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Classification of HIV Infection and Disease in Women from Rwanda: Evaluation of the World Health Organization HIV Staging System and Recommended Modifications

Alan R. Lifson, MD, MPH; Susan Allen, MD, DTM&H; William Wolf, BS; Antoine Serufilira, MD; Genevieve Kantarama, MD; Christina P. Lindan, MD; Esther S. Hudes, PhD; Francois Nsengumuremyi, MD; Henri Taelman, MD; and Jean Batungwanayo, MD
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From the University of California, San Francisco, California, and Central Hospital of Kigali and the Ministry of Health, Kigali, Rwanda. Requests for Reprints: Alan R. Lifson, MD, MPH, Division of Epidemiology, School of Public Health, University of Minnesota, 1300 South Second Street, Suite 300, Minneapolis, MN 55454-1015. Acknowledgments: As of this writing, our 4 Rwandan coauthors were alive and well. Half of the staff involved in data collection and more than half of the study participants are dead or missing. We express our profound appreciation for the many dedicated contributions made by all Rwandan staff associated with this project and by the women who agreed to participate in this study. Fearing the worst in many cases, we hope for their health and safety. Grant Support: By grant AI23980 from the National Institute of Allergy and Infectious Diseases and grant MH42459 from the National Institute of Mental Health.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1995;122(4):262-270. doi:10.7326/0003-4819-122-4-199502150-00004
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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.

Design: Prospective cohort study with 4 years of follow-up.

Setting: Kigali, Rwanda.

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

Measurements: 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.

Figures

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Figure 1.
Cumulative mortality (in months) among HIV-positive women in Rwanda on the basis of the World Health Organization (WHO) clinical staging system (described in the Appendix with adaptations as noted in text).
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Figure 2.
Cumulative mortality (in months) among HIV-positive women in Rwanda on the basis of the World Health Organization (WHO) laboratory staging system with total lymphocyte count only.666

Lymphocyte counts were categorized as follows: stage A, >2000 × 10 /L; stage B, 1000 to 2000 × 10 /L; and stage C, <1000 × 10 /L.

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Grahic Jump Location
Figure 3.
Cumulative mortality (in months) among HIV-positive women in Rwanda on the basis of the modified clinical staging system.
Grahic Jump Location
Grahic Jump Location
Figure 4.
Cumulative mortality (in months) among HIV-positive women in Rwanda on the basis of the modified laboratory staging system.
Grahic Jump Location
Grahic Jump Location
Figure 5.
Cumulative mortality (in months) among HIV-positive women in Rwanda on the basis of the combined clinical and laboratory staging systems.
Grahic Jump Location

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