ArticlesHIV-1 disease progression and AIDS-defining disorders in rural Uganda
Introduction
WHO estimates that of the 16 million people infected with HIV-1 worldwide, more than 10 million live in sub-Saharan Africa.1 Although progression rates of HIV-1 disease for Africans in Europe2, 3 and differences in progression of HIV-1 disease and AIDS-defining disorders between ethnic groups in the USA4 have been reported, few studies have addressed clinical manifestations and disease progression in Africa. AIDS cases were first reported in Uganda in 1985.5 By the end of 1995, more than 48 000 cases of AIDS had been reported.6 More than 1 million of a total population of 18 million are estimated to be infected with HIV-1.7 The management of patients with disease related to HIV-1 is difficult when yearly governmental health spending is only $3 per person. Hospital facilities are overwhelmed by the number of AIDS cases, budgets are strained, and drugs are often in short supply.8 The management of many young terminally ill patients puts health workers under a great deal of stress.
We report on the progression of HIV-1 disease and AIDS-defining disorders according to the proposed 1990 WHO staging system.9 Classification of stages is based on clinical criteria (including a performance scale) in four prognostic categories for adults who are confirmed as positive for HIV-1 antibodies. The staging is hierarchical; once a disorder classified in a higher stage develops, the individual remains in the higher stage irrespective of whether the disorder resolves. We chose this system because it should allow comparison of the natural history of HIV-1 infection, including survival times, in different communities and cohorts, since each stage represents the progression of immune deterioration and, therefore, prognostic significance. Stage 4 and AIDS are used synonymously in this paper.
We report on the natural history of HIV-1 infection and survival up to Dec 31, 1995, in a continuing, population-based, rural-cohort study in Uganda.
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Methods
Our natural-history cohort10 consisted of people who were recruited from a general-population cohort11 of about 5000 adults from 15 villages in rural south-west Uganda. That cohort, the general-population cohort, was established during 1989–90 to study the population dynamics of HIV-1 infection by annual censuses and serosurveys. In 1990, we randomly selected a third of all HIV-1-seropositive individuals from the initial survey round of the general-population cohort and invited them to enrol in
Results
By the end of 1995, 179 HIV-1-positive participants had been enrolled into the natural-history cohort–93 (50 men and 43 women) prevalent cases and 86 (37 men and 49 women) incident cases. The median ages on enrolment of the men and women were 31 and 29 years in the prevalent group, and 29 and 24 years in the incident group.
The median time between the estimated date of seroconversion and the next appointment for the 20 incident participants who seroconverted while in the cohort was 2 months
Discussion
Little is known about the natural history of HIV-1 infection in Africa,14 AIDS-defining disorders, or disease progression and survival by disease stage. Our findings are, therefore, important since the majority of people infected with HIV-1 live in Africa. Because of factors such as HIV subtypes, exposure to endemic diseases, nutritional status, and access to medical treatment, the findings of cohorts in resource-rich countries cannot be extrapolated to Africa. Estimated median time of
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