Management In Resource-limited Settings Research Articles

Agreement Between the World Health Organization Algorithm and Lung Consolidation Identified Using Point-of-Care Ultrasound for the Diagnosis of Childhood Pneumonia by General Practitioners.

The World Health Organization (WHO) case management algorithm for acute lower respiratory infections has moderate sensitivity and poor specificity for the diagnosis of pneumonia. We sought to determine the feasibility of using point-of-care ultrasound in resource-limited settings to identify pneumonia by general health practitioners and to determine agreement between the WHO algorithm and lung consolidations identified by point-of-care ultrasound. An expert radiologist taught two general practitioners how to perform point-of-care ultrasound over a seven-day period. We then conducted a prospective study of children aged 2 months to 3 years in Peru and Nepal with and without respiratory symptoms, which were evaluated by point-of-care ultrasound to identify lung consolidation. We enrolled 378 children: 127 were controls without respiratory symptoms, 82 had respiratory symptoms without clinical pneumonia, and 169 had clinical pneumonia by WHO criteria. Point-of-care ultrasound was performed in the community (n = 180), in outpatient offices (n = 95), in hospital wards (n = 19), and in Emergency Departments (n = 84). Average time to perform point-of-care ultrasound was 6.4 ± 2.2 min. Inter-observer agreement for point-of-care ultrasound interpretation between general practitioners was high (κ = 0.79, 95 % CI 0.73-0.81). The diagnosis of pneumonia using the WHO algorithm yielded a sensitivity of 69.6 % (95 % CI 55.7-80.8 %), specificity of 59.6 % (95 % CI 54.0-65.0 %), and positive and negative likelihood ratios of 1.73 (95 % CI 1.39-2.15) and 0.51 (95 % CI 0.30-0.76) when lung consolidation on point-of-care ultrasound was used as the reference. The WHO algorithm disagreed with point-of-care ultrasound findings in more than one-third of children and had an overall low performance when compared with point-of-care ultrasound to identify lung consolidation. A paired approach with point-of-care ultrasound may improve case management in resource-limited settings.

HIV/AIDS and lipodystrophy: implications for clinical management in resource-limited settings.

IntroductionLipodystrophy is a term used to describe a metabolic complication of fat loss, fat gain, or a combination of fat loss and gain, which is associated with some antiretroviral (ARV) therapies given to HIV-infected individuals. There is limited research on lipodystrophy in low- and middle-income countries, despite accounting for more than 95% of the burden of HIV/AIDS. The objective of this review was to evaluate the prevalence, pathogenesis and prognosis of HIV-related lipoatrophy, lipohypertrophy and mixed syndrome, to inform clinical management in resource-limited settings.MethodsWe conducted a structured literature search using MEDLINE electronic databases. Relevant MeSH terms were used to identify published human studies on HIV and lipoatrophy, lipohypertrophy, or mixed syndrome in low-, low-middle- and upper-middle-income countries through 31 March 2014. The search resulted in 5296 articles; after 1599 studies were excluded (958 reviews, 641 non-human), 3697 studies were extracted for further review. After excluding studies conducted in high-income settings (n=2808), and studies that did not meet inclusion criteria (n=799), 90 studies were included in this review.Results and DiscussionOf the 90 studies included in this review, only six were from low-income countries and eight were from lower middle-income economies. These studies focused on lipodystrophy prevalence, risk factors and side effects of antiretroviral therapy (ART). In most studies, lipodystrophy developed after the first six months of therapy, particularly with the use of stavudine. Lipodystrophy is associated with increased risk of cardiometabolic complications. This is disconcerting and anticipated to increase, given the rapid scale-up of ART worldwide, the increasing number and lifespan of HIV-infected patients on long-term therapy, and the emergence of obesity and non-communicable diseases in settings with extensive HIV burden.ConclusionsLipodystrophy is common in resource-limited settings, and has considerable implications for risk of metabolic diseases, quality of life and adherence. Comprehensive evidence-based interventions are urgently needed to reduce the burden of HIV and lipodystrophy, and inform clinical management in resource-limited settings.

Trauma training course: innovative teaching models and methods for training health workers in active conflict zones of Eastern Myanmar.

BackgroundMyanmar has struggled through decades of internal conflict, which has negatively impacted the country’s health outcomes. Recent government changes have brought hope and reduced conflict. The ethnic minority groups have suffered the brunt of the health consequences and reside in regions that lack health infrastructure, resources, and providers. Due to the chronic lack of healthcare providers within conflict areas, health workers (HWs) have been trained in an effort to fill the void. Research has shown that these non-physician clinicians positively impact health outcomes in developing countries. These HWs are supported by community-based organizations in collaboration with foreign non-governmental organizations. Started in 2000, the trauma training course was developed to meet the educational needs of these HWs.MethodsEssential procedures for HWs in conflict zones were identified, and teaching methods were adapted to develop models that were simple, reproducible, cost effective, and able to facilitate effective learning within the limitations of these challenging environments. This paper presents simulation models developed to teach trauma injury evaluation and management in resource-limited settings to HWs.ResultsMaterial and construction of the models described include breathing, chest, cricothyroidotomy, circulation, wound repair, fracture/dislocation, splinting, fasciotomy/amputation, and an animal model. In 2013, a pre/post test and post-training evaluation were completed, which demonstrated an increase in understanding of the material and satisfaction with the training.ConclusionsThe simulation models described engage the HWs in clinical skills practice specific to injury management, which builds upon the HWs existing knowledge and facilitates an increased understanding of life-saving procedures. Through observation of the HW performance and HW feedback, these simulation models have increased the understanding of trauma management. Limitations include lack of a graduated learning system for the HWs, logistics, and time constraints. Despite the barriers faced, we feel that this is a necessary program that has reduced morbidity and mortality due to traumatic injury in the geographic areas that the HWs serve. With the changing political environment in Myanmar and the development of peace agreements between the government and the ethnic minority groups, these HWs can be integrated into Myanmar’s evolving health system.

Clinical presentation, diagnostic evaluation, treatment and diagnoses of febrile children presenting to the emergency department at Muhimbili national hospital in Dar es Salaam, Tanzania

Introduction While there are many guidelines for the ED evaluation of febrile children, these are largely derived and validated in high-resource settings. There is limited literature documenting recommended or actual management in resource-limited settings. We describe the presentation, diagnostic evaluation, treatment, and ED diagnoses of febrile children under 5 years old presenting to an urban emergency department in Dar es Salaam. Methods This was a prospective observational study of children under 5 with fever or reported fever at Muhimbili National Hospital (MNH) ED. Treating physicians prospectively completed a standardized data form. Results We enrolled 105 children, median age 14 months, with 80% >6 months, and 64% male. Presenting symptoms included poor feeding (47.6%) vomiting (42.9%), cough (34.3), difficulty breathing (28.6%), and diarrhoea (22.9%). 78% had vital sign abnormalities and 82% had abnormal physical examination. Among those undergoing point-of care testing, 11/105 tested (10.5%) had hypoglycaemia, 9/103 (8.7 %) were malaria positive, 17/30 (56.7%) had positive urine dipstick testing, and 5/26 tested (19.2%) were HIV positive. Laboratory-based tests included CBC and chemistry (each performed in 95.2%), VBG (56.2%), CSF (5.7%), blood culture (5.7%), urine culture (10.5%), CSF culture (1.9%), and CXR of chest (25.7%) and abdomen (3.8%). Interventions included antibiotics (70%), antimalarial (12%), IV fluids (54%), and antipyretics (41%). Top ED diagnoses included malaria (24.3%), pneumonia (15.2%), septicaemia (9.5%), urinary tract infections (7.6%), acute watery diarrhoea with dehydration (6.7%), meningitis (4.8%), anaemia (4.8%), skin and soft tissue infections (4.8%), bowel obstructions (3.8%), and pulmonary tuberculosis, sickle cell disease, and hepatitis (2.9% each). Laboratory-based tests were often abnormal; culture results were often unavailable; Conclusion A wide range of presentations and management were documented. There was a high rate of positive diagnostic test results. Malaria and pneumonia were top diagnoses, but a wide range of infections were diagnosed.

Efficiency of an intervention package for arterial hypertension comprising telemanagement in a Cameroonian rural setting: The TELEMED-CAM study

IntroductionSub-Saharan Africa has a disproportionate burden of disease and an extreme shortage of health workforce. Therefore, adequate care for emerging chronic diseases can be very challenging. We implemented and evaluated the effectiveness of an intervention package comprising telecare as a mean for improving the outcomes of care for hypertension in Rural Sub-Saharan Africa.MethodsThe study involved a telemedicine center based at the Yaounde General Hospital (5 cardiologists) in the Capital city of Cameroon, and 30 remote rural health centers within the vicinity of Yaoundé (20 centers (103 patients) in the usual care group, and 10 centers (165 patients) in the intervention groups). The total duration of the intervention was 24 weeks.ResultsParticipants in the intervention group had higher baseline systolic (SBP) and diastolic (DBP) blood pressure, and included fewer individuals with diabetes than those in the usual care group (all p < 0.01). Otherwise, the baseline profile was mostly similar between the two groups. During follow-up, more participants in the intervention groups achieved optimal BP control, driven primarily by greater improvement of BP control among High risk participants (hypertension stage III) in the intervention group.ConclusionAn intervention package comprising tele-support to general practitioners and nurses is effective in improving the management and outcome of care for hypertension in rural underserved populations. This can potentially help in addressing the shortage of trained health workforce for chronic disease management in some settings. However context-specific approaches and cost-effectiveness data are needed to improve the application of telemedicine for chronic disease management in resource-limited settings.

The role of biomedical engineering in disaster management in resource-limited settings

The costs of natural disasters, such as earthquakes and floods, and of wars and other man-made catastrophes go beyond the immediate loss of life, property, infrastructure and livelihood. The public health crisis that unfolds over ensuing weeks and months leaves much deeper, permanent scars in the form of reduced quality of life and disrupted national economies.1 These effects are compounded in resource-limited settings, where catastrophes result in population displacement and undermine health facilities’ capacity to provide care, since fully-established disaster management programmes are often lacking.2 Large-scale disasters that displace populations and strain the existing health-care infrastructure, such as the 2004 Indian Ocean tsunami and the 2010 earthquake in Haiti, have two well-defined stages: the crisis during the event, and the slower, more devastating catastrophe that puts the lives of millions of people at risk. Local government response is often focused on the former, with little attention to the latter. Crisis management in remote settings is particularly complicated. In this perspective piece we argue in favour of improved management of large-scale disasters through investment in biomedical engineering.

Point of care ultrasound for sepsis management in resource-limited settings: time for a new paradigm for global health care

Dear Editor, We applaud the ESICM Global Intensive Care Working Group for its pivotal contribution to the improvement of sepsis management in developing countries [1]. Dunser et al. acknowledge that health-care practices of industrialized nations are not available to the majority of humanity. On the basis of this current reality the authors offer guidelines regarding approaches to the management of sepsis in limited-resource settings. Surprisingly, we found no mention of the use of point-of-care ultrasound (POC-US) [2] beyond a generic recommendation to ‘‘use imaging techniques when available’’ [1]. Since 1985 ultrasonography has been recommended for developing countries by the World Health Organization (WHO) [3], as an inexpensive, rapidly deployable, and portable tool with minimal side effects. This is true today more than ever. Notwithstanding the lack of randomized, controlled trials on POC-US use in the specific setting of sepsis, increasing scientific evidence suggests tremendous potential for this tool in managing critical patients with infectious diseases. POC-US can be of great aid in the diagnosis of infectious diseases in rural areas [4], and generically in the detection of septic foci in febrile states [5]. It has a significant impact on mitigating diagnostic uncertainty in undifferentiated shock, narrowing differential diagnosis [6], and improving the specificity of early recognition of hypovolemia [7] and septic shock cardiovascular patterns [8]. Lung ultrasound has indeed a broad spectrum of established applications in the diagnosis and management of respiratory infectious diseases [9]—the leading cause of childhood mortality in developing countries [10]. The potential of POCUS in sepsis management is wide [11], and includes procedure-guidance applications that are increasingly acknowledged as best practice [12, 13]. With regards to education, innovative ultrasound curricula have been shaped for non-imaging specialists [14]. Short-term POC-US training programs are proven to deliver adequate knowledge and skills to novices [15]. And proof-of-concept studies have been conducted in the screening for infection sources in resource-limited settings of tropical countries [16]. Furthermore, low-cost technology can now provide minimally POC-UStrained operators (paramedics, midwives) with tele-mentoring and second-opinion facilities [17], mitigating the impracticable availability of ‘‘experienced practitioners’’ in all settings. This is of paramount importance for sustainable healthcare delivery where the patient-tophysician ratio is dramatically high. The use of POC-US represents a paradigm shift for improving health-

Point of care ultrasound for sepsis management in resource-limited settings: response to Via et al.

Dear Editor, We thank Dr. Via and her colleagues for their constructive comments regarding our recent publication [1] and wish to congratulate the group on the very important and highly useful WINFOCUS initiative. The points brought up regarding the use of sonography in the diagnostic and therapeutic management of septic patients are valid with little further aspects to add. It should be noted that our publication is an attempt to provide some guidance to our colleagues on the care of the septic patient in resourcelimited settings. We appreciate it is not the final word, and as technology becomes more available we will certainly modify our protocols. In the suggested recommendations we primarily wanted to emphasize the importance of early recognition and treatment with widely available medications and tools. On the basis of previous surveys by our working group, the availability of sonography machines appears promising in middle-income countries (in Mongolia, 97.4 % of intensivists stated to have sonography constantly available [2]), but may be restricted in lowand very-low-income settings (in four Eastern provinces of the Democratic Republic of Congo, 38.1 % of intensivists stated to have sonography constantly available [3]). The availability of specific echocardiographic probes is even more restricted (four Eastern provinces of the Democratic Republic of Congo, 0 % [2]; Mongolia, 36.8 % [3]). Nevertheless, there is a place for technologies in low-resource settings especially if there are telehealth resources with expertise to assist if needed. Moreover, we feel that echocardiography has specific utility and is frequently used to judge ventricular function and filling and to guide volume resuscitation in children where central vascular access is unavailable or impractical. The role of echocardiography in the management of septic patients is indisputable. However, even those among us who come from the wellresourced countries, similar to the authors of the letter, recognize the challenges of availability of sonography devices and the lack of trained providers that need to be overcome prior to routine implementation. Until sonography, as well as other useful modern technologies, becomes more widely available, we suggest that clinical skills and judgment along with readily available tools are indispensable for early recognition and treatment of sepsis in resourcelimited settings. References

Erratum to: Recommendations for sepsis management in resource-limited settings

Erratum to: Recommendations for sepsis management in resource-limited settings

Recommendations for sepsis management in resource-limited settings.

PurposeTo provide clinicians practicing in resource-limited settings with a framework to improve the diagnosis and treatment of pediatric and adult patients with sepsis.MethodsThe medical literature on sepsis management was reviewed. Specific attention was paid to identify clinical evidence on sepsis management from resource-limited settings.ResultsRecommendations are grouped into acute and post-acute interventions. Acute interventions include liberal fluid resuscitation to achieve adequate tissue perfusion, normal heart rate and arterial blood pressure, use of epinephrine or dopamine for inadequate tissue perfusion despite fluid resuscitation, frequent measurement of arterial blood pressure in hemodynamically unstable patients, administration of hydrocortisone or prednisolone to patients requiring catecholamines, oxygen administration to achieve an oxygen saturation >90%, semi-recumbent and/or lateral position, non-invasive ventilation for increased work of breathing or hypoxemia despite oxygen therapy, timely administration of adequate antimicrobials, thorough clinical investigation for infectious source identification, fluid/tissue sampling and microbiological work-up, removal, drainage or debridement of the infectious source. Post-acute interventions include regular re-assessment of antimicrobial therapy, administration of antimicrobials for an adequate but not prolonged duration, avoidance of hypoglycemia, pharmacological or mechanical deep vein thrombosis prophylaxis, resumption of oral food intake after resuscitation and regaining of consciousness, careful use of opioids and sedatives, early mobilization, and active weaning of invasive support. Specific considerations for malaria, puerperal sepsis and HIV/AIDS patients with sepsis are included.ConclusionOnly scarce evidence exists for the management of pediatric and adult sepsis in resource-limited settings. The presented recommendations may help to improve sepsis management in middle- and low-income countries.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-012-2468-5) contains supplementary material, which is available to authorized users.

Cancer Pain Management in Resource-Limited Settings: A Practice Review

Pain in cancer is a common and burdensome symptom with different causes but in a significant number of cases it is undiagnosed and undertreated because of lack of skills for its assessment. Pain has significant negative impact on the patient and, therefore, it needs to be managed urgently and appropriately. In resource-limited settings, there are several barriers and challenges to pain management but even in these circumstances pain can be well managed with planned and innovative use of resources and if the World Health Organization public health system approach is used to ensure opioid availability.

Severe malnutrition and metabolic complications of HIV-infected children in the antiretroviral era: clinical care and management in resource-limited settings

More than 2 million children globally are living with HIV infection and >90% of these reside in sub-Saharan Africa. Severe acute malnutrition (SAM) remains a major problem for HIV-infected children who live in resource-limited settings (RLS), and SAM is an important risk factor for mortality. SAM in HIV-infected children is associated with complications including electrolyte disorders, micronutrient deficiencies, and severe infections, which contribute to the high mortality. Access to antiretroviral therapy (ART) has significantly improved the survival of HIV-infected children, although the response to ART of children with SAM remains undocumented in the literature. Immune and virologic responses to ART in RLS are similar to those of infected children in resource-rich settings, but delays in initiation of therapy have led to a high early mortality. Antiretroviral drug toxicities have been described in children who receive therapy and may affect their quality of life and long-term survival. Metabolic complications of ART include lipodystrophy, dyslipidemia, lactic acidosis, insulin resistance, and osteopenia. These complications have been well described in adults and children from developed countries, but data from RLS are limited, and these complications may be compounded by SAM. In this article we review the epidemiology, clinical presentation, and complications of SAM in HIV-infected children and the metabolic complications of HIV-infected children in the era of ART, and discuss future research priorities for RLS.

S2.4 New technologies to support STI screening and syndromic management in resource-limited settings

BackgroundHigh quality tests for detection of STIs are available but they are neither affordable nor available to patients in resource-limited settings. For patients presenting with STI symptoms, WHO recommends the...

Childhood Tuberculosis: Epidemiology and Natural History of Disease

Despite previous misperceptions that childhood tuberculosis (TB) is less relevant, since children tend to develop mild disease, contribute little to transmission and do not impact epidemic control, awareness is growing that TB is an important preventable cause of disease and death among children in TB endemic areas. At an operational level there remains an urgent need for feasible and implementable policies to guide management in resource limited settings. This manuscript reviews the epidemiology and natural history of TB in children in order to improve understanding of the various disease entities encountered and to provide the rationale for different management approaches.

Patient Retention and Adherence to Antiretrovirals in a Large Antiretroviral Therapy Program in Nigeria: A Longitudinal Analysis for Risk Factors

BackgroundSubstantial resources and patient commitment are required to successfully scale-up antiretroviral therapy (ART) and provide appropriate HIV management in resource-limited settings. We used pharmacy refill records to evaluate risk factors for loss to follow-up (LTFU) and non-adherence to ART in a large treatment cohort in Nigeria.Methods and FindingsWe reviewed clinic records of adult patients initiating ART between March 2005 and July 2006 at five health facilities. Patients were classified as LTFU if they did not return >60 days from their expected visit. Pharmacy refill rates were calculated and used to assess non-adherence. We identified risk factors associated with LTFU and non-adherence using Cox and Generalized Estimating Equation (GEE) regressions, respectively. Of 5,760 patients initiating ART, 26% were LTFU. Female gender (p<0.001), post-secondary education (p = 0.03), and initiating treatment with zidovudine-containing (p = 0.004) or tenofovir-containing (p = 0.05) regimens were associated with decreased risk of LTFU, while patients with only primary education (p = 0.02) and those with baseline CD4 counts (cell/ml3) >350 and <100 were at a higher risk of LTFU compared to patients with baseline CD4 counts of 100–200. The adjusted GEE analysis showed that patients aged <35 years (p = 0.005), who traveled for >2 hours to the clinic (p = 0.03), had total ART duration of >6 months (p<0.001), and CD4 counts >200 at ART initiation were at a higher risk of non-adherence. Patients who disclosed their HIV status to spouse/family (p = 0.01) and were treated with tenofovir-containing regimens (p≤0.001) were more likely to be adherent.ConclusionsThese findings formed the basis for implementing multiple pre-treatment visit preparation that promote disclosure and active community outreaching to support retention and adherence. Expansion of treatment access points of care to communities to diminish travel time may have a positive impact on adherence.

The marriage of science and optimized HIV care in resource-limited settings

Large-scale HIV management in resource-limited settings has been remarkably successful in a relatively short time frame. Once combination antiretroviral therapy (cART) became more universally available national treatment programs were able to provide much of the needed therapy which was originally prioritized towards patients with the most advanced and symptomatic disease. The current worldwide expansion of antiretroviral therapy is due to a large broad-based international effort in financing the antiretroviral drugs and infrastructure required for delivering treatment and care. Control of the HIV pandemic is now the primary objective. We need to learn more about optimal treatment choices and monitoring schemes appropriate in diverse resource-limited settings. We must build upon our existing and extensive knowledge base and target highly relevant research towards the affected populations in the countries where the patients reside. The international scientific community must address this urgent need with academic social scientific and economic support for the necessary critical research and training so desperately needed. (excerpt)

Childhood epilepsy: Management in resource-limited setting

Objective:To optimize the use of phenobarbital and/or phenytoin as frontline drugs for treatment of childhood epilepsy.Design:Before-and -after study.Setting:Epilepsy clinic at paediatric OPD, Sassoon General Hospital, Pune.Materials and Methods:Epilepsy is a condition in which seizures are triggered recurrently from within the brain. For epidemiological classification purpose epilepsy is considered to be present when two or more unprovoked seizures occur at an interval greater than twenty four hours apart. Seizures were classified as generalized and partial seizures, with underlying etiology investigated with EEG, CT scan in majority of the patients. Follow - up rate, seizure - control and antiepileptic drugs used among 151 children enrolled as on 31 March 2005 were compared with 106 children with new onset epilepsy enrolled as on February 2006. Eight children with breakthrough convulsion after a seizure free period of five to eighteen months were followed up after injection vitamin D. Nineteen children with poor control of seizures receiving polytherapy with newer antiepileptic drugs were assessed with frontline antiepileptic medication of phenobarbital and/or phenytoin. Serum calcium, phosphorus, alkaline phosphatase were done in seventy two consecutive children with seizure disorder.Results:During post protocol period good seizure control was achieved in 84.8% as against 80.7% and use of phenobarbital and/or phenytoin increased to 65.11% from 22.87%. Of the 8 cases with breakthrough seizures seven remained seizure free after vitamin D administration and with no dose enhancement of AED medications of the nineteen. Children receiving polytherapy thirteen children could be successfully switched to phenobarbital and/or phenytoin. Forty four (61%) children had hypocalcemia (less than 9 mg%), fifty seven (79%) children had raised alkaline phosphatase levels (more than 270 IU).Comments:Phenobarbital and/or phenytoin have been found to be effective frontline AED. Periodic administration of vitamin D plays a supportive role.

Skin Lesions: Mirror Images of Oral Lesion Infections

Skin lesions can be the presenting signs for HIV disease and are among the most prevalent manifestations throughout the course of HIV disease. Correlation of skin diseases and HIV disease staging has long been recognized and used to guide medical management in resource-limited settings. The purpose of this paper is to give a review of common skin infections presented in HIV-infected patients. Common skin infections presenting in HIV-infected patients include viral, fungal, mycobacterial, and bacterial infections, along with skin infestation. Key diagnostic points correlate with certain HIV disease staging for many skin diseases. These can help facilitate appropriate diagnosis and referral by health care personnel when treating HIV-infected patients who have skin lesions. Knowledge of common skin manifestations found in HIV-infected patients is essential for all health care personnel who work in the HIV field. Most skin infections presenting in HIV-infected patients can be treated effectively if the correct diagnosis and appropriate referral are made promptly.

HIV-1 subtype E progression among northern Thai couples: traditional and non-traditional predictors of survival

In the continuing effort to introduce antiretroviral therapy in resource-limited settings, there is a need to understand differences between natural history of HIV in different populations and to identify feasible clinical measures predictive of survival. We examined predictors of survival among 836 heterosexuals who were infected with HIV subtype CRF01_AE in Thailand. From 1993 to 1999, 269 (49.4%) men and 65 (25.7%) women died. The median time from the estimated seroconversion to death was 7.8 years (95% confidence interval 7.0-9.1). Men and women with enrolment CD4 counts <200 cells/microl had about 2 and 11 times greater risk of death than those with CD4 counts of 200-500 and >500, respectively. Measurements available in resource-limited settings, including total lymphocyte count (TLC), anaemia, and low body mass index (BMI), also predicted survival. Men with two or more of these predictors had a median survival of 0.8 (0.5-1.8) years, compared with 2.7 (1.9-3.3) years for one predictor and 4.9 (4.1-5.2) years for no predictors. The time from HIV infection to death appears shorter among this Thai population than among antiretroviral naive Western populations. CD4 count and viral load (VL) were strong, independent predictors of survival. When CD4 count and VL are unavailable, individuals at high risk for shortened HIV survival may be identified by a combination of low TLC, anaemia, and low BMI. This combination of accessible clinical measures of the disease stage may be useful for medical management in resource-limited settings.