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RESIDENT CORNER
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 69-73

Clinical correlates and profile of patients on antiretroviral therapy: A hospital-based cross-sectional study from a tertiary care institution of North India


1 Department of Community and Family Medicine, AIIMS, Bhubaneswar, Odisha, India
2 Department of Community Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Studies, Rohtak, Haryana, India
3 Department of Community Medicine, Kalpana Chawla Government Medical College, Karnal, Haryana, India

Date of Web Publication4-Jul-2019

Correspondence Address:
Soumya Swaroop Sahoo
Department of Community and Family Medicine, AIIMS, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCFM.IJCFM_38_19

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  Abstract 

Introduction: HIV/AIDS as a global pandemic has affected each and every region of the world. The HIV epidemic is dynamic in nature with relation to temporal changes, geographic distribution, and modes of transmission. India, though in the declining phase, is still confronting with the varied nature of the spread of the disease.
Materials and Methods: This hospital-based cross-sectional study was conducted among four hundred people living with HIV/AIDS (PLHIV) attending the antiretroviral therapy (ART) center of a tertiary care institute of North India. Data were collected from the patients using a predesigned pretested questionnaire maintaining confidentiality. The data were analyzed using simple proportion and percentages.
Results: The mean age of the study participants was 32.8 ± 7.4 years. The mean duration of ART intake was 24.5 ± 14.4 months. There was a significant improvement in clinical staging and CD4 count with ART intake among PLHIV. The most prevalent possible route of transmission was found to be heterosexual (85.5%) route.
Conclusion: The spread among the population, particularly in the younger age group, reinforces the fact that preventive strategies need to be initiated within the target population at an early stage. Health education and social campaigns are the mainstays for “getting to zero” target.

Keywords: Antiretroviral therapy, HIV/AIDS, people living with HIV, transmission


How to cite this article:
Sahoo SS, Khanna P, Verma R, Verma M. Clinical correlates and profile of patients on antiretroviral therapy: A hospital-based cross-sectional study from a tertiary care institution of North India. Indian J Community Fam Med 2019;5:69-73

How to cite this URL:
Sahoo SS, Khanna P, Verma R, Verma M. Clinical correlates and profile of patients on antiretroviral therapy: A hospital-based cross-sectional study from a tertiary care institution of North India. Indian J Community Fam Med [serial online] 2019 [cited 2019 Sep 17];5:69-73. Available from: http://www.ijcfm.org/text.asp?2019/5/1/69/262122


  Introduction Top


HIV/AIDS has rapidly established itself as one of the fastest growing epidemics since its inception. It has become, in the truest sense, the first international epidemic crossing oceans and borders. In about three decades since AIDS emerged as a major health concern, the epidemic has had a serious and in many places, a devastating effect on human development. HIV continues unabated as a major public health issue, with about 35 million deaths so far. Globally, one million people died from HIV-related causes in 2016. In absolute terms, globally, there were 36.7 million people living with HIV (PLHIV) at the end of 2016 with 1.8 million newly infected cases.[1] Every day, 4900 people die from HIV/AIDS and another 7300 people get infected with HIV.[2] It is one of the ten leading causes of global disease burden in low- and middle-income countries.[3]

India, albeit some recent gains, is still plagued by this epidemic, housing the third largest PLHIV, only after Nigeria and South Africa. The Indian epidemic is centered amid vulnerable populations at high risk for HIV. The concentrated epidemics are driven by unprotected sex between sex workers and their clients and by injecting drug use (IDU) with contaminated syringes. The HIV prevalence according to the HIV Sentinel Surveillance 2016–17 was female sex workers (FSW, 1.56%), men having sex with men (MSM, 2.69%), IDUs (6.26%), hijra/transgender (3.14%), long-distance trucker (0.86%), and single male migrant (0.51%).[4] The hallmark of the HIV/AIDS epidemic in India is heterogeneity; it follows the Type 4 pattern, where the epidemic shifts from the most vulnerable populations (such as FSW, IDU, and MSM) to bridge populations (clients of sex workers, STI patients, and partners of drug users) and then to the general population. The shift usually occurs when the prevalence in the first group exceeds 5%, with a 2–3 years' time lag between shifts from one group to another.[5] However, the introduction and implementation of antiretroviral therapy (ART) has been able to reduce mortality and morbidity, improve quality of life, and increase the life expectancy of HIV-infected individuals.

ART has changed the face of HIV/AIDS by leading to a decisive decrease in HIV-related morbidity and mortality among those with access to therapy. This has made the once “imminent killer” to a chronic manageable condition. Early diagnosis, ART, and treatment of opportunistic infections remain the pillars for the control of HIV replication, disease progression, and ultimately, the containment of the epidemic. The sociodemographic profile greatly affects the health-care-seeking behavior and practices of the infected population. Keeping these facts in mind, this study was undertaken to elucidate the epidemiological and clinical profile of HIV-positive patients on ART attending a tertiary care institute of Haryana.


  Materials and Methods Top


This cross-sectional descriptive hospital-based study was carried out from January 2014 to September 2014 at the ART center of a tertiary care institute of Haryana. This ART center serves not only the population of Haryana but also caters population of adjoining states of Punjab, Uttar Pradesh, and Delhi. A convenient sample of four hundred HIV-positive patients aged above 18 years and taking ART for at least 6 months were enrolled for the study. Informed written consent was obtained from the study participants before the start of the interview. The interview was conducted by the interviewer himself, and the responses were recorded using a predesigned and pretested semi-structured questionnaire. The questionnaire consisted of questions regarding sociodemographic characteristics such as age, sex, literacy status, marital status, occupation, and clinical presentation. Confidentiality and absolute anonymity of the individuals were maintained. Data were also obtained from the ART cards (white card) of the patients that were maintained at the ART center regarding the possible mode of transmission, functional status, and CD4 count of recruited individuals both at the start of ART and at the time of interview.

Ethics

Participation in this study was voluntary, and written informed consent was obtained from each study participant after a detailed description of study objectives and procedures. Moreover, the study participants had an opportunity to refuse or to discontinue participation at any time. Privacy was strictly protected by conducting the interviews at a private place, and we ensured the confidentiality of the respondents by removing all personal identifiers from the survey questionnaires. The permission for the study was obtained from the institutional ethics committee.

Statistics

Data were processed and analyzed using the Statistical Package for Social Sciences version 17.0 version (SPSS Inc., Chicago, IL, USA). The data were expressed in proportion and percentages; Chi-square test was used for categorical data. P < 0.05 was considered statistically significant at 95% confidence interval.


  Results Top


A total of four hundred patients were included in the study attending the ART center from January 2014 to September 2014. Male patients (247, 61.8%) outnumbered the female patients (153, 38.2%). The mean age of the study participants was 32.8 ± 7.4 years.

Nearly half (48.8%) of the study participants were in the 26–35 years' age group, whereas the age group of 45 years and more constituted the least (3.7%). More than two-thirds (69.8%) of the study participants were living with spouses, whereas rest (31.2%) were single (unmarried/separated/widowed). Among the female respondents, nearly one-fifth (18.3%) were widowed. Most (81.67%) unmarried individuals were males.

Nearly one-fifth (19.3%) of the study participants were illiterate, whereas few (6.2%) had completed graduation. Majority of patients were homemakers (27.8%) and farmers and laborers (36.8%) by occupation. Among males, farmers (143, 26.24%), businessmen (65, 11.93%), and drivers (53, 9.72%) constituted other occupations [Table 1].
Table 1: Sociodemographic characteristics of the study participants

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The mean duration of ART intake was 24.5 ± 14.4 months. Most (31%) of the study participants had taken ART for 13–24 months and only 76 (19%) for >36 months [Table 2].
Table 2: Duration of antiretroviral therapy taken by the study participants at the time of interview (n=400)

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On the basis of WHO clinical staging of AIDS, half of the individuals (50%) were in Stage II, 33.8% in Stage III while only 13% in Stage I at the start of ART, whereas at the time of interview, majority (54.5%) were in Stage I followed by Stage II (31.7%). This shows that there was a substantial reduction in stage of disease with the intake of ART. The association was also found to be statistically significant [Table 3].
Table 3: WHO clinical staging of AIDS of the study participants (n=400)

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At the start of ART, majority (58.3%) of the study participants had CD4 count of <200/mm3, whereas only 13% had >500/mm3. The mean CD4 count at the start of ART was found to be 189 cells/mm3. However, at the time of interview, more than three-fourths (76.7%) had CD4 count of >200 cells/mm3, with the mean CD4 count at the time of interview being 313 cells/mm3. This change in CD4 count was found to be statistically significant [Table 4].
Table 4: CD4 count of the study participants (n=400)

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The most common possible route of transmission was heterosexual (85.5%), whereas in 7.0% of the study participants, it was unknown. In a small group of patients, the possible mode of transmission was through blood transfusion (3.0%), intravenous drug use (2.8%), and homosexual (1.8%) [Figure 1].
Figure 1: Possible risk factor for transmission of HIV among the study participants (n = 400)

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  Discussion Top


The revamped roadmap aims at embarking on a strategy for ending the AIDS epidemic by 2030. Combined with a stronger focus on HIV prevention, reaching the 90–90–90 target – i.e., by 2020, 90% of all PLHIV know their HIV status, 90% of people diagnosed with HIV receive ART, and 90% of all people on HIV treatment achieve viral suppression – will enable to lay the groundwork to end the AIDS epidemic by 2030.[6] ART scale-up is the mainstay of effective HIV prevention, as experience in different parts of the world has demonstrated that expanding the use of ART is directly correlated with declines in new HIV infections.[7],[8]

HIV/AIDS strikes the root of every aspect of the society involving individuals, families, sectors, and institutions. It has ruined the social framework of many communities and countries, especially in those countries with a high burden of disease. A preponderance of males in this study may be due to the fact that they practice more high-risk sexual behavior than females. This is especially conspicuous in occupations such as drivers and army personnel where the job demands being away from home for long periods. Sexually active unmarried men, in general, are engaged in sexual risk behavior to meet physical needs and to relieve the loneliness and anxieties of home. Furthermore, nearly half of the participants were in the 26–35 year age group. HIV/AIDS generally affects the economically productive and younger age group, which forms the most important threat to the community. Adekeye outlined in their study that adolescents and youth remain the major propellers as well as victim of this pandemic.[9] Gallagher reported that the HIV infection rate is highest in the age group of 19–35 years. According to him, this portends danger for population structure as the younger people will die, leaving behind orphans who are usually cared for by older ones who are themselves dependents.[10] This situation has been viewed by Barnett and Blaikie as an impending disaster with serious implications for developmental issues and agricultural production.[11]

The distribution according to the educational status showed that the seropositivity was higher among the individuals with lesser education (primary and illiterate individuals). Low education and relative ignorance about safe sex practices contribute to a sizeable proportion of it. In terms of genderwise distribution of occupation, majority of male respondents were farmers, followed by laborers and drivers. Similarly, a higher proportion of laborers and drivers among PLHIV were reported in a study conducted by Subramanian et al. in South India.[12] The occupation of these two groups makes them vulnerable to practice high-risk behavior, which in turn leads to higher rates of HIV positivity among them. Most of the laborers being migrants act as a bridge population spreading HIV between urban and rural areas and between high-risk and low-risk groups. Among females, the higher proportion of HIV positivity among homemakers suggests that most of them had contracted the disease from their seropositive husbands. In our country, the female gender are particularly vulnerable to being exposed to HIV where inequalities, embodied in cultural or religious practices, make them increasingly economically and socially dependent on men.

Duration of ART along with proper adherence is crucial because PLHIV needs to take medications lifelong. According to the National AIDS Control Organization (NACO), timely intake of ART with a minimum of 95% adherence is required to avoid viral resistance and treatment failure. Duration of ART intake is influenced by many factors such as patient characteristics, location of health facilities, attitude of family members, and societal behaviors. The association between the ART and WHO clinical staging was found to be statistically significant. This manifests the effectiveness of ART as a modality of treatment in halting the progression and ameliorating the clinical course of the disease. As per the WHO recommendations, HIV/AIDS patients placed on ART show a definitive improvement in staging.[13]

Moreover, the WHO clinical staging system has been shown to be a practical and accurate way to manage HIV-infected patients, with international studies showing agreement between clinical manifestations included in the WHO staging system and laboratory markers including CD4 cell count and total lymphocyte count.[14],[15],[16],[17] In the present study, it was found that at the start of ART, majority (58.3%) of the study participants had CD4 count of <200/mm3, whereas only 13% had >500/mm3. The mean CD4 count at the start was 189 cells/mm3. At the time of interview, 76.7% of the individuals had CD4 count >200 cells/mm3, and the mean CD4 count was found to be 313 cells/mm3. This relationship was found to be statistically significant. These findings were comparable to the study conducted by Xiaoyan and Sato in China where they reported a significant improvement in CD4 count at the time interview, i.e., 48.9% of the study participants had count between 200 and 500 cells/mm3 and 20.2% of the patients had CD4 count >500 cells/mm3.[18] These data substantiate the fact that there is a marked and sustained CD4 response to ART among patients remaining on therapy.

According to the report – India HIV estimates released by the NACO,[19] heterosexual (88.2%) is the most common route of HIV transmission, followed by vertical transmission (5.4%), IDU (1.6%), and use of infected blood and blood products (1.0%). This emphasizes the fact that sexual, especially heterosexual transmission is the main propeller of the epidemic in most of India. Because of stigma associated with sexual route, a PLHIV (infected through sexual route) finds it difficult to share HIV status with his/her spouse/family. This leads to severe repercussions and in many cases unfortunately propagates the spread of the epidemic.

There are some limitations to our study. The reason “vertical transmission” does not figure in our study is may be because only those individuals who were above 18 years of age were selected. The cross-sectional nature of our study does not allow a causal relationship. The respondents were those who were actively seeking routine medical care. The degree to which the study is representative of the larger HIV-infected population is influenced by the potential selective factors associated with recruiting from HIV treatment settings.


  Conclusion Top


The study reinforces the fact that HIV is particularly prevalent in the younger age groups threatening the economically productive age group and the social thread of many families. An integrated approach emphasizing on its preventive aspect and spreading more awareness by educating people regarding the dreadful effects of this disease is mandated. Nevertheless, the role of ART as a definitive mode of therapy cannot be undermined. This study clearly demonstrates the improvement in clinical profile of patients, both in terms of clinical staging and CD4 count in the patients. This information can guide us on approaching the epidemic through a holistic population lens, for a more disseminated impact.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Joint United Nations Programme on HIV/AIDS. The Gap Report: 2012. Geneva: UNAIDS; 2012. Available from: http://data.unaids.org/pub/Report/20012/JC1700_thegapreort_2012_en.pdf. [Last accessed on 2017 Nov 10].  Back to cited text no. 2
    
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Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: Systematic analysis of population health data. Lancet 2006;367:1747-57.  Back to cited text no. 3
    
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National AIDS Control Organisation. Annual Report 2016-17. New Delhi: Department of AIDS Control, Ministry of Health and Family Welfare, Government of India; 2011. Available from: http://www.aidsdatahub.org/sites/default/files/publication/India_HSS_2016-17.pdf. [Last accessed on 2018 Jan 10].  Back to cited text no. 4
    
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National AIDS Control Organization. Country Progress Report India 2010. New Delhi: Department of AIDS Control, Ministry of Health and Family Welfare, Government of India; 2010. Available from: http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountries/india_2010_country_progress_report_en.pdf. [Last accessed on 2014 Nov 18].  Back to cited text no. 5
    
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UNAIDS. Fast-Track: Ending the AIDS Epidemic by 2030. Geneva: Joint United Nations Programme on HIV/AIDS; 2014.  Back to cited text no. 6
    
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Tanser F, Bärnighausen T, Grapsa E, Zaidi J, Newell ML. High coverage of ART associated with decline in risk of HIV acquisition in rural Kwazulu-Natal, South Africa. Science 2013;339:966-71.  Back to cited text no. 7
    
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Montaner JS, Lima VD, Harrigan PR, Lourenço L, Yip B, Nosyk B, et al. Expansion of HAART coverage is associated with sustained decreases in HIV/AIDS morbidity, mortality and HIV transmission: The “HIV treatment as prevention” experience in a Canadian setting. PLoS One 2014;9:e87872.  Back to cited text no. 8
    
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Adekeye OA. Adolescents and the HIV pandemic. J Postgrad Stud Assoc (Ilorin) 2005;3:23-8.  Back to cited text no. 9
    
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Gallagher P. Poverty Causes AIDS: The Actual Message of the Durban Conference. Conscience International; 2002. p. 34-7.  Back to cited text no. 10
    
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Barnett T, Blaikie P. AIDS in Africa: Its Present and Future Impact. London: Belhaven Press; 1991.  Back to cited text no. 11
    
12.
Subramanian T, Gupte MD, Dorairaj VS, Periannan V, Mathai AK. Psycho-social impact and quality of life of people living with HIV/AIDS in South India. AIDS Care 2009;21:473-81.  Back to cited text no. 12
    
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Malamba SS, Morgan D, Clayton T, Mayanja B, Okongo M, Whitworth J, et al. The prognostic value of the World Health Organisation staging system for HIV infection and disease in rural Uganda. AIDS 1999;13:2555-62.  Back to cited text no. 14
    
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