Evaluation of total Lymphocyte Count and Absolute Lymphocyte Count as a Surrogate Marker for CD4 Count to Initiate ART

INTRODUCTION: The burden of HIV remains high for patients and their families especially in resource limited settings. It is estimated that 40 million people with human immunodeficiency virus (HIV) reside in resource limited settings. Among them it is reported that 6 million require highly active anti retroviral therapy (HAART). Ideally the WHO recommends regular combined immunological and virological monitoring for all HIV infected patients. Analysis for viral loads and CD4 counts require not only sophisticated equipment, but in addition, highly skilled laboratory personnel. The initiation of antiretroviral therapy is based on CD4 counts of less than 350 cells/mm3 according to the World Health Organization (WHO) and National AIDS Control Organisation (NACO). The determination of CD4 count however in resource-limited localities is difficult. A total lymphocyte count (TLC) of <1200 cells/mm3 has been recommended in addition to WHO staging (stage II) of the disease, for the initiation of antiretroviral therapy in such localities. The use of absolute lymphocyte count as a marker for HIV progression has been argued in many quarters over the years . Studies have suggested that when the absolute lymphocyte count is used in conjunction with blood hemoglobin, gives a more sensitive marker for HIV progression. Also studies have demonstrated the usefulness of absolute lymphocyte count (ALC) or total lymphocyte count (TLC), in identifying patients who would benefit from initiating prophylaxis for acquired immunodeficiency syndrome (AIDS)-related opportunistic infections. This study is being conducted to evaluate the correlation of TLC and ALC to CD4 count for initiating HAART in HIV-infected patients, as there are fewer published studies on this subject, from resource-limited settings. AIMS AND OBJECTIVES: 1. To evaluate the correlation of CD4 counts with the TLC and ALC to suggest that these can be used as a surrogate for CD4 count to initiate ART in resource limited settings. 2. To determine a range of TLC and ALC cut-offs for predicting CD4 count <350 cells/μl, which is important for the initiation of ART and for CD4 count 200CELLS/μL. MATERIALS & METHOD: The present study was conducted on HIV seropositive patients admitted in any wards or attending outpatient departments of Government Rajaji Hospital, Madurai during the period of Jan 2016 to June 2016. The study included 100 cases of newly detected HIV positive patients. All subjects fulfilled eligibility criteria, and none of the exclusion criteria were included in the study. METHODOLOGY: A previously designed proforma is used to collect the demographic and clinical details of the patients. All the patients underwent detailed clinical evaluation, appropriate investigations. History was taken on details of unprotected sexual intercourse, blood transfusion ,IV drug abuse, repeated respiratory infections, fever, recurrent diarrhoea and unexplained weight loss. Presence of lymphadenopathy, oral ulcers, splenomegaly and peripheral neuropathy will be noted. Hemoglobin, complete blood count including total WBC count and differential count, blood urea, serum creatinine, blood glucose, liver function tests including serum bilirubin, serum transaminases, will be estimated. CD4 count, Total lymphocyte count and absolute lymphocyte count are also estimated .The study group was divided on the basis of CD4 count into >350 cells / cu.mm, 200 to 350 cells/cu.mm 100 to 200 cells/cu.mm and <100 cells/cu.mm amd mean for absolute lymphocyte count and total lymphocyte count and haemoglobin was studied in these groups. RESULTS: In our study 100 patients were randomly selected of which 67% were males and 33% were females. Majority of patients in our study were in reproductive age group (21 to 50 years). This indicates a trend of young and productive generation being affected; a reflection of the devastating effects India will face as the younger generation work force is affected. Most common mode of HIV transmission was heterosexual. Also there is a rise in transmission through male to male sexual contact. In our study TLC<1100 cells/cu.mm correlates with CD4 count <200 cells/μL and TLC < 1300 cells/ cu.mm correlates with CD4 count <350 cells /μL. In our study using WHO clinical staging 4 when correlated with CD4 count < 200 cells/μL we get a significant statistical p value. Patients with stage 4 had mean CD4 count 155.86 cells/μL and patients with CD4 count < 200 cells/μL were in stage 3 or stage 4(93%).The mean Hemoglobin for CD4 count <350 cells/μL is 6.26 gm% and the mean haemoglobin for CD4 count <200 cells/μL is 5.6 gm%. The mean ALC for CD4 count <350 cells/μL is 1066.56 cells/cu.mm. and the mean ALC for CD4 count