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HIV/AIDS Scenario in JN Hospital—A perspective

HIV/AIDS Scenario in JN Hospital—A perspective

Dr K Priyokumar Singh

HIV/AIDS once a dreaded and fatal disease to start with has now become a chronic manageable disease. This disease which was detected from the gay persons in LOS Angles in 1981 has been showing continuous and progressive medical achievements in regards to its effect on human body on diagnosis of complications and in its treatment modalities. With the availability of ART/HAART (Anti-retroviral Therapy/Highly active anti-retroviral treatment) from 1996 onwards this disease has changed from a medical challenge to a socio-economic human problem.

Manipur had the first HIVV/AIDS in the year of 1989-90 from a female IDU patient. The spectrum of the disease was then very confusing. There was no proper awareness of the disease amongst the medical professionals and the health authorities. There were no proper NGO/CBO’s working in HIV/AIDS. NACO gradually came into being and then the disease has been put under its strict vigilance.

To start with the management of this disease came up first for its awareness and to manage the various O.I’s (Opportunistic Infection) specific to HIV/AIDS. And many OI’s were not diagnosed properly leading to many avoidable deaths in Manipur and elsewhere. The diseases like Cryptococcal meningitis, Penicilliosis, Toxoplasmosis, Pnenmocystis Carinii Pneumonia (P.C.P), Cytomegalovirun retinitis (CMV-retinitis), malignancies lilie Kaposis Sarcoma, Lymphoma, Progressive muItifocal Leucoencephalopathy, (PMLE), etc were not properly diagnosed due to lack of knowledge and awareness, leading to many deaths which nowadays are being cured or prevented.

With the coming of ART, first with Zidovudine and followed by other drugs which are able to control HIV multiplication by various combinations of them called the HAART (Highly Activc Anti-Retroviral Treatment) has changed the very outlook of HJV/AIDS from fatal disease to a chronic manageable disease ARV drugs in the beginning was scantily available and were very costly. It was beyond the reach of common people and many persons succumbed to the disease. With the effort of various NGO/CBO’s and the NACO (National Aids Control Organization) started free ART roll out from April 2004. In Manipur, the first centre of free ART was at RIMS (Regional Institute of Medical Sciences). Then the free ART came to J.N. Hospital in the Dec. 2004. Since then this dreaded disease has been under medical control, but many new areas came up for further attention by various Government and NGO’s.

From the hospital records of J.N. Hospital Porompat a 5 year data was prepared which shows the trend and challenges in the management of HIV/AIDS in Manipul’.

Table 1 Hospital Admission 2003-2007

The table shows the decrease in male admission from78.68% in 2003 to 64% in 2007 whereas the female admission increasing from 21.32% in 2003 to 36% in 2007. The trend shows the importance of HIV/AIDS in the whole population particularly to the female population.
Table 2. Risk Factors

In Manipur, the most common mode of HIV transmission is through sharing of injecting equipments by people who inject drugs. Manipur being on the cross road of “Golden Triangle” of drugs trafficking route, it became the main route of transmission. Other routes of HIV transmission are also prevalent in the State as given in the table 2.

Manipur shows the heterosexual route being from 20.32% in 2003 to 27% in 2007, an increasing trend showing the importance of this route in HIV/AIDS transmission. The IDU spread has shown a downward trend from 62.08% in 2003 to 52.11 % in 2007. This shows the various importance of AIDS Awareness programmes by the Govt. & various NGO’s. But a lot more are to be done to bring down the rate of transmission.

Another serious situation in Manipur is about the Mother to Child Transmission (MTCT) which has shown rapid upward trend from 1.89% in 2003 to 11.1 % in 2007. This area should be given proper attention and the PPTCT programme need more effective application so as to bring down this rapid increase.

The mode of transmission by Blood transfusion has considerably declined in the coming years from a figure of 4.26% in 2003 to a figure of 0.79% by 2007. This is due to mandatory testing of blood for viral bodies before Blood transfusion.

Another area where we need a closer counseling for all patients of HIV-reactive route of transmission-“Non-specific” where no reason was given by the person. The figure varies from 10.2% in 2003 to 8.20% in 2007.

Coming to deaths from HIV/AIDS in J.N. Hospital, it is seen comprising from a figure of 18.95% in 2003 to 17.46 % in 2007, showing, no apparent increase in deaths, but a slightly decreased ratio. The figure is only from the Hospital records but the unreported deaths after discharging from hospital when terminally ill, are not in the record. This high death rate is mainly from the HIV/HCV co-infection which is a major challenge nowadays.

The opportunistic infection (O.I) in HIV/AIDS, which has seen recorded in the Hospital admission are shown as below:
1) Tuberculosis (both nulmonarv & extra-pulmonary)Table 3.

It shows that T.B. infections vary from 38.3% in 2003 to 32.27% in 2007. It is seen that TB is the commonest O.I. in HIV/AIDS as found by other outside studies. The programme needs more effective application to bring from the % of infection.
2) Cryptococcal Meningitis:

The figure shows that cryptococcalmeningitis is the O.I. next to T.B. and the % has shown a slight downward trend, but still very persistent in our Hospital.

3) P.C.P (Pneumocytis Carinii pneumonia)

This O.I. once a serious problem often confused with pulmonary tuberculosis has been decreasing from a figure of 18.48% in 2003 to 5.55% in 2007. The main reason for this decreasing trend may be due to HAART and the primary prophylaxis of co-triamoxazole.
4) Penicillosis (P. marneffii)
Penicilliosis is also common in HIV/AIDS in Manipur. For the first time in India, Penicilliosis was diagnosed from Manipur in J.N. Hospital. This is mostly a skin manifestation, previously misdiagnosed as molluscum contagiosum because of its similarity in skin lesion. If not diagnosed in time, it is a fatal disease. The treatment by Intraconazole is very satisfactory.
Table 3

The figure shows a decreasing trend in Penicililosis infection from 5.69% in 2003 to 4.76% in 2007.

The main reason for this trend may be due to the timely initiation of ART before the patients CD4 count falls much below 200 cells/cumm.

The cerebral toxoplamosis found in PLHA as an 0.1. is not that urtcommon. Cases with headache or seizure disorder in the young must be looked for this disease and treated properly so that no residual neurological deficiets which can handicap them occur. The primary prophylaxis of co-trimoxazole has prevented cerebral toxoplamosis to a great extent.

Other O.I’s like cytomegalorium retinitis (CMV-retinitis), Kaposis Sarcoma and progressive multifocalleucoeucephalopathy(PMLE), have become much rarer after the advent of ART.

HIV/HCV & HIV/HBV
These co-infections are now a major negative prognosis factor in the management of HIV/AIDS. They have the same route of transmission – IDU and transfusion of infected blood. Transmission by heterosexual and mother to child in rare, but also seen’ in MSM. The latest figure of these co-infection in J.N. Hospital as on the 12th July, 2011 is as follows. (3983 ART Patients)

 

Sex wise Distribution

The figures shows that HCV co-infection comprises 18.52%, HBV co-infection of 3.33% and both HCV/HBV co-infection is 0.62% indicating the HCV co-infection is far more than others. Amongst the sex factors, male comprises much more than females having 89.83% in HCV, 77.44% in HBV and 76% both viruses.

Risk Wise Distribution
(From personal series from 2005 – 2008)

The figure show the main route of HCV infection both with or without HIV is IDU- having a figure of 94.02% is co-infection and 62.5% is mono-infection. B.T. incidence is present but is getting decreased nowadays.
In J.N. Hospital the total death from HIV/AIDS patients as on 31/08/2011 is as follows:

The figure shows that HIV/HCV and HIV/HBV co-infection comprises 22.31% amongst the total deaths in our ART centre. The figure indicates the importance of having HCV & HBV treatment in order to bring down the deaths from the co-infection.

As on today, there is no Govt or NGO/CBOs programme to diagnose & treat these co-infections. The treatment of HIV is too costly to be affordable. This is leading to increased deaths in PLHA’s. Nowadays, people are no longer dying from HIV become of ART. Hence need for HCV treatment.

The latest figure of PLHA admission in Pre-ART and On ART as on 31-08-2011 is shown as follows:­

The figures indicate the increasing number of female PLHA as compared to male PLHA’s though males are still more infected. The pediatric figure is not mentioned here because of having a separate paediatric ART centre. But the increasing trend of paediatric HIV/AIDS is a matter of great concern which needs a better effective and preventive strategies.

A very significant issue in ART programme is about the increasing number of clients who are LFU (Lost to Follow-up). The figure in our centre is about 248 clients on ART since the beginning of ART ie from Dec 2004. This may lead to increased number of first line ART failure as well as the increased transmission of resistant viruses in the community. The main back bone of ART success is the adherence factor. Once this is not kept, a lot of unwanted complications may come up which may hamper ART success. Every effort should be done to make minimurn number of LFU in any ART centre.

Conclusion and challenges
ART is now a success story in India and elsewhere. Nowadays, people are not dying from HIV/AIDS. It is seen that the number of deaths from HIV co-infection in our ART centre is increasing day by day because of the simple reason of not having HCY treatment. More people are dying from these co-infections. As on today there has been no commitment either from the Govt or the NGOs for HCV/HIV & HBV/HIV as regard to its diagnosis & treatment.

Management of HIV/AIDS must be a holistic approach. The ART drugs are to be available all the time. The CD4 testing and Hb% & ALT are also necessary for a proper follow up of this disease. The CD4 testing is far from satisfactory in the two ART centres of Imphal E & W. The CD4 testing at Urkhrul, Chandel, CCpur & Thoubal are also having a lot of difficulties—it is either not done because of lack of infrastructure or lack of manpower. PLHA’s are suffering a lot in these centers.

The MTCT (Mother to Child transmission) needs to be geared up. There is lack of awareness about ART initiation in pregnant women in-respective of CD4 count. The prescription of Nevirapine both to the mother and infant is not properly followed. Moreover the institutional delivery of pregnancy is very low. It is known that mother to child infection is mostly during the birth of the baby less so during the pregnancy and at breast feeding. Thus the increasing number of MTCT should be brought down to a minimum.

The management of side effects of ART drugs has to be improved. The early detection of side effects of drugs and its timely replacement by the alternative drug has to be properly implemented. So also for the management of first line ART failure patients need proper functioning without any inconvenience to the client.

Now time has come for the treatment necessity for HCV/HIV co-infection. The treatment is too costly to be done by the majority of PLHA’s. This is giving an increased number of deaths from the co-infection, rather than HIV  alone. For HCV/HBV, there is need for HBsAg screening for all risk persons as well as the general population because HBV vaccination of 3(three) doses in the HBsAg negative person will prevent future infection. The programme is not yet fully practiced but stress is necessary for proper vaccination.

To conclude, all the treating doctors, nurses, the public health workers and the NGO/CBOs are to be fully aware of the various factors and co-factors regarding HIV/AIDS so that the people remain free of any HIV or Hepatitis viruses in our population.

Sources:- The Sangai Express

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  1. Dr Nabakanta Sharma MD
    November 18, 2011 at 7:17 am

    Nice paper

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