Opportunistic Infections and Hiv Clinical Disease

SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH

62 Vol 38 No. 1 January 2007

Correspondence: Dr Joseph Harwell, The MiriamHospital, Department of Medicine-Division of Infec-tious Disease, 164 Summit Ave, Providence, RI02906, USA.Tel: 401-793-4713; Fax: 401-793-4709E-mail:[email protected]

INTRODUCTION

Cambodia’s first case of HIV was reportedin 1991. Fueled by post-war political and eco-nomic instability, HIV prevalence in Cambodiarapidly increased. Although recent data indi-cate that HIV prevalence has begun to de-crease, without access to adequate economic,professional, and material resources, Cambo-dia has struggled to meet the HIV treatmentand prevention needs of its people as more ofthose infected present with advancing dis-ease. Approximately 1.9% of Cambodiansbetween 15 and 49 years of age are currentlyliving with HIV, and prevalence rates in sub-groups are significantly higher (NCHADS).

While HIV prevalence and risk behaviorsamong sentinel groups in Cambodia aretracked through annual surveillance, data re-garding the health of HIV positive individualsin the region are scarce (Inverarity et al, 2002;Senya et al, 2003; Vajpayee et al, 2003).Cambodia’s neighboring countries have simi-lar HIV transmission patterns, including highrates of HIV infection among sex workers;there are, however, also significant inter-coun-try differences. In both Thailand and Vietnam,for example, a significant percentage of re-ported HIV infections are among injection drugusers in urban centers (Anonymous, 2003a,b);whereas, in Cambodia, the population of in-jection drug users remains small (NationalCenter for HIV/AIDS, 2002). Given regional dif-ferences in pathogens and routes of HIV trans-mission, data collected from previous studiesmay not be generalizable to Cambodia.

With funding from sources such as TheGlobal Fund and the Clinton Foundation, Cam-

OPPORTUNISTIC INFECTIONS AND HIV CLINICAL DISEASESTAGE AMONG PATIENTS PRESENTING FOR CARE IN

PHNOM PENH, CAMBODIA

BN Kong1, JI Harwell2, P Suos3, L Lynen4, S Mohiuddin2, S Reinert5 and D Pugatch2

1University Research CO, LLC, Phnom Penh, Cambodia; 2Brown University, Providence,Rhode Island, USA; 3National Center for HIV, AIDS, Dermatology, and STD, Phnom Penh,

Cambodia; 4Institute for Tropical Medicine, Antwerp, Belgium;5Lifespan Information Services, Providence, Rhode Island, USA

Abstract. This prospective, cross-sectional study sought to assess the spectrum of HIV-asso-ciated complications and disease stage among individuals presenting for first-time care inPhnom Penh, Cambodia between November 2001 and September 2002. One hundred pa-tients participated in this study. All study participants presented with advanced stages of HIVdisease. Seventy-four percent of the subjects had CD4 cell counts <50 cells/mm3. Tuberculo-sis was the most common AIDS-defining illness among participants, with a prevalence of 43%.A spectrum of other opportunistic infections, including cryptosporidiosis (13%), severe bacte-rial infections (12%), cryptococcosis (12%), and Pneumocystis jiroveci pneumonia (10%), wasidentified. These findings underscore the need for widespread HIV treatment and prevention inthis setting. Increased screening for HIV and routine health maintenance for those infected areurgently needed in order to facilitate management of both opportunistic infections and thesecondary prevention of HIV infection.

HIV AND OPPORTUNISTIC INFECTIONS IN CAMBODIA

Vol 38 No. 1 January 2007 63

bodia has begun to scale-up HIV treatmentprograms. These programs must address theallocation of antiretrovirals and other scarcemedical resources. They must also establishprotocols for the management of opportunis-tic infections in a setting with limited diagnos-tic tools. A more in-depth understanding ofthe clinical manifestations of HIV will be im-portant for the development of HIV treatmentprograms and protocols.

This prospective study sought to add tothe existing data regarding clinical manifesta-tions of HIV in Cambodia, with the aim of con-tributing information necessary for effectiveand efficient scaling-up of HIV care in Cam-bodia. This was accomplished both by assess-ing the spectrum of opportunistic infectionsamong HIV infected individuals and by identi-fying patients’ presenting disease stage asdetermined by the HIV staging system of theWorld Health Organization (WHO, 2006).

MATERIALS AND METHODS

Study design and setting

A prospective, cross-sectional study wasconducted among 100 HIV positive patientspresenting for first time care at either SihanoukHospital Center of Hope (SHCH) or at thehospital’s HIV resource center in Phnom Penh,Cambodia between November 2001 and Sep-tember 2002. This study was reviewed andapproved by the institutional review boards ofBrown University, The Miriam Hospital, andSHCH. Written informed consent was ob-tained from all study participants.

Eligibility and enrollment

All adults who tested positive for HIV andwho presented for care for the first time on aMonday, Wednesday, or Friday, were eligibleto participate. Alternate days were chosen toallow for consent and data collection to becompleted given the high volume of potentialsubjects. HIV testing was performed in accor-dance with WHO recommendations (UNAIDS,

1997). Patients whose serum was reactive ontwo rapid assays (Abbott Determine and Dip-stick HIV 1+2), were considered HIV infected.Test results of enrolled patients were con-firmed by Western blot. Patients were referredto the study by HIV testing staff. All study sub-jects received standard pre- and post- HIV testcounseling.

Study procedure

Each participant completed a face to facequestionnaire concerning demographic infor-mation, HIV risk behaviors, HIV knowledge,clinical symptoms, and medical and family his-tory.

Blood samples were taken for completeblood count (CBC), electrolytes, lymphocytesubsets, and serum albumin. Chest X rays, apurified protein derivative (PPD) tuberculosistest, abdominal ultrasound, and a wet mountstool examination were also performed. Addi-tional tests were performed as clinically indi-cated. A stool culture, Clostridium difficile as-say for toxin a (Oxoid Toxin Detection Kit;Sykehuset Asker og Baerum), and modifiedacid-fast staining were conducted for patientspresenting with diarrhea. Non-induced spu-tum samples were obtained from patients pre-senting with a cough, dyspnea, or an abnor-mal chest X ray. This sputum was analyzedfor Gram stain, bacterial culture, acid-fastbacilli (AFB) stain and culture, and Pneumo-cystis jiroveci pneumonia (PCP) immunofluo-rescent stain. A routine and mycobacterialblood culture and a serum cryptococcal anti-gen test were performed for subjects present-ing with fever ≥38.5ºC. A lumbar puncture anda serum cryptoccocal antigen test were com-pleted for patients presenting with central ner-vous system symptoms. A needle aspirationwas performed to obtain a specimen for Gramand AFB stains for patients presenting withinflammatory peripheral lymph nodes. Whenpus was present upon incision or aspiration,a sample was taken for mycobacterial and rou-tine cultures.



Based on clinical and laboratory findings,each patient was assigned a disease stage inaccordance with WHO HIV disease stagingguidelines. In accordance with these guide-lines, only HSV cases with >1 month durationwere considered in assessing HIV diseasestage. As outlined in WHO guidelines, in thisstudy, chronic herpes simplex virus (HSV) wasdiagnosed on clinical grounds without confir-matory laboratory testing.

One month after enrollment, subjects re-turned to the hospital to review their studyresults. The following month, subjects wereasked to meet with study staff to ensure thatdata collection was complete.

All study subjects received standard medi-cal care, and treatment and prevention of op-portunistic infections were in accordance withhospital protocols, including cotrimoxazole forPCP prophylaxis. At the time of this survey, noantiretroviral therapy (ART) was available.

Data analysis and statistical methods

In testing for differences by gender, age,and occupation, the independent-samples t-test, and Pearson chi-square were used forcontinuous and categorical variables, respec-tively. Because the median age of participantswas roughly 35, we considered differencesamong individuals <35 vs ≥35 years of age.Occupation was divided into the followingcategories: farmers, laborers, businesspeople, and soldiers. Those involved in other,less common, occupations were consideredas a group. We used an alpha probability of0.05 as the threshold for statistical significancein two-tailed comparisons. All statistics wereperformed using Stata v.8 (Stata Corp, Col-lege Station, TX).

RESULTS

Study population

Of the 419 patients tested for HIV duringthe recruitment period, 119 (26.5%) testedpositive for HIV. A total of 100 individuals, 39

women and 61 men, participated in the study.Participants were between 20-56 years of age,with a mean age of 34.1 years (SD=7.7 years).Thirty participants were from Phnom Penh,and 70 were from surrounding provinces. Sev-enty-six participants were married, 4 were di-vorced, 11 were widowed, and 9 were unmar-ried. Thirty-six participants were laborers, 28were farmers, 15 were soldiers, and 21 re-ported other occupations.

Laboratory and clinical data

No statistically significant gender differ-ences in laboratory data were identified. Themedian value of the absolute lymphocyte count(n=89) was 855 cells/mm3 (range 170-9,300cells/mm3). The median hemoglobin value(n=88) was 9.25 g/dl (range 4.1-17.6 g/dl).

Among those whose CD4 cell countswere assessed (n=89), median absolute CD4cell count was 15 (range 0-274). Seventy-fourpercent of subjects had absolute CD4 counts≤50 cells/mm3, and in nearly 30% of partici-pants, CD4 counts were <10 cells/mm3.

PCP stains were performed on sputumfrom 36 of 45 subjects presenting with signsof pneumonia. Only 1 of 10 patients believedto have PCP on clinical grounds was found tohave a positive PCP stain on sputum. Morethan half (52.1%) of patients (n=96) had ab-normal chest X rays. Abnormal abdominal ul-trasound findings were recorded in 54.5% ofpatients (n=99). Of the patients (>50%) whoreported having acute or chronic (>3 weeks)abdominal pain, 73% had abnormal abdomi-nal ultrasound findings which included one ormore of the following: lymphadenopathy,hepatomegaly, splenomegaly, and splenic ab-scess. While those with abdominal pain weremore likely to have abnormal ultrasound find-ings, a substantial minority (20%) of asymp-tomatic patients also had abnormal findings.

Opportunistic infections and clinical conditions

Data on clinical conditions are presentedin Table 1. Upon study enrollment, 15 sub-



jects (35% of TB-infected subjects) presentedwith pulmonary tuberculosis (PTB), 18 sub-jects (42%) presented with extrapulmonary tu-berculosis (EPTB), and 10 subjects (23%) pre-sented with both PTB and EPTB. (Ninety-fivepatients underwent PPD testing. During the48-72 hour period following the PPD skin test,no patient developed any induration). Overall,TB of some form was the single most com-mon AIDS-defining illness, diagnosed in a to-tal of 43 patients.

There were two cases of histoplasmosisand no cases of penicilliosis. Two individualsreported mucocutaneous herpes simplex virus(HSV) infection for a duration of >1 month, and

4 additional subjects reported mucocutaneousHSV infections with a duration of <1 month.Weight loss >10% of body weight, oral can-didiasis, and oral hairy leukoplakia were themost common conditions identified among thestudy population; each of these clinical condi-tions affected more than 50% of all participants.Excluding these most common, but not AIDS-defining, HIV-associated complications, themajority (68%) of study participants had 1 or 2concurrent opportunistic infections, and 20%of participants presented with 3 or 4.

Upon analysis of the type of HIV-associ-ated complications among study participants,few statistically significant differences were

Table 1HIV-associated complications (n=100).

n M F p With Without p Phnom Provinces p(n=61) (n=39) infection infection Penh (n=70)

(n=30)

Oral hairy leukoplakia 90 98.4 87.2 0.022 - - - - - -Oral candidiasis 80 73.8 69.2 0.622 - - - - - -Weight loss (>10%) 63 59 69.2 0.302 - - - - - -Esophageal candidiasis 39 36.1 43.6 0.452 - - - - - -Tuberculosis

Extrapulmonary 28 31.2 23.1 0.381 35.4 33.5 0.27 24.1 29.6 0.583Pulmonary 25 24.6 25.6 0.906 36.16 33.4 0.116 27.6 23.9 0.703

Cryptosporidiosis 13 6.6 23.1 0.017 36.6 33.7 0.201 10.3 14.1 0.614 (with diarrhea)Severe bacterial infections 12 14.8 7.7 0.289 36.7 33.7 0.213 20.7 8.5 0.087Cryptococcosis 12 13.1 10.3 0.668 31.8 34.4 0.288 13.8 11.3 0.724Pneumocystis pneumonia 10 8.2 12.8 0.452 33 34.2 0.649 17.2 7 0.123Herpes simplex virus 6 6.6 5.1 0.769 31.7 34.2 0.435 3.5 7 0.492Vulvovaginal candidiasis 3 - 7.7 - 36.3 34 0.606 1.4 6.9 0.144 (women)Isosporiasis 2 0 5.1 0.074 26 34.2 0.136 3.5 1.4 0.509Histoplasmosis 2 1.6 2.6 0.747 21.5 34.3 0.019 3.5 1.4 0.509Non-typhoid Salmonella 2 1.6 2.6 0.747 32 34.1 0.705 3.5 1.4 0.509 septicemiaMycobacterium avium 2 3.3 0 0.253 29.5 34.2 0.401 0 2.8 0.361 bacteremiaMean # of complicationsa 1.6 1.5 1.7 0.271 - - - 1.7 1.5 0.275

aExcluding weight loss, oral candidiasis, and oral hairy leukoplakia

Gender (%) Age (yrs), mean Residence (%)



found by gender, age, or residence. Histoplas-mosis appeared to affect younger patients andhairy leukoplakia was seen more frequently inmales compared to females. The mean num-ber of HIV-associated complications wasroughly the same among persons of variousoccupations; the groups of farmers, laborers,soldiers, and participants with other employ-ment had a mean of approximately 1.5 HIV-associated complications each.

Fifty-nine subjects reported having per-sistent or intermittent diarrhea for more than1 month preceding the interview. Sixty-eightsubjects reported having a prolonged feverduring the same time period.

Disease staging

According to WHO staging system for HIVinfection, all 100 study participants presentedwith advanced stages of disease. Ten percentof participants had stage III disease, and 90%had stage IV disease. The percentage of stageIII and stage IV disease was similar amongboth women and men.

While all subjects presented with oppor-tunistic infections which reflected stage III orstage IV disease, some subjects also pre-sented with additional conditions associatedwith stage II disease. Weight loss <10% wasidentified in 11% of subjects and minor mu-cocutaneous findings were identified in 6% ofsubjects. Twenty-nine percent of participantsreported having herpes zoster within the pre-ceding five years.

DISCUSSION

With respect to clinical manifestations ofHIV infection, few statistically significant dif-ferences were found among the demographicgroups examined. One explanation may bethat the sample size was not adequate to de-tect subtle differences between groups. Dis-tribution of HIV-associated complications wassimilar among women and men. Anthropologicdata are scarce, but given the traditional role

of women as caregivers in society (Ministry ofWomen’s and Veteran’s Affairs, 2003), wemight have expected that men would presentearlier in their disease, whereas women mightdefer their own care while caring for others.This hypothesis was not borne out. We alsodid not find significant differences in the pro-file of complications among women and men.However, gynecologic issues were not a fo-cus of this study, and more research is nec-essary to examine this aspect of HIV disease.Further, we suspected that older persons mayhave been infected with HIV for longer, andtherefore would present at later stages of dis-ease. However, this hypothesis could not besupported. Older patients may have been in-fected later in life and, therefore, have thesame duration of infection as younger patients.Alternatively, those patients who have surviveduntil older age may be those with more robustimmune response. We also suspected thatsubjects’ exposure to various complicationsmay have varied by occupation or by resi-dence in rural or urban areas. However, giventhat persons may have one primary occupa-tion while supplementing their income withadditional activities, data regarding occupa-tion may be unreliable. The same may be saidfor residence, with many Cambodians mov-ing between urban and rural areas for work.

All patients presenting for care for the firsttime had advanced stages of HIV infection.Seventy-eight of 89 (88%) patients had abso-lute CD4 counts < 50 cells/mm3 renderingthem highly susceptible to a broad spectrumof HIV-associated complications. Based onWHO guidelines for the treatment of HIV inresource-limited settings (WHO, 2004), all pa-tients in this cohort were appropriate candi-dates for ART; however, no patients were re-ceiving ART. There is an urgent need for im-proved access to appropriate antiretroviraltherapy in Cambodia.

These findings indicate that clinical ex-amination is an efficient and cost effective



means of determining ART eligibility. Given thatall patients presented at advanced stages ofHIV disease, measuring CD4 cell counts maynot be necessary to ascertain eligibility for ARTat this stage of the Cambodian epidemic.There were similar findings in a retrospectivestudy conducted among another cohort atSHCH; 94% of patients eligible for ART wereidentified based on clinical criteria alone (Chelet al, 2004). As therapy becomes more widelyavailable, however, people may begin topresent while asymptomatic or at earlierstages of disease.

Despite the high prevalence of tubercu-losis among subjects, the results of all PPDskin tests were negative. This inconsistencybetween clinically diagnosed cases of tuber-culosis and PPD skin test results may be at-tr ibuted to several factors. In severelyimmunocompromised individuals with latenttuberculosis, a PPD test may not producesufficient induration (Markowitz et al, 1993).In addition, recent evidence suggests thatthere may be a link between ethnicity and re-sponsiveness to tuberculin skin tests amongpatients infected with pulmonary tuberculosis(Delgado et al, 2004). It is unlikely that inac-curate interpretation of skin tests resulted inthe under-representation of positive results,since all PPDs were thought to be completelywithout induration and were verified by morethan one clinician. As the inconsistency be-tween tuberculosis prevalence and PPD skintest results indicates, in this setting, PPD testshave little value in the diagnosis of tuberculo-sis in symptomatic HIV positive patients. Thor-ough clinical examination and screeningshould be conducted to identify tuberculosisamong patients with HIV. In addition, univer-sal screening for HIV should be conductedamong patients diagnosed with TB.

In this study, PCP staining on sputum ap-peared to have a low sensitivity. While this testis highly dependent on collection technique, itmay be more cost-effective to diagnose PCP

empirically in Cambodia, keeping in mind thatalternative diagnoses, such as fungal or my-cobacterial pneumonias, are also commonamong these patients. A more reliable tech-nique for PCP diagnosis would be the stainingof induced sputum or bronchoalveolar lavage(BAL) (Golden et al, 1986). However, inducedsputum carries a high risk of contamination andcontagion, and patients are often too hypoxicto perform a BAL safely.

The high prevalence of concurrent com-plications also has important implications forhealth care providers. While patients with HIVmay present with symptoms of one opportu-nistic infection, providers must be aware ofthe potential for concurrent infections. This isa major challenge in settings such as Cambo-dia where diagnostic capabilities are limitedand many diagnoses are made on clinicalgrounds. A patient’s failure to respond totherapy may represent an inaccurate diagno-sis or the presence of multiple, concurrent in-fections.

One potential limitation of the study is thatonly symptomatic patients suspected of hav-ing HIV were tested. This may have biased thestudy to enroll only those with advanced HIVdisease. Unfortunately, this reflects the realityin Cambodia; HIV is commonly diagnosed onlywhen patients present for care due to symp-tomatic disease. It is hoped that increasingavailability of antibody testing and effectivetreatment will facilitate diagnosis of asymp-tomatic patients who would also benefit fromprevention and care interventions.

Participants in this study presented at ad-vanced stages of HIV disease. New interven-tions should encourage individuals to seek HIVtesting earlier. Earlier diagnosis will both facili-tate prevention and treatment of opportunisticinfections among HIV-positive persons and helpto prevent secondary transmission. Develop-ment of cost-effective and clinically viable pro-tocols will play a significant role in the scaling-up of HIV prevention and care in Cambodia.



ACKNOWLEDGEMENTS

The authors of this paper would like tothank Poav Sovanna of the Cambodian RedCross for his invaluable contributions to thiswork. This investigation was supported by theFogarty International Center, National Instituteof Health, Program of International Training,AIDS International Training and Research Pro-gram (TW000237).

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Opportunistic Infections and Hiv Clinical Disease