Evidence-based Medicine: Time for a change? - Journal of Medical ...

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ORIGINAL ARTICLE An insight on HIV-1 discordant couples-A RIMS study 1 K. Felix Jebasingh, 2 Robinson Ningshen, 3 Th. Shanti Devi, 2 N. Biplab Singh , 4 S. Bhagyabati Devi, Abstract: Objective: To discuss the characteristics of the patients with Human Immunodeficiency Virus-1(HIV-1) infection, who has discordant partners and the postulated mechanism for their persistent HIV seronegativity from various literatures. Methods: We retrospectively analyzed HIV-1 discordant infected partners who were admitted in Medicine ward, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur from 2005 to 2010. Results: Out of the 25 infected patients with negative partners 22 were male and 3 were female. 3 patients were of HIV WHO stage III and others were of stage IV. The mean CD4 count of our patients is 119. 84% of the patients had infection through IDU. Only 4 patients had infection through heterosexual behavior. Conclusion: This retrospective study is to highlight that discordant partners do exist in our population. Through proper counseling and by advising safe sex, we can prevent HIV transmission to the non infected partners. Keywords: HIV; IDU-Intravenous Drug User; Discordant couples; CD4 count. Introduction: India is one of the hubs of HIV infection in this modernized world. HIV 1. P.G. Student , 2. Associate Professor, 3. Senior Resident, 4. Professor, RIMS, Imphal, Manipur. Corresponding author: Dr.Robinson Ningshen, MBBS., MD (General Medicine), Associate Professor, Department of Medicine, Regional Institute of Medical Sciences, Imphal, Manipur. Phone No: 9612159017. E-Mail: dr.ningshen@yahoo.co.in infection is predominantly a sexually transmitted disease worldwide .The most common mode of infection, particularly in developing countries, is heterosexual transmission 1 . According to NACO, in 2008 there are about 2.27 million people between 15 and 49 years of age, affected by HIV infection in India. Compared to the African countries the number of HIV infected is less. The major route of transmission is different in different parts of India. In India states like Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu have high HIV prevalence than the National prevalence. Manipur has the highest prevalence of HIV infection in the country. In 2008, the adult prevalence of HIV infection in India is 0.29% .This figure is much less, as compared to 2002 which was 0.45%. Manipur with a population of 0.2 percentage of total Indian population has 8 percent of the total HIV infected people in India. As per the 2008 report the overall HIV prevalence among different High Risk Groups were Intravenous Drug Users- IDU (9.2%), Male having Sex with Male -MSM (7.3%), Female Sex workers-FSW (4.9%) and STD clinic attendees (2.5%) .Low prevalence is seen among ANC clinic attendees (0.49%). Heterosexual behavior is the main route of transmission (87.1%) as per NACO 2008. But IDU is the main mode of transmission in North Eastern parts of India 2 . The prevalence of HIV infection among the IDU was 17.9%, FSW was 13% and MSM in Manipur was 16.4% in 2007 3 . We retrospectively studied the case files of HIV 20 JMS * JMS Vol 25 * Vol * No. 25 3 * No. * September, 1 * June, 2010 2011
ORIGINAL ARTICLE discordant couples, admitted in the Medicine Department, Regional Institute of Medical sciences (RIMS), Imphal. Our aim is to discuss the characteristic features and the possible postulated mechanism behind the discordance from the available literatures. Materials and Methods: This is a retrospective study of HIV-1 infected patients who have discordant partners, who were admitted under Medicine Department, Regional Institute of Medical Sciences (RIMS), Imphal from 2005 to 2010. HIV patients were diagnosed as per the NACO guidelines. The patients were all legally married and living together for not less than 2 years and the HIV- 1 seropositive status was known before the marriage and were practicing unsafe sex and had multiple issues. Seronegative partners were repeatedly negative for HIV antibody, tested every 3 months. Results: 25 HIV-1 infected patients, who had discordant partners, were admitted in Medicine Department, RIMS, Imphal. Out of 25 patients, 22 were male and 3 were female. The infected male: infected female ratio was 7.3:1. The mean CD4 count was 119. The mean age of our patients was 39.9 years. At presentation all the patients had at least one Acquired Immune Deficiency Syndrome (AIDS) defining opportunistic infection.84 % were IDU’s and remaining 16 % were heterosexuals. Of the 22 males, only one patient was a heterosexual and the remaining were IDU’s. The patients with IDU habits were addicted to illicit drugs for a period of more than 15-16 years. All the 3 females who had discordant husbands got infected through heterosexual behavior. Their children were negative for HIV infection. Out of 25 patients one patient had Hepatitis and other had Hepatitis C co-infection. Of the 25 patients 14 had Koch’s infection, 3 had pneumocystis carinii pneumonia (PCP) or pneumocystis jiroveci pneumonia, 3 had cryptococcal meningitis, 2 had cerebral toxoplasmosis, 1 had disseminated candidiasis, 1 had chronic intestinal isosporiasis, as opportunistic infections and 1 had Progressive multifocal leukoencephalopathy (PML) (Table-1).3 patients were of stage 3 HIV WHO staging and remaining were of stage 4 4 . Because of the non-availability of the viral load estimation for HIV -1, none of our patients had viral load estimation done. It is well defined that low CD4+ counts are associated with high levels of plasma viremia 1 . Since the CD4 count of all our patients was low and of WHO stage III/ IV infection at presentation, their viral loads were presumed to be high. All the patients were on antiretroviral therapy (ART) and were advised to practice safe sex. Table: 1. Characteristics of the HIV Infected Partners PCP-Pneumocystis carinii, IDU-Intravenous Drug User. PML- Progressive multifocal leukoencephalopathy. Discussion: Humans demonstrate significant variability in their susceptibility to Human Immunodeficiency Virus type 1 (HIV-1) infection. There are three groups of people, one with infection and disease manifestation, second who are persistently seronegative even after unprotected sexual behavior and third , though HIV infected but without the disease progression. Such variable HIV infective patterns have indicated that natural resistance to HIV-1 infection might be the reason behind 5 . In Pune, a prospective study was conducted to study the profile of HIV discordant couples and the secondary transmission rate. The study conducted from September 2002 for a period of 26 months found 457 discordant couples 6 .Kumarasamy et al did a cross sectional study to compare the clinical and JMS * Vol 25 * No. 13 * June, September, 2010 2011 21
Page 1 and 2: EDITORIAL Evidence-based Medicine:
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Page 9 and 10: ORIGINAL ARTICLE Introduction : As
Page 11 and 12: ORIGINAL ARTICLE associated with HI
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