HIV in the tropics: staging in the resource-limited setting

In 2010, the WHO updated HIV treatment guidelines for adults and children, expanding the eligibility of HIV-infected individuals for antiretroviral therapy (ART) on the basis of immunological staging. We discuss the barriers to HIV staging in under-resourced settings.

In industrialized countries, HIV-infected patients are immunologically staged using CD4 lymphocyte counts measured using flow cytometry, but reliable and timely CD4 testing is still not readily available for all patients in many poorly resourced countries. Often CD4 testing is only available in central hospitals and clinics and depends upon availability of reagents. This leaves clinical staging as the standard of care in many places. Significant discrepancies exist between clinical and immunologic staging. Lack of immunologic staging can lead to delayed or inappropriate initiation of ART, increased attrition before ART, and overall poorer outcomes as patients often initiate ART at lower CD4 cell count baselines. This has led to intensive efforts to develop cost-effective laboratory testing, particularly for accurate low-cost CD4 testing.

Simplified, low-cost alternatives for immunologic staging are vital to continued scale up of ART programs globally. Point-of-care CD4 testing in particular has shown promise in decreasing attrition rates before ART and improving overall mortality in resource-limited settings.