Screening HIV-positive pregnant women for antiretroviral therapy: Utility of self-reported symptoms

In developing countries, Mother-to-Child Transmission-Plus programmes propose to identify lifelong antiretroviral therapy (ART)-eligible women during antenatal care. Identification using AIDS-related symptoms is the most feasible screening procedure in resource-limited settings. It is not known if symptomatology in pregnant women is correlated with clinical criteria for ART initiation based on CD₄+ cell count or HIV-1 viral load. In this population of HIV-positive pregnant women from Rakai District, Uganda, 8-23% were eligible for treatment by CD₄+ cell count criteria, and <1% met WHO staging criteria for AIDS. Using one or more symptoms to predict CD₄+ cell count <350 cells/mm³, sensitivity was 100%, specificity 11%, positive predictive value (PPV) 25%, and negative predictive value (NPV) 100%. When using one or more symptoms to predict viral load ≥100,000 cps/mL, sensitivity was 100%, specificity 10%, PPV 6%, and NPV 100%. Initiation of treatment based on self-reported symptoms will over-treat because the majority of pregnant women with symptoms would not be eligible for treatment under current guidelines, but asymptomatic pregnant women are unlikely to require ART.