The clinico-epidemiological profile of the HIV epidemic in India is varied and depends on multitude of factors including geographic location. Thus, epidemiological data on HIV/AIDS relevant to a specific region are important in providing vital information to plan future control programs in that specific region. We conducted this clinic-based retrospective observational study to describe the clinico-epidemiological profile at presentation of HIV-infected patients over a period of five years from 2003 to 2007.
Male patients predominated the study group. Majority of patients were in economically productive age group. An observational study done at PGIMER, Chandigarh, during the period 1987-1996, among 622 HIV-infected patients revealed similar findings.(3
) Another retrospective cross-sectional study carried out in zonal referral center at Chandigarh from September 1999 to September 2005 showed male predominance among the study subjects.(4
) The findings of index study are also in consonance with the national level statistics provided by NACO-India.(1
Worldwide, the most common mode of transmission is through heterosexual route, particularly in developing countries.(5
) Predominant mode of HIV transmission in this study too was through heterosexual route and it remained the major mode of transmission throughout five years. This is in consonance with the national level statistics provided by NACO.(1
) Two other observational studies conducted at Chandigarh also showed similar findings.(3
Transmission through contaminated blood and blood products showed progressive decrease over the years. This was achieved by screening of voluntary donors for HIV and banning the professional blood donors. An observational study conducted during the period of 1987-1996 in similar setting showed progressive drop in percentage of patients acquiring infection through blood, blood products, and hemodialysis.(3
Another route of HIV transmission was IV/IM injections which showed a progressive increase over the years in index study. Approximately 3% of patients had unsafe medical injections as the only identifiable source of HIV acquisition according to data provided by NACO. In villages and small towns in developing countries, many patients reported receiving injections administered by unqualified medical practitioners without proper sterilization. These injections may contribute to the spread of HIV both within high-risk groups and between high-risk groups and the general population.
Gangakhedlkar et al
. showed high prevalence of HIV infection among females in general population, who were previously considered as a low-risk group in India.(6
) Recent surveillance data indicate that HIV epidemic is increasingly feminizing in India like in many other African countries.(7
) Most Indian females acquire HIV from their husbands as 90% of infected women reported to be married and monogamous.(10
) An observational study conducted among 28 139 married women who underwent intimate partner violence showed that physical violence combined with sexual violence by husband was associated with increased prevalence of HIV infection among married women in India.(13
) We also noted progressively increasing proportions of female patients from year 2004 onward. A six-year (2002-2007) Integrated Counselling and Testing Centre (ICTC) based study from North-western India showed progressively increasing percentage of HIV-infected female patients among all the attendees of ICTC except in year 2005.(14
) In the index study, mean CD4 count of male patients was significantly lower than female patients. This pattern was consistently seen in all the five years. The possible explanation would be that the majority of women acquired infection from their husbands. Men acquire infection due to their risky behaviors and pass it to their marital partners. As they acquire infection earlier than females, they present with advanced disease and lower CD4 counts compared with females. As a protocol, the spouses of these male patients were screened for HIV. Another reason for male predominance with advanced disease would be the disease pattern of HIV in India as HIV epidemic in Indian women is younger than that in men.
Several OIs occur in patients infected with HIV. The probability of HIV-infected individual developing an OI is influenced by level of immunosuppression, relative virulence of the potential pathogen, and exposure to the potential pathogen. An accurate estimate of type and burden of OIs among these patients will help us to plan and implement appropriate management strategies. Study done at the Royal Free Hospitals in London, England (1982-1995) reported 1 713 AIDS patients among 3 875 HIV-positive patients. The five most common AIDS-defining illnesses were Pneumocystis pneumonia (16.7%), esophageal candidiasis (15.2%), Kaposi sarcoma (13.2%), Mycobacterium avium
(9.6%), and CMV retinitis (9.5%).(15
) A retrospective observational cohort study from Singapore reported 834 cases having one or more AIDS-defining diseases among 1 504 patients studied. The most frequent causes were Pneumocystis pneumonia (35.7%), Mycobacterium tuberculosis
(22.7%), and herpes simplex (7.4%).(16
) In a study from tertiary care hospital, from Kolkata, oral candidiasis and Herpes Simplex Virus (HSV)-2 were the most common OIs.(17
) TB and Oropharyngeal candidiasis were the most common OIs reported in few other studies reported from India.(18
) Various forms of TB and Oropharyngeal candidiasis were the two main OIs observed in the present study. Patients developing OIs had lower CD4 counts as compared with previous studies reported from this subcontinent. One study from western India noted median CD4 count of 195/μl in patients with pulmonary TB while a study from eastern India reported median CD4 count of 137/μl.(17
) In index study, median CD4 count in these patients at presentation was 114/μl and patients with extrapulmonary TB had much lower median CD4 count of 92/μl. Patients with oral candidiasis have been reported to be having lower CD4 counts. It has been reported as a marker of immunosuppression. One study from Pune, India, documented CD4 count of 151/μl while another study from southern India reported CD4 count of 107/μl in these patients.(18
) Our index study showed median CD4 count of 101.5/μl in these patients. Substantial proportions of patients had CD4 count<200 at presentation with 51.4% of patients in year 2006 with this level of CD4 count. An observational study done at PGIMER, Chandigarh, during the period of 1987-1996 among 622 HIV-infected patients reported much lower percentage (29%) of patients with full-blown HIV disease.(3
) Importantly, index study has shown for the first time from this part of subcontinent that the CD4 count has not changed much at presentation to immunodeficiency clinic over the period of five consecutive years. This important finding calls for strengthening of various aspects of control program to detect HIV infection in early stages resulting decrease in morbidity and mortality.
Among the different infections affecting the CNS, cryptococcal meningitis is the most common HIV-associated condition both in developed and developing countries, contributing significantly to increased morbidity and mortality.(22
) Similarly, cryptococcal meningitis was the most common CNS OI found in this study. There was progressive increase in percentage of patients presenting with this OI over the study period of five years. Despite the higher number of pulmonary and extrapulmonary TB, number of TB meningitis was lesser than cryptococcal meningitis. This finding reemphasizes the importance of excluding cryptococcal meningitis in all HIV-infected patients presenting with features of CNS infection. Early diagnosis and effective treatment may considerably reduce the morbidity and mortality associated with this condition.
In conclusion, the majority of HIV patients were male in sexually active and economically productive age group. Most common mode of transmission was heterosexual route. Female patients presented at earlier stage of HIV infection as compared with male patient, throughout the study period of five years. Progressively increasing proportions of female patients were seen from the year 2004 onward. TB and oropharyngeal candidiasis were the most common OIs, whereas cryptococcal meningitis was the most common CNS OI. Among the patients with various OIs, pulmonary TB and cryptococcal meningitis showed progressively increasing trends over the study period of five years. Patients with extrapulmonary TB showed progressively decreasing trends over these five years. Patients developing OIs had lower CD4 counts as compared with previous studies reported from this subcontinent. Most of the patients were in advanced stage of HIV infection at the time of presentation and this has been the pattern in all the five years. These findings call for improving the various aspects of the AIDS control program.