Grey nails predict low CD4 cell count among untreated patients with HIV infection in Malawi.

BACKGROUND

Alternative criteria for initiating antiretroviral therapy to CD4 testing or clinical illness are needed in Malawi.

METHOD: We tested if grey nails could be used to identify patients with a CD4 cell count less than 200 cells/microl who had not yet presented with AIDS-defining illnesses.

RESULTS

Using a set of 242 photographs we showed good inter-observer agreement for grey nails (kappa = 0.66; P < 0.0001) and the positive predictive value of grey nails for a CD4 cell count of less than 200 cells/microl was 81% (chi < 0.0001).

CONCLUSIONS

Grey nails have been associated with HIV infection and we have shown significant correlation of this sign with a low CD4 cell count. For clinicians working in sub-Saharan Africa without access to CD4 cell count testing, grey or DB nails represent an additional staging sign to help identify a sub-group of patients likely to benefit from ART.