Predictors of Low CD4 Count in Resource-Limited Settings: Based on an Antiretroviral-Naive Heterosexual Thai Population

Costello, Caroline MPH*†; Nelson, Kenrad E MD‡; Jamieson, Denise J MD*; Spacek, Lisa MD, PhD‡; Sennun, Supaluk MS, RN§; Tovanabutra, Sodsai PhD∥; Rungruengthanakit, Kittipong MS§; Suriyanon, Vinai MD§; Duerr, Ann MD, PhD, MPH*

JAIDS Journal of Acquired Immune Deficiency Syndromes: 1 June 2005 - Volume 39 - Issue 2 - pp 242-248
Epidemiology and Social Science

Summary: A barrier to the appropriate provision of antiretroviral therapy to treat immunosuppressed HIV-infected persons in resource-poor countries is identifying who requires treatment. The World Health Organization (WHO) has suggested using a clinical algorithm combined with a total lymphocyte count (TLC) <1200 cells/mm3 as a surrogate for a CD4 count less than 200 cells/mm3 when it is not possible to measure the CD4 count. We evaluated various TLC levels, anemia, and body mass index and compared our data with the WHO criteria to develop a more sensitive algorithm to predict CD4 counts of <200 cells/mm3 and <350 cells/mm3 in 839 men and women from Thailand infected with HIV-1 subtype E (CRF01_AE). The December 2003 WHO guidelines had a sensitivity of 34.1% in men and 31.8% in women to detect persons with a CD4 count <200 cells/mm3 in this HIV-infected population from Thailand. The use of a TLC <1500 cells/mm3 or TLC <2000 cells/mm3 combined with anemia or WHO stage II infection doubled the sensitivity to detect persons with a CD4 count <200 (63.0% in men, 68.2% in women) with less than a 6% decrease in specificity.

From the *Centers for Disease Control and Prevention, Atlanta, GA; †Northrop Grumman, Atlanta, GA; ‡Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; §Research Institute for Health Sciences, Chiang Mai, Thailand; ∥Henry M. Jackson Foundation, Rockville, MD.

Received for publication August 19, 2004; Accepted November 22, 2004.

Support for the baseline (CSA-99-259) and follow-up (CSA-00-278) studies provided by the Contraceptive Research and Development (CONRAD) Program, Eastern Virginia Medical School, under a Cooperative Agreement with the United States Agency for International Development (USAID; HRN-A-00-98-00020-00), which, in turn, receives funds for AIDS research from an interagency agreement with the Division of Reproductive Health, Centers for Disease Control and Prevention (CDC).

The views expressed by the authors do not necessarily reflect the views of USAID, CDC, or CONRAD.

Reprints: Kenrad E. Nelson, Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205 (e-mail:

© 2005 Lippincott Williams & Wilkins, Inc.