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BMJ. British Medical Journal. 1991 Nov 9; 303(6811):1189-90.The article proposes that the clinical case definition for Acquired Immunodeficiency Syndrome in Africa is an unworkable concept, with the wrong definition, incorrect validation, improper use, and consequently is a poor surveillance tool. The definition was proposed by the World Health Organization in 1986 to satisfy the use in countries with limited diagnostic resources, and resources for serological testing. Critical review until now of this procedure was lacking. Currently serological testing is available and of high quality. It does not seem justifiable to continue using a provisional surveillance definition. Abandoning this classification procedure may also lead to the focus on problems other than opportunistic infections and AIDs. Clinical surveillance is important, but as well morbidity and mortality need monitoring. It is argued that the definition is an unworkable concept because patients with underlying immunosuppression disorders such as AIDs can not be easily distinguished from chronic disease patients; i.e., pulmonary tuberculosis, renal failure, uncontrolled diabetes, or diarrhea with weight loss. Clinical accuracy is insufficient. It is the wrong definition because pulmonary tuberculosis with a persistent cough cannot be distinguished for those HIV positive and those not. There is inconsistency in the WHO clinical definition and the Centers for Disease Control definitions of AIDs. The incidence of tuberculosis in countries with unmodified clinical case definitions may contribute to an inflated number of AIDs cases. The wrong standards were used to validate the WHO definition in evaluative studies. The reference sensitivity ranges indicate that the definition is insensitive to identifying seropositive patients. Also, the HIV status of patients does not equate with AIDs. Although designed for surveillance, the clinical case definition is used by doctors for individual patient management. Labeling a patient as having AIDs, when he is HIV negative, leads to negative consequences. Researchers compare African AIDs data with North American data with imprecise and noncomparable definitions. As a surveillance tool in countries with a fragmentary or without a vital registration system, it is an inaccurate tool. Alternatives to obtaining data about the spread and impact of HIV are cluster sampling, hospital surveillance of selected populations, anonymous testing of pregnant women or patients in sexually transmitted disease clinics. In Nairobi, a necropsy survey found that 16% had AIDs but 38% were HIV positive.
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.