Prevalence of Human Immunodeficiency Virus Seropositivity among Eye Surgical Patients at a Rural Eye Care Facility in South-Eastern Nigeria.

PURPOSE: To determine the prevalence of human immunodeficiency infection among patients who underwent surgery at a rural eye care facility in southeastern Nigeria.
MATERIALS AND METHODS: A retrospective chart review was performed for all patients who had undergone surgery and a pre-operative Human Immunodeficiency Virus (HIV) test, between August 2008 and July 2009 at the Eye unit of the Presbyterian Joint Hospital, Ohaozara, Ebonyi State, Nigeria. Data were analyzed for age, sex, type of surgery and HIV status. Frequency, percentage and 95% confidence intervals (CI) were calculated with univariate analysis and the parametric method.
RESULTS: A total of 380 cases were reviewed comprised of 228 males and 152 females (M:F= 1.5:1).The mean age of the cohort is 56 years (range, 4 years to 91 years). Fourteen patients (3.7%; 95% confidence interval 1.8 - 5.6) were HIV positive.
CONCLUSION: A high HIV sero-prevalence was reported in our study. Infection-control precautionary measures are indicated to minimize risk of HIV transmission to ophthalmic surgeons and allied health-workers.

INTRODUCTION

The rates of human immunodeficiency virus (HIV) infection in sub-Saharan Africa are high.1 Nigeria is among the countries with the highest burden of HIV in the world. In Ekiti state, Western Nigeria, the prevalence is 1.6 and 10% in Benue State, Northern Nigeria.2

Infection with HIV and acquired immunodeficiency disease (AIDS) are among the most difficult challenges facing surgeons worldwide. Surgeons are at risk of occupationally acquired infection as a result of intimate contact with the blood and other body fluids of HIV patients requiring surgery.3 A literature review revealed 33 reports of health care workers who had contracted HIV infection due to their occupation.4 The seropositive status of the majority of HIV positive patients may be unsuspected by the attending medical personnel who, as a result, may not apply universal infection-control measures.

Eye care facilities are scarce in rural Nigeria resulting in significant backlog of patients. In the literature, seroprevalence of HIV infection has been described among eye patients in urban hospitals.5–7 There is relative paucity of data on the HIV status of patients undergoing surgeries in rural hospitals.

The Presbyterian Joint Hospital is the only hospital in Ohaozara which is one of the 12 local government areas of Ebonyi State, southeastern Nigeria. It provides eye care to a population of 148,626 in 312 km2 . This hospital also provides service to parts of the Enugu State of southeastern Nigeria.

Our study aims to determine the prevalence of HIV seropositivity among patients who underwent ophthalmic surgery in a rural eye care facility in southeastern Nigeria.

MATERIALS AND METHODS

In this case-series, a chart review was performed on all patients who had preoperative HIV testing and ocular surgery at the Eye unit of the Presbyterian Joint Hospital, Ohaozara between August 2008 and July 2009. Data on age, sex, type of surgery and HIV status was analyzed.

HIV testing was performed with enzyme-linked immunosorbent assay (ELISA) and two confirmatory tests with Western blot (Bio-Rad laboratories Inc. Hercules CA, USA) were performed for those with positive results. All laboratory tests were performed by two board-certified laboratory scientists.

The data were analyzed using the statistical package for social sciences (SPSS-16 IBM, Armonk, New York, USA). Univariate analysis and the parametric method were used to calculate frequency, percentage, and 95% confidence intervals (CI).

RESULTS

The population was 380 patients who had undergone ophthalmic surgery.

There were 228 males and 152 females (M:F = 1.5:1). The mean was 56 + 17.53 years ranging between 4 years to 91 years.

The types of surgeries are presented in Table 1. Nearly 75% of cohort had undergone cataract surgery.

Table 1

Diagnosis of patients

The prevalence of HIV among study participants by age and sex is presented in Table 2. The overall prevalence of HIV among patients who underwent eye surgery was 3.7% (95% CI: 1.8 – 5.6).

Table 2

Prevalence of human immunodeficiency virus among patients who underwent eye surgeries

The frequency and percentage of HIV by type of eye surgery is presented in Figure 1. Half of HIV positive study participants had undergone cataract surgeries.

Figure 1

Distribution of human immunodeficiency virus positive patients by type of surgery

All surgeries were performed by one surgeon. In addition, there were six ophthalmic nurses and one optometrist supporting the surgeon in providing eye care.

DISCUSSION

The seroprevalence of HIV infection noted (3.7%) in our series was lower than that reported in a rural eye care facility in the Niger Delta area of Nigeria (7.31%).5 The difference may be due to the high burden of HIV in the Niger delta area (6.4%)2 compared to Ebonyi state (4.6%).2

Fifty per cent of the seropositive cases in our cohort had undergone cataract surgery.

However, while only 2.5% (7) of our patients who underwent cataract surgery were found to be HIV-positive, 5.5% in a study of patients in Cameroon series tested positive.8 The difference between studies is likely due to differences in the study population and sample size. Our study was performed in a rural area, where as Wilhem and colleagues reported data from an urban population with sample size twice that of ours.

In Benin, south Nigeria,6 Enugu, southeastern Nigeria7 and in Northern India,9 reduced seroprevalences of 2.6, 3 and 2.1% respectively were reported [Figure 2]. Similar to our study, both Nigerian studies were retrospective.67 However, all three studies were conducted in urban eye care centers.6–8 Differences in the studies may be further accounted for by differences in sample size, sampling methodology and study population (Northern India-Emergency and pre-surgery patients in a tertiary multi-purpose care centre; Benin, Portharcourt and Enugu-tertiary eye care centre).

Figure 2

Distribution of human immunodeficiency virus seroprevalence and confidence interval by centers of study amongst ophthalmic surgical patients

Out of the fourteen patients who were HIV positive in our cohort, 9(65.3%) were females (odds ratio 0.36) which concurs with previous studies.15–7

Due to the lack of economic and educational empowerment of women, in the typical rural African setting, they rarely seek medical care for their ailments. Most times they present to the hospital with advanced disease having first sought help from traditional and/or spiritual healers.

In our cohort, the highest number of HIV/AIDS (42.9%) patients was found among those between 21 years and 40 years of age. However, ocular surgeries in this age group are usually rare. Therefore, if not addressed as the mortality of this young generation increases there will be fewer older surgical patients.

The age range reported here is similar to the cohort of HIV – positive patients in Ukponwans and colleagues study who were between 25 years and 50 years.6

Kelen and colleagues10 reported the highest seroprevalence rate among men aged 30-34 years while Baker and colleagues11 found that all seropositive cases in their series were trauma victims between ages 25 years and 34 years.

In Onitsha, southeastern Nigeria, Nwosu12 reported that the mean age of HIV-positive patients was 31 years.

Even though these studies vary in type, study population, sample size, sampling methodology and duration, the ages of the patients support the fact that this disease is more prevalent amongst the sexually active population.

It is important to increase awareness amongst the sexually active population of the need for protective sex. Also it is important for the health care provider to offer the HIV positive patient the best available eye care service without discrimination. This is against the backdrop of strict adherence to universal precautionary measures in preventing patient to surgeon transmission of HIV infection.

This study is both retrospective and hospital-based. Limitations of such studies include bias in patients’ selection and unavailability or paucity of required information in the existing records. Hence, our results must be interpreted with caution.

We have found the seroprevalence of HIV/AIDS to be 3.7% (95% CI: 1.8-5.6) amongst patients who underwent ophthalmic surgery in a rural eye care facility.

The most common surgery was cataract surgery and 50% of the seropositive patients had undergone cataract surgery.

Precautionary infection-control measures are indicated to minimize the risk of HIV transmission to ophthalmic surgeons and other health-workers.

In communities with a high prevalence rate of HIV/AIDS, greater emphasis should be placed on health education to create awareness of the disease and method of prevention.

The HIV status of all patients undergoing surgery especially ocular surgery should be determined preoperatively.