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Access to antiretroviral (ARV) drugs is improving in sub-Saharan Africa but still constrained by several clinical and logistical obstacles. There is a need to develop affordable markers to guide initiation of treatment. We present a prospective cohort study of 779 patients participating in a TB prophylaxis trial. We performed separate analyses for anergic and nonanergic subjects. Prognostic factors for anergic and nonanergic subjects differed between groups. Individuals with anergy and constitutional symptoms were at the highest risk of death. Incident tuberculosis and CD4 < 200 cells/µL at enrollment were the strongest risk factors for death. HIV disease is associated with substantial morbidity and mortality in this population. The burden caused by tuberculosis is particularly high. Anergy is a strong and independent predictor of death. World Health Organization criteria to start ARV may be strengthened with the addition of DTH testing, an inexpensive and readily available tool in sub-Saharan Africa.
Received January 6, 2005. Accepted for publication June 8, 2005.
Acknowledgments: We are indebted to the study team that conducted the clinical trial that provided the data for this analysis: John L. Johnson, M.D., David L. Hom, M.S., Cissy Mutuluuza Kityo, M.B.Ch.B., Peter Nsubuga, M.B.Ch.B., M.P.H., Anita M. Loughlin, Ph.D., Hyun Yun, Ph.D., Peter N. Mugyenyi, M.B.Ch.B., and members of the Uganda-Case Western Reserve University Research Collaboration: Allan Chiunda, M. Kasujja, S. Kibende, M. Manning, A. Nakayiza, P. Nasige; G. Bwamiki, R. Byaruhanga, and R. Galiwango; P. Bajeneza, D. Guwatudde, S. Katabalwa, J. B. Mukasa, M. Odie, C. Opit, G. Olupot, A. Turyamureba, A. Abenakyo and L. Ndegumu, E. Kaggwa, H. Kabymera, G. Lumumba, R. Mukasa, and L. Oryema, G. Bukenya, A. Mulyabintu, B. Nansubuga, W. Bagundirire and M. Mwanje, J Nakibali, K. Kataliwa, M. Kato, J. Mulabbi, K. Edmonds, P. Kataaha, S. Kabengera, J. Okiror, E. Piwowar, B.S. Tugume, R. S. Wallis, W. Bukulu, F. Byekwaso, A. Gasisira, P. Kyambadde, H. Luzze, A. Mateega, F. Mubiru, C. Mukulu, R. Odeke, P. Gitta, A. Wajja, T. Aisu, E. Hatanga, M. L. Joloba, A. Morrissey, J. Kayungirizi, C. Kiramba, M. Mulindwa, G. Nalugwa, A. Rwamucece, G. Tumusiime, A. Adongo and E. Katende, M. J. Vjecha, G. Mpalanyi, P. Nasozzi, S. Nyole, G. Wasswa. We are also indebted to S. Okware, Ministry of Health; F. Engwau-Adatu, Head, Ugandan National Tuberculosis and Leprosy Programme; Uganda Tuberculosis Diagnostic Investigations Unit—Wandegeya, Kampala, Uganda. This work is part of a study submitted as partial fulfillment for a master’s in epidemiology and biostatistics by Dr. Jones-López at Case Western Reserve University, funded by the National Institutes of Health Fogarty International Center.
Financial support: This study was supported through a cooperative agreement between Case Western Reserve University and the Centers for Disease Control and Prevention (CCU-506716), the AIDS International Training and Research Program at Case Western Reserve University (Fogarty International Center, TW-00011), and the Division of AIDS, National Institutes of Allergy and Infectious Diseases, NIH (AI 32414).
* Address correspondence to Edward C. Jones-López, Division of Infectious Diseases and Center for Emerging Pathogens, UMDNJ—New Jersey Medical School, 185 South Orange Ave., MSB I-506, Newark, NJ 07103. E-mail: jonesec{at}umdnj.edu
Authors’ addresses: Edward C. Jones-López, M.D., M.S., Division of Infectious Diseases and Center for Emerging Pathogens, UMDNJ—New Jersey Medical School, 185 South Orange Ave., MSB I-506, Newark, NJ 07103. E-mail: jonesec{at}umdnj.edu. Alphonse Okwera, M.B.Ch.B., CWRU—National Tuberculosis and Leprosy Control Programme, P.O. Box 663, Kampala, Uganda, Telephone: +256-41-533-531, E-mail: core{at}mucwru.or.ug. Harriet Mayanja-Kizza, M.B.Ch.B., M.S., Department of Medicine, New Mulago Hospital, P.O. Box 7072, Kampala, Uganda, Telephone: +256-77-593-482, E-mail: hmk{at}afsat.com. Jerrold J. Ellner, M.D., Department of Medicine, UMDNJ—New Jersey Medical School, 185 South Orange Ave., MSB I-506, Newark, NJ 07103, Telephone: (973) 972-4595, Fax: (973) 972-5965, E-mail: ellnerjj{at}umdnj.edu. Roy D. Mugerwa, M.B.Ch.B., M.Med., Department of Medicine, Makerere University School of Medicine, P.O. Box 7072, Kampala, Uganda, Telephone: +256-78-260-095, E-mail: profrdm{at}imul.com. Christopher C. Whalen, M.D., M.S., for the Uganda-CWRU Research Collaboration, Department of Epidemiology and Biostatistics, CWRU School of Medicine, 2109 Adelbert Road, School of Medicine, WG37. Cleveland, OH 44106-4945. Telephone: (216) 368-4192, Fax: (216) 368-3970, E-mail: ccw{at}case.edu.
Reprint requests: Edward C. Jones-López, M.D., M.S., Assistant Professor of Medicine, Division of Infectious Diseases and Center for Emerging Pathogens, UMDNJ—New Jersey Medical School, 185 South Orange Ave., MSB I-506, Newark, NJ 07103, Telephone: (973) 972-7601, Fax: (973) 972-1141, E-mail: jonesec{at}umdnj.edu.
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