Use of nail and oral pigmentation to determine ART eligibility among HIV-infected Ugandan adults

objectives To evaluate the use of grey ⁄ distal banded nails as an indicator of advanced

immunosuppression, and thus eligibility for ART, in resource poor settings.

methods We tested whether grey ⁄ distal banded nails and ⁄ or oral pigmentation could be used to

identify patients with low CD4 cell counts at two cut-offs: <200 and <350 cells ⁄ ll in ART naive adults.

results Four hundred and three nail and oral cavities were photographed and assessed. Grey ⁄ distal

banded nails and ⁄ or oral pigmentation were significantly associated with a CD4 cell count <200 cells ⁄ ll

(P < 0.001), with a sensitivity of 66%, a specificity of 50% and a negative predictive value of 77%.

However, there was no association when a CD4 cell count cut-off of <350 cells ⁄ ll was used.

Inter-observer agreement (k 0.46) was fair ⁄ moderate.

conclusions While grey ⁄ distal banded nails and ⁄ or oral pigmentation are associated with low CD4

counts, the sensitivity and kappa score are too low for this method to be recommended as a tool to

guide ART initiation; large number of individuals eligible for ART would be missed.