Sanjim Chadha

Clinical and Microbiological Profile of HIV/AIDS Cases with Diarrhea in North India

Intestinal infections are a significant cause of morbidity and mortality in people living with HIV/AIDS (PLWHA) especially in developing countries. The present study was conducted to assess the clinical and microbiological spectrum in HIV/AIDS cases with diarrhea and to correlate the occurrence of such pathogens with stool characters, HIV seropositivity status, and CD4 counts. Stools from 154 HIV seropositive subjects and 50 HIV negative controls were examined by direct microscopy, fecal cultures, and serological tests (Clostridium difficile Toxin A, Cryptosporidium antigen, and Entamoeba histolytica antigen ELISA). CD4 T cell enumeration was done using FACS count (Becton Dickinson). The study showed a male preponderance (112 males and 42 females). Weakness, abdominal pain, and anorexia were the most common symptoms. Coccidian parasites were the most common cause of diarrhea in HIV seropositive cases. C. parvum was seen in 60.42% while Isospora belli in 9.03%. Amongst the bacterial pathogens C. difficile was detected in 18.06%, diarrheagenic Escherichia coli in 11.11%, and Shigella spp. in 2.78%. Pathogen isolation rates were more in HIV seropositive cases and subjects with low CD4 T lymphocyte counts. Regular monitoring of CD4 T lymphocyte counts and screening for enteric pathogens will help improve the quality of life for PLWHA.

Hepatitis B Infection in Microbiology Laboratory Workers: Prevalence, Vaccination, and Immunity Status

The risk of contracting HBV by health care workers (HCW) is four-times greater than that of general adult population. Studies have demonstrated that vaccine-induced protection persists at least 11 years. High risk groups such as HCWs should be monitored and receive a booster vaccination if their anti-HBsAb levels decrease below 10 mIU/mL. In view of the above this study was undertaken to assess the HBV vaccination of the HCWs and their immunological response. Seventy-two HCWs of the Department of Microbiology, Maulana Azad Medical College, New Delhi, India, were recruited and blood sample was drawn for serological tests (HBSAg, anti-HCV, anti-HBsAb, anti-HBeAb, and anti-HBcAb). Anti-HBs titers of >10 mIU/mL were considered protective. Thirty-four (47.3%) of the participants were completely vaccinated with three doses. 25 (73.5%) of the participants with complete vaccination had protective anti-HBsAb levels as against 8 (53.3%) of those with incomplete vaccination and 9 (39.1%) of those who were not vaccinated at all. One of our participants was acutely infected while 29 participants were susceptible to infection at the time of the study. All HCWs should receive three doses of the vaccine and be monitored for their immune status after every five years. Boosters should be administered to those who become susceptible.

A Comparison of Nested PCR Assay with Conventional Techniques for Diagnosis of Intestinal Cryptosporidiosis in AIDS Cases from Northern India

Cryptosporidiosis is a very important opportunistic infection and is responsible for significant morbidity and mortality in HIV/AIDS patients. Although current laboratory methods are generally considered adequate to detect high concentrations of oocysts, they fail to detect cases of cryptosporidiosis in many immunocompromised patients. The present study was done to determine the diagnostic efficacy of modified Ziehl-Neelsen (ZN), antigen detection ELISA, and a nested PCR assay for detection of Cryptosporidium in 58 adult AIDS cases with diarrhea from the ART clinic of Lok Nayak Hospital, New Delhi. Cryptosporidium was detected in 17 (29.4%), 39 (67.3%), and 45 (77.5%) cases by modified ZN staining, antigen ELISA, and nested PCR assay, respectively. Taking nested PCR as the gold standard, specificity of both modified ZN staining and Cryptosporidium antigen detection ELISA was 100% while the sensitivity of the tests was 37.8% and 86.6%, respectively. PCR was more sensitive than the other two diagnostic modalities but required a more hands-on time per sample and was more expensive than microscopy. PCR, however, was very adaptable to batch analysis, reducing the costs considerably. This assay can therefore have considerable advantages in the treatment of immunosuppressed individuals like AIDS patients, allowing their early diagnosis and decreasing the morbidity and the mortality.

Utility of Serum Neopterin and Serum IL-2 Receptor Levels to Predict Absolute CD4 T Lymphocyte Count in HIV Infected Cases.

A prospective study was carried out to evaluate the efficacy of serum neopterin and soluble IL-2 receptor (sIL-2R) concentrations in comparison to CD4 count to study the progression of HIV disease and monitor response to ART in HIV cases. One hundred newly diagnosed HIV seropositive subjects were recruited. CD4 counts were determined by FACS system. Serum neopterin and sIL-2R levels were measured using enzyme immunoassay. In our study, levels of neopterin and sIL-2R were significantly higher in subjects with CD4 <200 cells/μL (with S. neopterin levels of >25.1 nmol/L and sIL-2R levels of >47.1 pM as cutoff values for CD4 <200 cells/μL) compared to those in subjects with CD4 >200 cells/μL at baseline which indicate that these markers can be utilized for initiation of ART in HIV cases. The levels of these markers decreased significantly after initiation of ART. In patients with CD4 >200 cells/μL, these markers are helpful in predicting disease progression.

Chlamydia trachomatis Infection in HIV-Infected Women: Need for Screening by a Sensitive and Specific Test

Reproductive tract infection (RTIs)/sexually transmitted infections (STIs) are recognized as a major public health problem, particularly due to their relationship with HIV infection. Early detection and treatment of Chlamydia trachomatis infection (CTI) among HIV-infected and HIV-uninfected women may impact heterosexual HIV transmission. A total of 120 participants were enrolled: 30 HIV seropositive women with symptoms of RTIs, 30 HIV seropositive women without symptoms of RTIs, 30 HIV seronegative women with symptoms of RTIs, and 30 HIV seronegative women without symptoms of RTIs. One endocervical swab was collected from all participants and CTI was detected by real-time PCR (COBAS TaqMan CT Test, v2.0). CTI was detected in 4 (6.67%) HIV-infected women and in 1 (1.67%) HIV-uninfected woman (OR 4.214; 95% CI 0.457–38.865). Vaginal discharge was present in almost half of HIV-infected and HIV-uninfected women; lower abdominal pain was present in 11 (18.3%) of HIV-infected and in 9 (15%) of HIV-uninfected women. This study showed that CTI is more prevalent among HIV-infected females as compared to HIV-uninfected females. As the use of real-time PCR is not feasible in most hospitals, efforts should be made to develop a simple, sensitive, and specific test to identify women with CTI for prevention of sequelae and HIV transmission.

Enteric Pathogens, Immune Status and Therapeutic Response in Diarrhea in HIV/AIDS Adult Subjects from North India

Intestinal infection causing diarrheal disease is a dominant contributor to high morbidity and mortality in developing countries. This intervention study aimed to assess the response of specific anti-microbial and anti-retroviral therapy (ART) on enteropathogens identified in HIV/AIDS adult subjects from northern India. Seventy five ART naive (group 1) and seventy five ART adherent (group 2) HIV/AIDS adult subjects with diarrhea were enrolled. Stool samples from all subjects were examined for enteropathogens by wet mount, staining methods, culture and ELISA. Subjects with enteropathogens were started on specific therapy as per National AIDS Control Organisation, Government of Indias guidelines. Follow-up stool samples were examined after 2-4 weeks of completion of therapy for persistence/clearing of enteropathogens. CD4+ T lymphocyte count was done for all subjects. At enrollment, group 1 had 26.13% bacterial, 57.66% parasitic & 16.22% fungal pathogens while group 2 had 11.9%, 69.05% & 19.05% pathogens, respectively. Parasitic diarrhea was more common than bacterial diarrhea. The coccidian parasites (Cryptosporidium spp. & Isospora belli) were the common parasites identified. Clearance of enteric pathogens was significant after specific anti-microbial therapy (p = 0.0001). Persistence of enteropathogens was seen primarily for coccidian parasites. Clearance of enteropathogens after specific therapy and the diagnostic yield of stool specimens were influenced by the CD4+ counts. Immune competence coupled with specific anti-microbial therapy displays the best response against enteric pathogens.

Socio-demographic and immunological profile of HIV patients attending ART clinic in a tertiary care hospital in North India

Background: The epidemiology of HIV should be understood especially with regard to various socio-demographic factors because the most effective approaches for its prevention and control are awareness and life style changes. Aim: This study was undertaken to determine the socio-demographic characteristics and immunological profile of HIV seropositive patients attending the antiretroviral therapy (ART) clinic of Lok Nayak hospital in New Delhi, India. Methods: Two hundred and fifty two, HIV seropositive subjects were enrolled in the study irrespective of their ART status. Subjects were staged as per the World Health Organization (WHO) staging system and the socio-demographic data and clinical signs and symptoms were recorded for all subjects on a predesigned performa. CD4+ T lymphocyte count was determined by the Fluorescent Activated Cell Sorting (FACSCount TM ) system . Results: Mean age of study subjects was 33.6 years ± 8.3 years, 66.3% were males, 73.4% were married, 27.7% were illiterate. 32.9 % of subjects were employed in unskilled and semiskilled occupations. Majority of patients belonged to upper lower social class as per the modified Kuppuswamy’s scale. 72.2% had acquired infection through the heterosexual route. 66.3% of the cases were in WHO clinical stage I & II of illness at the time of registration. The median CD4+ T lymphocyte count for all patients was 279 Cells/ µl.

Disease progression and antiretroviral therapy in newly seropositive HIV subjects in a tertiary care hospital in North India

INTRODUCTION In developing countries the standard methods used to monitor HIV disease progression and therapy response are clinical assessment, CD4+ T lymphocyte count measurement, and plasma viral load (PVL) quantification. These tests require expensive equipment and skilled technicians, so monitoring HIV in resource-limited countries remains challenging as few laboratories can offer these tests free of cost. METHODOLOGY Newly diagnosed HIV seropositive subjects (n = 130) were categorized into three study groups: CD4 counts < 200 cells/µl (group A, 43 subjects); 200-500 cells/µl (group B, 44 subjects); and > 500 cells/µl (group C, 43 subjects). At recruitment, PVL estimation was performed for group A subjects only, who were then initiated on highly active antiretroviral therapy (HAART) and were followed up after six months for evaluation of response to HAART by measuring the CD4 counts and PVL. Groups B and C were followed up after six months to monitor disease progression by measuring only CD4 counts. RESULTS Among group A subjects, a rise in the median CD4 counts after six months of HAART was observed. At baseline, PVL ranged from 2636 to > 750,000 copies/ml with a median PVL at baseline of 165,000 copies/ml. At follow-up, 90% of the study subjects had undetectable levels of viraemia. Among group B and C subjects, a fall in the CD4 counts at follow-up was observed. CONCLUSIONS CD4 count is a powerful tool to determine response to antiretroviral therapy (ART) and monitor disease progression in HIV/AIDS. PVL is important to assess response to ART, especially in immunovirologic discordant responses.

Early Diagnosis of Primary HIV Infection by Fourth Generation ELISA in Spouses of HIV-Positive Patients and STD Clinic Attendees.

Dear Editor, Use of only antibody-based assays may delay or miss the diagnosis in individuals with recent HIV acquisition who are capable of transmitting HIV to others. By the use of improved diagnostic approaches like fourth-generation enzyme-linked immunosorbent assay (ELISA), HIV RNA PCR, these individuals can be diagnosed in a timely manner. Although nucleic acid testing is highly sensitive and specific, it is highly time consuming, laborious, and expensive. The current study was undertaken to assess the capability of fourth-generation ELISA to reduce the diagnostic window period in primary HIV infection. The study was conducted from April to October 2009. Eighty seven participants were recruited, which included spouses of HIV-sero-positive patients (77) and sexually transmitted disease (STD) clinic attendees with multiple sexual partners (10). Participants were tested for HIV using 3 different rapid antibody tests and second and third-generation ELISA. Sera that were negative by both rapid tests and ELISA were tested by fourth-generation ELISA (Genscreen plus Ag-Ab test: Bio-Rad Laboratories, Hercules, California). Samples positive by fourth-generation ELISA were confirmed by reverse transcription polymerase chain reaction (RT-PCR) using AMPLICOR HIV-1 Monitor test, version 1.5, following the standard procedure. Out of the 77 spouses, 12 were negative by the rapid tests and ELISA (both second and third generation). One out of these 12 sera was positive by fourth-generation ELISA. However, this patient exhibited a viral load of <400 copies/mL. Repeat RT-PCR was performed after 1 week, which exhibited a viral load of 1000 copies/mL. Out of the 10 STD clinic attendees, 7 were negative for HIV by rapid tests and ELISA (both second and third generation). Among these samples, on testing by fourth-generation ELISA, only 1 was found to be positive. This patient showed a viral load of 1726 copies/mL (Table 1). In our study, rapid tests and ELISA (both second and third generation) failed to detect 2 of the total 87 samples tested. In one study from India, the performance of fourth-generation ELISA was evaluated and it found discordant results in 0.03% cases compared to 2.2% in our study. On the contrary, another study gave conflicting results in which a suspected HIV-positive case was tested with a fourth-generation HIV screening test and was found to be negative but 7 days later, a second blood sample was tested for HIV antibodies and was found to be positive. The results of our pilot study indicate that fourth-generation ELISA may be able to detect a small number of persons, who may be in the window period of HIV infection; however, larger studies are required to validate this observation.