Inability-to-walk-unaided-a single WHO danger sign predicts in-hospital mortality in people with HIV under routine care conditions in a low-resource setting.

Abstract

Background: People with advanced HIV admitted to hospitals are at high risk of mortality. Serious illness can be identified using WHO-defined danger signs ("WHO score") or bedside scores like the quick Sequential Organ Failure Assessment (qSOFA) score.

Objectives: The study aimed at assessing clinical parameters as predictors of in-hospital mortality for people with HIV (PWH) admitted for routine medical care.

Study design: A prospective observational study of all PWH admitted to medical wards at Kamuzu Central Hospital, Lilongwe, Malawi.

Methods: WHO danger signs and qSOFA score were determined at the first encounter, CD4 count tests were performed, and discharge outcomes were recorded. The discriminatory power of different scores for predicting in-hospital mortality was assessed using the area under receiver-operating-characteristic curves (AUROCs).

Results: From November 2022 to May 2023, 401 adults aged ⩾18 years were admitted. Advanced HIV disease (CD4 < 200 cells/mm³) was present in 55.2% (95% CI 50.2-60.2). Overall, in-hospital mortality was 25.7% (95% CI 21.3-30.0). Neither sex, age, CD4 count, nor BMI < 18.5 was significantly associated with mortality. Both the WHO score and qSOFA score were significantly associated with increasing mortality. AUROC for WHO score and qSOFA were 0.68 (95% CI 0.61-0.75) and 0.71 (95% CI 0.64-0.78), respectively. Including BMI or CD4 did not significantly improve AUROC. Using only the individual danger sign "inability-to-walk-unaided" yielded a similar AUROC of 0.68 (95% CI 0.61-0.75).

Conclusion: Increasing WHO danger sign scores were associated with in-hospital mortality; adding BMI or CD4 did not improve predictive accuracy. Notably, the predictive information derived from a single parameter-inability-to-walk-unaided-was as effective as the complete WHO score and was easier to obtain. Given the challenges in comprehensive vital sign recording, this simple measure may prove valuable in triaging PWH admitted to hospitals in resource-limited settings such as Malawi.