Gupta Amita, Gupte Nikhil, Bhosale Ramesh, Kakrani Arjun, Kulkarni Vandana, Nayak Uma, Thakar Madhuri, Sastry Jayagowri, Bollinger Robert C
Division of Infectious Diseases Center for Clinical Global Health Education, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
J Acquir Immune Defic Syndr. 2007 Nov 1;46(3):338-42. doi: 10.1097/QAI.0b013e318157684b.
Some studies support the use of total lymphocyte count (TLC) as a surrogate marker for CD4 cell count to guide antiretroviral therapy (ART) initiation. However, most of these studies have focused on nonpregnant adults. In light of expanding ART access through prevention of mother-to-child transmission (PMTCT)-plus programs in resource-limited settings, we assessed the sensitivity, specificity, and positive predictive value (PPV) of TLC for predicting low CD4 counts in antepartum and postpartum women in Pune, India.
CD4, TLC, and hemoglobin were measured at third trimester, delivery, and 6, 9, and 12 months postpartum (PP) in a cohort of 779 HIV-infected women. Optimal TLC cutoff for predicting CD4 <200 cells/mm3 was determined via logistic regression where sensitivity, specificity, PPV, and an area under the receiver operating characteristic (ROC) curve were calculated.
Among the 779 women enrolled, 16% had WHO clinical stage 2 or higher and 7.9% had CD4 <200 cells/mm3. Using 2689 TLC-CD4 pairs, the sensitivity, specificity, and PPV of TLC <1200 cells/mm3 for predicting CD4 <200 cells/mm3 was 59%, 94%, and 47%, respectively. The sensitivity of TLC <1200 cells/mm3 cutoff ranged between 57% and 62% for time points evaluated. Addition of hemoglobin <12 g/dL or <11 g/dL increased the sensitivity of TLC to 74% to 92% for predicting CD4 <200 cells/mm3 but decreased the specificity to 33% to 69% compared to TLC alone. A combination of TLC, hemoglobin, and WHO clinical staging had the highest sensitivity but lowest specificity compared to other possible combinations or use of TLC alone. The sensitivity and specificity of TLC <1200 cells/mm3 to predict a CD4 <350 cells/mm3 was 31% and 99%, respectively.
Our data suggest that antepartum and PP women with TLC <1200 cells/mm3 are likely to have CD4 <200 cells/mm3. However, the sensitivity of this TLC cutoff was low. Between 45% and 64% of antepartum and PP women requiring initiation of ART may not be identified by using TLC alone as a surrogate marker for CD4 <200 cells/mm3. The WHO-recommended TLC cutoff of <1200 cells/mm3 is not optimal for identifying antepartum and PP Indian women who require ART.
一些研究支持使用总淋巴细胞计数（TLC）作为CD4细胞计数的替代指标，以指导抗逆转录病毒疗法（ART）的启动。然而，这些研究大多集中在非孕成年人。鉴于在资源有限的环境中通过预防母婴传播（PMTCT）强化项目扩大了ART的可及性，我们评估了TLC在预测印度浦那产前和产后妇女低CD4计数方面的敏感性、特异性和阳性预测值（PPV）。
对779名感染HIV的妇女队列在孕晚期、分娩时以及产后6、9和12个月测量CD4、TLC和血红蛋白。通过逻辑回归确定预测CD4<200个细胞/mm³的最佳TLC临界值，并计算敏感性、特异性、PPV和受试者工作特征（ROC）曲线下面积。
在纳入的779名妇女中，16%处于世界卫生组织临床分期2期或更高，7.9%的CD4<200个细胞/mm³。使用2689对TLC-CD4数据，TLC<1200个细胞/mm³预测CD4<200个细胞/mm³的敏感性、特异性和PPV分别为59%、94%和47%。在评估的时间点，TLC<1200个细胞/mm³临界值的敏感性在57%至62%之间。添加血红蛋白<12 g/dL或<11 g/dL可使TLC预测CD4<200个细胞/mm³的敏感性提高到74%至92%，但与单独使用TLC相比，特异性降至33%至69%。与其他可能的组合或单独使用TLC相比，TLC、血红蛋白和世界卫生组织临床分期的组合具有最高的敏感性但最低的特异性。TLC<1200个细胞/mm³预测CD4<350个细胞/mm³的敏感性和特异性分别为31%和99%。
我们的数据表明，产前和产后TLC<1200个细胞/mm³的妇女可能CD4<200个细胞/mm³。然而，该TLC临界值的敏感性较低。单独使用TLC作为CD4<200个细胞/mm³的替代指标，可能无法识别45%至64%需要启动ART的产前和产后妇女。世界卫生组织推荐的TLC临界值<1200个细胞/mm³并非识别需要ART的印度产前和产后妇女的最佳指标。
