Seroprevalence of HIV-2 and dual infection among HIV-infected individuals with clinical and laboratory features at a Tertiary Care Teaching Hospital, Mangalore: The present scenario.

Introduction: Human immunodeficiency virus (HIV) belongs to the Genus Lentiviruses and is made up of two main types HIV-1 and HIV-2 which are the causative agents of acquired immune deficiency syndrome (AIDS). It is well documented that HIV-1 infection is predominantly found, but HIV-2 infection has also been detected occasionally now and then. Objective: The objective of this study is to determine the seroprevalence of HIV-2 and dual infection in HIV-infected individuals along with the clinical presentation, co-infections, laboratory profile, and outcome of these patients. Materials and
Methods: This descriptive cross-sectional study was carried out at a Tertiary Care Teaching Hospital for 2 years from August 2013 to July 2015, after obtaining approval from the Institutional Ethics Committee. Patients confirmed having HIV infection, as per the National AIDS Control Organization guidelines were included in the study. The sociodemographic pattern along with clinico-laboratory details and outcome were noted. Results and Discussion: In the present study, out of a total of 214 confirmed HIV-infected individuals, 2.8% (n = 6) were HIV-2 and 1.4% (n = 3) were dual infected where 40-50 years age group were most commonly affected. Males were more commonly affected than females in a ratio of 8:1. The most common presentation was fever (n = 5) followed by gastrointestinal (n = 5) symptoms. The most common opportunistic infection (OI) was tuberculosis (TB) (n = 4) followed by oral candidiasis (n = 2). Majority had anemia (n = 5) with raised erythrocyte sedimentation rate. Furthermore, majority (n = 7) showed improvement on discharge, whereas two (n = 2) left against medical advice and outcome is unknown.
Conclusion: We conclude that the incidence of HIV-2 and dual infection does occur in our setup with males of older age group being more commonly affected where TB is the most common OI. Hence, clinicians should keep in mind that HIV-2 infection does occur and differentiating as HIV-1, HIV-2, or dual infection is important, to provide appropriate treatment which will result in decreased morbidity and mortality rates.

INTRODUCTION

Human immunodeficiency virus (HIV) belongs to the Genus Lentiviruses and is made up of two main types as follows: HIV-1 and HIV-2 which are the causative agents of acquired immune deficiency syndrome (AIDS).[123] It was believed to originate from West Africa and it is endemic there,[14] whereas in India, it was first reported from Mumbai in a 25-year-old prostitute in 1991 by Rübsamen-Waigmann et al.[5] Studies have shown that the doubling time for HIV-2 is nearly five times that of HIV-1.[1] In HIV-2-infected individuals, the sexual transmission is less efficient, less pathogenic, infecting older individuals with slower disease progression and CD4 T-cell decline but infection with HIV-2 does not protect against HIV-1 and dual infection may also occur.[134] HIV-2 can also progress to end-stage disease of AIDS and show resistance to nonnucleoside reverse transcriptase inhibitor which are the main group of drugs constituting antiretroviral treatment (ART). A combination of zidovudine-lamivudine and lopinavir-ritonavir have shown to be effective in suppression of both HIV-2 and dual infection.[1] It is well documented that HIV-1 infection is predominantly found, but HIV-2 infection has also been detected occasionally now and then.[67891011] The data in relation to the seroprevalence rate of HIV-2 among HIV-infected individuals is lacking from in and around Mangalore; hence, this study was conducted with the main objective to determine the seroprevalence and analyze the sociodemographic pattern, clinical and laboratory features of these infected individuals.

MATERIALS AND METHODS

This descriptive cross-sectional study was conducted at a tertiary care teaching hospital in Mangalore where approval from the Institutional Ethics Committee was obtained. All patients of all age group newly diagnosed with HIV or known cases who were admitted in the hospital, during the study from August 2013 to July 2015 were included, after obtaining informed consent. The inclusion criteria included cases that were confirmed having HIV infection, diagnosed following National AIDS Control Organisation (NACO) Guidelines (2007) on the basis of a single rapid test used (HIV TRI-DOT by Diagnostic enterprises) which if found positive was confirmed by another rapid test kit (RETROQUIC by Qualpro Diagnostics) and an ELISA kit (4th generation MICROLISA-HIV Ag and Ab by J Mitra and Co. Pvt. Ltd.) which were then reported as REACTIVE for HIV-1 or HIV-2 or dual infection where the diagnosis of HIV-1 or HIV-2 or dual infection is based mainly on the rapid tests used and those found negative were excluded from the study.[2] The sociodemographic profile included age, sex, and address; clinical presentation on admission; laboratory investigations such as complete blood hemogram, including hemoglobin levels, total leukocyte count, platelet count, and erythrocyte sedimentation rate (ESR); plasma glucose random; liver function test (LFT), including serum total protein, albumin, globulin, A/G ratio, total bilirubin, conjugated bilirubin, unconjugated bilirubin, AST, ALT, alkaline phosphatase; kidney function test (KFT), including serum urea and creatinine and electrolytes, including serum sodium, potassium, and chloride. Other test like sterile fluid analysis (CSF and ascitic fluid) for glucose, protein, lactate dehydrogenase, adenosine deaminase, total cell count, including lymphocytes and neutrophils percentage, blood culture and related tests which were sent when need arises were also noted.

Statistical analysis

The data were analyzed using IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, N. Y., USA) where mean, percentage, and Fisher's exact test were used to measure the association between the different variables.

P < 0.05 was considered statistically significant.

RESULTS

In the present study, where 214 confirmed HIV-infected individuals participated, it was found that majority were from 41 to 50 years age group constitutes 38.3% (n = 82) with a Male: Female ratio of 2:1 (M = 142, F = 72) where age group distribution is shown in Figure 1. It was observed that 33.2% (n = 71) were known cases of HIV with 23.4% (n = 50) on ART. Furthermore, majority 82.7% (n = 177) showed improvement on discharge whereas 5.6% (n = 12) expired and 11.7% (n = 25) left against medical advice. It was also found that 95.8% (n = 205) were HIV-1, 2.8% (n = 6) were HIV-2 and 1.4% (n = 3) were dual infected with HIV-1 and 2. All these 9 cases were >30 years of age with majority from 41 to 50 years age group (n = 4) followed by 51–60 years (n = 3). Males were more commonly affected with HIV-2 and dual infection than females in a ratio of 8:1. There were four (n = 4) cases of known HIV status out of which two (n = 2) were on ART. The mean hospital stay was 7 days with a range from 2 to 14 days which are summarized in Table 1.

Figure 1

The age-wise group distribution of human immunodeficiency virus-1, human immunodeficiency virus-2 and dual infection (human immunodeficiency virus-1 and human immunodeficiency virus-2)

Table 1

The sociodemographic pattern, history, co-infections, laboratory investigations, and outcome of Human immunodeficiency virus-2 or dual-infected patients

	Case 1	Case 2	Case 3	Case 4	Case 5	Case 6	Case 7	Case 8	Case 9
Age	51	67	58	39	48	58	50	50	42
Sex	Male	Male	Female	Male	Male	Male	Male	Male	Male
Days hospitalised	6	2	4	13	14	8	7	5	6
Address	Mangalore	Kasaragod	Kasaragod	Chikmangalur	Mangalore	Karkal	Kundapura	Mangalore	Beltangadi
Known case of HIV	No	Yes	No	Yes	No	No	Yes	Yes	No
On ART treatment	No	Yes	No	No	No	No	No	Yes	No
HIV 2/1 and 2	HIV 2	HIV 2	HIV 1 and 2	HIV 2	HIV 1 and 2	HIV 2	HIV 2	HIV 2	HIV 1 and 2
Pulmonary TB	No	No	No	No	No	No	No	Yes	No
Extrapulmonary TB	No	No	No	Yes	No	No	Yes	Yes	Yes
DOTS treatment	No	No	No	CAT 1	No	No	CAT 1	CAT 2	CAT 1
Oral candidiasis	No	No	No	Yes	No	No	No	Yes	No
CD 4 count	NA	NA	NA	55	NA	NA	NA	374	NA
Plasma glucose random (74-140 mg/dl)	88	111	112	188	80	162	157	108	144
ESR (upto 10 mm/1st h)	22	NA	54	60	3	109	80	98	31
Hb (>11.5 g/dl)	11.7	10.3	10.8	11.7	15.7	10.4	7.4	10.9	13.6
TLC (4000-11,000/cumm)	3100	7300	5300	7700	8000	5500	6700	2700	8400
Platelet count (150,000-500,000/cumm)	215,000	NA	NA	430,000	228,000	310,000	301,000	261,000	226,000
LFT	WNL	WNL	WNL	WNL	WNL	WNL	WNL	WNL	WNL
KFT	WNL	WNL	WNL	WNL	WNL	WNL	WNL	WNL	WNL
Blood culture	NS	NS	NS	Sterile	NS	NS	NS	Streptococcus pneumoniae	NS
Outcome	Improved	Improved	Improved	Improved	Improved	Improved	Improved	LAMA	LAMA

LAMA=Left against medical advice, WNL=Within normal limit, DOTS=Directly observed treatment, short-course, CAT=Category, NA=Not available, HIV=Human immunodeficiency virus, NS=Not sent, ESR=Erythrocyte sedimentation rate, Hb=Haemoglobin, TB=Tuberculosis, TLC=Total lymphocyte count, ART=Antiretroviral treatment, KFT=Kidney function test, LFT=Liver function test

The most common presentation was fever (n = 5) followed by gastrointestinal symptoms (n = 5) which included pain abdomen, abdominal distension, diarrhea, vomiting, nausea, and dysphagia followed by respiratory symptoms (n = 2), including cough and breathlessness and central nervous system (CNS) features (n = 2) such as headache, convulsions, altered sensorium, and neck rigidity. Others such as lymphadenopathy (n = 2), generalized weakness (n = 2), pain, and swelling (n = 2; where one had inguinal hernia and the other with varicose veins and cellulitis), splenomegaly (n = 2), hepatomegaly (n = 1), and diminution of vision (n = 1) were also noted.

It was observed that tuberculosis (TB) was the most common opportunistic infection (OI) occurring in these patients (n = 4) with extra-pulmonary TB (EPTB) being dominant where two were diagnosed as TB meningitis based on the CSF examination findings and one as abdominal TB according to ascitic fluid analysis which are summarized in Table 2. The other case was a known case of HIV with PTB who was on CAT 1 treatment and not responding and hence, treatment was changed to CAT 2. This patient also had a positive blood culture which grew Streptococcus pneumoniae. Two of the TB-infected individuals were co-infected with oral candidiasis/thrush and had low CD4 counts. The laboratory investigations showed that majority had anemia (n = 5) (44.4% [n = 4] having mild anemia whereas 11.1% [n = 1] had moderate anemia [n = 1]) with a raised ESR mean value of 57.1 mm/1st h, whereas normal mean values for plasma glucose random, platelet counts, total leukocyte count, LFT, KFT, and serum electrolytes were noted which are summarized in Table 1. Seven (n = 7) cases showed improvement on discharge from hospital, whereas two (n = 2) cases left against medical advice and outcome is unknown.

Table 2

Fluid analysis of patients with extra-pulmonary tuberculosis (2 cerebrospinal fluid and 1 Ascitic fluid)

Normal values	Sample	Glucose	Protein	LDH	Adenosine deaminase	Total cell count	Lymphocytes (%)	Neutrophils (%)
		40-70 mg/dl	15-45 mg/dl	Up to 0 IU/L	Up to 10 IU/L
Case 4	CSF	101	432.6	170	12.2	235	65	35
Case 7	Ascitic fluid	NA	NA	NA	60.12	1300	55	45
Case 9	CSF	46	1675.3	303	110.9	224	95	5

CSF=Cerebrospinal fluid, NA=Not available, LDH=Lactate dehydrogenase

DISCUSSION

In the present study where 214 confirmed HIV-infected individuals participated, it was found that majority were of the 41–50 years age group followed by 31–40 years while previous studies have reported that the 31–40 years age group to be the most commonly affected.[121314] Furthermore, males were more commonly affected than females, similar to a study conducted by Shahapur and Bidri.[14] We also observed that 33.2% (n = 71) were known cases of HIV out of which more than two thirds (n = 50) were on ART. The difference of age presentation may be due to the fact that now better diagnosis is available for this infection along with other OIs and with the availability of ART has resulted in decreasing the mortality rates and increasing the survival rate in terms of years of these patients. However among those infected with HIV-2 and dual infection, the most common age group infected was 41–50 years followed by 51–60 years with again males being more commonly affected, all infected were >30 years of age which is similar to a study by Kashyap et al., whereas Sonth et al. had reported more in <30 years of age.[78] This may be because HIV-2 doubling time is more than that of HIV-1, is less efficient for sexual transmission, less pathogenic, and slower disease progression which has resulted in prolong life in HIV-2-infected individuals than those infected with HIV-1.[14]

The prevalence of HIV-2 and dual infection in the Indian scenario is important for treatment and epidemiology. In this study, we found that 2.8% were infected with HIV-2 alone which is similar to a study conducted by Kannangai et al.[6] in South India, but Kashyap et al.[7] reported as low as 0.3% whereas Sonth et al.[8] reported as high as 13.15%. Furthermore, our findings for those who were dual infected was 1.4% which is similar to Tadokar and Kavathekar[9] study findings, but again studies have shown a range from 0% to 1.65%.[67891011] Our findings in relation to the prevalence of HIV-1, HIV-2, and dual infection of HIV-1 and 2 among HIV-infected individuals when compared to other studies are summarized in Table 3. These findings suggest that HIV-2 and dual infections are prevalent in and around Mangalore.

Table 3

The prevalence of human immunodeficiency virus-1, human immunodeficiency virus-2, and dual infection among human immunodeficiency virus-infected individuals in comparison with other studies

	Year published	Country	Population studied	Number of HIV positives included	Percentage of HIV 1 (n)	Percentage of HIV 2 (n)	Percentage of HIV 1 and 2 (n)	Male: female ratio	Age >30 years (%)
Kannangai et al.[6]	2003	South India	General	1700	97.53 (1658)	2.06 (35)	0.41 (7)	-	-
Kashyap et al.[7]	2010	New Delhi, India	General	1945	99.64 (1938)	0.3 (6)	0.05 (1)	6:0	5/7 (71.42)
Sonth et al.[8]	2010	Bagalkot, South India	Blood donors	350	86.85 (304)	13.15 (46)	-	4.75:1	18/46 (39.1)
Takodar et al.[9]	2013	Pune, India	General	242	96.7 (234)	1.65 (4)	1.65 (4)	-	-
Ingole et al.[10]	2013	Mumbai, India	General	5235	97.12 (5084)	1.83 (96)	1.05 (55)	-	-
Sabharwal et al.[11]	2014	Jaipur, North India	General	135	99.25 (134)	0.75 (1)	(0)	-	-
Present study		Mangalore, South India	General	214	95.8 (205)	2.8 (6)	1.4 (3)	8:1	9/9 (100)

HIV=Human immunodeficiency virus

Among the HIV-2-infected individuals, we observed that fever was the most common presentation followed by gastrointestinal and respiratory symptoms and the most common OIs which were seen are TB followed by candidiasis which are similar to other studies which have studied the clinical features of HIV as one but not separately as HIV-1 or HIV-2 or dual infection.[131415]

In relation to the four cases of TB, three had EPTB with two being CNS Tb and the other abdominal TB, whereas one case had a combination of both PTB and EPTB which is similar to a study by Jaryal et al.[16] where they had noted that EPTB (57.47%) was the most common form of Tb with the most common being CNS Tb (33.84%) followed by abdominal TB (26.15%), whereas in a study by Patel et al.[17] they had found that majority of HIV-infected individuals had PTB with EPTB at 46% followed by PTB at 40% and those with only EPTB at 10%. All the four patients were started or already on either DOTS CAT 1 or CAT 2 for treatment because we have a DOTS center attached to our institute which shows its effectiveness in the implementation of the revised national TB control program. Furthermore, in a study by Wejse et al.,[18] they had concluded that the HIV type associated risk of TB for dual infection, HIV-1 and HIV-2 alone was 7-, 6- and 2-fold when compared to uninfected HIV patients and that the clinical severity presentation and poor outcomes was also least for those infected with HIV-2 alone. CD4 count available for the two cases who had HIV with TB and candidiasis was <500 which is seen in other studies too.[1519]

In terms of laboratory investigations, all the mean values of the different tests were within normal limit except for raised mean ESR and anemia which was observed in 55.5% infected individuals with 44.4% and 11.1% had mild and moderate anemia which is similar to a study in South India by Subbaraman et al.[20] where they had reported an overall prevalence of 41% while in a study conducted in China by Jin et al.,[21] they had reported 39.2% overall anemia cases with 27.2%, 10.8%, and 1.2% being mild, moderate, and severe anemia.

Regarding the outcome of these cases, it was found that majority improved on discharge except for the cases who left against medical advice and outcome is unknown.

CONCLUSION

We conclude that the incidence of HIV-2 and dual infection does occur in our setup with males of older age group being more commonly affected. TB is the most common OI with EPTB being more common followed by candidiasis. Hence, clinicians should keep in mind that HIV-2 infection does occur and differentiating as HIV-2 or dual infection is important, to provide appropriate diagnosis and treatment which will result in decreased morbidity and mortality rates. So also laboratories, especially in the private sector, should sent retro-positive cases to integrated counseling and testing center (ICTC) which will then refer the HIV-2 positive cases to the nearest ART center for care, support and treatment where following the NACO guidelines confirmation in designated national and state reference laboratories will be done.[3] Otherwise, HIV-2 will become a major problem in the future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.