Background: Eligibility for antiretroviral therapy (ART) in HIV-infected patients is defined
either by a cluster of differentiation antigen 4 (CD4) count of less than 200cells/mm3
or clinical
diagnosis of WHO stage III and IV. Therefore, the decision to start ART becomes difficult when
CD4 cell count is not available. With limited laboratory infrastructure, the decision to start ART
is usually made based on clinical symptoms leading to late commencement of ART. This calls
for alternative criteria to see if nail discoloration (ND) correlates with low CD4 count among
untreated HIV infected patients. This will serve as a complementary screening tool for
identifying asymptomatic ARV naive HIV patients with a CD4 cell count of less than
200cells/mm3
which signifies severe immunosuppression.
Study Design and Setting: This was a quantitative cross-sectional descriptive and analytical
study involving adult ART naïve HIV infected patients in WHO stage I and II. Systematic
sampling was used to select the participants from all adult ART naïve HIV infected patients
attending APIN clinic, located at the Jos University Teaching Hospital (JUTH), Jos, Nigeria.
Data Collection: Face-to-face interviews, physical examination and relevant laboratory
investigations with selected participants were conducted using a questionnaire guide. Questions
on socio-demographic characteristics, clinical data, general physical examinations including
finger nail examination and photographing with subsequent laboratory investigations including
CD4 count and western blot were employed. Data Analysis: Variables were categorized and data analyzed using descriptive statistics
including the frequency, percentage frequency; mean and standard deviation of continuous
variables. Association between CD4 count of =200cells/mm3
and ND was tested using the chisquare
test with an alpha level of 0.05. Prevalence of ND, sensitivity, specificity, positive
predictive and negative predictive values and accuracy of the screening test of ND was
calculated.
Results: 394 patients had their fingernails photographed and assessed. It was shown that distal
banded and grey nails were the common types of ND seen with a prevalence of 38%. There was
an association between CD4 count =200cells/mm3
and ND (p<0.0001). CD4 count
=200cells/mm3
was a risk factor for developing ND (RR=2.3[1.8-3.6]). The association has a
sensitivity of 78%, specificity of 55%, positive predictive value of 50%, and negative predictive
value of 80% and accuracy of test 63%.
Conclusion: With a significant association (p<0.0001) and a sensitivity of 78%, ND can be a
useful clinical indicator of immune dysfunction mediated by HIV among patients in WHO stage
I or II. ND can either be a clinical sign or a symptom in HIV patients with a CD4 of =
200cells/mm3
as seen in the study as the specificity and sensitivity of ND compared favourably
with other WHO stage III diagnosis.
Recommendations: Nail discoloration should complement CD4 count as an additional staging
sign to help identify patients likely to benefit from ART especially in resource-limited settings.
Finally, all patients with grey or distal banded should be on co-trimoxaxole prophylaxis in line
with WHO /national guideline on the use of co-trimoxaxole for all HIV positive patients with a
CD4 cell count of =350cells/mm.