To determine the response on treatment-naïve HIV/AIDS patients to the Highly Active Antiretroviral Therapy (HAART) in terms of CD4 Count and Weight gain over a period of 2½ years. Patients with Acquired Immunodeficiency Syndrome (AIDS) were recruited under the Federal Government HighlyActiveAntiretroviral Therapy (HAART) programme at the University of Ilorin Teaching Hospital. The treatment regimen included Lamivudine, Starvudine and Nevirapine. The patients\' responses were evaluatedwith respect toCD4 count andweight over the period of treatment.The diagnosis ofHIV/AIDS wasmade on the basis of reactivitywith two different ELISAreagents, andCD4 countwas donewithDynalT4
Quantmethod. Theweights (kg.) of the patientswere taken atmonthly visit. The duration of treatment for the patients analysed ranged from 1 month to 14 months. Analysis of
CD4 count was possible in 105 patients. The mean post treatment CD4 count and weight were significantly higher than the pre-treatment values (p < 0.001 and p < 1.01) respectively. There were significant positive correlations (p < 0.05 and p < 0.001) between increases in CD4 count and weight respectively, and duration of treatment. In eight (8) patients,CD4Count reduced or remained the same in spite of treatment. TheHAARTregime is associatedwith increase inCD4Count andweight gain.While increases in CD4 Count and weight correlated with duration of therapy, there was no correlation between CD4 Count
increase andweight gain. Keywords: HIV/AIDS Antiretroviral Therapy CD4 Weight.  Nigerian Journal of Clinical Practice Vol. 11 (4) 2008: pp. 312-31

Iseniyi, JO

Odeigah, L

Olatunji, PO

Olawumi, HO

Salami, AK

English

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312INTRODUCTIONHighly Active Antiretroviral Therapy (HAART)refers to a category of treatment regimen usuallycomprising of 3 or more antiretroviral drugs that areexpected to reduce plasma viral levels below thelimits of detection (500 copies/mL). Most HAARTregimens include drugs from at least 2 of the 3classes of antiretroviral therapeutic drugs referred toas Nucleoside Reverse Transcriptase Inhibitor(NRTI), Non-Nucleoside Reverse TranscriptaseInhibitor (NNRTI), and Protease Inhibitors (PI) .Potent combination regimens offer the greatestlikelihood of reducing the replication of HumanImmunodeficiency Virus (HIV); facilitating CD4 Tcell expansion and delaying progression intoAcquired Immune Deficiency Syndrome (AIDS) .Although it is well established that treatment withHAART can lead to CD4 cell gain, full immunerecovery is often incomplete .Some Physicians tend to delay the use of HAARTuntil CD4 cell count falls to 200 in order to123Correspondence: Dr PO OlatunjiE-MAIL:poolatunji@ yahoo.comreduce the associated adverse effect, since it has beenobserved that this does not increase the mortality ratein HIV patients with good compliance . Mortality rateincreases if HAART is initiated below CD4 cell countof 200. Also, non-adherent patients have highermortality rates than those who are adherent withsimilar CD4 cell count. Above the CD4 cell count of200, medication adherence is the critical determinantof survival, and not the CD4 Cell count at whichHAART is begun. Treatment delay however, has beenfound to cause impaired functional immunereconstruction . It has been observed that after theinitiation of HAART, there is usually a rapid increasein CD4 cell count, and on the other hand, there is anearly fall in the count after interrupting therapy .HAART also has a positive effect on CD4 cell countin children with HIV infection . These changes mayhowever be affected by the co-infection withTuberculosis, which has been shown by Salami et alto be associated with a lower CD4 cell count.Involuntary weight loss or wasting is one of the mostcommon manifestations of HIV infection. It canoccur at any stage of infection, regardless of HAARTand indicates disease progression . HAART has435678Nigerian Journal of Clinical PracticeDecember 2008 Vol 11(4):312-315EFFECT OF HIGHLY ACTIVE ANTIRETROVIRAL THERAPY ON CD4 COUNTAND WEIGHT IN AIDS PATIENTS SEEN AT THE UITH, ILORINDepartments of *Haematology & Blood Transfusion ** Medicine, ***General Outpatient Department,University of Ilorin Teaching Hospital, Ilorin, Nigeria.To determine the response on treatment-naïve HIV/AIDS patients to the Highly ActiveAntiretroviral Therapy (HAART) in terms of CD4 Count and Weight gain over a period of 2½ years.Patients with Acquired Immunodeficiency Syndrome (AIDS) were recruited under the FederalGovernment Highly Active Antiretroviral Therapy (HAART) programme at the University of Ilorin TeachingHospital. The treatment regimen included Lamivudine, Starvudine and Nevirapine. The patients' responseswere evaluated with respect to CD4 count and weight over the period of treatment. The diagnosis of HIV/AIDSwas made on the basis of reactivity with two different ELISAreagents, and CD4 count was done with Dynal T4Quant method. The weights (kg.) of the patients were taken at monthly visit.The duration of treatment for the patients analysed ranged from 1 month to 14 months. Analysis ofCD4 count was possible in 105 patients. The mean post treatment CD4 count and weight were significantlyhigher than the pre-treatment values (p < 0.001 and p < 1.01) respectively. There were significant positivecorrelations (p < 0.05 and p < 0.001) between increases in CD4 count and weight respectively, and duration oftreatment. In eight (8) patients, CD4 Count reduced or remained the same in spite of treatment.The HAART regime is associated with increase in CD4 Count and weight gain. While increases inCD4 Count and weight correlated with duration of therapy, there was no correlation between CD4 Countincrease and weight gain.HIV/AIDSAntiretroviral Therapy CD4Weight.*HO Olawumi, *PO Olatunji, **AK Salami,***L Odeigah, *JO Iseniyi.ABSTRACTObjective:Methods:Results:Conclusion:Key Words: (Accepted 18 June 2007)L in ear R e gres s ion-2 50. 00 0. 00 250.00 500.00 750.00cd4 d-20. 00-10. 000. 0010.0020.00AAAAA AA AAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAA AAAAAAAAAAAAAAA AAAAAAAAA AAAAAA AAAAAw eig ht d = 8 .6 9 + 0 .00 * cd 4dR -Sq u are = 0.00Fi gure 1: Reg ress ion of in cre ase in CD 4 (cd 4d ) cou ntversus increas e in weig h t (wei ghtd) in H IV/ AI DS p atien ts o nHAART.313been observed to reduce the impact of HIV diseaseon body weight, in addition to the direct effect onappetite, body composition, and body fatredistribution .Studies have established the positive impact ofHAART especially in patients with serious weightloss of greater than 10% . Other studies havehowever shown that the weight gain of HIV patientson HAART is primarily fat with no changes in leanbody mass . Changes in body weight and Body MassIndex (BMI) have also been found not to correlatewith changes in CD4 or plasma HIV RNA. Patientswith good CD4 and RNA response to HAART wereas likely to experience increase in weight and BMI aspatients with lesser response to HAART . The aimof this review is therefore to examine: i. the responseof HIV/AIDS patients to HAART in terms of CD4Count and weight, ii. the relationship betweenincreases in CD4 Count and weight, and iii. anycorrelation between increase in CD4 Count andincrease in weight.The University of Ilorin Teaching Hospital is one ofthe centres approved by the Federal Government forits programme on the Highly Active AntiretroviralTherapy (HAART) for HIV/AIDS patients. Patientshad pre- and post-test counseling and were recruitedfrom February, 2002 based on reactivity of sera withtwo different ELISA methods. Each patient was thenexamined clinically and weights were taken beforecommencement of the antiretroviral therapy. TheCD4 Cell Count was determined using the Dynal T4Quant by Dynal Biotech ASA, Oslo, Norway.Patients were recruited if CD4 cell count was 200cells/l and below with or without AIDS-definingclinical features, if they had Stage III disease withCD4 cell count less than 350 cell/l, or Stage IVdisease regardless of CD4 cell count values, in linewith Nigeria's Guideline on the Antiretroviraltherapy . Treatment was done with three drugregimen comprising Starvudine, 40mg. twice daily,Lamivudine 150mg. twice daily, and Nevirapine,200mg. twice daily, all taken orally. While ontreatment, patients had their CD4 Cell Count andbody weight among other parameters, monitored andrecorded at three monthly intervals. Prophylacticantibiotics were not offered to the patients exceptthose with evidence of bacterial infections.Analysis of patients' responses in terms of increaseor otherwise of CD4 Cell Count and body weight wascarried out in 185 patients two years aftercommencement of the programme. The pretreatmentCD4 Count and weight were compared to those at thepoint of analysis using the Students' t test while theassociation between outcome measurements andduration of treatment was examined using regressionanalysis.91011121314MATERIALSAND METHODSRESULTSComparison between Pre-Treatment andPost-Treatment CD4 Cell Count and WeightCorrelation of Increase in CD4 Cell Countand Weight with Duration ofTreatmentPatients were recruited at different times during thetreatment period. One hundred and eighty-fivepatients, 91 male and 94 females aged 15 to 66 years,were analysed at the end of two years of the HAARTprogramme. Due to the combination of patientsdefaulting and financial incapacity, only 105 and 149patients respectively had pre and post treatment CD4Count and weight recorded along with period oftherapy. The period of treatment ranged from 1 to 14months with a mean of 5 months.The mean pre-treatment and post-treatment CD4Counts were 218±133 and 370±180 cells/cu. mm.respectively. The difference is statistically significant(p = 0.000). The mean pre-treatment and post-treatment weights were 52.1±10.6 and 59±10.5 kg.respectively, and the difference was statisticallysignificant (p = 0.000) as shown in Table 1. There wasa significant positive correlation between duration oftreatment and increase in CD4 Count (r = 0.24, p =0.013). There was a significant positive correlationbetween the increase in weight and duration oftreatment (r = 0.458, p = 0.000), see Table 2. Therewas no correlation between increase in CD4 cellcount and increase in weight (r = 0.0), see Table 2 andFigure 1. In eight patients the CD4 Count remainedthe same or reduced in spite of the retroviral therapy.Table 1:Table 2:Parameter Pre-treatmentPost-treatmentn pvalueCD4 cell count/cu. mm. 218±133 370±180 105 0.000Weight (kg) 52.1±10.6 59±10.5 145 0.013Parameters Correlated CorrelationCoefficientp valueIncrease in CD4 count vs.Treatment duration0.24 0.013Increase in Weight vs.Treatment duration0.458 0.000Increase in weight vs. Increasein CD4 cell count0.00 0.997Nigerian Journal of Clinical Practice Dec. 2008, Vol.11(4) Antiretroviral Therapy On Cd4 Count Olatunji et alAn index in the assessment of response toantiretroviral therapy.Only 8 patients experienced no improvement in CD4count in spite of treatment. This could be due toinadequate compliance to therapy, lack of response,or very low pre-treatment CD4 count. The kind of dietthat these patients were able to afford is another factorthat should be considered.In conclusion, this study has shown that the HAARTregimen conferred clinical improvement on patientsinvolved as the CD4 count and weight gain representgood indices of response to therapy. Government andNGOs should therefore proceed quickly with theplanned scaling up of the programme to make thedrugs available to more patients. The treatment ofinfected children and prevention of mother to childtransmission should be given the same coverage asfor the HAART programme.We wish to acknowledge the provision of theAntiretroviral drugs by the Federal Government ofNigeria at a subsidized price, which was affordable bymost patients. We are also grateful to Mrs. J.O.Iseniyi, who carried out the HIV screening and CD4cell count.HAART for thetreatment of infection with HIV-1. Biomedicineand Pharmacotherapy 1999; 53: 73-86.HIV treatments and highly activeantiretroviral therapy. Austr. Prescr. 2003; 26:59-61.Nadir CD4 T cell count and numberof CD28 and CD T Cells predict functionalresponse to immunization in chronic HIV-1infection.AIDS 2003; 17: 2015-2023.Starting HAART: is it wise towait?Ann of Intern Med. 2004; 140: 305-306.Changes in CD4 lymphocytecounts after interruption of therapy in patientswith viral failure on protease inhibitor-containing regimens. Royal Free Centre for HIVMedicine.AIDS. 2000; 14: 1717-20.Treatment with highly active antiretroviraltherapy in human immunodeficiency virus type1-infected children is associated with a sustainedeffect on growth. Paediatrics 2002; 109, E 25.ACKNOWLEDGEMENTREFERENCES1. Shafer RW, Vuilton DA.2. Palmer C.3. Lange CG.4. Schooley RT.5. Youle M, Jannocy G, Turnbull W, Tilling R,Loveday C et al.6. Verweel G, Van Russum AM, Hartwig NG,Wolfs TF, Scherpbier HJ, de Groot R.++ +DISCUSSIONThe treatment of HIV/AIDS has changedconsiderably over the last 20 years as knowledge andtreatment options have increased. HAART wasintroduced in 1996 in the industrialized countries andits effects have been established in those countries .Reports since 1999 in the United States of Americaand the Netherlands have associated the use ofHAART with reduction in viral load and increase inweight .Not much work has been done in this part of the worldon this subject before now because the drugs werevery expensive and unaffordable to many patientsuntil recently when it was subsidized by the FederalGovernment. Consequently, many more patients cannow afford to buy the drugs and this development hasmade this study possible.Analysis of the CD4 Cell Count was possible only on105 patients because the CD4 Cell Count is even moreexpensive than the drugs and some patients could notafford to pay. The mean post-treatment CD4 CellCount was significantly higher than the pre-treatmentone and there was a significant positive correlationbetween the post-treatment CD4 count and theduration of treatment. This is in keeping with workdone in the industrialized countries state above .Those with relatively lower CD4 Cell count pre-therapy had a more dramatic increase in CD4 Countthan those with relatively higher CD4 Count pre-therapy. This may be the reason for physicians'preference for delaying the use of HAART until theCD4 Cell Count falls to 200 cell/cu. mm. to avoid theadverse effects of the drugs and moreso when suchdelay does not increase the mortality rate . Thesephysicians however believe that mortality mayincrease if treatment is started at CD4 Cell Countbelow 200. In our study however, patients with CD4Cell Counts below 200 cells/cu. mm. did well on theHAART regimen, especially those who compliedwell with the drugs. Antibiotics were given only topatients with clinical, radiological, and laboratoryevidence of bacterial or mycobacterial infections,since we have previously reported them to beassociated with relatively lower CD4 cell count andreduced survival.The mean post-treatment weight of those patients wassignificantly higher than the pre-treatment weight,and there was significant positive correlation betweenthe weight gain and duration of treatment. The weightgain can be attributed to improvement in the clinicalcondition of the patients, reduction in psychologicalstress as well as a direct effect of the drug on theappetite. However, it is interesting to note that, in linewith the finding of Verweel et al among children,there was no correlation between increase in CD4 cellcount and increase in weight. This implies that weight1,2,81,81,847,136may not be useful as surrogate for CD4 cell count or314Nigerian Journal of Clinical Practice Dec. 2008, Vol.11(4) Antiretroviral Therapy On Cd4 Count Olatunji et al7. Salami AK, Olatunji PO, Oluboyo PO.8. Nemechek P, Polsky B, Gottlieb MS.9. TangAM, Forrester J,Apiegelman D.10. Zuniga-Roiz K, Hernandez-Daly AC, TorresKJ.Spectrum and prognostic significance ofopportunistic diseases in HIV/AIDS patients inIlorin, Nigeria. WAJM 2006; 25: 52-56.Treatment guidelines for HIV associatedwasting. Mayo Clin Proc 2000; 75: 386-94.Weightloss and survival in HIV-positive patients in theera of HAART. J Acquir immune defic. Syndr2002; 31: 230-236.HAART based on a PI sparing regimen,reconstitutes muscle mass in HIV-infectedindividuals with wasting syndrome but not inthose with moderate or no weight loss. XIVInternational AIDS Conference, Barcelona,2002AbstractWepe B5 993.11. Pernerstofer-Schoen H, Schindler K,Parschalk B.12. Wanke C, Ostrowsky B, Gerrior J, Hestnes J.13.14. Salami AK, Olatunji PO, Oluboyo PO,Akanbi II AA, Fawibe EA.Beneficial effects of PI on bodycomposition and resting energy expenditure: acomparison between HIV-infected and non-infected patients.AIDS 1999; 13: 2389-96.Effect of HAART on patients' weight and bodymass index. Int. ConfAIDS 1998; 12 : 1094.Federal Ministry of Health. Guidelines for theuse of Antiretroviral (ARV) Drugs in Nigeria.2005; page 31-31Bacterialpneumonia in the AIDS patients. WAJM 2006;25: 1-5.315Nigerian Journal of Clinical Practice Dec. 2008, Vol.11(4) Antiretroviral Therapy On Cd4 Count Olatunji et al

Effect Of Highly Active Antiretroviral Therapy On CD4 Count And Weight In AIDS Patients Seen At The UITH, Ilorin

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Effect Of Highly Active Antiretroviral Therapy On CD4 Count And Weight In AIDS Patients Seen At The UITH, Ilorin

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