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AIDS in Africa [letter]

Lauwers M; Ndoluvualu-Namata N; Goubau P; Desmyter J
NEW ENGLAND JOURNAL OF MEDICINE. 1991 Mar 21; 324(12):848.

Dr. Goodgame pleads for more openness in discussing the diagnosis of AIDS with the patient. On the other hand, he believes testing for HIV antibodies is largely unnecessary for diagnosis in Uganda, which has 1 of the highest prevalences in the world. Given, however, that the WHO clinical AIDS definition has a positive predictive value of 73% in Ugandan patients (or 83% if cough due to tuberculosis is excluded), 27% of patients in whom there is a clinical suspicion will be erroneously told they have AIDS--"dreadful and at times almost unbearable" news. In other parts of Africa with a lower prevalence this may be even less acceptable. In Gemena, northern Zaire, we evaluated the WHO clinical Aids definition, as modified by Colebunders et al., in 166 patients in 1988-1989. The positive predictive value was 61% (67% if patients with tuberculosis were excluded). This means a wrong diagnosis of AIDS in 1 of every 3 patients. The HIV seroprevalence in this population was 7.9%, as measured in a group of 340 healthy pregnant women. Another problem is the lack of sensitivity of the clinical case definition of AIDS, leading to the possible exclusion of 30-46% of African patients with HIV-related disease in the absence of testing for HIV antibodies. Many patients with AIDS would thus escape detection until they were ill enough to meet the diagnostic criteria. If a standard of care for patients with AIDS is to be achieved in Africa, as Dr. Goodgame proposes, correctly identifying the patients early in the course of the disease is necessary, and we do not believe this is possible without laboratory confirmation. We are aware of the problems that may arise when anti-HIV testing is introduced, and the questions raised (e.g. Who will be tested? What will be done when a positive result is found?) should be thoroughly discussed with the local health team before the test is introduced. In addition, screening of blood donors should have absolute priority over diagnostic testing if a choice has to be made because of the dearth of reagents. (full text)

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