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ARTICLE

Delayed-Type Hypersensitivity Skin Testing Predicts Progression to AIDS in HIV-infected Patients

Stephen P. Blatt; Craig W. Hendrix; Clifford A. Butzin; Theodore M. Freeman; William W. Ward; Rex E. Hensley; Gregory P. Melcher; Daniel J. Donovan; and R. Neal Boswell

1 August 1993 | Volume 119 Issue 3 | Pages 177-184

Objective: To evaluate the prognostic significance of cutaneous delayed-type hypersensitivity (DTH) skin testing in persons infected with HIV.

Design: Cohort study.

Setting: United States Air Force (USAF) Medical Center.

Patients: Consecutive sample of 889 HIV-infected USAF personnel or dependents undergoing their first staging evaluation from 1985 through August 1990 in the USAF HIV Natural History Study.

Measurements: All patients were evaluated with DTH skin testing including purified protein derivative and four control skin test antigens: mumps, candida, tetanus toxoid, and trichophyton. In addition, all patients underwent CD4⁺ T-cell surface marker determinations. The relation between DTH skin test response at first evaluation and progression to Walter Reed stage 6 (presence of an AIDS-defining opportunistic infection) was evaluated using Kaplan-Meier survival analysis.

Results: Patients with more than 400 CD4⁺T cells/mm³ are more likely than those having fewer than 400 CD4⁺T cells per mm³ to respond to at least one (94% compared with 67%, P < 0.001) or at least two (86% compared with 45%, P < 0.001) DTH skin tests. Mean CD4 counts are lower for anergic compared with nonanergic patients and for patients responding to a single control skin test compared with those responding to two or more skin tests (P < 0.05). The DTH skin test response at first evaluation was also found to predict progression to AIDS; the relative risk at 5 years of follow-up was 2.5 (95% CI, 1.2 to 5.2) for anergy compared with a single positive skin test and 3.0 (CI, 1.4 to 6.2) for a single compared with two or more skin test responses. The DTH skin test response at first evaluation was a predictor of progression (P < 0.001) when controlling for initial CD4 count and Walter Reed stage in a Cox proportional-hazards regression analysis.

Conclusions: The DTH skin test response, a functional measure of cellular immunity, is an independent predictor of progression to AIDS in persons with HIV.

Author and Article Information

From Wilford Hall U.S. Air Force Medical Center, Center for AIDS Research, Southwest Foundation for Biomedical Research, and the Military Medical Consortium for Applied Retroviral Research and Clinical Investigation Directorate, San Antonio, Texas.
Requests for Reprints: Stephen P. Blatt, Maj., USAF, MC, Wilford Hall USAF Medical Center/PSI-H, 2200 Bergquist Drive STE 1, Lackland Air Force Base, TX 78236-5300.
Acknowledgments: The authors thank all the physicians, nurses, technicians, and database personnel of the HIV unit as well as the Clinical Immunology Laboratory and the Allergy-Immunology Service for doing the skin tests and laboratory studies that made this work possible.
Grant Support: By the United States Army Medical Research and Development Command Grant no. DAMD 17-88-Z-8007.

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