.99%) [5], and a good correlation between total lymphocyte count and CD4 cell count in a Ugandan study [6]

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Results

Discussion

Conclusion