|Year : 2017 | Volume
| Issue : 1 | Page : 34-37
Pattern of comorbidities among highly active anti-retroviral therapy-naive HIV-infected adult Nigerian patients at initial diagnosis
RI Oko-Jaja1, A. T. O. Awopeju2
1 Department of Medicine, University of Port Harcourt Teaching Hospital, Rivers State, Nigeria
2 Department of Medical Microbiology and Parasitology, University of Port Harcourt Teaching Hospital, Rivers State, Nigeria
|Date of Submission||05-Sep-2016|
|Date of Acceptance||14-Sep-2016|
|Date of Web Publication||19-Apr-2017|
R I Oko-Jaja
Department of Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State
Source of Support: None, Conflict of Interest: None
Background: Comorbidities associated with HIV infection may have profound impact on the future clinical outcomes of infected patients. This study was carried out to assess the prevalence and types of comorbidities in newly diagnosed, highly active anti-retroviral therapy (HAART)-naïve adult HIV patients.
Methods: A retrospective study of 501 consecutive newly diagnosed, HAART-naïve HIV-infected patients was carried out between April 2014 and September 2015 at the University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria. Demographic characteristics, clinical data and comorbid disease condition at initial presentation were retrieved from the hospital records of study patients. Summary statistics was used to present discrete variables. Medians were calculated for continuous variables (age and CD4counts). Kruskal–Wallis test was used to compare the medians across the different groups, and the Dunn's post's test was used to compare medians between two groups.
Results: One hundred and sixty-one (32.1%) of 501 study patients were identified with comorbid conditions, of which 6 patients had more than one comorbid condition, indicating polypathology. The prevalence of comorbid conditions observed include renal disease (14.4%), hypertension (6.2%), tuberculosis (3.4%), oral thrush (2.4%), malaria (1.6%), urinary tract infection (2.2%), hepatitis-B (1%), diabetes mellitus (0.6%), while oesophageal candidiasis, herpes zoster, hepatitis-C and toxoplasmosis were 0.2% each. Comorbidities of infective origin were found predominantly in patients with WHO clinical class 3 and 4, corresponding with declining CD4cell counts. Renal disease was present in all four clinical stages of HIV.
Conclusion: Renal disease was the most prevalent comorbidity. Comorbidities of infective origin were found almost exclusively in patients with WHO clinical class 3 and 4. Findings highlight the need for detailed evaluation at initial presentation, prior to treatment initiation.
Keywords: Adult patients, comorbidity, highly active anti-retroviral therapy-naïve, HIV, polypathology
|How to cite this article:|
Oko-Jaja R I, Awopeju A. Pattern of comorbidities among highly active anti-retroviral therapy-naive HIV-infected adult Nigerian patients at initial diagnosis. Port Harcourt Med J 2017;11:34-7
|How to cite this URL:|
Oko-Jaja R I, Awopeju A. Pattern of comorbidities among highly active anti-retroviral therapy-naive HIV-infected adult Nigerian patients at initial diagnosis. Port Harcourt Med J [serial online] 2017 [cited 2020 Feb 19];11:34-7. Available from: http://www.phmj.org/text.asp?2017/11/1/34/204716
| Introduction|| |
HIV infection is a complex multifactorial disease with a large disease burden, especially in resource-constrained settings such as Sub-Saharan Africa. Its impact is multisectorial and constitutes major health, social and economic challenges. Comorbidities in HIV infection may be infective or non-infective, HIV-related or non-HIV-related and may arise as consequences of immunosuppression, or the state of chronic inflammation and immune activation, which may inflict injury on multiple organs leading to progressive and disseminated organ damage and ageing.,, These comorbidities often include infections and infestations (bacterial, viral, fungal mycobacterial and protozoal), metabolic states, malignancies, anaemia, hepatitis, renal disease, high blood pressure, heart disease and diabetes, among others.,, Comorbidities in HIV infection may cause further decline in health status arising from long-term toxicity in the infected individuals even when on highly active anti-retroviral therapy (HAART).,,
It has, therefore, become necessary for physicians to undertake thorough evaluation of HIV-infected patients at the earliest possible stage of contact with the health-care system to determine the presence and severity of these comorbid states, to optimise patient care and treatment outcomes. This study was carried out to assess the comorbid conditions in adult patients with HIV infection at the point of first presentation and diagnosis in the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria.
| Methods|| |
This was a retrospective study of 501 adult Nigerian patients who were diagnosed with HIV infection and subsequently commenced on combination HAART for the first time at the study site (UPTH, Port Harcourt, Nigeria) between April 2014 and June 2015. Patients were not previously diagnosed with HIV and were, therefore, ART-naïve. Comorbid conditions included disease conditions found in study patients at initial diagnosis of HIV at the study site. The ethical approval was obtained from the Research and Ethics Committee of the UPTH.
Demographic and clinical data and results of laboratory investigations which included basic haematologic indices, CD4 cell count, serum urea, creatinine, electrolytes, liver enzymes and blood glucose estimates and comorbid disease condition(s) at presentation were retrieved from the hospital records of study patients. The patients were divided into different groups of clinical stages of disease as described by the WHO. Renal function was determined by calculating the glomerular filtration rate, using the simplified modification of diet in renal disease formula as described by Cooper et al.
The Graphpad Prism software version 6 (Graphpad, San Diego, USA) was used to analyse the data. Summary statistics was used to present data on categorical variables such as comorbidity, sex, marital status and disease stage. Medians were calculated for continuous variables (age and CD4 cell counts). Kruskal–Wallis test was used to compare the medians across the different groups, and the Dunn's post's test was used to compare medians between two groups. P ≤ 0.05 was considered statistically significant.
| Results|| |
[Table 1] shows the basic demographic and clinical characteristics of the 501 patients in the study. Median age of the patients was 34 years (range: 18–74 years). Females were 322 (64.3%) and males were 179 (35.7%). Fifty-five (11.0%) of the study patients were in WHO clinical stage 1 of HIV infection, 76 (15.2%) were in clinical stage 2, 151 (30.1%) were in clinical stage 3 and 219 (43.7%) were in clinical stage 4. Two hundred and fifty-five (44.9%) of the patients were married, 145 (28.9%) were single, 11 (2.2%) were divorced, 6 (1.2%) were separated, 20 (4.0%) were widowed, while 94 (18.8%) did not disclose their marital status.
One hundred and sixty-nine comorbid conditions were found in 161 (32.1%) of the 501 study patients; 14 of these comorbid conditions were identified on 6 (1.2%) patients as polypathology (or concurrent presence of 2 or more comorbidities in one patient) as shown in [Table 2]. No comorbid condition was found in 340 patients (67.9%). The distribution of comorbid conditions is shown in [Table 1]. There was no stroke, cardiac failure or any solid or haematological malignancies in the study patients.
[Table 3] shows age, CD4 cell count and comorbid conditions of the study patients according to the (WHO) HIV clinical staging at presentation. The median age of patients in clinical stage 1 was 30 years, with median CD4 count of 623 cells/μL (IQR, 563–728); comorbid conditions in this clinical stage included hepatitis-B, hepatitis-C and urinary tract infection (UTI; n = 1 each). The median age of patients in clinical stage 2 was 31 years, with median CD4 count of 412 cells/μL (interquartile range [IQR], 373–438); however, no comorbid conditions were found among patients in this clinical stage. On the other hand, patients in clinical stage 3 had a median age of 35 years and median CD4 count of 271 cells/μL (IQR, 219–308); comorbid conditions among patients in this stage included tuberculosis (n = 16), oral thrush (n = 12), hepatitis-B (n = 4), UTI (n = 4) and diabetes mellitus (n = 3). In clinical stage 4, patients had a median age of 35 years, a median CD4 count of 99 cells/μL (IQR, 47–148), while associated comorbid conditions included systemic hypertension (n = 31), UTI (n = 6), oesophageal candidiasis (n = 3), hepatitis-B (n = 2), diabetes mellitus (n = 2), tuberculosis (n = 1) and toxoplasmosis (n = 1). There was no significant difference (P > 0.05) in the age distribution of the patients in the different clinical stages. However, there were significant differences (P < 0.05) in CD4 cell count between the different clinical stages.
|Table 3: Distribution of CD4 cell count and comorbidities in clinical stages of presentation|
Click here to view
| Discussion|| |
In this study of HAART-naïve HIV-infected adult Nigerian patients at their first presentation leading to diagnosis (and subsequent treatment with HAART), comorbidity was prevalent. Thirty-two per cent of these patients were found with comorbidities. This finding is higher than those of Guaraldi et al. and Denue et al. who reported comorbidity prevalence of <20% in similar ART-naïve HIV-infected adult patients. The most prevalent comorbidity in this study was renal disease, observed in 14.4% of the study population. This is in contradistinction to the report of Denue et al. which showed a chronic renal disease prevalence of 1.2% in HIV-infected adults in northeastern region of Nigeria. Renal disease may derive from direct viral injury to the kidney, and/or indirect effects attributable to chronic persistent systemic inflammation, collagen deposition and accelerated or premature organ ageing. Other possible causes of renal disease may include multiple drug use to treat undiagnosed intermittent febrile illnesses, abuse of nonsteroidal anti-inflammatory drugs, use of traditional herbal remedies or chronic glomerulonephritis.
The comorbidities are classifiable into two broad groups – infective and noninfective. Infective comorbidities may be a direct consequence of HIV-related immunodeficiency. On the other hand, noninfective comorbidities may be due to the premature ageing process sequel to chronic persistent systemic inflammation, reduced vascular endothelial reactivity and increased endovascular hypercoagulability in HIV-infection.,,,
The noninfective comorbidities comprised renal disease, hypertension and type 2 diabetes and constituted a majority (108/169, 63.9%) of all comorbidities found in the study. Infective comorbidities included pulmonary tuberculosis, oral candidiasis, UTI, malaria, hepatitis B, oesophageal candidiasis, varicella zoster, toxoplasmosis and hepatitis C, which collectively constituted a minority (37.5%) appeared to cluster in those patients in clinical stages 3 and 4 with lower CD4 cell counts. The presence of hepatitis B and C is difficult to interprete in these patients, but they are known to share same routes of transmission as HIV. Except for renal disease whose prevalence was very high, each disease prevalence was below its current local national figure, suggesting a complex mix of factors in determining comorbidities in treatment-naïve patients at initial presentation.
According to WHO clinical stage of HIV infection, a large majority (73.8%) of this study population were within stages 3 and 4. A first presentation and disease diagnosis at clinical stages 3 and 4 represents late presentation to care. Factors predisposing to late presentation or delay in seeking care in this setting may include poverty, ignorance of availability of medical care, logistic problems including cost of transportation from place of residence to hospital, superstition, traditional beliefs, fear of stigmatisation and health-seeking habits of individuals or groups.,,,, It has been reported that most individuals may not seek medical care in established health institutions early in their disease, especially in developing countries.
A median age of 34 years was observed among the study patients reflecting that our study population was young, in agreement with reports of other studies., HIV is known to mostly afflict the young, sexually active segments of populations in all regions globally. A higher female:male ratio (of 1.7:1) in this study was in agreement with reports of other studies , but may also be partly accounted for the well-known more positive health-seeking behaviours of the female gender, compared to their male counterparts.
This study had a number of limitations. It was a retrospective, single-centre study. Case file records often showed incomplete entries for some study patients and laboratory investigations were not extensive.
| Conclusion|| |
In this study, most (67.9%) of the study patients were without comorbid conditions. Renal disease was the most common comorbidity, followed by hypertension and tuberculosis. Infective comorbidities were found almost exclusively in the advancing stages of HIV disease (WHO clinical stages 3 and 4). Frequency of polypathology was low. Findings highlight need for detailed evaluation at initial presentation prior to treatment initiation, to optimise clinical outcomes. A larger, prospective multicentre study is advised.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Guaraldi G, Orlando G, Zona S, Menozzi M, Carli F, Garlassi E, et al. Premature age-related comorbidities among HIV-infected persons compared with the general population. Clin Infect Dis 2011;53:1120-6.
Denue BA, Gashau W, Ekong E, Ngoshe RM. Prevalence of non HIV related co-morbidity in HIV patients on highly active anti-retroviral therapy (HAART): A retrospective study. Ann Biol Res 2012;3:3333-9.
Boily MC, Alary M, Baggaley RF. Neglected issues and hypotheses regarding the impact of sexual concurrency on HIV and sexually transmitted infections. AIDS Behav 2012;16:304-11.
Hasse B, Ledergerber B, Furrer H, Battegay M, Hirschel B, Cavassini M, et al. Morbidity and aging in HIV-infected persons: The Swiss HIV cohort study. Clin Infect Dis 2011;53:1130-9.
Narayan KM, Miotti PG, Anand NP, Kline LM, Harmston C, Gulakowski R 3rd
, et al. HIV and noncommunicable disease comorbidities in the era of antiretroviral therapy: A vital agenda for research in low- and middle-income country settings. J Acquir Immune Defic Syndr 2014;67(Suppl 1):S2-7.
Adebayo SB, Olukolade RI, Idogho O, Anyanti J, Ankomah A. Marital status and HIV prevalence in Nigeria: Implications for effective prevention programmes for women. Adv Infect Dis 2013;3:210-8.
World Health Organization. WHO Case Definitions of HIV for Surveillance and Revised Clinical Staging and Immunological Classification of HIV-related Disease in Adults and Children. Geneva: World Health Organization, 2007. Available from: http://www.who.int
. [Last accessed on 2015 Dec 20].
Cooper RD, Wiebe N, Smith N, Keiser P, Naicker S, Tonelli M. Systematic review and meta-analysis: Renal safety of tenofovir disoproxil fumarate in HIV-infected patients. Clin Infect Dis 2010;51:496-505.
Deeks SG. HIV infection, inflammation, immunosenescence, and aging. Annu Rev Med 2011;62:141-55.
Vance DE, Mugavero M, Willig J, Raper JL, Saag MS. Aging with HIV: A cross-sectional study of comorbidity prevalence and clinical characteristics across decades of life. J Assoc Nurses AIDS Care 2011;22:17-25.
Egger M, Ekouevi DK, Williams C, Lyamuya RE, Mukumbi H, Braitstein P, et al. Cohort profile: The international epidemiological databases to evaluate AIDS (IeDEA) in Sub-Saharan Africa. Int J Epidemiol 2012;41:1256-64.
Prottengeier J, Koutsilieri E, Scheller C. The effects of opioids on HIV reactivation in latently-infected T-lymphoblasts. AIDS Res Ther 2014;11:17.
Odutayo A, Hirji N. Noncommunicable diseases in developing countries: Focus on research capacity building. JAMA Intern Med 2013;173:1031.
Katz IT, Ryu AE, Onuegbu AG, Psaros C, Weiser SD, Bangsberg DR, et al. Impact of HIV-related stigma on treatment adherence: Systematic review and meta-synthesis. J Int AIDS Soc 2013;16(3 Suppl 2):18640.
Mojumdar K, Vajpayee M, Chauhan NK, Mendiratta S. Late presenters to HIV care and treatment, identification of associated risk factors in HIV-1 infected Indian population. BMC Public Health 2010;10:416.
Lorenc A, Ananthavarathan P, Lorigan J, Jowata M, Brook G, Banarsee R. The prevalence of comorbidities among people living with HIV in Brent: A diverse London Borough. London J Prim Care (Abingdon) 2014;6:84-90.
Chua AC, Llorin RM, Lai K, Cavailler P, Law HL. Renal safety of tenofovir containing antiretroviral regimen in a Singapore cohort. AIDS Res Ther 2012;9:19.
[Table 1], [Table 2], [Table 3]