Classification of HIV infection and disease in women from Rwanda. Evaluation of the World Health Organization HIV staging system and recommended modifications.
OBJECTIVE
To develop a human immunodeficiency virus (HIV) staging system for sub-Saharan Africa on the basis of an evaluation of the World Health Organization (WHO) system and predictors of mortality.


METHODS
Prospective cohort study with 4 years of follow-up.


METHODS
Kigali, Rwanda.


METHODS
412 HIV-infected women recruited from prenatal and pediatric clinics.


METHODS
Clinical signs and symptoms of HIV disease, laboratory assays (including complete blood count and erythrocyte sedimentation rate), and cumulative mortality.


RESULTS
The WHO staging system includes a clinical and a laboratory axis. The clinical axis was revised by inclusion of oral candidiasis, chronic oral or genital ulcers, and pulmonary tuberculosis as "severe" disease (clinical stage IV); in addition, body mass index was substituted for weight loss in the definition for the wasting syndrome. The 36-month cumulative mortality was 7% for women in modified clinical stage I ("asymptomatic"), 15% for those in stage II, 19% for those in stage III, and 36% for those in stage IV (P < 0.001). The laboratory axis was revised by replacing lymphocyte count with hematocrit and erythrocyte sedimentation rate. The 36-month mortality was 10% for women in modified stage A ("normal" laboratory results) and 33% for those in stage B (erythrocyte sedimentation rate > 65 mm/h or hematocrit < 0.38) (P < 0.001). A single staging system combining clinical and laboratory criteria is proposed, with a 36-month mortality of 7% for women in combined stage I, 10% for those in stage II, 29% for those in stage III, and 62% for those in stage IV (P < 0.001).


CONCLUSIONS
On the basis of this analysis, a staging system relevant for sub-Saharan Africa is proposed that reflects the range of HIV-related outcomes, has strong prognostic significance, includes inexpensive and available laboratory tests, and can be used by both clinicians and researchers.
Lifson
A R
AR
University of California, San Francisco.
Allen
S
S
Wolf
W
W
Serufilira
A
A
Kantarama
G
G
Lindan
C P
CP
Hudes
E S
ES
Nsengumuremyi
F
F
Taelman
H
H
Batungwanayo
J
J
D017088:AIDS-Related Opportunistic Infections; D000293:Adolescent; D000328:Adult; D003906:Developing Countries; D005069:Evaluation Studies as Topic; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000145:classification* / Q000150:complications / Q000175:diagnosis* / Q000401:mortality; D006801:Humans; D009369:Neoplasms / Q000150:complications; D011446:Prospective Studies; D012432:Rwanda / Q000453:epidemiology; D014944:World Health Organization