|Year : 2017 | Volume
| Issue : 1 | Page : 15-19
Comparative analysis of some hematological and immunological parameters of HIV-positive patients at a tertiary HIV treatment center in Zaria, Nigeria
Ibrahim U Kusfa1, Aisha A Abubakar2, Haruna M Muktar3, Ismaila N Ibrahim4, Sani Awwalu3, Muhammad S Balogun5, Labaran Shehu6, Isiyaku Ahmadu6
1 Field Epidemiology and Laboratory Training Programme, Abuja; Department of Haematology and Blood Transfusion, Ahmadu Bello University Teaching Hospital, Zaria; National Tuberculosis and Leprosy Training Centre, Saye, Zaria, Nigeria
2 Field Epidemiology and Laboratory Training Programme, Abuja; Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
3 Department of Haematology and Blood Transfusion, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
4 Field Epidemiology and Laboratory Training Programme, Abuja; Department of Haematology and Blood Transfusion, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
5 Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria
6 National Tuberculosis and Leprosy Training Centre, Saye, Zaria, Nigeria
|Date of Web Publication||6-Mar-2018|
Ibrahim U Kusfa
Department of Haematology and Blood Transfusion, Ahmadu Bello University Teaching Hospital Zaria
Background: Human immunodeficiency virus (HIV) infection is a major public health problem in sub-Saharan Africa. In addition to immunological complications of the disease, hematological abnormalities have been documented as strong independent predictors of morbidity and mortality in HIV-infected individuals.
Objectives: To determine the effect of antiretroviral therapy (ART) on hematological and immunological parameters in HIV-positive patients.
Materials and Methods: This was a retrospective cross-sectional analytic study involving 90 HIV-positive treatment naïve patients aged 18 years and above attending a tertiary hospital over a 6-month period. Frequencies, proportions, and paired t test were performed using SPSS version 20.0 and the level of significance was set at ≤0.05.
Results: The mean (±SD) age of the study participants was 35.6 ± 9.65 years with females comprising of 56 (62%). The mean (±SD) values of the hematological parameters (at baseline and 6 months after initiation of ART) were: hemoglobin concentration [10.9 ± 1.95 vs 11.8 ± 1.83 g/dL, 95% Confidence Interval (CI); −1.1938, −0.5218, P value <0.001], white blood cell count (5.95 ± 2.84 vs 5.32 ± 1.75 × 109/L, 95% CI; 0.0691, 1.1843, P value <0.001), mean corpuscular volume (83.04 ± 6.90 vs 85.33 ± 7.44 fL, 95% CI; −3.9424, −0.6290, P value <0.001), mean corpuscular hemoglobin (MCH) (26.3 ± 2.93 vs 27.5 ± 3.44 pg, 95% CI; −1.7713, −0.5030, P value <0.001), MCH concentration (31.4 ± 1.86 vs 31.9 ± 1.71 g/dL, 95% CI; −0.9369, −0.1088, P value <0.001), lymphocyte count (37.0 ± 12.9 vs 38.7 ± 11.78%, 95% CI; −4.7148, 1.1170, P value <0.001), neutrophil count (46.6 ± 13.8 vs 46.4 ± 12.0%, 95% CI; −3.3644, 3.6444, P value <0.123), and CD4 count (222.3 ± 230.10 vs 284.2 ± 196.72 cells/μL, 95% CI; −96.2642, −27.5802, P value <0.001).
Conclusion: Anemia, neutropenia, and immunosuppression were the predominant findings in this study at recruitment. However, an improvement of these parameters was observed 6 months after commencement of ART among the HIV-positive treatment naïve patients. This showed that ART has improved both the hematological and immunological parameters in HIV-positive treatment-naïve patients.
Keywords: Antiretroviral therapy, hematological parameters, hiv-positive, immunological parameters, pretreatment
|How to cite this article:|
Kusfa IU, Abubakar AA, Muktar HM, Ibrahim IN, Awwalu S, Balogun MS, Shehu L, Ahmadu I. Comparative analysis of some hematological and immunological parameters of HIV-positive patients at a tertiary HIV treatment center in Zaria, Nigeria. Sub-Saharan Afr J Med 2017;4:15-9
|How to cite this URL:|
Kusfa IU, Abubakar AA, Muktar HM, Ibrahim IN, Awwalu S, Balogun MS, Shehu L, Ahmadu I. Comparative analysis of some hematological and immunological parameters of HIV-positive patients at a tertiary HIV treatment center in Zaria, Nigeria. Sub-Saharan Afr J Med [serial online] 2017 [cited 2018 Mar 19];4:15-9. Available from: http://www.ssajm.org/text.asp?2017/4/1/15/226660
| Introduction|| |
Human Immunodeficiency Virus (HIV) infection is a major public health problem with an estimated 36.7 million people living with the disease globally. About 24.7 million people now live with the disease in sub-Saharan Africa; out of which, 11.7 million (32.0%) are on antiretroviral therapy (ART). The prevalence of HIV infection in Nigeria varies from 1.8% in 1991 to 3.4% in 2015,with about 44.9% of people living with the disease in Nigeria are currently on ART. HIV infection has been reported in all the states of the federation, including Abuja, and the prevalence rates vary significantly from state to state and from zone to zone. The Federal Ministry of Health (FMOH) made its first attempt to assess the Nigerian HIV/acquired immunodeficiency syndrome (AIDS) situation by establishing the first HIV sentinel surveillance as a means of monitoring HIV/AIDS in the country.
AIDS is a systemic disorder caused by HIV and characterized by severe impairment and progressive damage to both cellular and humoral immune responses. In addition to immunological complications of HIV disease, hematological abnormalities have been documented as strong independent predictors of morbidity and mortality in HIV-infected individuals. Anemia in HIV-infected persons is associated with CD4 cell depletion and progression to AIDS and is one of the strongest predictors of HIV mortality and poor response to ART., However, measurement of lymphocyte count was earlier used as a surrogate for CD4 count before it became more widely available, especially in the developing world. ART prevents AIDS-related illness and death, and has been shown to have the potential to significantly reduce the risk of HIV transmission. Monitoring of hematological and immunological parameters in HIV-positive patients on ART is important during the course of their management. This study, therefore, seeks to assess the changes of these parameters in HIV-infected patients attending HIV treatment center in Zaria, Nigeria.
| Materials and methods|| |
It was a retrospective cross-sectional analytic study involving 90 HIV-positive (naïve) adult patients aged 18 years and above enrolled in HIV clinic of the National Tuberculosis and Leprosy Training Centre (NTBLTC) Saye Zaria from March to December, 2015.
NTBLTC is a national training institution set up to develop man-power for the successful implementation of the National Tuberculosis and Leprosy Control Program. It was established in 1988 and has a bed capacity of 140.
Diagnosis of HIV
Patients were diagnosed by utilizing two successive tests; (Determine™ HIV-1/2 SET, Alere Medical Co, Ltd, 357 Matsuhida, Matsudo-Shi, Chiba, 270-2214, Japan) and (Uni-Gold™ HIV, TRINITY BIOTECH PLC Bray, Co. Wicklow, Ireland) rapid (HIV 1/2 STAT-PAK®, CHEMBIO DIAGNOSTIC SYSTMS, INC. 3661 Horseblock Road, Medford, New York 11763, USA) test kits. A Stat-Pak was used if discordant results were obtained.
Full blood count and red cell indices; mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH) and MCH concentration (MCHC) were performed using Sysmex automated hematology analyzer (Sysmex Automated Hematology analyzer KX-21N; Sysmex Corporation Kobe, Kobe, Japan). CD4 T-lymphocytes count was determined using the Partec cyFlow® Counter flow cytometer (98/79/EC Partec GmbH, Münster, Germany). In this study, we defined anemia as hemoglobin <12 g/dL in both sexes, lymphocytosis as lymphocytes count >40%, neutropenia as neutrophils count <45%, and low CD4 count as CD4 count <200 cells/μL.
Ethical approval was obtained from the human research ethic committee of the NTBLTC.
Patients’ data were retrieved from hospital case folders over a 6-month period and the information entered into SPSS version 20.0 software. Frequencies, proportions, and paired t test were performed to compare sample means at baseline and 6 months after commencement of ART. A P value of ≤0.05 was considered to be significant.
| Results|| |
The mean (±SD) age of the study participants was 35.6 ± 9.65 years, aged from 18 to 65 years [Figure 1] and comprising of 56 (62.0%) females. Of the 90 participants, 62.2% were married and only 15.6% attained tertiary education. The mean (±SD) values of the hematological parameters at baseline and 6 months after initiation of ART were [Table 1]: hemoglobin concentration (10.9 ± 1.95 vs 11.8 ± 1.83 g/dL, 95% CI; −1.1938, −0.5218, P value <0.001), white blood cell count (5.95 ± 2.84 vs 5.32 ± 1.75 × 109/L, 95% CI; 0.0691, 1.1843, P value <0.001), MCV (83.04 ± 6.90 vs 85.33 ± 7.44 fL, 95%CI; −3.9424, −0.6290, P value <0.001), MCH (26.3 ± 2.93 vs 27.5 ± 3.44 pg, 95% CI; −1.7713, −0.5030, P value <0.001), MCHC (31.4 ± 1.86 vs 31.9 ± 1.71 g/dL, 95% CI; −0.9369, −0.1088, P value <0.001), lymphocyte count (37.0 ± 12.9 vs 38.7 ± 11.78%, 95% CI; −4.7148, 1.1170, P value <0.001), neutrophil count (46.6 ± 13.8 vs 46.4 ± 12.0%, 95% CI; −3.3644, 3.6444, P value <0.123) [Table 1]. The mean (±SD) value of immunological parameter was: CD4 count (222.3 ± 230.10 vs 284.2 ± 196.72 cells/μL, 95% CI; −96.2642, −27.5802, P value <0.001) [Table 1].
|Table 1: Hematological and immunological parameters of the study participants before and 6 months after initiation of ART|
Click here to view
| Discussion|| |
Hematological and immunological parameters are often affected in HIV-infected individuals with resultant worsening morbidity, mortality, and quality of life. The advent of ART has over the years dramatically improved the clinical and hematological outcomes of patients with HIV infection making it a manageable disease. Despite these glorious effects, there are still cases of drug-induced hematological derangement reported with the use of ART. The frequency of HIV infection in this study was found to be highest among the age group 18 to 37 years of age [Figure 1]. The implication of this is a reduction in workforce and loss of productivity as people within this age bracket are in their most productive years and are supposed to advance the socioeconomic development of the nation. This finding is similar to the studies conducted separately by the FMOH, Nigeria and Igbeneghu et al. in Southwestern Nigeria, with males-to-females ratio of 1:1.6 by Nasidi and Harry, though they also recorded higher male to female ratio. This difference might be due to a large sample size of the study participants by the FMOH.
Anemia was observed in the majority of patients, more in females than in males at recruitment in this study [Figure 2]. Although a similar finding was reported by Igbeneghu et al. in Nigeria, but the converse is the case by a report in Abidjan revealing anemia more among the HIV-positive males. Anemia was reported to be commoner in HIV-infected individuals compared to the general population.,, The anemia in this study population is characterized by a normocytic hypochromic picture mostly as reflected by the red cell indices [Table 1], which is also in keeping with the Abidjan study. However, a contrary report from a study in Mali indicates that the type of anemia found there was normocytic normochromic. Our observation of normocytic hypochromic anemia in this study may be due to the sequestration of certain elements of red blood cells during synthesis by macrophages. This would result in an insufficient hemoglobin formation in the cytoplasm, despite normal division of the nucleus. Again, anemia observed in this study could be due to the poor nutritional status of the study participants. It is also important to bear in mind that anemia in HIV-infected individuals can be multifactorial with conditions such as concomitant chronic medical conditions, opportunistic infections, nutritional deficiencies, and toxicities from antiretroviral medications also contributing. Hence, these differences may suggest that different factors predominant in diverse locations. A rise in hemoglobin level among these patients was observed 6 months after commencement of ART [Table 1].
|Figure 2: Baseline Haematological and Immunological parameters of the study participants. BCD4 Count = baseline CD4 count, BHb = baseline hemoglobin concentration, BLymphocytes Count = baseline lymphocytes count, BNeutrophils Count = baseline neutrophils count|
Click here to view
The mean white blood cell count in this study is within reference ranges, which may be due to lower evolution of the HIV infection [Table 1]. A study in Nigeria showed a high mean of WBC count among the HIV-infected persons. This could be due to different stages of HIV illness in the study population. Our study showed that most of the patients have lymphocytosis even though few of them have lymphopenia [Figure 2]. This is in contrast to the findings in Sagamu and other independent studies.,, Lymphocytosis found in this study could be due to abnormal expression of cytokines,, which is common in viral infections. Again, CD4 is one of the subsets of lymphocytes, other subsets could be responsible for the lymphocytosis in these patients. Lymphopenia found among few individuals in this study might be due to advance stage of the disease.
We have observed a high prevalence of neutropenia in this study [Figure 2]. The same observation was reported by Bleyere et al. and Munyazesa et al. working independently. This is a common finding in sub-Saharan Africa,, and may be due to HIV suppression of bone marrow, resulting in abnormal granulopoiesis. In addition, antigranulocyte antibodies have been described in HIV-infected persons, and this may be attributed to decreased production of granulocyte colony-stimulating factor. Coso and Gastaut however reported a lower prevalence of neutropenia in their study than in this study. This may suggest that different populations or races respond differently to HIV infection, hence suggesting molecular variabilities.
Normal platelet counts were observed in most of our patient in this study [Table 1]. This is contrary to some studies in Nigeria and in Rwanda which observed high prevalence of thrombocytopenia among the HIV-infected individuals, respectively. The normal platelet counts observed in this study may be attributed to different stages of HIV infection. This finding is also in consonance with the observation that thrombocytopenia is infrequent in developed countries. It is, however, important to note that thrombocytopenia has been shown to be one of the common hematological abnormalities in HIV-patients before Highly Active Antiretroviral Therapy (HAART) initiation in sub-Saharan countries. We also observed that few of the study participants have associated thrombocytosis as was the case in the Abidjan study. Thrombocytosis found in this study is one of the hematological features of iron deficiency anemia as seen in the red cell indices of these participants.
Profound immunosuppression was found in the majority of patients in this study [Figure 2], this is reflected by the very low level CD4 T-lymphocytes count. Similar observations were reported in Ouagadougou, Burkina Faso by Diallo and in Cotonou, Benin by Zannou et al., respectively. This observation may be due to the advanced stage of HIV infection in the study population. However, studies in Abidjan and Dar Es Salaam in Tanzania have reported low immunosuppression among their study populations, respectively., Patients who presented with profound immunosuppression are usually in stage C of HIV infection as against those in stage B. This may also be explained that most of the patients presented to the clinic at late stage of the disease or are unaware of their HIV status until their conditions worsen. We also observed a rise in CD4 count in these patients 6 months after commencement of ART [Table 1].
| Conclusion|| |
Anemia, neutropenia, and immunosuppression were the predominant findings in this study at recruitment. However, an improvement of these parameters was observed 6 months after commencement of ART among the HIV-positive (naïve) patients. This showed that ART has improved both the hematological and immunological parameters in HIV-positive treatment-naïve patients.
We recommend regular routine assessment of these hematological parameters at every follow-up visit, and early initiation and adherence to ART on every eligible HIV-positive patient according to the treatment policy of the World Health Organization (WHO).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Global AIDS Response Progress Report. Country Progress Report. Nigeria: GARPR; 2015. p. 9-38.
FMOH. National HIV Sero-prevalence Sentinels Survey. Abuja, Nigeria: Federal Ministry of Health; 2010.
Rudnicka D, Schwartz O. Intrusive HIV-1-infected cells. Nat Immunol 2009;10:933-4.
Bastos K, Shi Q, French A, Levine A, Greenblatt RM, Williams C et al.
Total lymphocyte count, hemoglobin and delayed-type hypersensitivity as predictors of death and AIDS illness in HIV-1 infected women receiving highly active antiretroviral therapy. J Acquir Immune Defic Syndr 2004;35:383-92.
Data-Martin JA, Gayet-Martinez JE, Martinez-Martin RE et al.
Risk factors and correlates for anemia in HIV treatment-naïve infected patients: a cross-sectional analytical study. BMC Res Notes 2010;3:230.
Siegfried N, Uthaman OA, Rutherford GW. Optimal time for initiation of antiretroviral therapy in asymptomatic, HIV-infected, treatment-naïve adults. Cochrane Database Syst Rev 2010;CD008272.
Igbeneghu C, Odaibo GN, Olaleye DO, Odaibo AB. Asymptomatic HIV infection and its impact on some haematological parameters in Iwo community, Southwestern Nigeria. World J Med Sci 2014;10:375-8.
Nasidi A, Harry TO. The Epidemiology of HIV/AIDS in Nigeria. AIDS in Nigeria: A Nation on the Threshold. Boston, Massachusetts: Harvard Centre for Population and Development Studies; 2006. p. 17-36.
Bleyere MN, Koukou LK, Konan AB, Sawadogo D, Yapo PA. Haematological status and progression of HIV infection in Abidjan (Côte D’ivoire). Int J Med Res Health Sci 2013;1:18-30.
Munyazesa E, Emile I, Mutimura E, Hoover DR, Shi Q, McGinn AP et al.
Assessment of haematological parameters in HIV-infected and uninfected Rwandan women: a cross-sectional study. BMJ Open 2012;2:pii. e001600. doi: 10.1136/bmjopen-2012-001600.
Diallo DA, Baby M, Dembélé M, Kéita A, Sidibé AT, Cissé IA et al.
Frequently, risk factors and prognostic value of anemia associated with HIV/AIDS in the adult in Mali. Bull Soc Pathol Exot 2003;96:123-7.
Bagnara GP, Zauli G, Re MC, Furlini G, Giovannini M, Ranieri S et al.
Impaired GM-CSF production by cultured light density mononuclear cells and T lymphocytes correlates with the number of circulating CFU-gm in HIV-1 seropositive subjects. J Cell Cloning 1991;9:239-50.
Belachew T, Legesse Y. Risk factors for anaemia among pregnant women attending antenatal clinic at Jimma University Hospital, southwest Ethiopia. Ethiop Med J 2006;44:211-20.
Adewuyi JO. Determination of red cell indices In. Companion to practical haematology, a manual for the practical haematology course in the medical undergraduate programme in developing countries. 1st ed. Unilorin Nigeria: Klobex Academic Publishers; 2007. p. 12-24.
Erhabor O, Ejele OA, Nwauche CA, Buseri FI. Some hematological parameters in human immunodeficiency virus (HIV) infected Africans: the Nigerian perspective. Niger J Med 2005;14:33-8.
Ogun SA, Adelowo OO, Familorni OB, Adefuye OB, Alebiosu C, Jaiyesimi AE et al.
Spectrum outcome of clinical disease in adults living with AIDS at the Ogun State University Teaching Hospital. East Afr Med J 2003;80:513-8.
Obirikorang C, Yeboah FA. Blood hemoglobin measurements as a predictive indicator for the progression of HIV/AIDS in resource-limited setting. J Biomed Sci 2009;16:102.
Aboulafia DM, Mitsuyasu RT. Hematologic abnormalities in AIDS. Hematol Oncol Clin North Am 1991;5:195.
Mugisha JO, Shafer LA, van der Paal L, Mayanja BN, Eotu H, Hughes P et al.
Anaemia in a rural Ugandan HIV cohort: prevalence at enrolment, incidence, diagnosis and associated factors. Trop Med Int Health 2008;13:788-94.
Firnhaber C, Smeaton L, Saukila N, Flanigan T, Gangakhedkar R, Kumwenda J et al.
Comparisons of anaemia, thrombocytopenia, and neutropenia at initiation of HIV antiretroviral therapy in Africa, Asia, and Americas. Int J Infect Dis 2010;14:e1088-92.
Kimura S, Matsuda J, Ikematsu S, Miyazono K, Ito A, Nakahata T et al.
Efficacy of recombinant human granulocyte colony-stimulating factor on neutropenia in patients with AIDS. AIDS 1990;4:1251-5.
Mauss S, Steinmetz HT, Willers R, Manegold C, Kochanek M, Häussinger D, Jablonowski H. Induction of granulocyte colony-stimulating factor by acute febrile infection but not by neutropenia in HIV seropositive individuals. J Acquir Immune Defic Syndr Hum Retrovirol 1997;14:430-4.
Coso D, Gastaut JA. Anomalies hématologiques non tumorales au cours de l’infection á HIV. In: Sebahoun G, editor. Hématologie clinqueet biologique. Paris: Arnette Iniatives Santé; 1998. p. 305-8.
Vannappagari V, Nkhoma ET, Atashili J, Laurent SS, Zhao H. Prevalence, severity and duration of thrombocytopenia among HIV patients in the era of highly active antiretroviral therapy. Platelets 2011;22:611-8.
Diallo I. Traitement ARV á Ougadougou chez 71 patientssuivis pendant 1 an: modalités-résults-limits. Théseméd, no. 41, UFR/SDS. Burkina Faso: Université de Ouagadougou; 2002. p. 109.
Zannou DM, Kinde-Gazard D, Vigan J, Adè G, Sèhonou JJ, Atadokpèdé F et al.
Clinical and immunological profile HIV infected patients in Cotonou, Benin. Med Mal Infect 2004;34:225-8.
Massawe SN, Urassa EN, Nyström L, Lindmark G. Anaemia a chronic health problem in women of reproductive age in Dar es Salaam. Acta Obstet Gynecol Scand 1999;78:573-9.
Centers for Diseases Control and Prevention (CDC). From the centers for disease control and prevention, revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. JAMA 1993;6:729-30.
[Figure 1], [Figure 2]