Gayathri Veluri

Abstract

Introduction: The present study is an attempt to evaluate and document HIV incidence and progression among women in and around Srikakulam, a remote town in the north coastal Andhra Pradesh. The results throw light on a greater effort required to be mobilized towards preventive and therapeutic care in women in rural areas. Material & Methods: This is a retrospective study, using the data collected from ICTC (from April 2007 to March 2011) and ART center (from April 2007 to February 2010) of RIMS General Hospital, Srikakulam. The study is focused on the development of CD4 counts at regular intervals among women on ART. Opportunistic infections, deaths, transfers and the profiles of CD4 counts have also been analyzed. Results: There is a+ significant percentage of responsiveness to therapy in the younger age group. Tuberculosis is significant in being the commonest opportunistic infection causing death with a percentage of 16.4. Maximum number of deaths (27.8 %) were associated with CD4 counts as low as 0 – 50 per cu mm, and there is a decrease in the percentages of deaths at higher range of CD4 counts. As a baseline parameter, the CD4 counts of 50 HIV seronegative women between the ages of 15-45 years are estimated. The average is 972 cells /cumm. Conclusion: In spite of an overall decrease in the severity of the epidemic, the problem persists among women in the rural set up. The present study throws light on the need of special programmes which focus on early detection, early initiation of ART, counseling regarding barrier methods applicable to females and monitoring therapy in women.

Key Words: HumanImmuno Deficiency Virus, Anti Retro Viral Therapy, Integrated Counseling and Testing Center ( ICTC) CD4 counts, National AIDS Control Organisation ( NACO),Opportunistic infections (OI), Highly active anti retro viral therapy (HAART).

Manuscript received: 10th Sep 2013, Reviewed: 16th Sep 2013
Author Corrected: 30th Sep 2013, Accepted for Publication: 1st Oct 2013

Introduction

HIV infection in a developing country like India is unique, as the progressive ill health is projected on a background of poverty and inadequate medical care. Among the HIV infected, women in India suffer more on account of social, cultural, economic, biological and clinical factors which keep females at a higher risk [1]. Women in India are mostly illiterate and financially depend on others for their nutrition and health [2]. Majority of HIV seropositive women in India are married and reported monogamous [3]. Vertical transmission from a pregnant women to the fetus is well documented [4] . HIV infection among women is associated with a greater than two fold risk of having cervical cancer, TB, invasive candidiasis and many other Opportunistic Infections.

Triple drug therapy (HAART) alone can significantly alter HIV disease progression. The challenging issues in India are inadequately trained human resources and the incapacity of the health system to utilize ART drugs optimally along with inadequate training of health care personnel, laboratory monitoring and drug distribution. The present place of study is a small town in the North East of Andhra Pradesh surrounded by a number of satellite villages and tribal areas. Anti Retroviral Therapy (ART) centre has been established in the hospital, in March 2007. As per the NACO guidelines, all the seropositive individuals are referred to ART centre, where they are counseled and baseline CD4 counts are done. Those with CD4 counts of less than 250/mm3 are started on ART and are followed up on regular basis at every six month interval.

The present retrospective study is undertaken at ART centre, in the tertiary care hospital. Detailed information was collected about all women who attended the ART centre from the date of inception, up to 03 visits (one and a half years). All the factors determining the clinical course of HIV are analyzed.The results of the present study throw light on the issues to be solved and methodologies to be developed to contain HIV infection among women in India.

Material and Methods

The data collected at ICTC and ART Center (April 2007 to March 2011) is included in the present study. The critical analysis of the data is focused on the development of CD4 counts at regular intervals among women on ART. Opportunistic infections, deaths, transfers and the profiles of CD4 counts have been analyzed. Due to poor documentation of data, the details regarding HIV status of spouse and children, occupation/ income and educational status could not be obtained.

Results

Table 1: Year wise percentage of HIV seropositivity among women

In Table – 4, an attempt is made to tabulate the ranges of CD4 counts among patients who died while on ART. Maximum number of deaths (27.18%) were associated with counts as low as 0-50. Deaths occurred even at CD4 counts above 200, as shown in the table. However, there is a gradual decrease in the percentages of deaths at higher range of CD4 counts. As a baseline parameter, the CD4count of 50 HIV seronegative women between the ages of 15-45 years are estimated. The average is 972 cells / mm3, which is correlating with Murugavel et al [5, a study done in healthy adult population in Chennai, India.

Discussion
Since more than two decades, the AIDS pandemic in India has grown as a major public health problem with medical, psychosocial and economic consequences at individual and at national level. The median HIV prevalence in A.P. is 1.25% in low risk groups, being higher than all the other states in India [6]. Apart from factors such as sexual practices, the other risk factors in females are male – female age differences, anatomical peculiarity of genitalia, asymptomatic S.T.Ds in women, blood transfusions etc. In India, women are in a poor position to question their husbands about their extramarital encounters, to negotiate condom use or refuse to have sex. Forced sexual encounters invariably end in bruises and injuries to genitalia, favoring transmission of HIV.

Percentage of HIV seropositivity among women attending ICTC has a gradual decline, from 21.2% to 12.7%. This is in coincidence with the control of HIV epidemic in India with effective national policies as well as involvement of voluntary organisations in the control of the epidemic. More awareness regarding HIV is another reason responsible for large number of person are coming for volunteer testing. CD4 cells are the major cell types affected. ART reconstitutes the immune system and improves survival [7]. However the rate and extent of CD4 + T cell recovery varies widely. In the present study (Table-II), a significant improvement of CD4 counts is observed in the younger age groups 15-25 years and 26-35 years. The percentage of older women who have responded to ART by increasing CD4 counts is however less compared to the younger age group.

For reasons which are yet to be identified, younger women responded better than older women to ART as per the data. According to Shaeferet al [8], younger patients have a significantly larger increase in CD4 cells after 48 weeks of ART. This is probably related to a better functioning immune system in the young, reacting positively to compensate for the depleting CD4 cells. Such mechanism may not be possible as age advances, due to decompensated immune system.

In the present study tuberculosis occupied the first place with a percentage of 16.4% as the commonest Opportunistic Infection causing death in HIV positive individuals while still on ART. As already documented, TB- HIV confection is a major world health problem and according to WHO, nearly a quarter of the HIV deaths were due to tuberculosis in 2007. In developing countries like India, tuberculosis presents as a pulmonary disease. It is also a well documented fact that the most common OI in HIV infected is pulmonary tuberculosis [9]. Risk of death in HIV- TB patients is 3.5 times greater than the risk in HIV positive patients without TB with matched CD4 counts [10]. In other countries like Uganda, HIV- TB was 1.4 % among the total HIV infected patients [11]. In a study at Baltimore, USA, the incidence of HIV- TB was 3.6% [12]. A study in Sub Saharan Africa [13] has shown that HIV - TB patients have a significantly lower median CD4 count increase, compared to the non TB counterparts while on ART.

In the present study (Table – IV), as much as 27.18% of deaths while on ART occurred with a CD4 count range of 0 – 50 cells / mm3. The number and percentage of deaths were lower at higher ranges of CD4 counts. Literature is not available regarding the average CD4 counts at the time of death of Indian patients on ART. However, it can be stated that the individual risks and complications associated with Opportunistic Infection determine the time of death and not CD4 counts alone. Opportunistic infections always occur at lower CD4 counts, and further reduce the immune competence of the patients.

Conclusion

There are very few studies on HIV disease among Indian women. In spite of active intervention by Government Of India and NGOs, only about 80% of women improved with ART as per the present study. Therefore it might be stated that special programmes are needed to focus on early detection, early initiation of ART, counseling regarding barrier methods applicable to females and above all, monitoring therapy among women in India to achieve better survival rates with ART.

Funding: Nil, Conflict of interest: Nil
Permission from IRB: Yes

References

1. Usha KB, Rewari BB. Diagnosis and management of HIV/ AIDS, a clinician’s perspective. 1st ed. B.I Publications Private Limited; 2004. ch 18 P. 264-279.

2. Gilks CF. Natural history of HIV-AIDS. In: Manson’s Tropical Diseases.21st ed. W B Saunders: 2003 .Ch 20 P. 411.

3. Gangakhedkar RR, Bentley ME, Divakar AD .Spread of HIV infection among married monogamous women attending STD clinics in India . JAMA 1997; 278 : 2090 – 2092. [PubMed]

4. Patubidn VG, Daftary SN. Natural course of HIV. In: Shaw’s Text Book of Gynecology. 15th ed. Elsevier’s Publications; 2010. Ch 11: 148.

5. Murugavel KG, Balakrishnan P, MohankrishnanJ, Solomon SS, Shankar EM ,. Establishment of T-lymphocyte subject reference intervals in a healthy adult population in Chennai, India. Indian J Med Res 2009;129:59-63. [PubMed]

6. Usha KB, Rewari BB. Diagnosis and management of HIV/ AIDS, a clinician’s perspective. 1st ed. B.I publications Private Limited ; 2004. ch 18 P. 2-9.

7. Wilkins EGL.Humanimmuno deficiency virus infection and the Human acquired immunodeficiency syndrome. Davidson’s Principles and Practice of Medicine.20th ed. John A.A Hunter ,Churchill Livingstone- Elsevier publication 2006;ch14 P. 399-401.

8. Shaefer M, James D, Henry Z, Amy C, Martin G, James G. Effect of age on baseline CD4+ and CD8+ cells and response to ART over 48 weeks in a large clinical trial database. Presented at the 1st Int. Workshop on HIV & Aging, 4-5 Oct 2010, Baltimore, USA.

9. Solmon S, Kumarswamy , Anuradha S, Vennila R, Pal JA. TB and HIV infection – an association. Indian J Med Microbiol 1994, 12: 313 – 4.

10. Kumarasamy N, Solomon S, Flanigan TP, Hemalatha R, Thyagarajan SP, Mayer KH. Natural history of human immunodeficiency virus infection among adults in Mumbai. Nat Med J India 2003;16: 126-31.

11. Nakanjako D, MayanjaKH ,Ouma J , Wanyenze R, Mwesigine D, Namle A, Sse MJ, Senkusu J, Colebunders R, Kamya MR :Tuberculosis and human immunodeficiency virus co-infection and their predictors at a hospital based HIV/AIDS clinic in Uganda. Int J Tuberc lung Dis 2010;14: 1621-8.

12. Martinson NA, Barnes GL, Moultion LH, Msandiwa R, Hausler H, Ram M, Mclntyre JA, . New regimens to prevent tuberculosis in adults with HIV infection. N Eng J Med 2011; 365 (1) ;11-20. [PubMed]

13. Hermans SM, Kiragga AN, Schafer P, Kambugu A, Hoepelman A1, Manabe YC. Incident tuberculosis during antiretroviral therapy contributes to suboptimal immune reconstitution in a large urban HIV clinic in sub-saharan Africa.http://blogs.plos.org/plos/2010/10/epigenetics-2010-a-new-collection-from-the-plos-journals/.

Year	No of women attending ICTC	No of women Positive for HIV	% Positivity
2007- 2008 Apr - Mar	1569	333	21.22
2008- 2009 Apr- Mar	1352	342	25.3
2009- 2010 Apr- Mar	2495	362	14.5
2010- 2011 Apr- Mar	2329	295	12.66

S. No	Age Group	Total No of women on ART	Women with Increasing CD4 counts No / %	Women with Decreasing CD4 counts No / %	Deaths No / %	Transfer No / %
1	15 - 25	267	216 80.90	7 2.6	28 10.50	16 6
2	26 - 35	653	531 81.30	7 1.30	95 14.50	20 3
3	36 - 45	337	262 77.70	11 3.30	55 16.30	9 2.70
4	>45	90	67 74.40	5 5.50	17 18.90	1 1.10

Sl. No	Cause of Death	No. of deaths	Percentage
1	Tuberculosis	32	16.4
2	Ari	27	13.8
3	Jaundice	27	13.8
4	Diarrhoea	21	10.8
5	Candidiasis	15	7.7
6	Gross anemia	25	12.8
7	Not documented	48	24.6
8	Total no of Deaths	195	100

Sr. No	Range of CD 4 count (no/cumm)	Number of deaths	Percentage
1	0 -50	53	27.18
2	51 – 100	35	17.9
3	101 – 150	28	14.36
4	151- 200	33	16.92
5	201- 250	20	10.26
6	251 – 300	14	7.18
7	>300	12	6.15