{"id":7076,"date":"2005-09-14T01:31:39","date_gmt":"2005-09-14T00:31:39","guid":{"rendered":"http:\/\/moomango.co.uk\/htb\/?p=7076"},"modified":"2014-03-31T17:47:57","modified_gmt":"2014-03-31T17:47:57","slug":"does-who-clinical-stage-reliably-predict-who-should-receive-arv-treatment","status":"publish","type":"post","link":"https:\/\/i-base.info\/htb\/7076","title":{"rendered":"Does WHO clinical stage reliably predict who should receive ARV treatment?"},"content":{"rendered":"

Polly Clayden, HIV i-Base<\/strong><\/p>\n

In resource-limited settings with limited access to laboratory facilities it has been suggested that WHO eligibility criteria can be used to guide treatment initiation decisions in the absence of CD4 counts.<\/strong><\/p>\n

A South African study conducted by Neil Martinson and co-workers in and presented by Glenda Gray assessed the proportion of adults staged as WHO I or II but with CD4 counts <200 cells\/mm3<\/sup> [1]. The study also looked at predictors for being assessed as stage I or II, but having a CD4 count below 200 cells\/mm3<\/sup>.<\/p>\n

Current WHO criteria recommend initiating therapy in stages III and IV and in stage II if total lymphocyte count is <1200 [2].<\/p>\n

The study was conducted at two primary healthcare facilities, an urban site in Soweto and a rural site in Limpopo Province. It was a cross sectional, operational study with a total of 2000 patients, 1500 from the urban site and 500 from the rural. The median CD4 count was 246 cells\/mm3<\/sup> (range 126-426 cells\/mm3<\/sup>) across both groups. The median CD4 at the urban site was 233 cells\/mm3<\/sup> (range 111-411 cells\/mm3<\/sup>) and 203 cells\/mm3<\/sup> at the rural site (range 91-375 cells\/mm3<\/sup>). See Table 1.<\/p>\n

Table 1: CD4 cells\/mm3 and interquartile range by stage<\/strong><\/p>\n\n\n\n\n\n\n\n
WHO stage<\/strong><\/td>\nUrban (n) <\/strong><\/td>\n IQR<\/strong><\/td>\nRural (n)<\/strong><\/td>\n IQR<\/strong><\/td>\n<\/tr>\n
I<\/td>\n339 (302)<\/td>\n199-525<\/td>\n413 (78)<\/td>\n267-615<\/td>\n<\/tr>\n
II<\/td>\n194 (123)<\/td>\n123-370.5<\/td>\n270 (128)<\/td>\n143-420.5<\/td>\n<\/tr>\n
III<\/td>\n154 (241)<\/td>\n67-279<\/td>\n147 (285)<\/td>\n56-279<\/td>\n<\/tr>\n
IV<\/td>\n176 (8)<\/td>\n30-450<\/td>\n105 (33)<\/td>\n51-327<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

The investigators reported that 23.9% (urban 25.0% and rural 14.5%) of patients classified stage I had CD4 counts <200 cells\/mm3<\/sup>. For stage II the total was 46.1% (urban 50.4% and rural 37.9%).<\/p>\n

Dr Gray noted that wrong staging of patients was slightly more common in the urban site than the rural site but this was not found to be a predictor in a multivariate analysis. In both univariate and multivariate analyses male gender was a predictor for mistaging as stage I or II with CD4 count <200 cells\/mm3<\/sup> (gender female vs male: univariate and multivariate 0.6 [0.4-0.8]).<\/p>\n

The investigators also looked at patients staged as III or IV with CD4 <350 cells\/mm3<\/sup>. See Table 2.<\/p>\n

Table 2: CD4 strata WHO stages III and IV<\/strong><\/p>\n\n\n\n\n\n
Stage<\/strong><\/td>\n<200 <\/strong><\/td>\n200-350<\/strong><\/td>\n >350<\/strong><\/td>\n<\/tr>\n
III<\/td>\n62%<\/td>\n20%<\/td>\n18%<\/td>\n<\/tr>\n
IV<\/td>\n59%<\/td>\n15%<\/td>\n26%<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

The investigators summarised: \u009338-50% of adults staged as II and 15-25% staged as I had CD4 counts under 200 cells\/mm3<\/sup>. Approximately 80% of adults staged in WHO III and IV had CD4 <350 cells\/mm3<\/sup>. Experience appears to reduce \u0091mistaging\u0092. Men are more likely to be staged as I or II but have CD4<200 cells\/mm3<\/sup>.\u0094<\/p>\n

Comment<\/h3>\n

WHO staging is not a good instrument for primary care particularly to recognise advanced disease.<\/strong><\/p>\n

CD4 counts in all settings will ensure relatively well people with low CD4s won\u0092t miss out on ARVs until they are really ill. The WHO staging needs to be reassessed.<\/strong><\/p>\n

References:<\/p>\n

    \n
  1. Martinson N, Heyer A, Steyn J et al. Does WHO clinical stage reliably predict who should receive ARV treatment? 3rd IAS Conference on HIV Pathogenesis and Treatment, Rio de Janeiro, 2005. Abstract WeFo0304.<\/li>\n
  2. WHO guidelines. Download pdf file:
    \nhttp:\/\/www.who.int\/entity\/hiv\/pub\/guidelines\/clinicalstaging.pdf<\/a> (492 k)<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    Polly Clayden, HIV i-Base In resource-limited settings with limited access to laboratory facilities it has been suggested that WHO eligibility criteria can be used to guide treatment initiation decisions in the absence of CD4 counts. A South African study conducted …<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[4,38],"tags":[91],"class_list":["post-7076","post","type-post","status-publish","format-standard","hentry","category-conference-reports","category-treatment-access","tag-ias-3rd-2005"],"_links":{"self":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts\/7076","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/comments?post=7076"}],"version-history":[{"count":0,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts\/7076\/revisions"}],"wp:attachment":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/media?parent=7076"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/categories?post=7076"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/tags?post=7076"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}