International Journal of Epidemiology 2000;29:369-375
© International Epidemiological Association 2000
Underestimation of Mycobacterium tuberculosis infection in HIV-infected subjects using reactivity to tuberculin and anergy panel
a Instituto Nacional de Salud Pública, México.
b Instituto Nacional de Diagnóstico y Referencia Epidemiológicos (INDRE), Mexico.
c PanAmerican Health Organization, USA.
d UNAIDS, formerly at PanAmerican Health Organization.
e Office of HIV/AIDS Policy, Office of Public Health and Science, Office of the Secretary of Health, Department of Health and Human Services, USA, formerly at the National Institutes of Health, USA.
Reprint requests to: Dr José Luis Valdespino Gómez, Secretaría Académica, Instituto Nacional de Salud Pública/Escuela de Salud Pública de México, Ave. Universidad 655, Cuernavaca, Mor. CP62508, Mexico. E-mail: jvaldesp{at}insp3.insp.mx
Background This study aimed to evaluate purified protein derivative (PPD) reactivity and its interrelationship with anergy panel and CD4+ lymphocytes in HIV-infected subjects as compared to PPD reactivity in HIV-uninfected individuals in a tuberculosis endemic and high Bacillus Calmette-Guérin (BCG) coverage environment.
Methods Clients of four Mexico City HIV detection centres were screened for HIV-1 antibodies (ELISA or haemagglutination, Western Blot); reactivity to PPD (Mantoux PPD, 5TU RT-23), Candida (1:1000, 0.1 ml), and tetanus toxoid (10Lf, 0.1 ml); and CD4+ T cells. Active tuberculosis was excluded. Informed consent was obtained.
Results From 5130 clients 1168 subjects were enrolled; of these 801 (68.6%) were HIV positive. Reactivity to PPD among HIV-positive subjects was found in 174 (22%), 261 (32.6%), and 296 (37%), at PPD cutoff levels of 
10 mm, 5 mm, and 2 mm as compared to 224 (61%) of 367 HIV-negative individuals’ reactors to PPD (10 mm) (P < 0.001). After exclusion of anergic individuals using two cutoff levels for cutaneous allergens (
2 mm and 5 mm), PPD reactivity between HIV-infected and uninfected individuals continued to be significantly different. Only HIV-infected individuals with CD4+ T cells 500 cells/mm3 had similar reactivity to PPD as HIV-uninfected individuals. Variables associated with PPD reactivity were CD4+ T cell counts, BCG scar, HIV infection and age.
Conclusions PPD reactivity was useful to diagnose tuberculosis infection only among HIV-infected individuals with CD4+ counts 500 cells/mm3. Among individuals with lower counts, lowering cutoff levels or using anergy panel did not permit comparable reactivity as that observed among HIV-uninfected individuals.
Keywords Tuberculin test, HIV, anergy, BCG vaccine, CD4 lymphocytes, delayed-type hypersensitivity
Accepted 11 August 1999
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