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.
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.
  
  
  METHODS
  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/mm(3). A scoring system based on these variables had a negative predictive value of 87% for excluding subjects with CD4 cell counts <100 cells/mm(3); 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.
authors.affiliation: Infectious Diseases Research Unit, Department of Clinical Sciences in Malmö, Faculty of Medicine, Lund University, Sweden; sten.skogmar@med.lu.se.
authors.forename: Sten
authors.initials: S
authors.lastname: Skogmar
authors.affiliation: Infectious Diseases Research Unit, Department of Clinical Sciences in Malmö, Faculty of Medicine, Lund University, Sweden; Health Ministry, Addis Ababa, Ethiopia.
authors.forename: Taye T
authors.initials: TT
authors.lastname: Balcha
authors.affiliation: Oromia Regional Health Bureau (ORHB), Addis Ababa, Ethiopia.
authors.forename: Zelalem H
authors.initials: ZH
authors.lastname: Jemal
authors.affiliation: Research and Development Unit, Skåne University Hospital, Lund, Sweden.
authors.forename: Jonas
authors.initials: J
authors.lastname: Björk
authors.affiliation: Department of Public Health, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Wakgari
authors.initials: W
authors.lastname: Deressa
authors.affiliation: Department of Medical Microbiology, Faculty of Health Sciences, Linköping University, Sweden; Department of Clinical Microbiology and Infectious Diseases, Kalmar County Hospital, Sweden.
authors.forename: Thomas
authors.initials: T
authors.lastname: Schön
authors.affiliation: Infectious Diseases Research Unit, Department of Clinical Sciences in Malmö, Faculty of Medicine, Lund University, Sweden.
authors.forename: Per
authors.initials: P
authors.lastname: Björkman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D060085:Coinfection / Q000150:complications* / Q000175:diagnosis / Q000276:immunology; D003430:Cross-Sectional Studies; D005002:Ethiopia / Q000453:epidemiology; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy / Q000276:immunology; D006801:Humans; D016867:Immunocompromised Host; D008297:Male; D008875:Middle Aged; D012720:Severity of Illness Index; D014397:Tuberculosis, Pulmonary / Q000150:complications* / Q000175:diagnosis / Q000276:immunology; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents
keywords: CD4 cell; Ethiopia; HIV; scoring system; timing of ART; tuberculosis