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JAMA. 1988 Dec 9; 260(22):3286-9.In Africa, as in many developing countries where AIDS has been documented, the specific serologic test for antibody to the human immunodeficiency virus is not feasible, and the case definition of the Centers for Disease Control is impracticable because facilities for diagnosing the opportunistic infections are inadequate and the clinical spectrum of AIDS is different in tropical countries. The World Health Organization developed a clinical case definition at a 1985 AIDS workshop in the Central African Republic. It was tested to determine its generalizability in Zaire, and the present paper is a report on experience using the definition to identify AIDS in Uganda. A clinical case of AIDS is defined by the presence of at least 2 major signs and 1 minor sign. The major signs are fever for more than 1 month, weight loss greater than 10%, and chronic diarrhea for more than 1 month. The minor signs are persistent cough for more than 1 month, pruritic dermatitis, herpes zoster, oropharyngeal candidiasis, ulcerated herpes simplex, and general lymphadenopathy. The presence of disseminated Kaposi's sarcoma or disseminated cryptococcosis is sufficient by itself to diagnose AIDS. The Uganda study included 1328 patients at 15 hospitals. 562 patients (42%) tested positive by enzyme-linked immunosorbent assay, and 776 (58%) tested negative. 424 patients (32%) met the world Health Organization clinical case definition for AIDS. The World Health Organization definition had a sensitivity of 55%, a specificity of 85%, and a positive predictive value of 73%. However, so many of the patients in this sample had active tuberculosis that it was decided to substitute "persistent cough for more than 1 month without concurrent tuberculosis" as a minor sign in place of "cough for longer than 1 month." With this modification 350 patients met the clinical case definition for AIDS. Sensitivity dropped to 52%, but specificity rose to 92%, and positive predictive value rose to 83%. Moreover, 26% of the seropositive females indicated amenorrhea as a symptom. Addition of amenorrhea to the modified case definition gave it a sensitivity of 56%, a specificity of 93%, and a positive predictive value of 86%. However, this is the 1st report of amenorrhea as a symptom of AIDS, and it may only be a symptom of severe weight loss in women of childbearing age. The findings in the Ugandan experience support the generalizability of the modified World Health Organization clinical case definition of AIDS and its use for surveillance purposes in Africa.
Washington, D.C., National Academy Press, 1988. x, 239 p.The Committee for the Oversight of AIDS Activities presents an update to and review of the progress made since the publication 1 1/2 years ago of Confronting Aids. Chapter 1 discusses the special nature of AIDS (Acquired Immunodeficiency Syndrome) as an incurable fatal infection, striking mainly young adults (particularly homosexuals and intravenous drug users), and clustering in geographic areas, e.g., New York and San Francisco. Chapter 2 states conclusively that HIV (Human Immunodeficiency Virus) causes AIDS and that HIV infection leads inevitably to AIDS, that sexual contact and contaminated needles are the main vehicles of transmission, and that the future composition of AIDS patients (62,000 in the US) will be among poor, urban minorities. Chapter 3 discusses the utility of mathematical models in predicting the future course of the epidemic. Chapter 4 discusses the negative impact of discrimination, the importance of education (especially of intravenous drug users), and the need for improved diagnostic tests. It maintains that screening should generally be confidential and voluntary, and mandatory only in the case of blood, tissue, and organ donors. It also suggests that sterile needles be made available to drug addicts. Chapter 5 stresses the special care needs of drug users, children, and the neurologically impaired; discusses the needs and responsibilities of health care providers; and suggests ways of distributing the financial burden of AIDS among private and government facilities. Chapter 6 discusses the nomenclature and reproductive strategy of the virus and the needs for basic research, facilities and funding to develop new drugs and possibly vaccines. Chapter 7 discusses the global nature of the epidemic, the responsibilities of the World Health Organization (WHO) Global Program on AIDS, the need for the US to pay for its share of the WHO program, and the special responsibility that the US should assume in view of its resources in scientific personnel and facilities. Chapter 8 recommends the establishment of a national commission on AIDS with advisory responsibility for all aspects of AIDS. There are 4 appendices: Appendix A summarizes the 1986 publication Confronting Aids; Appendix B reprints the Centers for Disease Control (CDC) classification scheme for HIV infections; Appendix C is a list of the 60 correspondents who prepared papers for the AIDS Activities Oversight Committee; and Appendix D gives biographical sketches of the Committee members.