Study of infections among human immunodeficiency virus/acquired immunodeficiency syndrome patients in Shadan Hospital, Telangana, India.

BACKGROUND: Human immunodeficiency virus (HIV) pandemicity is a major concern today as it causes greater loss of productivity than any other disease. HIV infection leads to profound immune deficiency and patients become highly susceptible to opportunistic infections (OIs). HIV epidemic in India is heterogeneous in nature, both in terms of routes of transmission as well as geographical spread. AIMS: (1) Determine prevalence of OIs among HIV-seropositive patients and their relation to CD4 count and to focus on the routes of transmission. (2) Analyze the route of transmission.
METHODS: This is a single-center prospective study including all the patients attending acquired immunodeficiency syndrome (AIDS) care center during the period of January 2014 to December 2014.
RESULTS: Among 71 patients included in this study, mean age was 30 years, 57.7% (41 patients) were male, 42.3% (30 patients) were female. Mean CD4 cell count of the study group was 260.11 and of patients on antiretroviral therapy increased subsequently to 553.37 cells/ml. Among the infections, the prevalence of candidiasis, tuberculosis (TB), tinea infections, seborrheic dermatitis, giardiasis, cryptosporidiosis, and Entamoeba histolytica were 36.6%, 29.58%, 4.22%, 2.82%, 4.22%, 1.4%, and 1.4%. Most predominant routes were heterosexual transmission at 94.3%. It was followed by vertical transmission seen in 2.8%. Homosexual transmission is 1.4% and intravenous drug abuse 1.4%.
CONCLUSION: The frequency of infections among HIV/AIDS patients has got a similar linear relation with CD4 cell count. This study reports data will serve as a matrix for future evaluation. It is concluded that candidiasis, TB are the most common infections in the HIV-seropositive patients in the present study group.

INTRODUCTION

Human immunodeficiency virus (HIV) pandemicity is a major concern today as it causes greater loss of productivity than any other disease (2008).[1] According to report on the global acquired immunodeficiency syndrome (AIDS) epidemic by joint UN program, young people aged 15–24 account for estimated 45% of new HIV infections worldwide (2008).[2] The first case of HIV/AIDS was detected in India in Tamil Nadu and ever since the spread of HIV/AIDS across the nation has been relentless. There are 2.29 million people living with HIV/AIDS (PLHA) in India with an estimated adult prevalence of 0.31%. According to the annual report of NACO, out of the estimated number of PLHA, 39% are females and 3.5% are children (2010–2011).[3] According to the annual report of the National AIDS Control Organization, Government of India, the magnitude of the infection is second only to that of South Africa (2009).[4] According to Mukhopadhya et al., the progressive destruction of immune system by chronic HIV infection leading to progressive fall in the level of CD4 cells (<200/μL to <50/μL) is known to be responsible for the occurrence of infections (e.g. tuberculosis [TB], candidiasis, parasitic diarrhea, etc.,) by a variety of opportunistic microorganisms (1999).[5] Death in HIV infection is mostly due to opportunistic infections (OIs). Pulmonary disease is one of the most common complication of HIV infection, and approximately 1/3rd of all AIDS-related deaths are related to TB.[6] Merchant et al.[7] from Mumbai reported that among OIs, pulmonary TB (PTB) and extrapulmonary TB (EPTB) were 24.47% and skin lesions, chronic diarrhea, oral candidiasis, recurrent lower respiratory tract infection, and pneumocystis pneumonia were 22.10%, 15.08%, 14.73%, 8.42%, and 3.88%, respectively (2001). In another study, a poll from Karnataka reveal that 39.03% were TB, recurrent diarrhea is 30.99%, oral candidiasis 21.13%, and recurrent bacterial pneumonia 12.68%. Sharma et al. reported a higher prevalence of TB (71.1%) among hospitalized HIV patients in a tertiary care hospital in Delhi. HIV infection is predominantly sexually transmitted and most common mode of infection, particularly in developing countries is heterosexual transmission including India.

The widespread use of effective chemoprophylaxis for OIs and the use of highly active antiretroviral therapy (HAART) have resulted in a delay of onset of AIDS, longer survival, and change in the pattern of OIs in developed world. The present study was undertaken to estimate the specific OIs, their relation with CD4 count, and to focus on routes of transmission in secondary ART center.

METHODS

This is a single center prospective study during the period of 2014 January and 2014 December in HIV AIDS patients coming to Shadan Hospital DVL outpatient department. These patients were already diagnosed HIV positive. All the patients who were registered were included in this study after taking written consent. Every patient had a monthly follow-up. These patients were thoroughly examined and investigated extensively for the diagnosis of OIs. According to Centre for Disease Control and Prevention, a specific OI was diagnosed on the basis of standard clinical definition and by laboratory procedures (Morbidity Mortal Weekly Report, 1999).[8] Patients were advised to initiate ART when their CD4 cell count was <250 per ml. According to existing guidelines of NACO, ART drugs were supplied from nearby ART center. CD4 counts were estimated by FACS count flow cytometer every 6 monthly. Stool samples were processed for the investigation of parasitic pathogens. Parasite detection was done as per the standard protocol. Direct wet mount preparation (saline and iodine) and wet preparation from formal ether concentrated samples were used for the detection of protozoan trophozoites, cysts and helminthic eggs, and larva. For the detection of coccidian parasites, smears of stool samples were prepared and stained with modified acid-fast method.[910] Early morning expectorated sputum samples were collected in sterile containers. For the detection of bacterial pathogens, samples were processed for Gram-stain, Zeihl and Nelson stain, and aerobic culture on selective and enrichment media (Lowenstein–Jenson media, chocolate agar, and Macconkey agar) as per the standard methods.[11] Two oral swabs were taken from each patient. One swab was used for wet mount (10% KOH, i.e. potassium hydroxide) and Gram-stain. The other swab was inoculated on Sabouraud's Dextrose Agar with antibiotics. The growth obtained was identified for yeasts as per the standard protocol by the manual of medical mycology, NIMS and Global Hospital, including germ tube test, chlamydospore formation, sugar assimilation, sugar fermentation, and urease test (2006).[12] All the data were entered by use of standardized collection form that documented age, sex, mode of transmission, date of HIV detection, presenting symptom and OIs, CD4 counts, different blood investigations, and treatment. Data entry, database management, and analysis were done with the use of SPSS 17. Descriptive statistics were used to calculate frequency mean, median, mode, and standard deviation.

RESULTS

Among 71 patients included in this study in Shadan Hospital, mean age was 30 years, 57.7% (41 patients) were male, 42.3% (30 patients) were female; mean CD4 cell count of the study group was 260.11 and of patients on ART increased subsequently to 553.37 cells/ml. Sixty patients out of 71 presented with some infection, whereas 11 patients did not have any OI and it was observed that their CD4 count was above 350.

Incidence of opportunistic infections [Tables 1 and 2]

Candidiasis [Figure 1] was the most common opportunistic infection in our study group with 31% incidence, that is it was seen in 22 patients out of 71 patients. Prevalence of TB was 29.58% that is it was seen in 21 patients out of 71 total patients. Tinea infections [Figure 2] were seen in 4.22% of patients that is 3 out of 71 total study group. Seborrheic dermatitis was seen in 2 patients out of 71 that is 2.82% incidence among OIs. Recurrent furunculosis was seen in 4.22% of patients that is 3 out of 71 total study group. Herpes zoster [Figure 3] HZ was seen in 2 patients out of 71 that is 2.82% incidence among OIs and it was multidermatomal. Herpes genital infection [Figure 4] was seen in 2 patients out of 71 that is 2.82% incidence among OIs. Giardiasis was seen in 4.22% patients that is 3 patients among our study group of 71 patients. Cryptosporidiasis was seen in 1.4% patients that is 1 among 71 total patients. E. hystolytica is seen in 1.4% patients that is 1 out of our 71 study group patients.

Figure 1

Oral candidiasis in 35 years male patient with CD4 count of 360 on antiretroviral therapy

Figure 2

Extensive tinea in a 65-year-old male patient with CD4 count of 160 irregularly on antiretroviral therapy

Figure 3

Herpes zoster multidermatomal in a 17-year-old male patient with CD4 count of 210 irregularly on antiretroviral therapy

Figure 4

Herpes genitalis in a 26-year-old male patient with CD4 count of 510 not on antiretroviral therapy

Route of transmission

Most predominant route was heterosexual transmission. It was seen in 67 out of 71 total patients (94.3%). It was followed by vertical transmission seen in 2 out of 71 cases (2.8%). Homosexual transmission and intravenous drug abuse were seen in 1 (1.4%) cases each.

DISCUSSION

During the study period, the average age group was 30 years and male:female ratio was 1.36:1. On evaluation, we have found among OIs candidiasis was very common at 36.61% and TB 29.58%. Among TB patients, 57.14% were having PTB and 42.86% were having EPTB.

It has been observed that 80.29% of HIV-infected patients had any one of the OIs. Mean CD4 cell count of the study group was 260.11 and of patients on ART increased subsequently to 553.37 cells/ml. In our study, the most common mode of transmission in our patients is heterosexual.

It is concluded that candidiasis in TB is the most common OIs in the HIV-seropositive patients in the present study group. This correlates with the study conducted by Patel et al.[13] in which candidiasis and TB were seen in 32.67% and 22.77%, respectively, and also with the study conducted by Madkar et al.[14] in which TB and candidiasis were the two most common OIs [Table 2]. The present study reflects that among HIV or AIDS frequency of OIs has a similar linear relationship with CD4 cell count. The natural history of OIs has changed during the HAART era and incidence of all OIs is markedly reduced. Improved hygienic practices, regular examination, and appropriate antimicrobial prophylaxis can reduce the substantial morbidity and mortality caused by OIs in patients with HIV infections. With better knowledge and diagnosis of the OIs, clinicians and health planners can treat HIV patients more effectively. This will contribute to increased life expectancy among HIV-seropositive patients. However, this study once again proves that spectrum of OIs among various patient groups varies significantly.

Table 2

Break up of infections in HIV/AIDS cases

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 1

Percentage of opportunistic infections in human immunodeficiency virus/AIDS patients