Clinical profile of HIV infected patients attending a HIV referral clinic in Pune, India.

Background & objectives: Human immunodeficiency virus (HIV) has infected several million individuals in India. Various interventions have been implemented for early detection and prevention of transmission of HIV infection. This has progressively changed the clinical profile of HIV infected individuals and this study documents the clinical presentation of individuals positive for HIV in 2010, in Pune, Maharashtra, India. Methods: This cross-sectional study included subjects who had come to the HIV referral clinic for HIV testing from January to December 2010. children as well as individuals with indeterminate HIV result were excluded from the study, and data for 1546 subjects were finally analysed. Results: The HIV positivity rate among all referred cases for the year 2010 was 35 per cent (male 55% and females 45%). The median age (Q1, Q3) was 31 (25.75, 39) yr. The median CD4 cell count for all HIV infected individuals (whose CD4 count was available n= 345) was 241 cells/μl and for asymptomatic HIV infected individuals was 319 cells/μl. There were 673 (43.5%) symptomatic and 873 (56.5%) asymptomatic participants. Fever, breathlessness, cough with expectoration, weight loss, loss of appetite, generalized weakness, pallor and lymphadenopathy (axillary and cervical) were found to be associated (p< 0.001) with HIV positivity. On multivariate analysis, history of herpes zoster [AOR 11.314 (6.111-20.949)] and TB [AOR 11.214 (6.111-20.949)] was associated with HIV positivity. Interpretation & conclusions: Signs and symptoms associated with HIV positivity observed in this study can be used by health care providers to detect HIV infection early. Moreover, similar to HIV testing in patients with tuberculosis, strategies can be developed for considering Herpes zoster as a predictor of HIV infection.

Use of first line antiretroviral therapy from a free ART programme clinic in Pune, India - A preliminary report.

Background & objectives: The treatment outcomes under national antiretroviral therapy (ART) programme are being evaluated in some ART centres in the country. We carried out this study to analyze the impact of first line antiretroviral therapy in HIV infected patients attending a free ART roll out national programme clinic in Pune, India. Methods: Antiretroviral naive HIV infected patients attending the clinic between December 2005 and April 2008 and followed up till March 31, 2011 were included in the analysis. The enrolment and follow up of these patients were done as per the national guidelines. Viral load estimations were done in a subset of patients. Results: One hundred and forty two patients with median CD4 count of 109 cells/μl (IQR: 60-160) were initiated on treatment. The median follow up was 44 months (IQR: 37-53.3 months). Survival analysis showed that the probability of being alive at the end of 5 years was 85 per cent. Overall increase in the median CD4 count was statistically significant (P<0.001). It was significant in patients with >95 per cent adherence (P<0.001). In 14 per cent patients, the absolute CD4 count did not increase by 100 or more cells/μl at the end of 12 months. Viral load estimation in a subset of 68 patients showed undetectable levels in 61 (89.7%) patients after a median duration of 46 months (IQR: 38.3-54.8). Interpretation & conclusions: The first line treatment was effective in patients attending the programme clinic. The adherence level influenced immunological and virological outcomes of patients.

Mortality in HIV infected individuals in Pune, India.

Background & objectives: With the presence of HIV epidemic for more than two decades in India, rise in the number of HIV related deaths is expected. Data on mortality in HIV infected individuals from prospective studies are scanty in India. We report here data on mortality in a systematically followed cohort of HIV infected individuals at Pune, Maharashtra, India Methods: A total of 457 HIV infected individuals were enrolled in a prospective study in Pune between September 2002 and November 2004. They were evaluated clinically and monitored for CD4 counts at every quarterly visit. Mortality data were collected from the records of hospital facilities provided by the study. If the death occurred outside such hospitals; relatives of the participants were requested to inform about the death. Results: Median CD4 count in study participants was 218 cells/µl (95% CI: 107-373) at baseline. The median duration of follow up was 15 months (IQR: 12, 22). Mortality was higher in antiretroviral therapy (ART) naive patients compared to those who received treatment (16.59 vs. 7.25 per 100 person years). Participants above 35 yr of age, CD4 count less than or equal to 100 cells/µl at baseline, tuberculosis at any study time point and ART status were independently associated with high mortality [(RR=1.97; 95% CI: (1.23, 3.14), P=0.005, (RR=33.20, 95%CI (7.59, 145.29), P<0.001, (RR=2.38, 95% CI (1.38, 4.09), P= 0.002 and RR=5.60, 95% CI (3.18, 9.86), P<0.001, respectively]. Interpretation & conclusions: High mortality at advanced immunosuppression highlights the importance of early detection of HIV infection. Emphasis needs to be given at timely diagnosis and management of tuberculosis and ART initiation. It is important to create awareness about availability of free antiretroviral drugs in the government ART roll out programme.

Drug resistance pattern of Mycobacterium tuberculosis in seropositive and seronegative HIV-TB patients in Pune, India.

BACKGROUND & OBJECTIVE: Tuberculosis is the commonest opportunistic disease in persons infected with human immunodeficiency virus (HIV). Emergence of drug resistant isolates of M. tuberculosis highlights the need for continuous monitoring of drug resistance to antituberculosis drugs. Considering the reported high prevalence of drug resistance in HIV infected tuberculosis patients, we studied the anti-tuberculosis drug resistance pattern of M. tuberculosis in HIV seropositive and seronegative tuberculosis patients in Pune, Maharashtra, India. METHODS: A total of 70 M. tuberculosis isolates, 30 from HIV seropositive and 40 from HIV seronegative tuberculosis patients with no previous history of anti-tuberculosis treatment, were isolated from sputum samples on Lowenstein-Jensen (LJ) medium, confirmed by conventional biochemical tests and stored at -70 degrees C. They were revived by subculturing on LJ medium and tested for drug resistance against four first-line antitubercular drugs by BACTEC Mycobacterial growth indicator tube 960 (MGIT 960) system. RESULTS: Of the 30 isolates from HIV infected patients, 10 per cent were resistant to isoniazid (H), 6.6 per cent to streptomycin (S), 6.6 per cent to ethambutol (E) and 10 per cent were multi drug resistant (MDR). Of the 40 M. tuberculosis isolates from HIV uninfected individuals, 10 per cent were resistant to H, 2.5 per cent to S, 2.5 per cent to E, and 2.5 per cent isolates were MDR. INTERPRETATION & CONCLUSION: The prevalence of drug resistant M. tuberculosis isolates among HIV seropositive tuberculosis patients was similar to that of HIV seronegative TB patients, indicating HIV infection may not be associated with drug resistant tuberculosis. However, considering the results from other studies and a high prevalence of HIV-TB infection in the country, monitoring of drug resistance in M. tuberculosis isolates needs prioritization to ensure success in national tuberculosis control programme.

Human immunodeficiency virus (HIV) & sexually transmitted diseases (STDs).

Among various factors associated with the sexual transmission of HIV, sexually transmitted diseases (STDs) seem to contribute significantly. Hence, the efforts for prevention and control of HIV have to rely largely on STD control measures. In the developing countries, both prevalence and incidence of STDs are very high. STDs impact women's health adversely for a variety of reasons such as more susceptibility than men, asymptomatic nature of infection, etc. Enormous evidence is available indicating that both ulcerative and inflammatory STDs increase the risk of HIV infection. STDs promote HIV transmission by facilitating HIV shedding in the genital tract, causing disruption of normal epithelial barrier and by deploying and activating HIV susceptible cells at the site. The effect of STD treatment intervention was studied in three controlled clinical trials conducted in Africa. Though the STD treatment intervention was shown to reduce the STD incidence in all the three studies, the decline in HIV incidence was noticed in only one of them, which, might be attributed to the differences in the study designs. To obtain reliable epidemiological data on various STDs in different communities and regions, countrywide development of adequate laboratory infrastructure for accurate diagnosis of STDs, increased outreach of awareness programmes to communities in the rural areas are some of the key issues in the fight against HIV epidemic in India.

Incident HIV infection among men attending STD clinics in Pune, India: pathways to disparity and interventions to enhance equity.

Systematic disparities in rates of HIV incidence by socioeconomic status were assessed among men attending three sexually transmitted disease (STD) clinics in Pune, India, to identify key policy-intervention points to increase health equity. Measures of socioeconomic status included level of education, family income, and occupation. From 1993 to 2000, 2,260 HIV-uninfected men who consented to participate in the study were followed on a quarterly basis. Proportional hazards regression analysis of incident HIV infection identified a statistically significant interaction between level of education and genital ulcer disease. Compared to the lowest-risk men without genital ulcer disease who completed high school, the relative risk (RR) for acquisition of HIV was 7.02 (p < 0.001) for illiterate men with genital ulcer disease, 3.62 (p < 0.001) for men with some education and genital ulcer disease, and 3.02 (p < 0.001) for men who completed high school and had genital ulcer disease. For men with no genital ulcer disease and those with no education RR was 1.09 (p = 0.84), and for men with primary/middle school it was 1.70 (p = 0.03). The study provides evidence that by enhancing access to treatment and interventions that include counselling, education, and provision of condoms for prevention of STDs, especially genital ulcer disease, among disadvantaged men, the disparity in rates of HIV incidence could be lessened considerably. Nevertheless, given the same level of knowledge on AIDS, the same level of risk behaviour, and the same level of biological co-factors, the most disadvantaged men still have higher rates of HIV incidence.