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Accepted wisdom in the assessment of a person with HIV is that the Erythrocyte Sedimentation Rate (ESR) is not a useful test. Although initially considered as an indicator of disease progression [, ], later studies disagreed [] or demonstrated only a negligible fall in CD4 count with rising ESR [].

Although the use of ESR to predict the development of AIDS is still under investigation in the developing world [], it is considered less helpful in countries with easy access to CD4 monitoring. The ESR does not predict acute illness in HIV [] and when measured, it is not uncommon to discover values in triple figures in otherwise asymptomatic individuals with normal CD4 counts: in one recent study, 27% of Tanzanian patients with an ESR > 120mm/hr still had a CD4 count greater than 200/mm 3 []. As such, it is rare to find recent data on ESR levels in HIV positive people except from Africa [,, ], and it has not been published as an independent variable in any of the large prospective cohort studies. I would argue that this approach is short-sighted, especially given what we have learned regarding cardiovascular disease in the last decade, across many disciplines.

Indeed a chronically elevated ESR is potentially very informative: •. It reflects immune activation, correlating well with cytokines including Interleukin-6 and Tumour Necrosis Factor-alpha, a finding documented both in other chronic inflammatory conditions [, ] and in heart failure patients []. These molecules are known to be associated with endothelial damage, consistent with the presumed inflammatory nature of atherosclerosis []; predictably, both ESR and pro-inflammatory cytokines show a positive relationship with soluble endothelial markers including E-Selectin, von Willebrand Factor (vWF) and soluble Intercellular Adhesion Molecule-1 (sICAM-1) [,, ]. Inflammatory cytokines [, ] and endothelial markers [,,, ] have consistently been shown to be elevated in HIV positive patients, although their levels have not been stratified by ESR to my knowledge.