PROFOUND IMMUNOSUPPRESSION ACROSS THE SPECTRUM OF OPPORTUNISTIC DISEASE AMONG HOSPITALIZED HIV-INFECTED ADULTS IN ABIDJAN, COTE-DIVOIRE

Objectives: To describe the spectrum of opportunistic disease in HIV-i nfected patients admitted to hospital in Abidjan, Cote d'lvoire, and t o describe the level of immunosuppression at which these diseases occu r. Design: Cross-sectional study. Setting: In-patient wards of the Uni versity Hospital Infectious Diseases Unit.Patients: A total of 250 adu lt patients recruited by systematic sampling at the point of hospital admission. Main measures: HIV status; CD4 count; diagnoses, confirmed by microbiological/radiological investigations whenever possible; and outcome of hospitalization (death or discharge). Results: Overall, 79% patients were HIV-positive. The most frequent diagnoses in HIV-positi ve patients were septicaemia (20%, with non-typhoid salmonellae, Esche richia coli and Streptococcus pneumoniae the most common organisms), H IV wasting (16%), meningitis (14%), tuberculosis (TB; 13%), isosporias is (10%), cerebral toxoplasmosis (7%) and bacterial enteritis (7%). Mo st HIV-positive patients had evidence of severe immunosuppression: 39% had CD4 counts < 50 x 10(6)/l, 17% had 50-99 x 10(6)/l, and 20% had 1 00-199 x 10(6)/l. In-hospital mortality among HIV-positive patients wa s 38% compared with 27% among HIV-negative patients [age-adjusted odds ratio (OR), 1.5; 95% confidence interval (Cl), 0.7-2.9]. Among HIV-po sitive patients, the highest case-fatality rates were among patients w ith meningitis, toxoplasmosis and TB: in a multivariate analysis the s trongest independent risk factors for death were an abnormal level of consciousness (OR, 9.3; 95% CI, 3.5-24.6), a haemoglobin concentration below 8 g/dl (OR, 4.2; 95% CI, 1.4-12.8) and age > 40 years (OR, 3.9; 95% CI, 1.5-10.2). Conclusions: Our data show that, as in industriali zed countries, most HlV-infected individuals admitted to and dying in hospital in Abidjan are profoundly immunosuppressed. Potentially preve ntable infections are the main causes of in-hospital morbidity and mor tality among HlV-infected persons in Abidjan, and the evaluation of ap propriate primary prophylactic regimes is a priority.