—To identify differences in purified protein derivative (PPD) tuberculin positivity and skin test anergy rates by human immunodeficiency virus (HIV) serostatus, CD4+ lymphocyte count, and other risk factors in intravenous drug users (IVDUs); and to evaluate the appropriateness of the Centers for Disease Control (CDC)—recommended definition for a positive PPD tuberculin skin test result in HIV-1—seropositive patients.
—Nested case-control and cross-sectional analyses.
—Community-based cohort of IVDUs.
—Two hundred sixty HIV-1—seropositive and —seronegative IVDUs, drawn from an unselected cohort, were skin-tested for sensitivity to PPD tuberculin, mumps, and Candida antigens using the Mantoux method.
—Positivity to PPD tuberculin, skin test anergy.
—Even using the CDC definition of an induration 5 mm or greater in diameter in HIV-1 seropositives, this group was substantially less likely to be PPD tuberculin positive than HIV-1 seronegatives (13.8% vs 25.2%; P=.02). In the HIV-1 seropositives the relative odds of being PPD positive varied depending on whether 10 mm or greater (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.2 to 0.7), 5 mm or greater (OR, 0.5; 95% CI, 0.2 to 0.9), or 2 mm or greater (OR, 0.7; 95% CI, 0.4 to 1.3) was used to define a positive test result. The mean diameter induration in the HIV-1—seropositive group was 2.6 mm vs 5.4 mm in the seronegative group (P =.005). Skin test anergy (to mumps and Candida) appeared to explain the differential. Anergy was substantially higher in the HIV-1 seropositive group and increased as the CD4+ lymphocyte count fell (χ2 for linear trend, 24.5; P<.0001). An inverse linear trend for PPD positivity and CD4+ lymphocyte count was also observed (χ2 for trend, 6.1; P =.01). In multivariate analyses, being 35 years of age or older and being HIV-1 seronegative were significantly associated with PPD positivity, while history of previous police arrest was of borderline significance. Only HIV-1 seropositivity was significantly associated with anergy.
—There findings show that CDC-recommended definition of an induration 5 mm or greater in diameter for PPD tuberculin positivity in HIV-1 seropositives significantly underestimates the "true" infection rate (using the PPD positivity rate in HIV-1 seronegatives as the criterion standard). A definition of 2 mm or greater would appear to be a better cutoff for reducing misclassification in HIV-1 seropositives. This study also confirms that delayed-type hypersensitivity is seriously depressed in HIV-1 seropositive IVDUs and that anergy testing is mandatory to properly assess a negative PPD test result.(JAMA. 1992;267:369-373)
Graham NMH, Nelson KE, Solomon L, Bonds M, Rizzo RT, Scavotto J, Astemborski J, Vlahov D. Prevalence of Tuberculin Positivity and Skin Test Anergy in HIV-1—Seropositive and —Seronegative Intravenous Drug Users. JAMA. 1992;267(3):369-373. doi:10.1001/jama.1992.03480030047035