Clinical signs and symptoms in the assessment of immunodeficiency in men with subtype C HIV infection in Harare, Zimbabwe

Abstract

Purpose: Providing low-cost interventions such as co-trimoxazole as prophylaxis against opportunistic infections among HIV-infected individuals depends on the identification of those at risk. This article describes the prevalence of self-reported signs and symptoms and CD4 cell counts in a cohort of 447 HIV seropositive men. A scoring system using self-reported signs and symptoms was developed and tested in the prediction of low CD4 cell counts. This approach may allow health care providers in low-resource settings to predict severe immunodeficiency and to provide care. Method: Data on clinical manifestations of HIV infection and blood samples for HIV serology were collected prospectively from an ambulatory cohort of men seen at their workplace at enrollment and every 6 months thereafter. CD4+ cell counts were obtained on samples testing positive on ELISA. Using data reduction techniques and logistic modeling, we developed a prognostic score system. Results: 20% of the men had CD4+ cell counts below 200. All reported signs and symptoms were more frequent in men with less than 200 CD4+ cell counts compared to men with CD4+ cell counts greater than 200. History of malaria, fever, lymphadenopathy, persistent diarrhea, persistent cough, and skin infections robustly predicted low CD4+ count. A scoring system equation was developed based on the coefficients of the multivariate logistic regression: 1x(tuberculosis) + 3.2x(herpes zoster) + 4.5x(malaria) + 5.7x(fever) + 5.8x(cough) + 8.2x(lymphadenopathy) + 8.5x(skin infection). Setting the score cutoff value greater than or equal 5, the model had moderately high sensitivity of 61% and specificity of 72%. The scoring system had an overall classification error rate of 30%. Conclusion: By using this simple scoring system, physicians can correctly identify 72% of patients who do not require immediate intervention, thereby channeling scarce resources to those who have both low CD4+ cell counts and symptoms and are most likely to benefit from prophylactic and antiretroviral interventions.