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WHO Staging Criteria vs CD4 Screening for ART Eligibility in Rural Rakai District, Uganda
Joseph Kagaayi*1, F Makumbi1, P Nakamya1, Z Namukwaya1, G Nakigozi1, M Wawer2, D Serwadda3, P Opendi1, and S Reynolds4,5
1Rakai Hlth Sci Program, Uganda; 2Columbia Univ, Mailman Sch of Publ Hlth, New York, NY, US; 3Makerere Univ, Kampala, Uganda; 4NIAID, NIH, DHHS, Bethesda, MD, US; and 5Johns Hopkins Univ, Baltimore, MD, US
Background: In
resource-limited settings with no access to CD4 screening, World Health Organization
(WHO) clinical staging criteria are being used to determine ART eligibility.
Since ART initiated after the onset of advanced immunosuppression has been shown
to be less effective (higher rates of mortality and morbidity due to immune
reconstitution inflammatory syndromes and increased risk of opportunistic
infections), timely initiation is essential. We evaluated the WHO clinical
staging criteria compared to CD4 screening.
Methods: HIV-infected adults
were screened by WHO clinical staging and CD4 cell count in the Rakai Health
Sciences Program PEPFAR funded ART service. Clinical assessments were conducted
by trained medical officers and all participants were also screened for CD4
cell count using FACSCount at the same visit. WHO clinical staging as a
predictor for ART need was compared to CD4 cut-off values of ≤200 or ≤350
cells/mm3.
Results: We evaluated 1128
HIV-infected adults of whom 565 (50%) had a CD4 cell count ≤350 cells/mm3
and 343 (30%) had a CD4 cell count ≤200 cells/mm3. A high
proportion of patients with CD4 ≤350 (333 of 565; 59%) or CD4 ≤200
(161 of 343; 47%) did not satisfy the criteria for WHO clinical stage 3 or 4,
which would render them ineligible for ART based on WHO staging criteria alone.
Conclusions: In this rural
setting, exclusive use of the WHO clinical staging criteria would miss a high
proportion of ART-eligible patients. Expanded access to low-cost, simple, CD4
screening technologies is urgently needed to assess ART eligibility in
resource-limited settings.
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