Progression to symptomatic disease in people infected with HIV-1 in rural Uganda: prospective cohort study Commentary: Virus, host, or environment?

Abstract

Objectives: To estimate the rate of progression from seroconversion to symptomatic disease in adults infected with HIV-1, and to establish whether the background level of signs and symptoms commonly associated with HIV-1 in uninfected controls are likely to affect progression rates. Design: Longitudinal, prospective cohort study of people infected with HIV-1 and randomly selected subjects negative for HIV-1 antibodies identified during population studies. Setting: Study clinic with basic medical care in rural Uganda. Subjects: 275 patients infected with HIV-1 (107 prevalent cases and 168 incident cases) and 246 controls negative for HIV-1 antibodies. Main outcome measures: Signs and symptoms of HIV disease, as determined by stages 2 and 3 of the World Health Organization clinical staging system. Results: The median time from seroconversion to WHO stage 2 was 25.4 months and to stage 3 was 45.5 months. 43% of the participants infected with HIV-1 had signs or symptoms by two years after seroconversion. The most common clinical conditions used to define progression of disease were weight loss, mucocutaneous manifestations, bacterial infections, chronic fever, and chronic diarrhoea. Although the rates of these conditions (apart from minor weight loss) were significantly higher in the participants infected with HIV-1, they were also relatively frequent in the control group. Herpes zoster, oral candidiasis, and pulmonary tuberculosis were not common events in the control group and therefore were more indicative of infection with HIV-1. Conclusions: Disease progression associated with infection with HIV-1 seems to be rapid in rural Uganda. This is most likely due to the high prevalence of conditions in the general population that could be taken as symptoms and signs of infection with HIV-1. What is already known on this topic The few studies that have reported time from seroconversion to HIV-1 symptomatic disease in poor countries suggest that this interval is shorter than in rich countries What this study adds Progression from seroconversion to symptomatic disease seems to be rapid in rural Africa The apparent rapid disease progression in rural Africa is most likely to be due to the high prevalence of what could be taken as symptoms and signs of HIV-1 in the general population Objectives: To estimate the rate of progression from seroconversion to symptomatic disease in adults infected with HIV-1, and to establish whether the background level of signs and symptoms commonly associated with HIV-1 in uninfected controls are likely to affect progression rates. Design: Longitudinal, prospective cohort study of people infected with HIV-1 and randomly selected subjects negative for HIV-1 antibodies identified during population studies. Setting: Study clinic with basic medical care in rural Uganda. Subjects: 275 patients infected with HIV-1 (107 prevalent cases and 168 incident cases) and 246 controls negative for HIV-1 antibodies. Main outcome measures: Signs and symptoms of HIV disease, as determined by stages 2 and 3 of the World Health Organization clinical staging system. Results: The median time from seroconversion to WHO stage 2 was 25.4 months and to stage 3 was 45.5 months. 43% of the participants infected with HIV-1 had signs or symptoms by two years after seroconversion. The most common clinical conditions used to define progression of disease were weight loss, mucocutaneous manifestations, bacterial infections, chronic fever, and chronic diarrhoea. Although the rates of these conditions (apart from minor weight loss) were significantly higher in the participants infected with HIV-1, they were also relatively frequent in the control group. Herpes zoster, oral candidiasis, and pulmonary tuberculosis were not common events in the control group and therefore were more indicative of infection with HIV-1. Conclusions: Disease progression associated with infection with HIV-1 seems to be rapid in rural Uganda. This is most likely due to the high prevalence of conditions in the general population that could be taken as symptoms and signs of infection with HIV-1. What is already known on this topic The few studies that have reported time from seroconversion to HIV-1 symptomatic disease in poor countries suggest that this interval is shorter than in rich countries What this study adds Progression from seroconversion to symptomatic disease seems to be rapid in rural Africa The apparent rapid disease progression in rural Africa is most likely to be due to the high prevalence of what could be taken as symptoms and signs of HIV-1 in the general population