Clinical and laboratory predictors of survival in Gambian patients with symptomatic HIV-1 or HIV-2 infection

Abstract

Objectives: To determine which clinical and immunological features of patients with symptomatic HIV-1 and HIV-2 infection best predict survival in The Gambia.

Methods: All patients presenting to two hospitals in The Gambia between January 1987 and June 1990 with symptoms or signs suggesting chronic HIV infection were tested for HIV-1 and HIV-2 antibodies. Eighteen HIV-1 and 31 HIV-2-infected patients were recruited to the study, investigated intensively on admission and followed up until the end of 1990. Presenting clinical features, such as Karnofsky score, diagnosis of AIDS according to World Health Organization Bangui or Centers for Disease Control criteria and number of associated infections, together with five immunological measurements, as well as type of HIV infection, were related to length of survival using proportional hazard models fitted to Kaplan-Meier plots of survival times.

Results: Karnofsky score and diagnosis of AIDS were the best clinical predictors of survival. Type of HIV infection or number of associated infections did not predict outcome. The most powerful laboratory predictors were log(e) serum neopterin level, CD4 cell count and log(e) serum beta 2-microglobulin (beta 2M) level. The estimated median survival times (90% confidence interval) of the HIV-1 and HIV-2-infected were six (4-11) and 13 (9-20) months, respectively. These survival times do not differ significantly.

Conclusions: The Karnofsky score and measurements of serum neopterin or beta 2M, which are easier and cheaper to perform than CD4 counts, may prove to be useful guides to prognosis for HIV infection in Africa.

PIP: Researchers analyzed data on 49 symptomatic patients with HIV-1 or HIV-2 at either the Royal Victoria Hospital in Banjul or the Medical Research Council Hospital in Fajara, the Gambia, between January 1987 and June 1990 to determine what clinical and laboratory factors best predicted survival in an African country. Patients with HIV-1 died at a faster rate than those with HIV-2 (median = 6 and 13 months, respectively), yet the difference was not significant. Diagnosis of AIDS and the Karnofsky score were strong clinical predictors of survival (p = .001 for AIDS vs. AIDS related complex (ARC), p = .003 for AIDS vs. not AIDS and p = .0001 for Karnofsky score, respectively). On the other hand, number of infections on admission, age, and HIV type were not related to survival. The most powerful laboratory predictors for survival included log(e) neopterin level (p = .001), log(e) beta 2 microglobulin level (p = .002), number of CD4 lymphocytes (p = .001), percentage CD4 lymphocytes (p = .003), and number of lymphocytes (p = .009). High levels of serum neopterin and beta 2 microglobulin and low numbers of CD4 cells or lymphocytes predicted poor survival times. The multivariate analysis showed that only CD4 counts (p = .015), log(e) neopterin (p = .005), and log(e) beta 2 microglobulin levels (p = .05) were laboratory predictors of survival assuming a diagnosis of ARC or AIDS. ARC patients with neopterin levels or or= 50 nmol/1 had 12 (6-26) and 26 (13-51) months to live, respectively. These corresponding figures for those with AIDS were 4 (3-6) and 9 (5-17) months. The median survival times were essentially the same for beta 2 microglobulin levels of 5 nmol/1. Physicians can use the easy to use Karnofsky score and laboratory measurements of serum neopterin or beta 2 microglobulin to make a prognosis for HIV infection in Africa. The advantages of these 2 laboratory procedures over CD4 counts are they are simpler and less expensive.