HUMAN T HELPER CELLS IN HIV-1-

INFECTED INDIVIDUALS ON GENERIC

HAART IN UNIVERSITY OF PORT
HARCOURT TEACHING HOSPITAL.

SUMMITTED

BY

DR. E. G. UDOAKA, MBBCh

TO

THE NATIONAL POSTGRADUATE MEDICAL

COLLEGE OF NIGERIA IN PARTIAL
FULFILMENT FOR THE AWARD OF FMC PATH
PART II FINAL EXAMINATION

APRIL, 2009

CERTIFICATION I

1
I hereby certify that this work was carried out by me, Dr. E. G.

Udoaka of the Department of Haematology at the University of Port

Harcourt Teaching Hospital, Choba, Port Harcourt.

Signature:

Date:

2
 CERTIFICATION II

I hereby certify that this work was carried out by Dr. E. G. Udoaka

in the Department of Haematology at the University of Port Harcourt

Teaching Hospital, Choba, Port Harcourt.

Dr. C. A. Nwauche

Ag. Head, Department of Haematology,

Blood Transfusion and Immunology

Signature:

Date:

3
 CERTIFICATION III

We certify that this work was carried out by Dr. E. G. Udoaka in

the Department of Haematology at the University of Port Harcourt

Teaching Hospital, Choba, Port Harcourt.

Supervisors:

1. Prof. O. A. Ejele MBBS (Benin), M.Sc (Birm.), DCP (Lond.),

FMCPath,FWACP. Professor and Consultant Haematologist,

University of Port Harcourt Teaching Hospital, Port Harcourt,

Rivers State.

2. Dr. C. A. Nwauche, B.Med.Sc (Physiology), MBBS, M.Sc

(Lond.), FWACP. Senior Lecturer and Consultant

Haematologist,Ag. Head, Department of Haematology,

University of Port Harcourt Teaching Hospital, Port Harcourt,

Rivers State.

Date:

4
 ACKNOWLEDGEMENT

My sincere thanks go to my supervisors Prof. O. A. Ejele and Dr. C.

A. Nwauche for whole heartedly supervising this work and for the

assistance and encouragement received during this study.

I also thank my beloved wife for standing by me and continuously

encouraging me to forge ahead with this work.

Above all, I give God Almighty thanks for the vision and provision to

carry out this study.

Dr. E. G. Udoaka

April, 2009

5
 DEDICATION

This work is dedicated to my wife, children and God Almighty for

always being there for me.

Dr. E. G. Udoaka

6
TABLE OF CONTENTS

PAGE

1. Title Page i

2. Certification (i) ii

3. Certification (ii) iii

4. Certification (iii) iv

5. Acknowledgement v

6. Dedication vi

7. Table of Contents vii

8. Abstract viii

9. Introduction 1-7

10. Aims and Objectives 8

11. Literature Review 9-37

12. Patients and Methods 38-43

13. Figures and Tables 44-48

14. Results 49-50

15. Discussion 51-56

16. Conclusion and Recommendations 57-58

17. References 59-64

18. Appendix 65-66

7
 ABSTRACT

One hundred patients who were on highly active antiretroviral treatment

+
(HAART) were examined. CD4 cell counts, using manual dynabeads

method, were performed.

The patient’s age group range was between 20-60 years and were

randomly selected, 53 were females while 47 were males. Initial

testing was at entry i.e. before commencement of HAART and the

rest were at 4- monthly intervals for one year.

There was a statistically significant increase in CD4+ cell count (P =

0.001) at 16 weeks and 32 weeks over the baseline CD4+cell count.

However, 6 patients at 32 weeks did not show any statistically

significant increase ( P = 0.7) in the CD4+cell count at 16 weeks. It

is possible these patients may have attained their normal CD4+cell

counts. There was also a corresponding increase in weight of

patients over the same period of study.

These results of 94% increase in CD4+ cell count is an indication of

the efficacy of HAART in these patients.

8
 INTRODUCTION

The Human immunodeficiency virus (HIV) infection constitutes a

huge public health problem in Nigeria and the world at large. The

infection has been spreading at an alarming rate for the past two

decades especially in Sub-Saharan Africa.1

The first alert for an emerging new epidemic called the Acquired

Immune Deficiency Syndrome (AIDS) was reported by the Centre

for Disease Control (CDC) in United State in 1981. The presenting

characteristics of the syndrome included vulnerability to potentially

life threatening opportunistic infections, a profound decrease in the

CD4+ T-lymphocyte count and was presently seen in homosexuals

who hitherto developed a rare multicentric form of skin cancer

called Kaposi’s Sarcoma.2

The initial recognition of this syndrome amongst homosexuals,

intravenous drug abusers and haemophiliacs (who had received

blood transfusion and blood products) was reminiscent of

transmission routes of Hepatitis B virus and had suggested a

transmissible agent as a likely cause of AIDS.2

9
In 1983 and 1984, a new virus called HIV was isolated and

identified as the causative agent of AIDS by Montagnier and co-

workers at the Pasteur Institute, and by Gallo and Associates at the

National Cancer Institute.3 By 1985-1986 the chief route of HIV

transmission (i.e.Blood,sexual contact and mother to child),the main

target cells(CD4+T-Lymphocytes and macrophages) and the

antibody test for HIV had been established. By the year 2007 about

33.0 million people have been reported to be living with HIV; 4 out of

this, 2.0 million were in North America,Western and Central Europe,

5.0 million in Asia and 22 million in Sub-Saharan Africa. More than

25 million people have died from AIDS and its associated illnesses

since 1981.Women accounted for 50% of all HIV/AIDS cases in2007

men 42% and children born to infected mothers, 8%.4 The

seroprevalence for adult in Sub-Saharan African is 5.0%

In United States of America a cumulative total of 571,378 people

living with HIV/AIDS including adults and children above 13 years

has been reported by CDC at the end of 2007 bringing the total

number to 1,051,875 cases since 1981. Out of this 50% have been

reported to have died. AIDS has become the leading cause of death

in the United States of America amongst males aged 25-44 years,

10
accounting for 23% of deaths in this age group and has been noted

to be the third leading cause of death for women in this age group

(accounting for 11% of deaths).2,3 By the end of the year 2007,two

million people died of AIDS despite the recent improvements in

access to antiretroviral drugs .Out of which 1.5 million came from

Sub-Saharan Africa.

The period between 1993-1998 recorded a dramatic decline due to

increased awareness of disease prevention and availability of highly

potent antiretroviral drugs such as protease inhibitors and other

antiretroviral agents.

In Africa the scenario is indeed terrible as 67% of cases globally are

seen in the Sub-Saharan Region. In Botswana about 1 in every 3 is

said to be HIV positive.4,5 In Nigeria by the end of 2007, it was

estimated that 3.1% of the population were living with HIV, which

translates to close to 2.4 million adults. This is the second largest

number in Africa after South Africa. The cross geographical

prevalence in Nigeria is as follows: North West 3.3%; South West

4.0%; North East 5.4%; North Central 5.5%; South East 5.8%;

South-South 7.7o/o.6

11
Estimated number of deaths due to AIDS in 2007 was put at

170,000

This study centre Port Harcourt (Rivers State) falls into the area

with the highest prevalence rate of 7.7%.The prevalence rate of

Rivers state is 6.4%.

The impact created by HIV on the economy and manpower is quite

enormous. In United States of America $90 billion was budgeted to

tackle HIV infection by the year 2000.7,8

In sub-Saharan Africa there has been a drop in the labour force in

all areas due to HIV infection and a resultant low productivity 4. This

in turn has led to poor income generation, increase in dependency

ratio and children dropping out of school.9

The HIV/AIDS pandemic has no respect for social class. In the

University of Nairobi 100 staff both academic and non-academic

died from HIV/AIDS and AIDS related illnesses per annum5. In

Africa as at 2002 about 3 million people have died of AIDS and over

the last 20 years AIDS has claimed the lives of almost 20 million

people worldwide. AIDS has reduced the average life expectancy in

Africa by 15 years2.In Uganda life expectancy has declined from

12
58.6 to 42.5 years as a consequence of the HIV epidemic10.Also in

Kenya 1.1 million children are orphans.As of 2005,2.1 million people

died of AIDS.10

These alarming figures of morbidity have posed a big challenge to

clinicians and scientists to attempt proffering solutions to this

scourge. The development of antiretroviral drugs for treatment of

HIV patients has helped in reducing the mortality arising from AIDS

and other AIDS- related illnesses.

In countries where antiretroviral drugs have been in place there is a

reduction in mortality compared to poor nations where access to

antiretroviral therapy is not readily available. The use of

antiretroviral drugs is still far from the goal of achieving a cure.

However, this palliative treatment has helped in boosting the

immune status of these patients thereby alleviating the problems of

immunosuppression and prolonging life. The treatment of HIV

patients using the antiretroviral drugs entails monitoring using both

clinical and laboratory parameters. The WHO categorized available

tests into four:11

1. Absolute minimum test

2. Basic test

13
3. Desirable test

4. Optional test

The essence of this is that nobody is denied treatment and which

ever test is done depends on the availability of facilities.

The absolute test is a pre-requisite for introduction of

antiretroviral therapy in a national programme and includes HIV

antibody test, Packed cell volume and haemoglobin.

Basic tests are commonly used in clinical settings and are needed

to provide potential life-prolonging care to millions of people. For

example, white Blood cell count with differentials, serum alanine-

aminotransferase and Aspartate- aminotransferases.

Desirable test makes monitoring and evaluation of programme

effectiveness easily achievable. For example the above tests and

CD4 count are good means of monitoring a patient’s response.

Optional tests are used in resource- rich settings, for example viral

load estimation.11

14
In hospitals, in resource-poor settings, the following tests: absolute

minimum test, basic tests and desirable tests, are available for

evaluation and monitoring of HIV patients on antiretroviral drugs.

The aim of this study was to evaluate one of the testing/monitoring

parameters of the desirable tests which is CD4 count in HIV patients

undergoing a specific HAART regimen.

15
 AIMS AND OBJECTIVES

1. To evaluate the efficacy of Lamivudine, Stavudine and

Nevirapine (a specific HAART combination) using CD4 cell

count as a parameter for assessment of response to

treatment.

2. To evaluate the clinical benefits of Lamivudine, Stavudine and

Nevirapine combination therapy.

3. To generate data that will be utilized for policy formulation

with regards to anti-retroviral therapy in our environment.

16
 LITERATURE REVIEW

AETIOLOGY OF HIV INFECTION AND AIDS

The aetiologic agent for AIDS is the human immune deficiency virus

(HIV). It is the most complex and extensively studied virus in

medical history perhaps due to its devastating effect.

HIV belongs to the retroviral family, a family of DNA provirus that is

integrated into the host cell genome. It also belongs to the lentivirus

subclass.

HIV is subdivided into two types: HIV-1 and HIV-2.

HIV-1 is the most predominant worldwide isolate from HIV

seropositive patients. HIV-2 is endemic among people in West

Africa. The strain of HIV-1 that accounts for most of the worldwide

pandemic of AIDS is the group M strains.

Another recognized group of HIV-1 that causes AIDS different from

the M strain is the group O strain. The group O strains are not

consistently tested for by standard assays for HIV antibody

detection.

17
HIV VIRION

The mature HIV virus is an icosahedral particle measuring

approximately 110 nanometers. The outer envelope is acquired

during viral budding and is studded with 72 spikes formed by two

major viral envelope glycoproteins (gp 120 & gp 41). The central

core contains: four viral proteins (p24 – the major capsid protein,

p17 – a matrix protein, p9 and p7), two copies of the HIV RNA

genome to which p7 – a matrix protein, p9 are bound and three viral

enzymes (reverse transcriptase, integrase and protease) that are

essential for viral replication.

18
 HIV VIRION

gp 120

Lipid bilayer
gp 41
Single stranded HIV RNA
(2 copies)

P24 capsid

P9
S
Reverse Transcriptase
P nucleocapsid
7

S
P17 matrix
Integrase

Protease

Figure 1:Diagram of mature HIV virion showing envelope proteins

(gp 120, gp41) in lipid bilayer, core proteins (p24, p17, p9, p7),

diploid single-stranded HIV RNA, and viral enzymes (reverse

transcriptase, integrase, protease) required for replication3

19
HIV GENOME

The generic complexity and heterogeneity accounts for its

pathogenicity. It is a 9-kilobase single-stranded HIV RNA genome

that has three genes (gag, env, pol) essential for retroviral

replications and at least six additional genes that mediate regulatory

or other functions.The Long Terminal Repeats(LTR) are also found in

HIV flanking the functional genes and are responsible for viral

integration by integrase into the host genome.

20
 Table 1 HIV Genes12

HIV GENE Protein Product Function in Life Cycle of HIV

Gag Gag/core protein Viral core proteins P24: Major capsid protein
precursor P17: Matrix protein
P9: Binds to viral RNA
P7: Binds to viral RNA
Env Env/Envelope Viral envelope proteins
protein Gp120: major envelope
Protein, mediates virion
binding to cell surface
Receptor (CD4)

Pol Reverse Converts single-stranded viral RNA into viral

transcriptase DNA duplex.
Integrates viral DNA duplex into host cell
genome as provirus DNA. Cleaves core
precursor pol protein into functional core
proteins.
Tat Tat protein Essential regulatory protein, transactions for
expression of all viral genes.
Rev. Rev protein Regulatory protein activates expression of HIV
structural and enzymatic genes.
Vif Vif protein Involved in viral budding and infectivity of new
virion
Vpu Vpu protein Promotes release of budding virion from host
cell.
Nef Nef protein Regulatory protein (essential for pathogenicity
of HIV)
Vpr Vpr protein Regulatory protein, role uncertain.

21
LIFE CYCLE OF HIV

The chief target cells for HIV infection are the CD4+T – lymphocytes

and macrophages. The CD4 are expressed on the surface of T-

lymphocytes,macrophages,langerhan giant cells,haemopoietic stem

cells and anal mucosal cells. A second coreceptor such as CCR5 or

CXCR4 in addition is necessary for HIV-1 to gain entry to

cells.Infection is initiated by the binding of virion envelope gp120 to

the CD4 receptor on the host cell then to the coreceptor.

CCR5 is a co-receptor for binding macrophage -tropic strains of HIV-

1,whereas CXCR4 is the coreceptor for lymphocyte-tropic strains of

HIV-113.Individuals who possess deletions in CCR5 and produce

mutant forms of the protein may be protected from HIV-1

infection.The requirement for a coreceptor for HIV fusion with cells

provided new targets for antiretroviral therapy.After the initial

sequential binding of the viral envelope glycoprotein gp120 to the

host CD4+T cells, there is a conformational change in gp120

allowing it to bind to either of the CD4 chemokine co-receptors.Once

bound to the co-receptors there is gp41 mediated fusion of viral and

cellular membranes and the viral core and its components – viral

RNA, gag gene protein, and pol gene enzymes are then released

into the host cell cytoplasm.

22
The viral reverse transcriptase converts the single stranded viral

RNA into a single stranded DNA and then into Double Stranded viral

DNA particle. The double stranded viral DNA is transported to the

host cell genome as covalently linked HIV provirus DNA.

The HIV provirus DNA may establish a virus producing infection or a

latent infection depending upon host factors particularly whether the

infected cell is in an activated or resting state.

In favourable cellular environment, the provirus DNA is copied by

the host cell RNA polymerase into viral RNA transcripts that become
spliced into several messenger RNA for precursor proteins encoded
by the gag, pol and env genes. The core protein precursor is cleaved
by the HIV protease. Once assembled, the HIV core containing HIV
RNA (2 copies), core proteins (P24, P17) and pol enzymes (reverse
transcriptase, integrase and protease) moves to the cell surface,
acquires HIV envelope proteins (gp120 , gp41) which then buds
through the plasma membrane and is released as infectious virions.
The latently affected cells do not express viral DNA, viral proteins or
virions but is replicated as DNA by the host cell DNA polymerase
and is transmitted to its progeny through cell division.
Antiretroviral drugs targeting these enzymes are currently in use .

23
NATURAL HISTORY OF HIV INFECTION

The natural history of HIV disease is grouped into primary HIV

infection, the acute retroviral syndrome, the HIV-Specific immune

response through a period of clinical latency to clinically apparent

disease (AIDS- defining illness) and finally death from AIDS.3,14

24
Graph of Natural history of HIV in Relation to CD4+ T-

Lympocytes and Viral Load14

25
PRIMARY HIV INFECTION

The individual acquires the infection and remains asymptomatic for

sometime before clinical manifestations. The duration of clinical

latency varies widely among individuals irrespective of mode of

transmission, viral pathogenicity, host resistance, intrinsic and

specific immune responsiveness.

There are also some HIV seropositive long-term, non-progressors

who have continued to be healthy without evidence of disease or

immune defect for ten or more years after primary HIV infection.3

ACUTE RETROVIRAL SYNDROME

This presents as mononucleosis – like syndrome and develops in 40-

70% of patients at 3-6 weeks after exposure. Symptoms include

fever, headache, sore throat, erythematous rash, diarrhoea and

generalized lymphadenopathy.

There may be leucopenia, anaemia, thrombocytopenia, a typical

lymphocytosis,elevated liver enzymes and

hypergammaglobulinaemia . The peripheral blood CD4/CD8 ratio

also declines.

26
HIV viraemia, P24 antigenaemia, viral transmission, and replication

in lymph nodes occur in this stage.

Antibody- specific response and cellular immune response follows

the primary infection. Serum testing for HIV antibody such as ELISA

(Enzyme-linked immunosorbent Assay) and Western blot (showing 2

or more bands of reactivity with Gag, Env or pol proteins) is positive

in most individuals within 1-3 months after primary infection and

95% positivity within 6 months.3,14

CLINICAL LATENCY

This is the asymptomatic period of HIV infection and has a median

duration of about 10 years though it could be shorter. The

peripheral blood CD4 count returns to normal or stabilized at lower

level or declines slowly over time. The plasma level of HIV viraemia

tends to reach a steady state at the end of acute retroviral

syndrome and so viral load is quite high. During this period of viral

latency cellular infection by HIV is active in the lymphoid tissue and

other tissue compartments.3

27
CLINICALLY APPARENT DISEASE

This symptomatic stage is consequent upon progression of disease

and profound deterioration of the immune system that occurs over a

period of time. The constitutional symptoms include fever, weight

loss, fatigue, night sweat, diarrhoea, persistent and generalized

lymphadenopathy.

The CD4 – T lymphocytes count goes down to the range of between

200 to 400cells/mm3, plasma viraemia and P24 antigenaemia

continue to rise.

The CD4 count continues to fall to a level that defines AIDS (CD4 count less

than 200 cells/mm3) and then predisposes one to opportunistic infections,

neoplastic transformation, HIV encephalopathy, wasting syndrome and

progressive multifocal leukoencephalopathy.3.14

28
PATHOGENESIS OF HIV INFECTION

Besides the direct cytopathic effect of HIV on cells, the mainstay of

HIV infection is immunosuppression by both cellular and humoral

mechanisms. This is due to release of proinflamatory cytokines from

activated stromal cells in the bone marrow and T-helper cells.

NORMAL IMMUNITY

An immunocompetent individual has cellular as well as humoral

mechanisms of natural immunity, acquired immunity mediated by

CD4/CD8 T- cells and specific antibody synthesized by B cells which

protect the host from a myriad of infectious agents such as viruses,

bacteria, fungi and parasites. Macrophages play a pivotal role in the

process of presenting antigenic peptides to specific T-cells,

phagocytic activity and secretion of cytokines. Dendritic cells found

in peripheral lymph nodes especially germinal centres and other

places have long cytoplasmic processes that can localize and

present antigens to responsive T or B-cells.

Natural killer cells kill infected target cells directly or indirectly by

antibody-dependent cellular cytotoxicity. CD4 T-cells have

helper/inducer functions in both cellular and humoral arms of

specific immunity. By cell-to cell contact and local release of

29
cytokines, antigen-responsive CD4+T cells transmit activating

signals to cytotoxic CD8 T-cells, antibody-producing B-cells and

macrophages.4

IMMUNE DEFICIENCY IN HIV INFECTION

Depletion of CD4+ T cells is central to the pathogenesis of HIV

infection.

CD4+ T-CELL

CD4 is first expressed on thymocytes along with CD8. It is a

member of the immunoglobulin supergene family and is a single –

chain transmembrane glycoprotein. Each molecule is associated with

the T-cell- specific tyrosine kinase P56 protein. CD4 and CD8 act as

co-receptors during T-cell activation by antigen.15

CD4 is a 55 kilodalton (55-KD) monomeric glycoprotein that shares

structural features with other receptor molecules encoded by genes

within the immunoglobulin supergene family located at the short

arm of chromosome 12. It consists of 5 external domains, a stretch

of hydrophobic transmembrane residues and a cytoplasmic tail of 40

residues. The terminal amino region has extensive homology to

immunoglobulin light-chain variable region. The amino acid domain

30
forms an intermolecular heterodimer on the T-cell surface. The

cytoplasmic region of CD4 contains 5 serines and threonines, one or

more of which is phosphorylated by protein kinase C upon activation

of T-cells by phormol esters on exposure to antigen. Subsequently

the CD4 glycoprotein is internalized concomitant with T-cell

activation. CD4 and CD8 form integral part of the functional T-cell

receptor complex required for T-cell activation and function upon

exposure to specific antigen. CD4 is also the receptor molecule for

HIV infection.9, 13

Internalization of CD4 upon T-cell activation is thought to facilitate

entry of the virus into those T-cells that are stimulated specifically in

an antigen driven immune response. Monoclonal antibodies specific

for the CD4 glycoprotein can block HIV infection. Also genetically

engineered soluble CD4 can compete with CD4 cells for HIV binding

thereby reducing disease progression.

Disease progression in patients infected with HIV correlates with

depletion of blood T-cell that expresses CD4.16

CD4 is expressed by nearly all T-cells . Most mature thymocytes and

all peripheral T-cells express either CD4 or CD8 but not both. Blood

31
T-cells that solely express the CD4 surface antigen are designated

helper T-cells and they produce 65% of the blood T-cells

lymphokines. Helper T-cells produce lymphokines upon activation by

foreign antigens presented by major histocompatibility complex(MHC)

molecules expressed on the surface of antigen presenting cells. Mature

CD4 T-cells are divided into three subsets designated Th1, Th2, and

Th0 depending on the type of cytokines they produce.

Th1 is the source of interleukin – 2 (il-2), interferon-gamma,

tumour Necrosis factor-B, Tumour Necrosis factor-a and GM-CSF.

Th2 is a predominant source of IL-4, IL-5, IL-10, and IL-13.

Th0 produces all those cytokines and may represent a precursor

population to the other two subsets.17

CD4 and CD8 facilitate T-cell antigen recognition by intersecting

with the glycoproteins of the MHC. CD4 binds to nonpolymorphic

regions of MHC class II molecule.

The depletion of peripheral CD4 T-cells and progression to AIDS is

driven by the HIV viral burden. HIV directly and indirectly mediates

the destruction and depletion of mature CD4 T-cell and also

depletion of CD4 progenitor cells in bone marrow, thymus and

32
peripheral lymphoid organs, resulting in failure of compensatory T-

cell production and eventual collapse of the immune system.18

DIRECT HIV-MEDIATED CYTOPATHIC EFFECTS

Viral cytopathic effects have been observed in cultures of Human

peripheral CD4 T-cells and macrophages infected in vitro with HIV.

The cell kill may involve single cells, cell-cell fusion with syncytium

formation. Another mechanism of direct viral cytotoxicity includes

the accumulation of unintegrated viral DNA which is cytotoxic and

the excessive production and accumulation of gp120 which mediates

virus fusion.19

HIV-SPECIFIC IMMUNE RESPONSES

Normally CD8 T-cells recognize and by contact kill virus-expressing

cells of the same MHC class I phenotype. Activated human CD8 T-

cells are cytotoxic to HIV-infected CD4 cells with surface expression

of env, gag and pol encoded proteins, or cytotoxic to uninfected

CD4 cells with surface- bound envelope proteins. CD8 T-cells can

also produce chemokines that suppress HIV replication in cultures of

acutely infected CD4 T-cells without necessarily killing them. CD8 T-

cell has a pivotal role In the control of HIV infection. The number

and cytotoxic activity of circulating HIV-Specific CD8 T-cell is

33
inversely correlated with the plasma HIV RNA viral load in untreated

patients at different stages of infection.20

The body’s response to antigen by producing antibodies is also seen

in HIV infection. The main antigen is the gp120 of HIV. As infection

progresses. enhancing antibodies appear that bind to the viral

envelope without destroying it and facilitate virus entry into

macrophages and natural killer cells by way of IgG- Fc receptors on

the surface of these cells.

Antibodies to viral envelope proteins can also induce antibody-

dependant cellular cytotoxicity (ADCC) mediated by natural killer

cells and macrophages. In ADCC, target cells bearing surface

antigens such as HIV- gp120 or gp41 are killed when coated with

specific antibody and bound via lgG - Fc receptor to Nk cells or

macrophages.

The Natural Killer( Nk) cells and cytotoxic CD8 T-cells also produce

pore-forming molecules called perforin or cytolysin which have

structural and functional similarity to C9 of the complement system

and bind to cell surface membranes, forming transmembrane

channels that lead to osmotic death of target cells.

34
AUTOIMMUNITY IN HIV INFECTION

A large variety of auto-antibodies to lymphocytes, platelets,

neutrophils, erythrocytes, myelin, CD4, HLA have been detected in

the serum of patients with HIV infection22 .These antibodies then

cause T-cell B-cell dysregulation and molecular mimicry.

About 13-32% of patients are found to have associated auto-

antibodies.22

B-CELLS DYSFUNCTION IN HIV INFECTION

B-cells in HIV patients manifest many functional abnormalities such

as polyclonal activation, hypergammaglobulinaemia. Antibody

production, impaired primary and secondary antibody responses to

microorganisms, especially encapsulated bacterial antigens. The

possible explanation for B-cells hyperactivity is the reactivation of

latent Epstein Bar Virus(EBV) infection or the induction and

secretion of stimulatory cytokines (IL-6) by activated or HIV-

infected macrophages.2

HIV INFECTION OF LYMPHOID ORGANS

Lymph nodes, adenoids, tonsils are the main-anatomical sites of

HIV infection in the early and clinically latent stages of infection.

The frequency of lymphoid organ’s infection is 10-25 times greater

than in peripheral blood. HIV virions are seen in the intracellular

35
spaces along the extended processes of follicular dendritic cells in

the hyperplastic germinal centres of lymph nodes both in early and

clinically latent stages of HIV infection.3

As infection progresses the architecture of the lymph nodes,

germinal centres and follicular dendritic cells network becomes

disrupted apparently contributing to a rising level of plasma

viraemia.3

HIV INFECTION OF BONE MARROW

HIV infects the bone marrow progenitor cells,stromal cells and

accessory cells resulting in varying degrees of myelodysplasias and

abnormal haemopoiesis.Infection of marrow accessory cells,T

lymphocytes,macrophages,fibroblasts and dendritic cells will lead to

overproduction of cytokines which have inhibitory effect on marrow

progenitor cells.The patient may present with varying degrees of

anaemia,thrombocytopaenia and leucopaenia which correlates with

disease progression.

36
OPPORTUNISTIC INFECTION AND CANCER DEVELOPMENT IN

HIV INFECTION

HIV-infected patients develop opportunistic infections as the

immune system begins to deteriorate. They are also prone to

certain forms of cancers such as Kaposi’s sarcoma, non-Hodgkin’s

lymphoma most often of B-cell type and extranodal origin as in

brain and gastrointestinal tract, squamous cell carcinoma of cervix

and cancer of the anus.

Infections such as cytomegalovirus (CMV). Human Papilloma virus

(HPV), Hepatitis B virus and Human herpes virus type 8 have been

found to be associated with HIV- associated Kaposi’s sarcoma15.

MEASUREMENT OF CD4 COUNT

This is a standard test used for staging HIV infection, formulate the

differential diagnosis of patient’s complaints, to make therapeutic

decisions regarding antiretroviral treatment and prophylaxis for

opportunistic pathogens. It is also a relatively reliable indicator of

prognosis that complements the viral load assay.

CD4 count and viral load independently predict clinical progression

and survival23.

37
TECHNIQUE

The standard for determining CD4 count uses flow cytometers and

haematology analyzers and requires fresh blood (less than 18hrs.

old). An alternative method uses Enzyme immunosorbent Assay

(EIA) for example TRAX CD4 test kit24, as well as immunomagnetic

cell isolation using Dynabeads M-450 CD4 kit.

NORMAL VALUES

For most laboratories the reference value ranges between 800-1050

cells/mm3 with a range representing two standard deviations of

approximately 500-1400 cells/mm3,24. In Port Harcourt the

reference value ranges between 475-903 cells/mm,3,25while in Jos

the reference value ranges from 497-1330 cells/mm3.26

FREQUENCY OF TESTING

This depends on the total count on presentation. With CD4 <350

cells/mm3,it is done every 3-4 months; CD4 count >350 cells/mm3

every 3-6 months; CD4 <50 cells/mm3 optional.27

38
FACTORS THAT INFLUENCE CD4 CELL COUNT

These include analytical variation, seasonal and diurnal variations28,

some intercurrent illnesses and corticosteroids. The CD4 count is the

product of three variables the white blood cell count, percentage of

cells that are lymphocytes and the percentage of CD4 cells.

The lowest level is obtained at 12:30 pm and peak values at 8.30

pm.28 These variations do not clearly correspond to the circadian

rhythm of corticosteroids. Modest decrease in the CD4 count has

been noted with some acute infections and with major surgeries.

Acute administration of corticosteroids will cause a profound

decrease in CD4 count but chronic administration does not cause a

significant decrease.29

Co-infection with HTLV-1 may give high CD4 in the presence of

immune suppression from HIV infection. Splenectomy may also give

a high CD4 count. Gender, age, risk category, psychological stress,

physical stress and pregnancy have minimal effect on CD4 count.29.

The CD4 count may be used as a marker of HIV infection in patients

for whom serologic results are delayed or in patient who refused the

test. With CD4<200 cells/mm3 we are dealing with AIDS.

39
According to the CDC(Centre for Disease Control) HIV infection is

classified into stage 1-4 according to its clinical presentations and

CD4 count:30

CDC 1 :Recently observed illness with seroconversion.

CDC 2: Well,no generalized lymphadenopathy.

CDC 3: Well ,with generalized lymphadenopathy.

CDC 4: Significant constitutional disease(AIDS Related Complex or

AIDS) ranging from fever,night sweats,weight loss greater than

10% of initial body weight,diarrhoea for over one month.Other

manifestations such as neurological,opportunistic infections and

neoplasias are also seen.

MANAGEMENT OF HIV INFECTION AND AIDS

As of now the disease does not have a cure. However, the

administration of highly active antiretroviral therapy (HAART)and

treatment of any other complications arising from immuno-

deficiency has remained the mainstay of treatment31.

There are several antiretroviral drugs available in the markets but

the high cost has limited their availability to only a very few

privileged patients, but of recent the Federal Government of Nigeria

40
in its desire to reduce the scourge of mortality arising from HIV has

made drugs available for use free.

Initially a monotherapeutic approach was adopted but because of its

very high rate of drug resistance, combination therapy is

recommended. The optional approach to treatment of HIV patients

requires confirmation of diagnosis, obtaining baseline investigations,

identification of active infections and treating them, prophylaxis to

prevent opportunistic infections and treatment of primary HIV

infection to slow immunologic deterioration.2

Drug therapy is designed to maximize clinical benefits, minimize or

prevent toxicity and maintain comfort and function. There are six

classes of antiretroviral drugs currently available in the market.32

1.The Nucleoside Reverse Transcriptase Inhibitors e.g. abacavir,

zidovudine,didanosine,lamivudine, stavudine, zalcitabine.These

are modified version of cellular nucleosides.The drugs enter the

cell and undergoes intracellular phosphorylation and sebsequently

incorporated into the evolving DNA chain under the action of

reverse transcriptase enzyme.

41
2.Protease Inhibitors e.g. amprenavir, indinavir, nelfinavir, ritonavir,

saquinavir.They bind to HIV protease, inhibiting the cleavage of

post-transcriptional proteins thereby preventing assemblage of new

virion.Has high genetic barrier to resistance.

3. Non-nucleoside Reverse Transcriptase inhibitors e.g.

delavirdine, efavirenz,nevirapine.Binds to reverse

transcriptase and cause a conformational change inhibiting reverse

transciptase in HIV-1. Has low genetic barrier to resistance.

4.Fusion Inhibitors e.g enfuvirtide.Binds to a region called HR1 on

viral gp41 thereby terminating the fusion process.

5.Integrase Inhibitors e.g raltegravir,elvitegravir.The drugs inhibits

strand transfer of viral DNA and prevents the incorporation of the

completed HIV DNA copy into the host DNA cell.

6.C0-receptor antagonists e.g marovirox,vicrivirox.Binds to

chemokine co-receptors leading to a conformational change

preventing interaction with the V3 loop of HIV-1 gp120.

These drugs are marked with adverse drug reactions including

hypersensitivity reactions, haematological complications and general

gastrointestinal complications.The side effects of nevirapine includes

skin rashes,hypersensitivity reactions.Lamivudine toxicity is

associated with pancreatitis,lipodystrophy.The most worrisome side

effect of stavudine is peripheral neuropathy33. These reactions could

42
be so severe that death ensues. However, individual complications

are treated accordingly.

There are several antiretroviral drugs combinations viz

zidovudine/lamivudine/nevirapine33;lamivudine/stavudine/efavirenz;

lamivudine/stavudine/nevirapine etc

Here the commonly used regimen employs the triple therapy in

which we combine two nucleoside reverse transcriptase inhibitors –

Lamivudine, stavudine and non-nucleoside Reverse Transcriptase

inhibitors Nevirapine34. This has proven to be effective in our

environment.35

Also the attraction to this combination is its availability and

relatively low cost.Despite these ,as of june 2006 only 23% of

people living with HIV in Sub-Saharan Africa had access to

antiretroviral drugs.36It is recognized that HAART has resulted in a

decline in mortality from HIV in both developed and developing

countries. In Nigeria as of 2006 only 10% of people living with HIV

had access to antiretroviral drugs.36

The introduction of a protease inhibitor and recently fusion,integrase

and co-receptor inhibitors has helped in reducing drug resistance.

Usually an initial drug trial for 2 weeks to watch out for adverse side

effects, is adopted, and thereafter patient is monitored and

reassessed monthly.

43
The adoption of a multidisciplinary approach in the treatment of HIV

patients is of immense value. Besides the administration of HAART

other associated problems are also treated. These include the

administration of antituberculosis in cases of associated

tuberculosis, treatment of skin infections and other complications

that may arise from the disease itself and drugs used in the

treatment.

Counselling such as pretesting,post-testing,pretherapy,nutritional

and adherance are essential before commencement of HAART.

There has to be a psychological work up as several patients are

depressed. So the need for pre-treatment counselling is very

important. Awareness on how the infection can be spread within and

outside the household is created and patients encouraged to guard

against it. The practice of protected sex, avoidance of sharing of

sharp objects, un-sterilized blades etc are advised.

Its been estimated that between 30-35% 0f HIV patients presents

with depression.37,38

Nutritional rehabilitation is also very important. Most of the patients

are malnourished or undernourished, so the need for good nutrition.

Emphasis is not to limit the number of meals to the usual three

times a day but to advise patients to eat balanced diets for as

44
many times as possible.

The patients are also advised to comply with HAART and possible

side effects and risk of resistance due to non compliance explained

to patients.

Other medical problems which are not limited to HIV infections such

as malaria, upper respiratory tract infections,Immune Reconstitution

Inflammatory Syndrome(IRIS) etc are also treated. Diarrhoeal

disease is treated with the use of anti-diarrhoeal drugs . Anaemia

and other haematological complications arising from the disease

itself or complicating the drugs used in treatment are corrected.

By and large the general well- being of the patient and prolongation

of life can be achieved if all the above steps are taken and patients

encouraged to continue treatment irrespective of constraints.

45
 PATIENTS AND METHODS

POPULATION

A total of 100 confirmed HIV positive patients from the Department

of Haematology and Blood Transfusion of the University of Port

Harcourt Teaching Hospital and referrals from other hospitals were

recruited. They were fifty (53) females and forty seven (47) males.

CLINICAL FEATURES

The patients presented with various clinical features:Sixty one(61%)

presented with reccurrent fever lasting over two weeks,42% with

cough ranging from one week to four weeks,37% with unexplained

weight loss ,six months prior to presentation.Other findings included

diarrhoea seen in 24% of patients, rashes 12%,malaise 10%,recurrent boils

3% and pustular discharge from the ear.There were no complaint in

4% of the patients

INCLUSION CRITERIA

1. Confirmed HIV positive patients aged 18-60 years.

2. Patients with CD4 count less than 500 cells/mm3 of blood.

46
EXCLUSION CRITERIA

1. Patients below the age of 18 years.

2. Patients who were non-compliant to clinic attendance and

antiretroviral therapy.

3. Patients who were positive to HBsAg and HCV screening.

4. Patients with CD4 count > 500 cells/mm3.

CLINICAL PARAMETERS

The clinical parameters included: age, sex, weight, antiretroviral-

naive patients, clinical presentation of patients, social life, occupation and

past medical history.

METHOD

Immunomagnetic cells isolation using Dynabeads M-450 CD14 and

Dynabeads M-450 CD4 were used following the procedure

recommended by the manufacturers39. This provided a fast and

reliable method for capture of CD4 T-cells. The cells were captured

directly from whole blood by density gradient centrifugation. During

a short period of centrifugation the CD4 positive T-cells bound to

Dynabeads CD4, and subsequently the rosetted cells were isolated

after washing using a magnet (Dynal MPC). The test is easy to

47
perform in view of lack of trained personnel to handle

flowcytometers, haematology analysers and EIA. It was also

cheaper for patients considering our poor economic state. Moreover

flowcytometer, haematology analysers and EIA were not available at

University of Port Harcourt Teaching Hospital. The CD4 cell count

was done every 4 month’s for 1 year

SAMPLE COLLECTION:

Three-Four microlitre of blood was collected by clean venepuncture

from each patient into a clean plastic EDTA bottle using size 21G

needle after an informed consent. Each sample was mixed gently

and thoroughly to prevent clotting. The sample was kept at room

temperature and ran within 4-6 hours of sample collection.

REAGENTS AND APPARATUS

1. Three-four microlitre of EDTA preserved fresh whole blood.

2. Capped micro-tubes.

3. Microscope

4. Neubauer counting chamber and cover slip

5. Automatic Micropipette and tips

48
6. Magnetic particle concentrator

7. Spiral mixer

8. Buffer

9. Lysine solution

10. Acridine orange

11. Dynabeads M450-CD14

12. Dynabeads M450-CD4

13. Petri dish with filter paper impregnated with distilled water.

PROCEDURE

Pipette 225 microlitres of buffer into a microtube, then add 250

microlitres of EDTA preserved whole blood and 25 microlitres of

dynabeads M-450 CD14 solution .The mixture was spunned for 10

minutes using a spiral mixer.

It was then removed and placed in a magnetic particle concentrator

for 2 minutes. Two hundred microlitres of the demonocyted blood

was transferred into another microtube, then 200 microlitres of

buffer and 25 microlitres of Dynabeads M-450 CD4 were added. The

mixture was spunned for another 10 minutes using a spiral mixer

and thereafter placed in magnetic concentrator for 2 minutes. This

was washed three times with buffer and supernatant decanted

carefully. The CD4 cells were attracted to the side of the microtube

49
and 50 microlitres of lysine solution added, agitated and allowed to

stand for 5 minutes.Thereafter Acridine orange was added and

allowed to stand for another 5 minutes. The Neubauer chamber was

charged with the mixture and CD4 cells counted using x 40

objective of light microscope. The cells in the central ruled areas of

the new improved neubauer chamber were counted and multiplied

by 10 to convert the volume counted from 0.1ml to 1mm3.

PRECAUTIONS

1. It was ensured that the micro-tubes were well capped with

the content during spinning to avoid spillage so as not to

reduce the final CD4 count.

2. The test was carried out within 6 hours of sample collection to

ensure adequate yield of CD4 cells count.

OTHER USEFUL PARAMETERS FOR MONITORING OF

PATIENTS ON HAART

Full Blood Count(FBC),Erythrocyte Sedimentation Rate(ESR) and

Weight were also measured

50
STATISTICAL ANALYSIS

The data obtained were analysed using a computer with EPI info

version 6 software, 2003 edition. The level of significance used was

0.05 (p<0.05)

51
Table 2: The frequency of male & female in the study

population.

Sex Frequency Percentage Cumulative

F 53 53.0% 53.0%

M 47 47.0% 100.0%

Total 100 100.0%

52
Figure 2: Age distribution of the study population in years
26%

20 – 30
9% Y ye
31 - 40
46%
41 - 50

19% 51 - 60

53
Figure 3: Baseline CD4 count 1 distribution.

1%

100 – 200
31%
31%
201 - 300

301 - 400

> 400
37 %

54
Figure 4: CD4 count 2 distribution.

10.8%
10.8%
100 - 200

201 - 300

32% 301 - 400

46.0% > 400

55
Figure 5: CD4 count 3 distribution.

2.7%
29.7%
100 - 200
29.7%
201 - 300

301 - 400

> 400
37.9%

56
 RESULTS

One hundred confirmed retroviral-positive patients (53 females) and

(47 males) were studied. The mean age was 36.92 years (SD 9.19)

with a range of 20 – 60 years.

On comparison of the results between baseline CD4 count (CD4

count 1) with CD4 count 2 at week 16, the baseline CD4 range is

100-480 with a mean +1 SD of 253.890 + 82.576 while the CD4

count 2 (week 16) range is 140 – 880 with a mean +1 SD of

329.459 + 122.564 (and a p-value of 0.00000.) The week 32 CD4

count 3 range is 100-600 with a mean +1 SD of 364.054 + 99.790

(and a P-value of 0.00000.)

On comparison of the results between baseline CD4 counts and the

CD4 count at 16 weeks there were significantly increased counts

(P≤0.00000.) The same pattern was seen at 32 weeks. At baseline

37% of the study population presented with a CD4 count between

201-300 cells/mm3 and there was an increase to 37.9% and 38.7%

at 16 weeks and 32 weeks respectively.

At baseline the lowest Total Lymphocyte Count(TLC) of 0.48x10 9/L

and highest TLC of 5.3x109/L were recorded.There was no

57
significant diference between week 16 TLC and that of week 32

(p=0.1)

The lowest baseline ESR of 13mm/hr Westergreen and highest

value>150mm /hr Westergreen were recorded.At week 16, lowest

and highest ESR were 10mm/hr Westergreen and 63mm/hr

Westergreen respectively.The week 32 lowest and highest results

were 9mm/hr Westergreen and 40mm/hr Westergreen respectively.

The lowest and highest baseline Packed Cell Volume(PCV) were 16%

and 43% respectively.At week 16 the lowest and highest PCV were

32% and 45% respectively.The lowest and highest PCV at week 32

were 33% and 45% respectively.

The lowest and highest baseline platelets count were 90x10 9/L and

524x109/L respectively.At week16 the lowest and highest platelets

count of 165x109/L and 400x109/L respectively were recorded.Week

32 lowest and highest platelets count were 200x109/L and 400x109.

Three percent (3%) presented with eosinophilia of 3.16x109

Monocytes count were within normal range (0.73x109)

The lowest and highest body weights at baseline were 36

kilogrammes(kg) and 97kg respectively.Week 16 lowest and highest

body weights were 45kg and 107 respectively.The lowest and

highest body weights at week 32 were 46kg and 107kg respectively.

58
DISCUSSION

In this study the CD4 cell counts at baseline were below normal

values with the lowest value of 100 cell/mm3 and highest value of

480 cells/mm3.This can be explained by the fact that the exclusion

criteria in this study excluded patients with CD4 count above 500

cells/mm3. Patients with CD4 cells count below 100 cells/mm3 are

more likely to be very ill with AIDS and could not be managed on

out-patient basis.

CD4 cell count has been reported to be on the decline with

worsening HIV/AIDS infection.40 Stein DS.etal, reported that CD4

count level is related to disease progression and survival in patients

with HIV infection.Survival outcome amongst HIV/AIDS patients40is

determined by the level of CD4 count of the patient.The higher the

CD4 count of the patient,the higher the immune status. The decline

in CD4 cells of HIV/AIDS patients could be as a result of direct

attack of the CD4 cells by the virus. Using the combination of

nucleoside reverse transcriptase inhibitor (NRTI) – Lamivudine and

Stavudine and Non-Nucleoside Reverse Transcriptase Inhibitor

(NNRTI) – nevirapine for treatment helps in reducing infectivity of

59
the CD4 cells. This is also explained by the inverse relationship

between CD4 cells and viral load. The greater the CD4 cell count the

fewer the viral load14.

Several factors play a role in the decline of CD4 cells count of HIV

patients on treatment including non-compliance to drugs, drug

resistance and associated opportunistic infections. In this study,

there was a 6% decline in CD4 cell count among the population

studied with the antiretroviral regimen used. Since compliance was

measured based on clinic appointments and direct questioning on

the use of the drugs one cannot really ascertain whether this

subpopulation actually complied with drug ingestion.The antiretroviral

drugs help in reconstituting the immune system hence increase in

CD4 cell count.

The patients studied did not receive any other immune booster

drugs except the antiretroviral drugs and it was found that there

was a significant increase in CD4 cell count at week 16 above the

baseline( P < 0.05.) Similar picture was seen at week 32 ( P <

0.05). However between week 16 count and week 36 some patients

(15%) did not show a significant increase in CD4 cell count. That is

there was no sustained rise in CD4 count after week 16. Here, drug

60
resistance and non- compliance could be a factor and some may

have attained peak CD4 count levels.The only measure of

compliance/adherence was based on regular clinic attendance and

questioning.

The lowest TLC of 0.48x109/L seen at baseline correlated with the

lowest baseline CD4 count of 100 cells/mm3. At week 16 the TLC

increased to 1.6x109/L and this correlated with the increase in CD4

count following HAART.However the week 32 TLC did not show any

significant increase (P=0.10.) This is due to the presence of CD4

receptors on T-lymphocytes.

The lowest PCV of 16% was recorded at baseline but at week 16 it

was 32% while at week 32 it was 33%. There was a significant

increase at week 16 (P<0.05) while there was no significant

increase at week 32 (P=0.20).Fifteen (15%) of the patients at

baseline presented with anaemia which may be due to

autoantibodies produced against the red cells21 or marrow

suppression from HIV infection30.

The lowest platelets count of 90x109/L was recorded at

baseline.However platelets count normalized at week 16 and week

32.Two(2%) of the patients presented with thrombocytopenia

(platelets count <100x109/L).Autoimmune antibodies against the

platelets may be a factor.

61
Three(3%) of the patients presented with eosinophilia ( eosinophil

count >0.5x109/L).Patients with HIV infection are proned to

parasitic infections which could be the cause.However screening for

parasitic organisms was not done.Following treatement with HAART

and antihelminthic(albendazole) the eosinophil count returned to

normal.(0.35x109/L)

The lowest baseline ESR was 13mm/hr Westergreen and the highest

was >150mm/hr Westergreen.That is all the patients presented with

raised ESR.At week 16 minimum ESR recorded was 10mm/hr

Westergreen ,which is within normal range was seen in 15 patients

(15%).At week 32 the ESR had droped to 40mm/hr Westergreen in

47 patients (47%) against >150mm/hr Westergreen recorded at

baseline.The improvement in ESR may be due to alleviation of

anaemia and response to therapy.

The weight of the patients also showed a significant increase (P <

0.05) in the population studied. The lowest baseline weight was

36kg and the highest 97kg. At week 16 the average minimum

weight was 45kg and average maximum weight 0f 107kg. Week 32

weights did not show any significant change against week 16. This

can be explained by the fact that most of the patients might have

attained their pre HIV/AIDS positive weight.

62
The increase in weight vis-à-vis the CD4 cell count showed the

response of these patients to the combination of drugs used.

Smit E etal reported increased weight loss in patients with severe

HIV- infection.41

The drugs are also said to stimulate appetite, with increased

feeding, thereby causing weight gain. Good nutrition would have

also helped in boosting the immune system of individuals.

The bulk of the patients studied, 62.2% ,were people within the age

of 20 – 40 years with the rest, accounting for only 37.8% ,within

the age of 41 – 60 years. The lowest age was 20 and the oldest 60

years. These ages were randomly selected with no bias. The people

within the age of 20 – 40 years can also be said to fall into the

sexually active group. Females accounted for the greater percentage

(53%) of the study population. The low percentage of study

population (9%) of patients in the age group 51 – 60 years may

correlate with lower sexual activity amongst this age group.

This study shows that CD4 count monitoring is a reliable monitoring

parameter for measurement of therapeutic outcome in HIV-1

infected patients.In these patients the clinical features improved

with treatment and increased in CD4 count.

63
LIMITATION

This study used the Dynabeads method for CD4 count measurement

which is very cumbersome and time consuming. A fast, more

accurate method should be employed for CD4 count measurement.

I strongly recommend the flowcytometric method for sample

analysis which is less cumbersome and more reliable for CD4 count

measurement.

64
CONCLUSION

This study has shown that the treatment of HIV/AIDS patients with

the HAART combination Lamivudine, Stavudine and Nevirapine, is

highly effective. Most of the patients studied showed a significant

rise in CD4 count at week 16 and at week 32. Only 6% showed no

significant rise in CD4 count.

Most of the patients monitored over the period showed a significant

increase in weight over the baseline weight. However (10%) did

not show any significant increase in weight. There is a strong need

for adequate nutrition in the treatment of HIV/AIDS patients.

Besides CD4 count and weight, the TLC and ESR may be strong

markers for monitoring HIV Progression during treatment in

resource-poor settings.

The age and sex of patients did not play any significant role in this

study.

65
RECOMMENDATION

Since this combination Lamivudine, stavudine and Nevirapine has

been proved to the effective, it should be regarded as the gold

standard for the treatment of HIV/AIDS patients especially in

resource -poor settings like ours.

66
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72
APPENDIX

ADCC Cytotoxicity
C Complement
CD Cluster of Differentiation
CMV Cytomegalovirus
DNA Deoxyribonucleic Acid
EBV Epstein Barr Virus
EDTA Ethylene Diamine Tetra-acetic Acid
EIA Enzyme Immunosorbent Assay
ELISA Enzyme LinKed Immunosorbent Assay
FC Crystallizable fragment
GM-csf Granulocyte Monocyte-Colony Stimulating factor
gp glycoprotein
HAART Highly Active Antiretroviral Therapy
HBSAG Hepatitis B Surface Antigen
HCV Hepatitis C Virus
HIV Human Immunodeficiency Virus
HLA Human Leukocyte Antigen
HPV Human Papilloma Virus
HTLV Human T-lymphotropic Virus
IgG Immunoglobulin G.
IL Interleukin
KD Kilodalton
MHC Major Histocompatibility Complex
NK Natural killer

NNRTI Non-nucleoside Reverse Transcriptase Inhibitor

NRTI Nucleoside Reverse Transcriptase Inhibitor

73
RNA Ribonucleic Acid

74