EPIDEMIOLOGY AND SOCIAL SCIENCE Body Mass Index at Time of HIV Diagnosis A Strong and Independent Predictor of Survival Marianne A. B. van der Sande, MD, MPH, PhD,* Maarten F. Schim van der Loeff, MD, MSc, PhD,*† Akum A. Aveika, BSc,* Saihou Sabally, MD,* Toyin Togun, MD,* Ramu Sarge-Njie, MSc,* Abraham S. Alabi, PhD,* Assan Jaye, PhD,* Tumani Corrah, FRCP, PhD,* and Hilton C. Whittle, FMedSci* Background: Identification of basic prognostic indicators of HIV infection is essential before widespread antiretroviral therapy can be implemented in low-technology settings. This study assessed how well body mass index (BMI:kg/m 2 ) predicts survival. Methods: BMI within 3 months of HIV diagnosis was obtained from 1657 patients aged 15 years, recruited in a seroprevalent clini- cal cohort in The Gambia since 1992 and followed up at least once. Baseline CD4 + counts and clinical assessment at time of diagnosis were done. Results: The mortality hazard ratio (HR) of those with a baseline BMI <18 compared with those with a baseline BMI 18 was 3.4 (95% CI, 3.0–3.9). The median survival time of those presenting with a BMI <16 was 0.8 years, in contrast to a median survival of 8.9 years for those with a baseline BMI 22. Baseline BMI <18 remained a highly significant independent predictor of mortality after adjustment for age, sex, co-trimoxazole prophylaxis, tuberculosis, reported wast- ing at diagnosis, and baseline CD4 + cell count (adjusted HR = 2.5, 95% CI 2.0–3.0). Sensitivity and specificity of baseline BMI <18 was comparable to that of a CD4 + count <200 in predicting mortality within 6 months of diagnosis. Discussion: BMI at diagnosis is a strong, independent predictor of survival in HIV-infected patients in West Africa. In the absence of sophisticated clinical and laboratory support, BMI may also prove a useful guide for deciding when to initiate antiretroviral therapy. Key Words: Africa, survival, HIV-1, HIV-2, body mass index, CD4 + count, cohort (J Acquir Immune Defic Syndr 2004;37:1288–1294) T here is a pressing need to develop and test simple and af- fordable clinical criteria to guide interventions such as highly active antiretroviral treatment (HAART) in sub- Saharan Africa. In particular, the optimal starting time for HAART needs to be determined, because the expense of the drugs, potential side effects, and concerns about adherence, safety, and development of resistance must be balanced against the expected benefits of reduced morbidity and mor- tality. Unfortunately, access to laboratory facilities, which could support such decisions, is often limited in sub-Saharan Africa. The use of plasma viral load (PVL) and CD4 + measure- ment to guide initiation of treatment in resource-poor environ- ments has been challenged, as there is a lack of data to support such an expensive strategy. 1 Thus, it is important to evaluate simple clinical criteria that might assist decisions about the start of HAART. Weight loss is a frequent symptom in HIV infection. Se- vere weight loss of >10% of body weight due to HIV infection itself is a common condition in HIV infection, which is used as a diagnostic criterion in the classification of HIV disease 2 (1993 Centers for Disease Control [CDC]). Weight loss can also be due to a range of underlying conditions. Before HAART was available, both the wasting syndrome and mal- nutrition had been associated with poor survival in studies in industrialized countries, which were independent of immuno- suppression as assessed by CD4 + counts. 3,4 In most of sub- Saharan Africa, the background level of common infections 5 and undernutrition is high, regular recorded weights in adults are rare, and few adults are able to document changes in their body weight. Thus, in sub-Saharan Africa, weight loss is usu- ally not reliably reported or documented. We considered that a low body mass index (BMI) (weight in kilograms divided by height in meters squared) at the time of initial HIV diagnosis could be a robust, affordable, and easily applicable clinical marker that may correlate well with survival. This analysis aimed to test this hypothesis in a seroprevalent cohort of HIV-1, HIV-2, and HIV dually in- fected patients. METHODS Subjects The first case of HIV infection in The Gambia was iden- tified in 1986. Since then, all HIV patients diagnosed at or re- Received for publication October 20, 2003; accepted February 5, 2004. From the *Medical Research Council Laboratories, Fajara, The Gambia; and †London School of Hygiene and Tropical Medicine, London, UK. Funded by the Medical Research Council, UK. Reprints: Marianne van der Sande, Laboratories Fajara, PO Box 273, Banjul, The Gambia (e-mail: mvdsande@mrc.gm). Copyright © 2004 by Lippincott Williams & Wilkins 1288 J Acquir Immune Defic Syndr • Volume 37, Number 2, October 1 2004