Virological and Immunologic Outcome of HIV Infected Drug Experienced Adults in North Central Nigeria

Momoh Belinda Eseohe¹, Ruth Awayimbo Jaggu¹, Anowai Clementina O², Kingsley Anyiam¹, David Ishaleku¹ and Adamu Ishaku Akyala^1*
*Correspondence: Adamu Ishaku Akyala, Department of Microbiology, Faculty of Natural and Applied Sciences, Nasarawa State University, Keffi, Nasarawa State, Nigeria, Tel: + 07030983655, Email:

Keywords

Suppression • Virological • Immunological • Mortality • Morbidity

Abbreviations

AIDS: Acquired Immunodeficiency Syndrome • HIV: Human Immunodeficiency Virus • HAART: High Antiretroviral Active Therapy • ART: Antiretroviral Therapy • VL: Viral Load • WHO: World Health Organization

Introduction

The human immunodeficiency virus (HIV) has continues to become a global public health burden with 39.7 million of people living with HIV globally in 2020 [1]. In Sub-Sahara Africa region, it’s estimated that over 70% of HIV new infection occurs annually with increase in morbidity and mortality [2]. Over the years, high active antiretroviral therapy (HAART) has been used to reduce HIV related morbidity and mortality [3]. There has been great transformation in HIV infection management from been fatal to a manageable chronic disease due to HAART [4]. In resource limited countries, rapid scale-up of anti-retroviral therapy (ART) for HIV (AIDS) and it has been successful [5]. In Nigeria, significant progress has been in terms of HIV prevention and control with programs been implemented that has reduced related HIV complications [6]. This program includes scale-up of ART treatment with optimal access. Nigeria also helped the “test & treat” approach a 2016 WHO consolidated guideline on the use of anti-retroviral drugs for the management for HIV infection. There has been usable decline. In the annual new infection in Nigeria as a result of scaleup of HIV care related services. Despite rapid scale up of HIV related service delivery in Sub-Sahara Africa and other resource constrain countries, there has been increase in HIV drugs resistances which has become a challenge in many national ART roll-out programs [6], it has become pertinent to have a robust treatment monitoring response approach [7].

Plasma HIV RNA titer and CD4+ cell count is used in clinical practice to monitor treatment response; they are also used as diagnostic Manuel to evaluate disease progression. In the absence of viral load testing platform in resources constrain settings, CD4+T cell count is used to monitor the ART. Increase in CD4+ T cell count is associated with decrease in HIV viral load for a sustained response to HAART [7].

In clinical practice, Virological and immunological response to ART can be measured by the ability of the immune system to suppress viral replication which is time dependent. However, it’s critical evident for policy makers in Nigeria to review treatment response which it has become a challenge due to lack of adherence [8].

In order to meet up with the joint United Nations program on HIV/AIDS (UNAIDS), “90-90-90” initiative whose mandate was to achieve 90% viral suppression by 2020 among people receiving treatment [9], which was reviewed and updated for 2030 [10]. Nigeria Government alongside partners have in recent times implemented viral load in tertiary and secondary health care facilities, however there’re paucity of data and information regarding immunological status and viral suppression outcome of patients on HAART. There’s need to generate evidence base data to inform policy makers and to serve as a guide for improved treatment [11].

What is already known on this topic?

• The primary goal of ART is to suppressed HIV RNA lower than the detectable level.

• Due to lack of HIV RNA monitoring platforms in resource constrain settings, patients are supposed to continue on first line ART until virological failure progresses to a 50% decrease.

What this study adds

• Introduction of ART Program in Nigeria has showed good response in reducing HIV-RNA viral load to undetectable level.

• Our research showed better outcome of Nevirapine based regimen than Efavirenz based.

Research Methodology

Study design

We enrolled 474 HIV infected adults who are on HAART seeking for health care services at Federal Medical Center, Keffi in North Central Nigeria between December 2019 to march 2020. Considering assumption of 95% level of confidence 15% marginal error we used simple proportion formula to determine. Sample size from a previous study [12], by taking 30% base on this assumption, we calculated a sample size to be 474 during the 4-month study period. HIV RNA viral load was done on all the participants enrolled. We used a system random sampling technique to enroll participants.

Patient’s data collection tools procedure

We used key informant interview for a face to face interview and a structured questionnaire to collate socio-demographic data. We review medical records to determine duration since ART initiation, History of opportunities infection, history of TB treatment, as eligibility criteria which forms basis for clinical data.

Clinical operational definition

At any point within in time within 6 months after HAART commencement, a Virological suppression level of <1000 copies Viral load (VL) was consider for HIV-RNA level in Nigeria, CD4+ cell count is defined base on CD4+ cell reference range as favorable (≥466 cell/mm³ for female and ≤ 400 cell/mm³ for male) and unfavorable (≤ 400 cells/mm³ for male and < 466 cell/mm³ for female).

Sample collections and preparation

A treatment phlebotomist was assigned to collect 5ml of blood sample using a K3 BD EDTA vacutainer disposal tube. The specimen was well labelled with patient ID and separated into two vails, one for HIV viral load testing and the former for CD4+ cells count. For viral load analysis, a whole blood sample tube was centrifuged for 10min at 1500 rpm where plasma was separated and aliquot and store at -20.

Plasma viral load quantification

A (QIAGEN Gm6H, Hilden, Germany) Q1 Amp viral RNA Mini-Kit was used to extract Hiv-1 DNA following Standard operational procedure according manufactures instruction. The HIV RNA was quantify using Real-time PCR (COBAS Amplipre/COBAS Taq-MAN Analyzer (Roche Diagnostic USA). A three phase process was employed which include HIV-1 RNA isolation, formation of complementary deoxyribonucleic acid (CDNA) generation from reverse transcription of target RNA and amplification of targeted cDNA by Simo Haneous polymerase chain reaction. Specific probes of oval-labelled target florescence oligonucleotide were used for the quantification and detection, and amplification of target CDNA.

CD4+ T-lymphocytes using flow cytometry

A BD Bioscience San Jose, CA USA flow cytometry system was used to enumerate CD4+ T Lymphocytes following standard operation procedure according to the manufacturers instruction. A reagent (Tro-count) containing CDA5, CDA, CD3 monoclonal antibodies labelled with (FITC, Res.p, PE, PerCD) dyes are mixed with anti-coagulated lysed red blood cells and whole blood using lysing solution A (BD Bioscience) multi-set BD software is used to enumerate absolute CD4+ cells count.

Data quality

Throughout our laboratory procedure, we used data quality control (QC) measure to guaranteed reliability of our findings. All materials, equipment and laboratory process were controlled adequately. Pre-analytical and post analytical quality assurance was carried out as part of control check on the COBAS Amplipre/COBAS Taqman and The FACS calibur TM analyzers. We used 16 HIV positive as a pretest to check for validity of the questionnaire before actual data collection.

Ethical considerations

Ethical approval was obtained from the Ethical Review Board of Federal Medical Center, Keffi. Prior to enrollment in the study, all participants were informed as consent on the objectives and background of the study. Information was provided toward the risks and benefits of the current study. Similarly, a designated questionnaire and data were collected after obtaining returned informed consent. Anonymity and confidentiality of the study participants were maintained.

Statistical analysis

All data were cleaned and checked for completeness in excel version 2019 before they were exported to Epi-info version 7.1 Descriptive analysis were done and presented as tables. We used binary logistics regression to identify associated risk factors and strength of association.

Results

A total of 474 HIV infected adults placed on HAART were enrolled into the study. Urban residency (20.3%) and male (69.1%) were majority among the study cohort with a median ae of 31 years (29-40years interquartile range (IGR) age of the study cohort with 18 and above 60years as minimum and maximum ages respectively. From the 474 cohort that were enrolled 34.6% were on WHO baseline clinical stage IIV and 57.8% of cohort were on HAART, started treatment regimen in less than a year with 42.2% diagnosed and confirmed with HIV infection between 1-5years. 57.8% were transferred into the center as a major reason for enrolment. 57.8% has history of TB treatment in the past while 42.2% of the study participants who were eligible for treatment initiation were determine by CD4+ counts with a median interquartile range of 180 (92-300) cells/mm³ (Table 1). From our result using the bivariate binary logistic regression analysis, baseline CD4+ counts, Residency, WHO baseline stage and duration on HAART were significantly associated with favorable immunological outcome Virological suppression. However, in multivariable binary logistics regression analysis, CDA4+ T cell count of <200 cell/mm³ (aOR: 0.40 j 95% CI (0.21-2.1), Urban residency (ADR: 1.44; (1.0-2.1) were significantly associated with favorable outcomes (Table 2). Viral Load testing at age between 10-30 years (aOR= 1.22 95% CI (0.57-1.67), CD4+ T cells absolute counts (aOR= 2.3 95% CI (1.2-4.1), duration HAART were significantly associated with viral suppression.

From Tables 3 and 4 stating the immunological status of people with HIV in North Central Nigeria, 211 out of 474 participants which accounts for 44.5% has viral load <500 copies/mL with CD4+ T cells cell/mm³ mean of 308 at 95% CI (300-360). 178 cohorts had their CD4+ cells between 201-250 cells/mm³ with 140 copies of viral loads less than 400 copes accounting for 78.6% with 18% viral loads above 1000 copies/mL. Out of the 474 participants enrolled into the study, 142 had viral load less than 400 copies/mL with 121 between 400-999 and 211>1000 copies/mL. In our study we discovered a decrease in CD4+ T Cells count with increase in age at average CD4+ cells of 400 cells/mm³ at age 31-40years in Table 2 COR: ft.22 (0.57-1.67). In this study, we correlate the immunological and Virological response outcome of different ART regime currently been prescribed for eligible HIV infected adult who are enrolled for commence treatment as described in Tables 5 and 6. Among the common ART regimes combinations are Nevirapine/lamivudine/Tenofavirines (NUP/3TC/TDF) was found to be more effective in terms of viral load response with minimal Virological failure [13].

Discussion

One of the greatest achievements in Nigeria HIV program the last two decades is the scale up of ART services, which has consistently suppressed HIV RNA to an undetectable level reducing rise of clinical progression [14]. Despite the success recorded, there’re challenges been faced by the program which include; poor adherence and drug resistance which have led to treatment failure? For this reasons stated above, WHO recommended routine viral load testing for ART monitory [15].

Despite achieving 72% Virological suppression in our study, it differs from other previous studies. It’s consistent with studies in Ethiopia [15] with 90%, South Africa (94%) and Ghana (89.6%) respectively. Similarly studies in Ethiopia reveal 88.1% of patients enrolled on ART shows Virological suppression. Our study also reveals treatment outcome can be impaired if ART is initialized at advance stage of the disease [16]. From our study, remarkably 50.2% of cohorts were enrolled at stage 3 or 4 WHO baseline conditions which were recommend to achieve Virological suppression by 2020 [17].

Remunerable, from our study, we characterize and analyze with comparison Virological and immunological response in sex and age our results reveals older age is more susceptible to Virological failure (p=0.02) compared to participants who are young. The immunological recovery was seen in 60.8 to 90.2% of the total study population out of the different regimen adopted in Nigeria, NVP/3TCTDF and NUP/3TC/ART had better immunological and Virological responses among people living with HIV (AIDS) in North central Nigeria. Our study concord with a study done among Chinese population, where 12.1% Virological failure rate was observed with 3TC combined drugs [18].

Our study revealed better outcome with Nevirapine based regimen than Efivirenz based regimen (p=0.03) which is in line with a similar study in India [19]. Keeping insight similar geographical, socio-cultural and similar HIV epidemics Nigeria and India share in common. Comparison between our study and that of India is realistic, so we can infer that Nevirapine base combination is better than Efavirenz base regimen. Although a study in Botswana suggest that Efavirenze combination drugs are better than Nevirapine regimen combination drugs are better than Nevirapine regimen [20]. Discrepancy in prevalence of HIV type 1 and 2 subject in Nigeria and Botswana might account.

The study conducted in India looked at Virological and immunological outcome in terms of significant effects on ART, but we didn’t look at the above the above clinical presentation [21].

Conclusion

Our study reveals sub-optimal virological level of suppression that requires strong commitment by all USAIDS program in achieving the 90% target of USAIDS 90-90-90 BY 2020. Low immunological status was observed at age (>40years) with CD4+ cell counts of 250 cells/mm³ which are associated with Virological suppressions. Age enrollment was negatively associated with immunological outcome at age 18-30years. Urban residency and CD4+ baseline of 200 cells/mm³ was positively associated. We recommend enrollment on HAART at higher CD4 cell count levels in order to achieve the USAIDS plan of 90-90-90.

Author Contributions

M.B.E conceptualized and designed the study, A.I A, K.A and JRA analyzed the data, D.T and A.C.O revised the manuscript for intellectual and scientific content, and developed the results and discussion section. A.I.A and J.R.A reviewed and revised the manuscript. All Authors read & agreed to publish the version of the manuscript.

Acknowledgments

We thank Pharmacist Envuladu of the Clinical Pharmaceutical Unit of Federal Medical Center, Keffi for the data access and his push for us to secure ethical clearance.

Limitations

The Data analyzed in this study is for a sub-population, and may influence the generalizability of this results, compared in a larger population.

Funding

This study received no external funding.

Conflict of Interest

The author declared that there is no Conflict of Interest.

References

1. Lawn, Stephen D, Landon Myer, Linda-Gail Bekker, and Robin Wood. “CD4 cell count recovery among HIV-infected patients with very advanced immunodeficiency commencing antiretroviral treatment in sub-Saharan Africa.” BMC Infect Dis 6 (2006): 59.
2. UNAIDS. “Global AIDs Update.” (2016).
3. Vidya, Vijayan KK, Krithika Priyadarshini Karthigeyan, Srikanth P. Tripathi, and Luke Elizabeth Hanna. “Pathophysiology of CD4+ T-cell depletion in HIV-1 and HIV-infections.” Front Immunol 8 (2017): 580.
4. Escada, Da Silva RO, Luciane Velasque, Sayonara Rocha Ribeiro, and Sandra Wagner Cardoso, et al. “Mortality in patients with HIV-1 and tuberculosis co-infection in Rio de Janeiro, Brazil - associated factors and causes of death.” BMC Infect Dis 17 (2017): 373.
5. UNAIDS. “Global HIV/AIDS Statistics.” 2017.
6. WHO. “Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection.” 2013.
7. Kelley, Colleen F, Christina M. R. Kitchen, Peter W. Hunt, and Benigno Rodriguez, et al. “Incomplete peripheral CD4+ cell count restoration in HIV infected patients receiving long-term antiretroviral treatment.” Clin Infect Dis 48 (2009): 787-794. 
8. Smith, Colette J, Caroline A. Sabin, Mike S. Youle, and Sabine Kinloch‐de Loes, et al. “Factors influencing increases in CD4 cell counts of HIV-positive persons receiving long-term highly active antiretroviral therapy.” J Infect Dis 190 (2004): 1860-1868.
9. Moore, Richard D, and Jeanne Keruly. “CD4+ cell count 6 years after commencement of highly active antiretroviral therapy in persons with sustained virologic suppression.” Clin Infect Dis 44 (2007): 441-446.
10. Hoenigl, Martin, Antoine Chaillon, David J. Moore, and Sheldon R. Morris, et al. “Rapid HIV viral load suppression in those initiating antiretroviral therapy at first visit after HIV diagnosis.” Sci Rep 6 (2016).
11. Sarfo, FS, MA Sarfo, A Kasim, and R Phillips, et al. “Long-term effectiveness of first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based antiretroviral therapy in Ghana.” J Antimicrob Chemother 69 (2014): 254-261.
12. Cohen, Myron, Ying Q. Chen, Marybeth McCauley, and Theresa Gamble, et al. “Prevention of HIV-1 infection with early antiretroviral therapy.” N Engl J Med 365 (2011): 493-505.
13. Donnell, Deborah, Jared M Baeten, James Kiarie, and Katherine K Thomas, et al. “Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis.” Lancet 375 (2010): 2092-2098.
14. Wudineh, Fisseha, and Bereket Damtew. “Mother-to-child transmission of HIV infection and its determinants among exposed infants on care and follow-up in Dire Dawa City, Eastern Ethiopia.” AIDS Res Treat (2016): 1-6.
15. Kazanjian, Powel. “UNAIDS 90-90-90 Campaign to End the AIDS Epidemic in Historic Perspective.” Milbank Quarterly 95 (2017): 408-439.
16. WHO. “Guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy.” Geneva 2017.
17. Kwakye-Nuako, Godwin, Johnson Nyarko Boampong, Mark Kweku Dong, and Dorcas Obiri-Yeboah, et al. “Modulation of cyptosporidiosis by CD4 levels in chronic diarrhoea HIV/AIDS individuals visiting Tarkwa Municipal Hospital, Ghana.” Asian Pac J Trop Dis 6 (2016): 770-775.
18. Casotti, Janaina AS, Luciana N Passos, Fabiano JP Oliveira, and Crispim Cerutti. “Factors associated with paradoxical immune response to antiretroviral therapy in HIV infected patients: A case control study.” BMC Infect Dis 11 (2011): 306.
19. Kelly, Christine, Katherine M. Gaskell, Marty Richardson, and Nigel Klein, et al. “Discordant immune response with antiretroviral therapy in HIV-1: A systematic review of clinical outcomes.” PLoS One 11 (2016): e0156099.
20. Gezie, Lemma D. “Predictors of CD4 count over time among HIV patients initiated ART in Felege Hiwot referral hospital, Northwest Ethiopia: A multilevel analysis.” BMC Res Notes 9 (2016): 377.
21. Vinikoor, Michael J, Jessica Joseph, Jonas Mwale, and Melissa A. Marx, et al. “Age at antiretroviral therapy initiation predicts immune recovery, death, and loss to follow-up among HIV-infected adults in urban Zambia.”” AIDS Res Hum Retrovir 30 (2014): 949-455.