A Study of Gastrointestinal Manifestations in HIV/AIDS Patients

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1 Original article A Study of Gastrointestinal Manifestations in HIV/AIDS Patients B. N. Paudel*, A. Khanal**, P. Paudel***, S. Sharma****, G. B. Singh***** Abstract This study was conducted at the ART clinic of Seti Zonal Hospital Dhangadi. This ART center is the center for clinical based targeted intervention program for the control of STI/ AIDS and management of opportunistic infections. The objective of the study was to record the prevalence of common GI manifestations according to the age group and CD4 count. Common GI manifestations were diarrhea in 534 cases, pain abdomen with loss of appetite 503 cases, oral thrush 8 cases & esophageal candidacies 5 cases. Key Words Diarrhea, esophageal candidacies, oral thrush, opportunistic infection. Introduction GI manifestations are the common manifestations among HIV infected patients.,2 According to recommended WHO clinical staging; oral thrush (oropharyngeal ulceration, candidacies) are found in second stage; oral candidacies, chronic diarrhea (diarrhea more than one month), oral hairy leukoplakia in third stage and esophageal candidacies, chronic diarrhea with cryptosporidiosis and isosporiosis, HIV wasting syndrome (>0% of weight loss with either > 30 days of diarrhea or > 30 days of unexplained fever and weakness) in fourth stage. 3,4 In span of less than three decades, HIV/AIDS has emerged as the single most challenge to public health, human rights and development of this new millennium. 5 By the end of 2007, it was established that 33.2 million people ( million) across the world were living with HIV and 70,000 of these people were living in Nepal.6, 7 Nepal is experiencing transition in HIV epidemic8. Various predisposing factors are prevalent for the rapid spread of HIV in Nepal. Migration is one of the many social factors that have contributed to the AIDS epidemic 9,0,,2,3. According to data by an international organization, migrants who crossed national borders increased from 0 million in 985 to 75 million in 2000, while a similar number of people may exist as internal migrants within national borders5,6. HIV virus is retro virus which uses its RNA and host s DNA to make viral DNA.,2 It has a long incubation period.,2 It causes severe damage to and eventually destroys the immune system by utilizing the DNA of CD4 lymphocytes to replicate itself. In the process, the virus destroys the CD4 lymphocytes. After several years, the person s immune system will be very weak, he/she is vulnerable to diseases that he/she could normally fight off. These diseases (diarrhea, oral thrush, oral candidacies, * Physician, Seti Zonal Hospital, Dhangadhi, Focal person ART clinic Dhangadhi **General Physician, NAMS, Bir Hospital ***Registrar, Paropakar Hospital,Thapathali **** Assosciate Professor, Department of Gastroenterology, TUTH ***** Medical Sperientendent and Gynaecologist, Seti Zonal Hospital, Dhangadhi

2 cryptosporidiosis, tuberculosis, pneumonia, Kaposi s sarcoma etc.) are called opportunistic infections because they take advantage of the weakened immune system to cause disease.,2 In our study more HIV positive patients were seen to be suffering from diarrhea; oral thrush and oral candidacies were recorded in people with low CD4 count (<200). done before institution of ART; that included physical examination, WHO clinical staging, performance scale, CBC, VDRL, LFT, RFT, R/E of urine, CXR P/A view, sputum for AFB for 3 days and CD4 counts measurement. Certain diseases are manifested in CD4 count below 50, in 5-00, in and in CD4 between , and above The study's CD4 count groups are in keeping in line with this, however we have split the count group into and since treatment is started at CD4 count below 350. Materials and Methods Retrospective data of HIV reactive patients who directly visited or were referred to ART clinic Seti Zonal Hospital, Dhangadhi Nepal for counseling and treatment of HIV infection from Magh 2063 to end of 2064 was used in the study. Data s of a total of 032 patients entered within the time frame described were included. Age, sex, address, mode of transmission, literacy, and socioeconomic status were recorded. In cases with diarrheal manifestations the stool samples were sent for microscopic examination. Suspected cases of HIV (not laboratory proved) and STI cases, which came for treatment, were excluded from the study. Limitation Due to lack of laboratory facility of stool culture, limited resources and efficient microscopist, the investigations were minimum. Three rapid tests: Determine, Unigold & Capillus were used to confirm the HIV infection in the study group. Complete clinical examination was Results In the study, GI manifestations were seen according to age group and CD4 counts. Gastrointestinal manifestion in Seti Zonal Hospital according to Age Group <5 6 to 4 5 to 20 2 to 30 3 to 50 5 to 60 >60 Age Group (years) (total no. of patients) common manifestations 0. Diarrhea 2. Oral thrush 3. esophageal candidacies 3 4. Pa in a bdom en w ith loss of appetite total

3 <5 6-4 Diarrhea 5-20 Oral thrush 2-30 esophageal candidacies >60 Pain abd / appetite loss The table shows that among 032 study cases most of them suffered from diarrhea (5.74%). The second presentation was pain abdomen with loss of appetite(48.74%), oral thrush at 7.84% and esophageal candidacies 5.52%. The most affected age group was 3-50 years, among them manifestation of diarrhea 75.09%, esophageal candidacies 7.92%, oral thrush 62.98% and pain abdomen with loss of appetite 54.27%. Most of the manifestations were combined manifestations; for example, diarrhea with pain abdomen and loss of appetite, oral thrush and intermittent diarrhea, & esophageal candidacies and diarrhea. The study, although not depicted in form of bar pr pie diagram also showed that these manifestations were combined with other presentations like weight loss, fever, fatigue and chest infection etc. Relationship between number of CD4 and GI OIs <50 5 to 00 0 to to to 500 >500 NO. of CD4 common OIs Diarrhoea Oral thrush esophageal candidasis Pain abdomen with loss of appetite 29 total

4 <50 Diarrhoea Oral thrush esophageal candidacies >500 Pain abdominal/appetite loss This table shows that gastrointestinal manifestations mostly appeared in the CD4 count between 0200 and Diarrhoea was found in 35.0% people with CD and in 33.70% with CD , oral thrush was found in 25.92% with CD and in 8.5% with CD , esophageal candidacies was found in 33.33% with CD and in.76% with CD Discussion The study revealed that the younger age group was most affected by the HIV infection because this is the most sexually active while the other aspect is that this is also the most creative, productive and responsible age group, meaning there is the dire need for programs aimed at intervening this trend and protecting this productive age group from such a deadly infection.. 5,6,5, 6, 7 In this study, amongst the gastrointestinal manifestations, diarrhea was most common i.e in 5.74%. mostly in people with CD4 count in between 0200 and Conclusion Despite gastrointestinal manifestations like diarrhea, oral thrush and pain abdomen being common and earlier presentations in HIV infected persons; however the patients in our study group were seen to be coming late for health checkup in ART clinic Dhangadhi. This reflects the need to educate HIV infected people about the different manifestations of the disease and the need to visit hospital at the earliest. In the age group of 3-50 years, diarrhea was record high at 75.09%, esophageal candidacies 7.92%, oral thrush 62.96% and pain abdomen with loss of appetite 54.27%. The ART center is the only one that is established in the far west region, but still there is limited physical and human resources to deliver quality service. It was seen that the CD4 count plays vital role on OIs manifestation.3,4,8 Low number of CD4 correlates with serious OIs (PCP, MAC, Lymphoma, esophageal candidacies etc). This study revealed that the gastrointestinal manifestations of diarrhea, pain abdomen, oral thrush and esophageal candidacies were found Although the lab lacks in many necessary facilities, the most inspiring and heartening fact is that there is CD4 machine which is indispensable for ARV therapy and monitoring of the immune system of the patients.

5 This study shows laboratory services should be expanded and enhanced with introduction of new and advanced techniques in the ART clinic.. Lurie MN, Williams BG, Zuma K et al. The impact of migration on HIV- transmission in South Africa: a study of migrant and nonmigrant men and their partners. Sexually Transmitted Diseases 2003; 30: Estelle AS, Gruskin S. Vulnerability to HIV/STIs among run women from migrant communities in Nepal: A health and human rights framework, Reproductive Health Matters 2003 : Pokharel BJ. Aryal S. Bhattarai A. Pyakuryal A. Suvedi BK Situation Analysis of HIV/AIDS in Nepal Final Draft. Teku, Kathmandu; National Centre for AIDS and STD control December W T A Todd; D N J Lockwood, F J Nye, E G L Wilkins, PB Carey. Infection and Immune Failure. C Haslett, E R Chilvers, N A Boon, N R Colledge, John A A Hunter; eds. Davidson s Principles & Practice of Internal Medicine; 9th edition; Churchill Livingstone; Edinburgh; 2002: Basnet J. Gurubacharya VL. HIV/AIDS prevalence and rising factors among migrant and non-migrant males of Achham district in far-western Nepal. Volume-/ Report submitted to Family Health International/Nepal. New Era Health education campaigns regarding diarrheal diseases should be executed. References. Clinical management of HIV/AIDS FHI Nepal December 2005;pg Clinical HIV/AIDS care Guidelines for Resource-poor setting. Lut Lynen Insitute of Tropical Medicine, Antwerp Second Edition April 2006:7-47, WHO.WHO.CDC care definitions for AIDS wkly epidemilo. rec. 98:6: WHO.Interior WHO clinical staging of HIV/AIDS. HIV/AIDS case definitions for surveillance. http.// linicalstaging.pdf 5. UNDP, HIV/AIDS and Development in South Asia: Regional Human Development Report UNAIDS, Report on the Global AIDS epidemic: 4th Global report, June National Centre for AIDS and STD Control (2003), National HIV/AIDS strategy ( ) Nepal. Ministry of Health National Centre for AIDS and STD Control. 8. Subedi B K, Transition of HIV epidemic in Nepal. Kathmandu University Medical Journal (2006), Vol. 4, No., Issue 3, Decosas J. Adrien A Migration and HIV, AIDS 997: (suppl. A) : S77-S Mabey D. Mayaud P. Sexually transmitted diseases in mobile populations. Genitourin Med 997: 997: 73: 8-22.

6 6. Poudel KC. Okumura J. Sherchan JB. Jimba M. Murakami Wakai S. Mumbai disease in far western Nepal: HIV infection and syphilis among male migrant returnees and non-migrant Tropical Medicine and International Health 2003: 8: Poudel KC. Jimba M, Okumura J. Joshi AB, Wakai S. Migrant risky behaviors in India and at home in far western Nepal Tropical Medicine and International Health 2004: 9: National Guidelines on ART NCASC. Nepal. Draft June therapy.

Global and National trends of HIV/AIDS

Research and Review Insights Research Article ISSN: 2515-2637 Global and National trends of HIV/AIDS Hikmat Bahadur Raya* Lecturer, Department of Population Studies, Tribhuvan University, Terhathum M.