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Development of a clinical scoring system for assessment of immunosuppression in patients with tuberculosis and HIV infection without access to CD4 cell testing - results from a cross-sectional study in Ethiopia.

Skogmar, Sten LU ; Balcha, Taye LU ; Jemal, Zelalem H; Björk, Jonas LU ; Deressa, Wakgari; Schön, Thomas and Björkman, Per LU (2014) In Global Health Action 7.
Abstract
Background : Currently, antiretroviral therapy (ART) is recommended for all HIV-positive patients with tuberculosis (TB). The timing of ART during the course of anti-TB treatment is based on CD4 cell counts. Access to CD4 cell testing is not universally available; this constitutes an obstacle for the provision of ART in low-income countries. Objective : To determine clinical variables associated with HIV co-infection in TB patients and to identify correlations between clinical variables and CD4 cell strata in HIV/TB co-infected subjects, with the aim of developing a clinical scoring system for the assessment of immunosuppression. Design : Cross-sectional study of adults with TB (with and without HIV co-infection) recruited in Ethiopian... (More)
Background : Currently, antiretroviral therapy (ART) is recommended for all HIV-positive patients with tuberculosis (TB). The timing of ART during the course of anti-TB treatment is based on CD4 cell counts. Access to CD4 cell testing is not universally available; this constitutes an obstacle for the provision of ART in low-income countries. Objective : To determine clinical variables associated with HIV co-infection in TB patients and to identify correlations between clinical variables and CD4 cell strata in HIV/TB co-infected subjects, with the aim of developing a clinical scoring system for the assessment of immunosuppression. Design : Cross-sectional study of adults with TB (with and without HIV co-infection) recruited in Ethiopian outpatient clinics. Clinical variables potentially associated with immunosuppression were recorded using a structured questionnaire, and they were correlated to CD4 cell strata used to determine timing of ART initiation. Variables found to be significant in multivariate analysis were used to construct a scoring system. Results : Among 1,116 participants, the following findings were significantly more frequent in 307 HIV-positive patients compared to 809 HIV-negative subjects: diarrhea, odynophagia, conjunctival pallor, herpes zoster, oral candidiasis, skin rash, and mid-upper arm circumference (MUAC) <20 cm. Among HIV-positive patients, conjunctival pallor, MUAC <20 cm, dyspnea, oral hairy leukoplakia (OHL), oral candidiasis, and gingivitis were significantly associated with <350 CD4 cells/mm3. A scoring system based on these variables had a negative predictive value of 87% for excluding subjects with CD4 cell counts <100 cells/mm3; however, the positive predictive value for identifying such individuals was low (47%). Conclusions : Clinical variables correlate with CD4 cell strata in HIV-positive patients with TB. The clinical scoring system had adequate negative predictive value for excluding severe immunosuppression. Clinical scoring systems could be of use to categorize TB/HIV co-infected patients with regard to the timing of ART initiation in settings with limited access to laboratory facilities. (Less)
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author
organization
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type
Contribution to journal
publication status
published
subject
in
Global Health Action
volume
7
publisher
Co-action Publishing
external identifiers
  • pmid:24560255
  • scopus:84904389882
ISSN
1654-9880
language
English
LU publication?
yes
id
1af4984a-44ff-4a36-9a89-b554cc329805 (old id 4334295)
alternative location
http://www.ncbi.nlm.nih.gov/pubmed/24560255?dopt=Abstract
date added to LUP
2014-03-05 20:15:29
date last changed
2017-01-01 05:50:54
@article{1af4984a-44ff-4a36-9a89-b554cc329805,
  abstract     = {Background : Currently, antiretroviral therapy (ART) is recommended for all HIV-positive patients with tuberculosis (TB). The timing of ART during the course of anti-TB treatment is based on CD4 cell counts. Access to CD4 cell testing is not universally available; this constitutes an obstacle for the provision of ART in low-income countries. Objective : To determine clinical variables associated with HIV co-infection in TB patients and to identify correlations between clinical variables and CD4 cell strata in HIV/TB co-infected subjects, with the aim of developing a clinical scoring system for the assessment of immunosuppression. Design : Cross-sectional study of adults with TB (with and without HIV co-infection) recruited in Ethiopian outpatient clinics. Clinical variables potentially associated with immunosuppression were recorded using a structured questionnaire, and they were correlated to CD4 cell strata used to determine timing of ART initiation. Variables found to be significant in multivariate analysis were used to construct a scoring system. Results : Among 1,116 participants, the following findings were significantly more frequent in 307 HIV-positive patients compared to 809 HIV-negative subjects: diarrhea, odynophagia, conjunctival pallor, herpes zoster, oral candidiasis, skin rash, and mid-upper arm circumference (MUAC) &lt;20 cm. Among HIV-positive patients, conjunctival pallor, MUAC &lt;20 cm, dyspnea, oral hairy leukoplakia (OHL), oral candidiasis, and gingivitis were significantly associated with &lt;350 CD4 cells/mm3. A scoring system based on these variables had a negative predictive value of 87% for excluding subjects with CD4 cell counts &lt;100 cells/mm3; however, the positive predictive value for identifying such individuals was low (47%). Conclusions : Clinical variables correlate with CD4 cell strata in HIV-positive patients with TB. The clinical scoring system had adequate negative predictive value for excluding severe immunosuppression. Clinical scoring systems could be of use to categorize TB/HIV co-infected patients with regard to the timing of ART initiation in settings with limited access to laboratory facilities.},
  articleno    = {23105},
  author       = {Skogmar, Sten and Balcha, Taye and Jemal, Zelalem H and Björk, Jonas and Deressa, Wakgari and Schön, Thomas and Björkman, Per},
  issn         = {1654-9880},
  language     = {eng},
  publisher    = {Co-action Publishing},
  series       = {Global Health Action},
  title        = {Development of a clinical scoring system for assessment of immunosuppression in patients with tuberculosis and HIV infection without access to CD4 cell testing - results from a cross-sectional study in Ethiopia.},
  volume       = {7},
  year         = {2014},
}