TABLE OF CONTENTS
Page
Title page……………………………………………………………….…………..i
Abstract……………………………………………………………………………ii
Project certification……………………………………… ………………………….v
Dedication………………………………………………………………………….vi
Acknowledgement…………………………………………………………….…..vii
Table of contents………………………………………………………………….ix
List of tables……………………………………………….…………………….xi
CHAPTER ONE : INTRODUCTION…………….………………………………….1
1.1 Background………………………………………………………………………………………..1
1.2 Design ……………………………………………………………………………………………..5
1.3 Aim ………………………………………………………………………………………………..6
1.4 Objectives………………………………………………………………………………………..6
CHAPTER TWO : LITERATURE REVIEW……………..…………………….8
2.1 Disease burden of HIV / AIDS……………………………………………………………..8
2.2 WHO Clinical staging for HIV/AIDS…………………………………………………..9
2.3 Antiretroviral drugs…………………………………………………………………………..12
2.4 Antiretroviral therapy……………………………………………………………………….13
2.4.1 WHO key recommendations on antiretroviral therapy……………………14
2.5 Serum selenium, zinc and magnesium in HIV infection……………………….21
2.5.1 Selenium in HIV infection………………………………………………………………22
2.5.2 Zinc in HIV infection……………………………………………………………………..25
2.5.3 Magnesium in HIV infection…………………………………………………………..29
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2.6 Body mass index………………………………………………………………………………31
2.7 Hypertension………………………………………………………………………………….34
2.8 Diabetes mellitus…………………………………………………………………………….38
2.9 Dyslipidaemia………………………………………………………………………………..40
2.10 Aminotransferases………………………………………………………………………….43
CHAPTER THREE : MATERIALS AND METHODS…………………………….47
3.1 Subjects…………………………………………………………………………………………47
3.2 Controls………………………………………………………………………………………….48
3.3 Data and sample collection………………………………………………………………49
3.4 Materials…………………………………………………………………………………………50
3.5 Analytical procedure for vitros DT60 II chemistry analyzer………………52
3.6 Analytical procedure for cyflow CD4 analyzer……………………………………53
3.7 Analytical procedure for sysmex KX-21N haemogram analyzer………54
3.8 Analytical procedure for atomic absorption spectrophotometer………..56
3.9 Data analysis……………………………………………………………………………………56
CHAPTER FOUR : RESULTS AND TABLES………………………………………..57
CHAPTER FIVE : DISCUSSION………………………………………………………….77
CONCLUSION…………………………………………………………………………………….89
RECOMMENDATIONS……………………………………………………………………….89
REFERENCES…………………………………………………………………………………….90
APPENDIX……………………………………………………………………………………….106
ETHICAL APPROVAL………………………………………………………………………118
xi
LIST OF TABLES
Table 1 : Serum minerals, lipid profile, fasting blood sugar and body mass index
in control subjects and HIV positive subjects before and after 6 months on
HAART ………………………………………………………………………………………page 57
Table 2 : Age, systolic blood pressure, diastolic blood pressure, arterial pulse
rate, serum aspartate aminotransferase, alanine aminotransferase, CD4
count and haemoglobin of control subjects and HIV positive subjects before and
after 6 months on HAART……………………………………………………………….page 59
Table 3 : Serum lipids and haemoglobin in HIV positive patients before and
after HAART………………………………………………………………………………….page 61
Table 4: Serum minerals, fasting blood sugar, CD4 count , body mass index,
arterial pulse rate, systolic and diastolic blood pressures and age of male control
subjects and male HIV patients before and after HAART…………………page 63
Table 5: Serum minerals, fasting blood sugar, CD4 count , body mass index,
arterial pulse rate, systolic and diastolic blood pressures and age of female
control subjects and female HIV positive patients before and after
HAART…………………………………………………………………………………………page 65
Table 6: Serum minerals, body mass index, fasting blood sugar, CD4 count ,
systolic and diastolic blood pressures, arterial pulse rate and age of female and
male HIV positive patients before HAART……………………………………….page 67
xii
Table 7: Serum minerals, body mass index, fasting blood sugar, CD4 count,
systolic and diastolic blood pressures, arterial pulse rate, and age of female and
male HIV patients after HAART………………………………………………………page 69
Table 8 : Correlation between parameters of control subjects…………..page 71
Table 9: Correlation between parameters of HIV patients before
HAART……………………………………………………………………………………….. Page 73
Table 10: Correlation between parameters of HIV patients 6 months on
HAART…………………………………………………………………………………………page 75
ii
ABSTRACT
The introduction of highly active antiretroviral therapy (HAART) has
significantly improved life expectancy among HIV positive individuals.
However the impact of this treatment on individual micronutrients, other
biochemical parameters and cardiovascular risk has not been well elucidated in
this environment.
This study evaluated cardiovascular risk factors, selenium, zinc, magnesium,
lipid profile, fasting blood sugar, haemoglobin, CD4 count and transaminases
among human immunodeficiency virus (HIV) afflicted Nigerian subjects on
HAART.
Subjects are HIV afflicted adult patients who presented consecutively at Imo
State University Teaching Hospital Orlu, who are HAART naïve and agreed to
written consent. A total of 99 volunteers comprising 51 patients and 48 HIV
sero-negative adults as control participated. Their body weight, height, blood
pressure, arterial pulse rate were measured, 10 ml of fasting venous blood
samples were also taken before commencing HAART and at 6 months on
iii
HAART. Samples were analyzed for lipid profile, blood sugar, magnesium,
zinc, selenium, haemoglobin and CD4.
Serum magnesium, zinc and selenium were significantly lower in HIV patients
before HAART (p < 0.05) compared with control. However, serum levels of
these minerals significantly increased after HAART compared to pre-HAART
values.
Serum aspartate aminotransferase (AST) concentration was significantly higher
after HAART compared with control.
Serum triglyceride (TG) significantly increased following HAART compared to
control while high density lipoprotein (HDL) increased compared to preHAART values (p<0.05). There was no significant change in total cholesterol
before or after HAART compared to control.
CD4 count increased significantly in HIV patients while on HAART compared
to values before HAART. However these values were lower than control value.
Haemoglobin (Hb) significantly increased in HIV patients while on HAART
when compared to these patients before HAART.
Blood sugar levels were similar in all groups.
In conclusion, HAART was beneficial to the patients as it enhanced CD4 count,
haemoglobin, and HDL but it increased serum triglyceride. HAART also
improved low magnesium, zinc and selenium observed in HIV. This study
iv
suggests that the non protease inhibitor-based HAART may however predispose
HIV patients to cardiovascular risk and that supplementation of these minerals
may not be necessary in HAART.
1
CHAPTER ONE
INTRODUCTION
1.1 Background
The introduction of the Highly Active Antiretroviral Therapy (HAART) has
spectacularly changed the prognosis of Human Immunodeficiency Virus (HIV)
infection by greatly prolonging the life span of subjects. Unfortunately HAART is
associated with increased cardiovascular risks resulting in myocardial infarction
occurring in younger age groups (SoRelle , 1998; Sklar and Masur, 2003 ) . Poor
lipid profile, impaired glucose tolerance and in a few cases frank diabetes mellitus,
redistribution of body fat (lipodystrophy) including abdominal obesity have all
been reported (Shaw et al, 1998; Green, 2002; Riddler et al, 2003; Domingo et al,
2008 ). Other studies showed similar metabolic changes, although to a lower extent
in HIV positive subjects not on any antiretroviral medication and concluded that
HIV infection itself was in part responsible for the increased cardiovascular events
(Carl and Tien, 2004; Caarr and Ory, 2006; Gross, 2006; Mujawar et al, 2006;
Rasheed et al, 2008.). Initially it was thought that the protease inhibitors (PI’s)
2
were responsible for these changes. It is now known that non PI-based HAART
also has the same metabolic effect, although the PI’s are worst, with ritonavir at the
lead (Papdopoloulos et al, 1998; Levy et al, 2000; Shahmahesh et al, 2001; Fontas
et al, 2004.). A study showed a clear evidence that HIV-1 protein and antiretroviral
drugs cause endothelial dysfunction, a key step in cardiovascular disease , although
the extent of contribution of each is unclear (Kline and Sutliff, 2008) . Most of
these studies were done in advanced countries; a record was found of a study done
in Africa, still this was a case report of HAART – induced diabetes mellitus (Bakari
et al, 2007). The well documented racial \ ethnic and social variation in
cardiovascular risk makes it important to evaluate the changes in cardiovascular
risk factors in HIV positive black subjects on HAART in a developing country
with racial and social environment widely apart from those of advanced countries.
A study had found a strong race / ethnic difference in plasma lipids in HIV-1-
infected individuals on antiretroviral therapy (Foulkes et al, 2006).
Besides, the high rate of cellular turnover of the immune system make it a major
user of nutrients, hence, immune function depend highly on nutritional status. This
nutritional need increases even further in acute or chronic infection including HIV.
3
This explains in part the deficiencies in nutrients including trace elements widely
reported in HIV infected subjects. (Baum et al ,1997; Wellinghausen et al, 2000;
Jonenz-Exposito et al, 2002; Foulkes et al, 2006; Jones et al, 2006; Bakari et al,
2007; Khalili et al, 2008.) . The severity of nutrient deficiency has been shown to
be a strong determinant of disease progression (Baum et al, 1997).
Selenium deficiency was found to be an independent predictor of survival in HIV
infection (Baum et al, 1997). Supplementation of this mineral increased serum
concentration by 50% and reduced coronary heart disease risk by 24% (even
though this is inconclusive) and also reduced symptoms of heart disease although it
did not reverse immunological and heamatological parameters (Cirelli et al, 1991).
Another study showed that selenium deficiency worsened cardiovascular risk
factors in healthy Saudi males (Alisa et al, 2008). Another team of researchers
suggested that selenium supplementation in HIV-infection could be of great
interest in protecting cells from oxidative stress and improve survival (DelmasBeauvleux, 1996).
Zinc deficiency was found in 23% of HIV-infected persons, with serum
concentration comparable in treated and untreated patients (Wellinghausen et al,
4
2000). Another team reported zinc deficiency in 40% men and 36% women on
HAART (Jones et al, 2006).
Low plasma and erythrocyte magnesium was reported in HIV, but even lower in
HIV subjects who consume alcoholic beverages (regularly) (Bogden et al, 2000 ).
In children infected with HIV, however, routine monitoring of serum
micronutrients may be unnecessary in the absence of any specific clinical
indication of deficiency (Henderson et al, 1997).
Again reports of these nutrient deficiencies on black HIV subjects are very few.
Besides, there are no reports on nutrient changes in HIV subjects after HAART is
commenced.
Hepatotoxicity is one of the complications of HAART. Life threatening acute toxic
hepatitis was reported in Turkey of a HIV positive patient on HAART (Gokengin
and Yamazhan, 2002) including nevirapine, a non nucleoside reverse transcriptase
inhibitor (NNRTI). Mitochondrial toxicity induced by nucleoside reverse
transcriptase inhibitors (NRTI’s) is believed to be responsible for various adverse
effects of NRTI’s. The NRTI , didanosine was found to be associated with the
lowest peripheral blood mononuclear cells (PBMC’s) mitochondrial DNA
(mtDNA) thus with the highest risk of long-term adverse effects (Saitoh et al,
5
2007). Drug history, liver enzyme studies among others could identify the probable
cause of liver disease in 78% of HIV infected patients on HAART (Ocama et al,
2008; ). Significantly low prealbumin was found in HIV infected subjects (Baum et
al, 1997). Analysis of serum levels of liver enzymes in Nigerian subjects on
HAART may then be useful.
1.2 Design
This was a prospective study with HIV positive cohorts recruited from the Institute
of Human Virology of Nigeria (IHVN)-assisted HIV/AIDS treatment unit of the
Imo State University Teaching Hospital (IMSUTH) Orlu, a new Teaching Hospital
located in a sub-urban area of South Eastern Nigeria. All consecutive eligible
subjects who gave consent were recruited.
The local ethics standard of the hospital for biomedical research was respected and
written approval secured from the Hospital Ethics Committee.
The research also conformed to the Helsinki declaration on biomedical research.
Written informed consent was secured from each participant.
6
Only male and female subjects 18 years and over were recruited. All eligible
participants had laboratory confirmation of HIV infection, were drug
(antiretroviral) naïve and were prequalified by the hospital clinician responsible for
HAART administration as suitable to commence HAART based on WHO
recommendations.
1.3 Aim
The aim of this study is to evaluate the side effects of HAART and its effects on
serum minerals on HIV positive Nigerians.
1.4 Objective
The objective of this study is to evaluate the changes in cardiovascular risk factors
in HIV positive black subjects in a developing country receiving HAART.
To evaluate possible nutritional (micronutrient and body mass index) changes in
HIV infected African subjects as they commence HAART.
7
To evaluate the changes in liver enzymes and lipid profile in HIV subjects
receiving HAART.
To make suggestions based on identified cardiovascular risks and depleted
micronutrients that will improve the management of these patients.
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