Abstract

Introduction: Human immunodeficiency virus (HIV) infection represents the most common cause of acquired immune deficiency leading to AIDS. CD4 is found on immune cells like T cells, macrophages and monocyte. HIV infects CD4 cells and in the absence of suitable therapy leads to CD4 cell lymphopenia. The progressive decline in CD4 cells eventually leads to the development of haematological abnormalities, opportunistic infections, wasting, cancer and death.

Aim: The study compared the haematological profiles to the CD4 count among HIV patients attending ART at Komfo Anokye Teaching Hospital and Obuasi Government Hospital.

Materials and Method: a cross sectional analytical study involving 385 selected patients with HIV in Ashanti Region was done. CD4 count and Full blood count were performed to determine the immune status of the patients and haematological parameters.

Results: Out of 385 HIV patients enrolled in the study, the mean age, weight, and duration of therapy was 40.62 years old, 58.33 kg, and 6.17 years respectively. A higher proportion of the study participants were females (73.7%), married (42.7%), had HIV-1 (97.7%) and informal education (83.0%). CD4 count was directly associated with haemoglobin levels (r=0.32), WBC count (r= 0.23) especially with neutrophils. However, CD4 count was negatively associated with lymphocyte count (r= -0.14).

Conclusion: This study revealed that there is a strong association between CD4 counts and the severity of anemia and neutropenia in HIV/AIDS patients. Anemia and neutropenia in HIV patients can be considered as good clinical indicators to predict and access the underlying immune status.   

KEY WORDS: HIV/AIDS, CD4 count, neutropenia,

Background

Human immunodeficiency virus (HIV) infection represents the most common cause of acquired immune deficiency and leads to the clinical disease referred to as Acquired Immune Deficiency Syndrome (AIDS) (1). HIV infects CD4 cells and in the absence of suitable therapy leads to insightful CD4 cell lymphopenia. The progressive decline in CD4 cells eventually leads to the development of opportunistic infections, wasting, cancer and death (1). Acquired Immune Deficiency Syndrome is caused by HIV and is characterized by progressive damage to the body’s immune system which results in a number of opportunistic infections, immunological and haematological complications (2). Haematological abnormalities are the most common problems in HIV and these include all extractions of blood cells (3). CD4 T lymphocyte serves as a marker for immune status. Marked immune compromise, as evidenced by a low CD4 lymphocyte count, is now less frequently encountered among individuals with access to HAART, because most guidelines recommend treatment for individuals with CD4 lymphocyte counts below 200 cells/mm3 and consideration for starting treatment if the CD4 lymphocyte count is less than 350 cells/mm3(4). According to World Health Organization (5) guidelines, preventive therapy should be started when an HIV positive person who has no symptoms registers a CD4 count under 200 cells per cubic millimeter of blood. Haematological complications among HIV patients are mostly marked with cytopenias such as anaemia, neutropenia, lymphopenia and thrombocytopenia (6&7). The incidence and severity of cytopenia generally correlate with the stage of the disease with anaemia being the most commonly encountered haematological abnormality and a noteworthy predictor of progression to AIDS (8&9). Anaemia and neutropenia are generally instigated by insufficient production of blood cells (because of suppression of the bone marrow by the HIV infection through abnormal cytokine expression and alteration bone marrow microenvironment) (10). Thrombocytopenia is caused by immune-mediated destruction of the platelets, in addition to inadequate platelet production. The incidence and severity of cytopenia are generally correlated to the stage of the disease. Other causes of cytopenia in these patients include treatment-related adverse events or secondary to the opportunistic infections or malignancies, or other pre-existing or coexisting medical problems. Optimal management of the underlying HIV infection is essential, and mild cytopenia in asymptomatic patients may need no specific management. (6, 10&11).

Materials And Methods

The study was a cross-sectional study from December 2018 to April 2019, and involved HIV patients who attended ART at Komfo Anokye Teaching Hospital (KATH) and Obuasi Government Hospital. KATH is located in Kumasi, the regional capital of Ashanti region with a total projected population of 4,780,380(KATH Annual Report, 2000). It is the second largest teaching Hospitals in the country. The geographical location of the 1200- bed KATH, the road network of the country and commercial nature of Kumasi make the hospital accessible to all the areas that share boundaries with Ashanti region and others that are further away. As such, referrals are received from all the northern regions (namely, Northern, Upper East and Upper West regions), Brong Ahafo, Central, Western, Eastern and parts of the Volta regions. Obuasi government Hospital is a district hospital located in Obuasi Municipality; Mensah-Krom.

They provide general healthcare for both citizens of Obuasi and neighbouring villages. The hospital has about seven departments and since most people from the rural areas are being referred there, it has a well-furnished ward for females, males and children. The hospital has an ART department where HIV patients are being managed. Three hundred and eighty-five (385) HIV patients were randomly selected from the study population.

Sample Collection

Five milliliters (5mls) of venous blood was collected aseptically from each participant into ethylene diamine tetra-acetic acid (EDTA) tube using disposable syringe. The blood samples were used for full blood count (FBC) and CD4 count.

Full Blood Count Determination

The full blood was determined using a haematological analyser (sysmex XT4000i with it company name being Sysmex Europe GmbH). This analyser was invented in Europe. It is an automatic Haematology system that utilizes the power of hydrodynamic focusing, fluorescent flow cytometry and Spectrophotometry technologies. This involves the use of electrical impedance, diode laser and fluorescent lights and SLS method to provide the sensitivity needed for measuring and differentiating cell types in whole blood and body fluid samples. It also has five main channels for performing its function. Hence, these technologies enable the XT4000I to consistently classify normal WBC, RBC and PLT population from abnormal populations. The tube containing the patient’s specimen would be inverted for about 5 – 10 times to ensure that the content of the tube is well mixed. The tube would be uncapped and then placed in the sample holder of the analyser. The aspirate button would be pressed for the analyser to aspirate the required volume of blood for the analyses. After about 20 seconds, the result would be ready and printed from the analyser.

CD4 count

CD4 count was performed by using FACS count (Becton Dickson, Singapore) as per the protocol given by the manufacturer. CD4 counts were measured routinely in the first visit and during the follow-up visits. For this study, each time a participant presented with any hematological manifestation, their most recent CD4 count was used for the analysis. Patients in whom no CD4 count was available were excluded from the analysis. The relationship between CD4 counts and various hematological manifestations was analyzed.

Results

Table 1 shows the baseline characteristics of the study population. The mean age, weight, and duration of therapy was 40.62 years old, 58.33 kg, and 6.17 years respectively. A higher proportion of the study participants were females (73.7%), married (42.7%), had HIV-1 (97.7%), and informal education (83.0%)

The haematological and immune status of the study participants is shown in Table 2. The median haemoglobin, WBC count, platelet count, neutrophil count, lymphocyte count and CD4 count were 11.55 g/dl, 4.67x10³/μl, 225.0x10³/μl, 1.89x10³/μl, 2.40x10³/μl, and 378.0 cells/µl respectively

Table 3 shows the distribution of CD4 count and haematological parameters among the study population. The prevalence of anaemia, leukocytopenia, and thrombocytopenia was 67.0%, 45.7%, and 7.3% respectively. Ten (3.3%) of the study participants had thrombocytosis. The proportion of study subjects with neutropenia, and lymphopenia was 30.3% and 4.7% respectively. The distribution of study subjects with CD4 count <200 cells/µl, 200-500 cells/µl, and >500 cells/µl were 26.0%, 35.7%, and 38.3%, respectively.

Table 4 shows the comparison of haematological profile by immune status. Subjects with CD4 count <200 cells/µl presented with significantly lower haemoglobin level (10.20 g/dl) compared to those with CD4 count of 200-500 cells/µl (12.10 g/dl) and >500 cells/µl (12.1 g/dl) respectively. Additionally, subjects with CD4 count <200 cells/µl had significantly

reduced WBC count (4.26x10³/μl) compared to subjects with CD4 count > 500 cells/µl (4.90x10³/μl), though within normal ranges. Furthermore, participants with CD4 count of 200-500 cells/µl had significantly lower neutrophil count (1.70x10³/μl) compared tos participants with CD4 count > 500 cells/µl (2.0x10³/μl).

Figure 3.

Figure 1. Linear association between haematological parameters and CD4 count among the study population

As shown in figure 1 below, CD4 count was directly associated with haemoglobin levels (r=0.32), WBC count (r= 0.23). However, CD4 count was negatively associated with lymphocyte count (r= -0.14).

Discussion

Haematogical complications are a common cause of mortality in HIV infected patients. Cytopenias are most frequent during the advance stage of the disease (3). We evaluated various haematological manifestations on 385 patients who presented to the clinic. We also correlated the final haematological diagnosis and the parameters of the patients to their CD4 count. In our present study, we found out that, with our demographic characteristics, majority of the patients were females (73.7%), married (42.7%), had HIV-1 (97.7%), and informal education (83.0%) and had a mean age of (40.62±10.01 years, range 12-72) which correlates with(12) whose findings showed that, a higher proportion of the study participants were found to be in the middle and low socio- economic class, married and females.

Secondly, anemia, leukopenia especially neutropenia were common findings in this study. This was also documented in different studies (13,14 &15). The prevalence of anemia in this study (67%) was higher than study done in India in 2002 (16) and 2008 (17) which was 30.8% and 65.5% respectively, Southern India 41% (18), Brazil 37.5% (19). This may be due to the difference in study population, socio-demographic characteristics of study subjects and study design methods. Also, the prevalence of neutropenia in our study was (30.3%) which was slightly correlated to a study done by (20) which showed that neutropenia incidence was from 13%-44%. On the other hand, prevalence of thrombocytopenia (7.3%) in this study was lower than reports from a study done by(21) which presented as (6.6%). This possible cause of thrombocytopenia may be due to immune destruction of platelets. It is known that many chronic human diseases may have an underlying autoimmune mechanism (22).

Furthermore, in our study 26.0% were cases of CD4 counts <200cells/µl which was lower than a study by (17) which presented 92.4%. Also, 35.7% were cases of CD4 counts between 200-500cells/µl and 38.3% were cases of CD4 counts >500 cells/µl which was higher than a study by (17) which presented 7.6% cases of CD4 counts >200cells/µl.

The cumulative incidence of anemia with haemoglobin levels (10.20g/dl) with a p-value ( <0.0001) which is statistically significant was highest among patients who had CD4 lymphocyte count <200cells/µl and lowest among patients who had CD4 counts >500 and 200- 500cells/µl with hemoglobin levels of 12.1g/dl in our study which agrees to a work done by (17)where the incidence of anemia was higher in patients with CD4 counts <200cells/µl. and lower in those with CD4 counts >500cells/µl. HIV infected individuals with anaemia are at risk for progression to AIDS and mortality, recovery from anemia has been associated with a decreased risk of deaths. We did not estimate the survival in patients with and without anemia, as this was a descriptive study, though the literature clearly indicates it does affect the survival. (23).

Moreover, patients with CD4 count <200 cells/µl had significantly reduced WBC count (4.26x10³/μl) compared to patients with CD4 count > 500 cells/µl (4.90x10³/μl), though within normal ranges. Previous studies done by (24) suggested that there is increase WBC count with decreased CD4 count. Furthermore, participants with CD4 count of 200-500 cells/µl had significantly lower neutrophil count (1.70x10³/μl) compared to participants with CD4 count > 500 cells/µl (2.0x10³/μl) which does not agree with work done by (20) which shown that the incidence of neutropenia was 0.8% in HIV patients with CD4 count >700cell/ml. Though a fall in the CD4 levels during neutropenia is observed, it is difficult to comment as the estimations of CD4 rely on the total leukocyte count. We also found out that platelet count of 224.50×10³/µl ,221.00×10³/µl and 235×10³/µl compared to CD4 count were < 200, 200-500 and >500cells/µl respectively. Lymphocyte counts of 2.34×10³/µl, 2.47×10³/µl and 2.40×10³/µl compared to CD4counts were < 200, 200-500 and >500cells/µl respectively. p-values of platelets and lymphocyte were (0.797) and (0.507) respectively which are statistically insignificant.

In our study, CD4 count was directly associated with haemoglobin levels (r=0.32), WBC count (r= 0.23) which is not in agreement with a work done by (20) where there was a strong negative association between CD4 count and anaemia and neutropenia. Surprisingly, CD4 count was negatively associated with lymphocyte count (r= -0.14). This may be due to the measurement of only CD4 count with the exclusion of CD3 and CD8.

Conclusion

This study revealed that there is a strong association between CD4 counts and the severity of anemia and neutropenia in HIV/AIDS patients. Anemia and neutropenia in HIV patients can be considered as good clinical indicators to predict and access the underlying immune status. Though a fall in the CD4 levels during neutropenia is observed, it is difficult to comment as the estimations of CD4 rely on the total lymphocyte counts. However, the relation between anemia and disease progression is straightforward and quite useful for the treatment of patients. It can also help hospitals without equipment’s for CD4 counts to estimate the levels of CD4 cells using the hemoglobin level and absolute neutrophil count of the patients.

Recommendation

Policy makers of the health sector are to encourage HIV patients to check up their CD4 count regularly and also to enforce that haematological parameters should be performed for every patient and to start HAART when it is appropriate in order to reduce the prevalence of anaemia and neutropenia. We also recommend done that work should be done on newly diagnosed patients since most work done by other researchers shows a correlation between CD4 count and lymphocyte count.

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