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Total Lymphocyte Count and World Health Organization Pediatric Clinical Stage as Markers to Assess Need to Initiate Antiretroviral Therapy Among Human Immunodeficiency Virus-Infected Children in Moshi, Northern Tanzania

Johnson, Opemipo O. BS*; Benjamin, Daniel K. PhD; Benjamin, Daniel K. Jr MD, PhD, MPH*; Schimana, Werner MD; Tillekeratne, L Gayani MD*; Crump, John A. MB, ChB, DTM&H¶∥§**; Landman, Keren Z. MD; Kinabo, Grace D. MD, MMed; Mmbaga, Blandina T. MD, MMed; Msuya, Levina J. MD, MMed; Shao, John F. MD, MSc, PhD††; Swai, Mark E. MD; Cunningham, Coleen K. MD*

The Pediatric Infectious Disease Journal: June 2009 - Volume 28 - Issue 6 - p 493-497
doi: 10.1097/INF.0b013e3181950b7f
Original Studies

Background: The World Health Organization (WHO) has recommended the use of clinical staging alone and with total lymphocyte count to identify HIV infected children in need of antiretroviral therapy (ART) in resource-limited settings, when CD4 cell count is not available.

Methods: We prospectively enrolled children obtaining care for HIV infection at the Kilimanjaro Christian Medical Centre Pediatric Infectious Diseases Clinic in Moshi, Tanzania between March 2004 and May 2006 for this cohort study.

Results: One hundred ninety two (89.7%) of 214 children met WHO ART initiation criteria based on clinical staging or CD4 cell count. Several low-cost measures identified individuals who met WHO ART initiation criteria to the following degree: WHO stages 3 or 4 had 87.5% (95% CI, 82.8–92.1) sensitivity and, by definition, 100% (CI, 100–100) specificity; WHO recommended advance disease TLC cutoffs: sensitivity = 23.9% (95% CI, 17.3–30.5) specificity = 78.2% (95% CI, 67.3–89.1). Low TLC was a common finding, (50 of 214; 23%); however, it did not improve the sensitivity or specificity of clinical staging in identifying the severely immunosuppressed stage 2 children. Growth failure or use of total lymphocyte counts in isolation were not reliable indicators of severe immunosuppression or need to initiate ART.

Conclusion: The use of total lymphocyte count does not improve the ability to identify children in need of ART compared with clinical staging alone. Low absolute lymphocyte count did not correlate with severe immunosuppression based on CD4 cell count in this cohort.


From the *Department of Pediatrics, Duke University Medical Center, Durham, NC; †John E. Walker Department of Economics, Clemson University, Clemson, South Carolina; ‡Department of Pediatrics, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; §Department of Medicine, Duke University Medical Center, Durham, NC; ¶Department of Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania; ∥Kilimanjaro Christian Medical College, Tumaini University, Moshi, Tanzania; **Duke Global Health Institute, Duke University, Durham, NC; and ††Department of Microbiology and Clinical Laboratory, Kilimanjaro Christian Medical College, Tumaini University, Moshi, Tanzania.

Accepted for publication November 13, 2008.

Supported by Duke University Center for AIDS Research (CFAR)—an NIH funded program (P30 AI 64518); NICHD RO HD42920-02; (to D.K.B.); an NIH Research Supplements fellowship, grant 5U01-AI27535-17S1 (to O.O.J.).

Address for correspondence: Coleen K. Cunningham, MD, Duke University Medical Center, Erwin Road, P.O. Box 3499, Durham, NC 27710. E-mail:

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© 2009 Lippincott Williams & Wilkins, Inc.