Clinical Manifestations of Treatment Naïve HIV Infected Patients in Pakistani Population

Research Article

Austin Virol and Retrovirology. 2016; 3(1): 1019.

Clinical Manifestations of Treatment Naïve HIV Infected Patients in Pakistani Population

Ahmad F¹, Imran M¹, Yusuf NW², Atif M¹, Akram N¹, Fatima Z³ and Waqar AB¹*

¹Department of Medical Lab Sciences (DMLS), FHAS, ICBS, Pakistan

²Department of Pathology, Allama Iqbal Medical College, Pakistan

³Department of Radiological Sciences and Medical Imaging (DRSMI), FHAS, ICBS, Pakistan

*Corresponding author: Ahmed Bilal Waqar, Department of Medical Lab Sciences (DMLS), Imperial Post Graduate Medical Institute (IPGMI), FHAS, ICBS, 25 B Lower Mall, Lahore, Pakistan

Received: May 27, 2016; Accepted: June 23, 2016; Published: June 27, 2016


The Human Immunodeficiency Virus (HIV) infection is a global burden with the most prevalence in sub-Saharan Africa. Although the prevalence of HIV in Pakistani population is low but it is ranked as a high risk country. The current study was designed to investigate the clinical manifestation of 600 HIV untreated patients from several major cities of Punjab, the largest province of Pakistan. These patients were tested for other co-infections like Hepatitis B virus (HBV), Hepatitis C virus (HCV) and Tuberculosis (TB). CD4+ and CD8+ T lymphocytes profile of all the subjects was also determined by fluorescence activated cell sorting (FACSCalibur) using BDTritestCD4/CD8/CD3 antibodies. The results showed that in all untreated HIV subjects, CD4+ T lymphocytes were decreasing with the disease progression, while the primary level of CD8+ T lymphocytes cells was decreased but later on it kept increasing. The ratio of CD4+ T lymphocytes /CD8+ T lymphocytes was also decreased with disease progression.

Keywords: HIV; CD4+; TB; Transmission; Infection


Human Immunodeficiency Virus (HIV) is one of the major viral infections worldwide. HIV infection leads to a progressive failure of immune system leading to Acquired Immuno-Deficiency Syndrome (AIDS). Since its discovery in 1983, HIV infection is the subject of major focus as numbers of patients are increasing with each passing day. Now HIV infection is a global dilemma [1]. According to recent estimates, worldwide 37 million people are living with HIV infection with the addition of 3.1 million new cases each year. Thus HIV infection is becoming an alarming threat to world population. In Pakistan, approximately 83,468 individuals are living with HIV-1 infection. In total 18 AIDS control centers in Pakistan; only 7568 individuals living with HIV-1 (PLHIV-1) are registered. Out of these registered cases only 3211 adult and 70 children were on Antiretroviral Therapy (ART) [2]. As the treatment facility against HIV-1 is increasing day by day, therefore the life span of infected people is also increasing. Additionally, the recent advances in ART are also preventing the onward HIV-1 transmission as the treatment suppresses the viral on set and reservoir.

There are two types of HIV viruses depending on the origin. HIV- 1 is believed to be originated from chimpanzee (SIV1), while HIV-2 is believed to be originated from monkey (SIV11). Thus both types of viruses have zoonotic origin and now successfully infecting humans. The most prevalent type of HIV infection across the world is HIV-1 infection [3].

HIV-1 is a retrovirus and deviates from the central dogma of Molecular Biology (DNA to RNA; RNA to protein). After entry into CD4+ T-cell, HIV-1 RNA is converted to DNA and integrates into the host genome. The host machinery and energy is exploited to produce viral proteins. The structure of HIV-1 shows that it comprises of envelop, outer lipid bilayer, two outer surface glycoproteins, gp41

and gp120; two layers, matrix layer of MA proteins and capsid layer of CA proteins. The capsid layer surrounds a layer of core proteins containing two single strands of RNA along with reverse transcriptase and integrase protein [3]. There are four HIV-1 accessory proteins (Nef, Vif, Vpu, and Vpr). These proteins facilitate the evasion of viral escape from both the cell mediated and the intrinsic immune system. These proteins modify the hostile environment of the host cell to ensure the viral persistence, dissemination and transmission [4].

HIV-1 infection leads to the development of symptoms within 2-6 weeks in 40-90% patients. These symptoms are flu, fever, fatigue, night sweats, lymphadenopathy, headache, nausea and diarrhea. As these symptoms are also associated with other diseases such an influenza and tuberculosis therefore, the primary care clinicians generally do not diagnose early HIV-1 infection [5,6]. Antibodies against HIV-1 are formed within 3-12 weeks [7].

HIV-1 life cycle is characterized by three phases. The first phase of HIV infection, early or acute infection is commonly diagnosed by detectable HIV-1 RNA or p24 antigen [8,9]. Soon after HIV-1 infection, antibody test is useless as HIV-1 antibodies are produced in 3-12 weeks. Therefore, the suspected patients must be screened for HIV-1 RNA. Low copy numbers of HIV-1 RNA i.e. less than 10,000 copies per/ml represent false positive result as acute HIV-1 infection causes a high copy number of HIV-1 RNA, i.e. more than 100,0000 copies per/ml [10,11]. HIV-1 treatment at acute stage lower viral set point [12-14], reduces virus reservoir [15], disease progression and viral mutation [16]. However, early treatment is also linked with prolonged exposure to ART which may play a role in the development of drug resistance, drug toxicities and serious side effects on individual’s quality of life. The second phase is connected with low viral titer in the blood and may last for years. The third and the last stage are characterized by high viral count and severe drop in CD4+ T-cells leading to a weak immune system.

According to the current treatment guidelines of adult HIV infected subjects the treatment initiation should be with 2 different nucleoside reverse transcriptase inhibitors e.g. amivudine/abacavir, emtricitabine/tenofovir disproxil fumarate and their efficiency is further boosted up by a nonnucleoside reverse transcriptase inhibitor (efavirenz or rilpivirine) or integrase strand transfer inhibitor (dolutegravir, elvitegravir, or raltegravir), or inhibitor (darunavir or atazanavir). The treatment failure is rapidly confirmed and drug resistance test may be performed before switching therapy. There are also available alternative treatment options. Treatment switching due to cost effects, adverse side effects or inconvenience should not jeopardize antiretroviral potency [17].

Current study focuses on the clinical aspects of HIV/AIDS subjects residing in the largest province of Pakistan (Punjab). HIV/ AIDS patients were investigated for the presence of diseases like HBV, HCV and TB. This study gives an overall clinical association of co-infection in untreated HIV/AIDS subjects.

Material and Methods

The current study was conducted at the Department of Pathology, Allama Iqbal Medical College, Lahore Pakistan. There were included 600 HIV/AIDS treatment naïve subjects from April 2012 to Feb 2013. The department has a reference laboratory of Punjab AIDS Control Program (PACP), for their lymphocytes profiling (CD4+ count) of HIV infected subjects. All the enrolled subjects were already diagnosed with HIV infection and referred from multiple centers of PACP, Pakistan. HIV infected treatment naïve subjects of both genders; male and female were included without any age restriction. Written permission was taken from all the enrolled subjects that their clinical findings may be published in a scientific journal without disclosing their identity.

Blood samples were collected in a sterile K3EDTA (Ethylene Diamine Tetra Acetic Acid) tube for lymphocyte profiling and in a sterile BD vacutainer rapid serum tubes for detection of HCV, HBV co infections.

CD4+ /CD8+/CD3+profiling

CD4+ /CD8+/CD3+profile were determined by BD Tritest CD4/CD8/CD3 antibodies using TruCount Tubes through BD FACSCalibur flow cytometer. The blood samples were processed immediately within 2 hours of samples collection. Lyse no wash method was performed using whole blood for acquisition of sample. BD Tritest CD4/CD8/CD3 antibodies which include fluorochrome labeled monoclonal antibodies were used to perform CD4+ /CD8+/ CD3+profiling.

HBV, HCV and TB Detection

HBV diagnosis was performed by accurate diagnostic kit, USA which is based on immunochromatographic technique having approximately 95% accuracy. HCV detection was done by accurate diagnostic kit with relative sensitivity, specificity, and accuracy of >99.8%, 99.9%, and 99.9%, respectively. Later on, positive cases were further confirmed by Enzyme-Linked Immunosorbent Assay (ELISA) and Polymerase Chain Reaction (PCR). Pulmonary TB was diagnosed by clinical features along with physical examination and radiograph (Chest X-ray). Further confirmation of TB was done by three consecutive sputum smears examination for Acid Fast Bacilli (AFB) using Ziehl-Neelsen staining technique (Z-N stain)


Six hundred treatment naive HIV subjects were selected for the current study. The age of patients ranged between 04-68 years and the mean age of 31.80 and standard deviation of 10.903. Percentage frequency of gender wise HIV infection of male, female and transgender was; 64.1%, 33.3% and 2.5%.

The history data of HIV patients revealed that infected needles (25%) use was the major possible route of HIV transmission followed by heterosexual contact (20%), intravenous drug use (17.5%), surgery (10.8%), spouse of HIV infected person (8.3%), male sex with male (7.5%), blood transfusion (6.7%) and vertical transmission (3.3%) as shown in Table 1.