Clinico-epidemiological study of HIV patients in Trivandrum

Introduction

The HIV pandemic has spread word wide since 1981. In spite of that it is now well known that the epidemiological and clinical features differ greatly from country to country. The epidemiological features depend upon the social and cultural practices of those people which may again vary from region to region.[1],[2] The clinical features and opportunistic infections of HIV infection may depend on the organisms and parasites endermic in that country. Pulmonary tuberculosis is very common in HIV patients in India, while Pneumocystis carinni pneumonia is very common in Western Countries because this organisms are endemic in these countries respectively.[3] Keeping these factors in mind we undertook this study to elucidate the epidemiological and clinical features of HIV patients in our city, Trivandrum located in the southern part of India.

Materials and Methods

This study is a retrospective descriptive analysis of the STD case record of HIV patients who attended the STD clinic of the Department from 1996 to 2001. Incomplete case records were excluded from the study. The epidemiological and clinical aspects of each patient were recorded in the computer using he dbase software and then analysed in detail.

Results

A total of 121 patients were analysed it the study. The total number of new patients with Dermatological conditions who attended the OF wing of the Department each year of the stud) period was on an average 14715 patients. Thus HIV patients accounted for 0.82% of the total. In the 121 HIV patients analysed, there were 8′A males (67.8%), 36 females (29.8%) and children (2.4%). The male/female ratio was 2.3:1. The age group distribution of the patients is given in [Table - 1]. The maximum number of patient; were seen in the age group 21-30, 48 patient (39.6%) followed by age - group 31-40, 46 patients (38%). Together age group 21- 40 constituted 77.68% of the patients. The least age group was 3 years and the maximum age group was 63 years. There were no patients in age group 11-20.

Occupa-tion wise skilled workers comprising masons, mechanics, tailors, carpenters and painters constituted the maximum of 16 patients (13.2%). Drivers 12 (9.91 %), business people 12(9.91 %) and manual workers 10 (8.26) were the other common group of people. Together this group constituted 50 pa-tients (41.32%).93 patients were married (76.85%) and 28 unmarried (23.15%). 21 couples were affected. In 20 couples the husband was the source of the infection and in one couple the wife was the source of the infection. 3 women were pregnant at the time of diagnosis of HIV infection.

Sexual transmission was the commonest route accounting for 95 patients (78.5) This was follower by blood transfusion patient: (5.78% and ma-ternal to child 3(2.47%). No definite route could be ascertained in 16 patients. There were no cases due to IN drug abuse. Heterosexual con-tact was the commonest type of sexual contact seen in 86 patients (71.1 %), followed by bisexual con-tact in 7 patients and homosexual contact in 2 patients (1.65%). 82 patients (67.76%) had un-protected sexual contact while 39 patients (29.75%) had at least one contact protected by the user of condom. 43 patients had premarital contact (PMC), 15 patients extramarital contact (EMC) and 16 patients had both PMC and EMC. The remaining patients denied any history of PMC or EMC. The source of contact was commercial sex workers (CSW) in 53 patients. In 14 cases a known friend was the source of contact while in 4 cases the contact was casual. Habits like smoking, alcohol and chewing were present in 51 patients (42.14%).

Clinically 69 patients (57.02%) were symptomatic, 30 patients (24.8%)asymptomatic and 22 patients (18.18%) had AIDS defining con-dition. 37 patients (30.57%) had other STD,s [Table - 2]. Syphilis was the commonest STD seen in 15 patients (12.39%), followed by herpes genitails 9 (7.43%), condylomata acuminata in 8 (6.16%), Gonorrhoea 3 (2.47), NGU 1 (0.83%) and tri-chomoniasis 1 (0.83%). Late latent syphilis was the commonest type seen in 8 patients, followed by secondary syphilis in 5 patients and 2 cases of early latent syphilis. 69 potients (57%) had cuta-neous manifestations [Table - 3]. Oral candidiasis was the commonest mucocutaneous manifestation seen in 20 pa-tients (16.5%). This was fol-lowed by in-sect bite re-action 7(5.78% and pruritic papules of HIV 7(5.78). There was a relatively high incidence of pyoderma 5 (4.13%), herpes zoster 5 (4.13%), seborrhoeic dermatitis 4 (3.30%) and ichthyosis 4 (3.30%). Oral hairy leukoplakia and hidradenitis suppurativa were seen in 30 patients (24.80%).Tuberculosis was the commonest systemic manifestation and opportunistic infections [Table - 4] were seen in 16 patients (13.2%). Out of this 13 patients had pulmonary tuberculosis and 3 patients lymph node tuberculosis. Pyrexia of unknown origin (PUO) was seen in 4 patients (3.30%) and HIV wasting syndrome in 3 patients (2.47%). One patient had diffuse infiltrative lymphocytosis syndrome (DILS).

Discussion

The total number of patients in the 5 years study was 121 patients. This may seem a relatively low number. This is because the Department of Dermatology where the study was done is note the only Department where HIV patients are seen. HIV patients are also seen in the Infectious Disease Department of the institution. The male/female ratio of 2.3:1 indicates more females are being affected then previously. This could also be attributed to the fad that in a high literacy state like Kerala there is increased awareness among the female population leading to voluntary testing and detection. This is in contrast to a study done in Delhi where it was found that the knowledge and awareness of HIV/AIDS in working women in hostels was very poor. The maximum number of patients were seen in the age group 21-40 also indicates that the most productive and efficient group of people are being affected by HIV infection. In the present study the source of contact in the majority of the patients was with CSW′s in Mumbai. This is because a large number of people in Kerala are employed in the middle East countries and Mumbai is the main transit city to Middle East countries. The incidence of HIV in CSW′s in Mumbai is very high. This factor also explains that the maximum number of patients in our study were skilled workers as these group of people are employed maximum in the Middle East countries. In our study drivers and business people constituted the second commonest group of people. In spite of NACO torgetting adolescent and young age unmarried people, 93 patients in the present study were married. The commonest route of transmission was by sexual contact seen in 78.5%. This is the standard pattern seen world wide. However in this study the sexual transmission rate was much lower than the National rate of 84%. An important finding in our study is that there were no cases due to IN drug abuse. This can be explained by the fact that IN drug abuse is very rare in the state of Kerala. Heterosexual contact was the commonest type of sexual contact (71.1 %). The incidence of homosexual contact was only 1.65% as this type of contact is not rampant in our state. The relatively high level of unprotected contact seen in the patients in this study (67.76%) shows that in spite of intense condom promotion by NACO the message had not effectively reached the masses. In this study 43 patients had PMC and the commonest source of contact was CSW′s. The people who had PMC′s were relatively in the young age group. Thus in future those group of people should be targetted for counselling and condom use and promotion.

Majority of the patients in this study were symptomatic clinically (57.02%) and 2 patients had AIDS defining conditions. The incidence of other STD′s in the patients studied were relatively high [Table - 2], syphilis being the commonest STD is again in conformance with other previous studies[5]. But some other studies done elsewhere in India showed chancroid as the commonest STD in HIV patients[6]. Interestingly latent syphilis seen even though it is known that the ulcerative STD′s are high risk group of HIV This could be explained by the fact that since after acquiring HIV infection it takes years for clinical symptoms to manifest and by the time the patient develops symptoms and is diagnosed as HIV the patient would be in latent stage of syphilis as the ulcers and the skin lesions of syphilis would have disappeared by now. But still then in this study there was a high incidence of herpes genitalis and condyomata acuminata [Table - 2], confirming the fact that genital ulcerative disease is a high risk group for HIV infection. 57% of the patients had cutaneous manifestations. This fortifies the fact that the skin is an important organ for the manifestation of HIV infection. Oral candidiasis was the commonest cutaneous manifestation. This finding is in uniformity with other studies done in India.[7] This is also in contrast with studies done in Western countries where pruritic papules of HIV are the commonest cutaneous manifestation.[8] There was a high incidence of young age onest herpes zoster in our study [Table - 3]. Study done by Das et al also showed increased incidence of young age onset icthyosis was also showed increased incidence of young age onset herpes zoster[9].Thus herpes zoster occurring in young age group can be a marker for underlying HIV infection. Similarly a high incidence of recent onset ichthyosis was also seer in this study. Other skin diseases like seborrhoeic dermatitis, pyodermas, oral hairy leucoplakia seer in this study are common cutaneous manifestatior of HIV as reported elsewhere.[7]

Tuberculosis was the commonest systemic manifestation seen in 16 patients [Table - 4].This is in conformance with other studies done in Indic where again TB was the commonest systemic manifestation of HIV[7]. This is because TB is endemic in India. Patients with HIV and TB rapidly downgrade and have a high mortality and the incidence of multi drug resistant bacilli is also very high in India. PCP pneumonia, AIDS dementia complex and CMV retinitis [Table - 4] were the other AIDS defining conditions seen in this study. One pediatric HIV patient had DILS syndrome which is very common in these group of people.[10] Skilled workers constituting maximum number o-cases, married people being in the majority, pool condom usage and no cases due to IN drug abuse are the unique features of this study. Sexual transmission rate being much less than the National average is another epidemiological highlight a - this study. A high incidence of other STD′s accounting for 30.57% is an important clinical highlight of this study. High incidence of younc age herpes zoster and recent onset ichthyosis is the other clinical highlights of this study. In future as the number of HIV/ AIDS cases are bound to increas in our country we can expect profound changes in the epidemiological and clinical spectrum of the HIV.