A Study of Pap Smears in HIV-Positive and HIV-Negative Women from a Tertiary Care Center in South India

OBJECTIVES

The aim of this work was to study the spectrum of epithelial abnormalities on Pap smears of HIV-positive women categorized as per the Bethesda System of Reporting Cervical Cytology, to correlate them with CD4 lymphocyte counts, and to compare them with the spectrum of abnormalities seen in a HIV-negative control group. Study Design and Methodology: The present study was a 6-year retrospective study conducted in the Department of Pathology at Kasturba Medical College, Mangalore, which included 150 Pap smears from HIV-positive and HIV-negative women, respectively. The Pap-stained slides of the cases were retrieved and studied. The data collected were tabulated and analyzed. A statistical study was performed using SPSS software. The χ2 test was used to analyze the data and a p value < 0.05 was considered to be significant.

RESULTS

Pap smear abnormalities were twice as high in HIV-infected women (12%) as compared with HIV-negative women (6%; p = 0.006, RR = 2). Negative for intraepithelial lesion/malignancy was the most common finding (88%), which was further subdivided into inflammatory, atrophic smear, non-specific, candidiasis, and bacterial vaginitis groups. The percentage of epithelial abnormalities was 12%, including: atypical squamous cells of undetermined significance, 5.55%; atypical squamous cells, cannot exclude HSIL, 16.66%; low-grade squamous intraepithelial lesion, 5.55%; high-grade squamous intraepithelial lesion (HSIL), 61.11%, and squamous cell carcinoma, 11.11%. The highest incidence of intraepithelial lesions in HIV-positive females was in the age group of 34-49 years. CD4 cell counts fell in the range of 200-500 cells/mm3 in most of the HIV-positive patients (68.75%), but was not found to be statistically significant.

CONCLUSION

Routine Pap smear examination is advocated in women with HIV as the prevalence of epithelial cell abnormalities was found to be 12%, which was twice as high as compared to the HIV-negative control group. Although there was no correlation of epithelial cell abnormalities with CD4 counts, a higher rate of the cases with epithelial abnormalities were observed to have CD4 cell counts of 200-500 cells/mm3.

Depression, anxiety, stress and stigma in informal caregivers of People Living with HIV (PLHIV)

Informal caregivers are unpaid individuals who help friends or family members who cannot fully care for themselves. However fulfilling the act of helping debilitated individuals, exposure to another person's traumatic experiences often results in psychological distress. Caregiver's stigma towards HIV worsens this. Hence, this study aims to assess the effect of stigma on the mental health of caregivers so that their needs for support can be determined. A cross sectional hospital based study was carried out in Mangalore, India on 150 informal caregivers of PLHIV. The HIV Stigma Scale was used to assess stigma and DASS-21 was used to assess depression, anxiety and stress. Of the 150 caregivers, 20% marked one or more items on the stigma scale. Frequency of depression, anxiety and stress was 46%, 27% and 8% respectively. Most caregivers who had stigma and anxiety were of those patients diagnosed for a shorter duration of time (≤5 years) n = 20, p = 0.05 and n = 26, p = 0.03 respectively. Spouses of PLHIV (n = 31, p = 0.005), sero-positive caregivers (n = 25, p = 0.03) and those living with patients (n = 39, p = 0.01) suffered most from anxiety. Stress was significantly associated with depression (83%, p = 0.007) and anxiety (66.6%, p = 0.001) in caregivers. In conclusion, more of depression and anxiety was observed among the participants than stress. Stigma was seen in 20% of the participants. Stigma was not significantly associated with depression anxiety and stress.

Clinicoepidemiological Profile of Elderly PLHIV Attending a Tertiary Care Center in South India

BACKGROUND

Physicians are coming across a considerable number of HIV-positive patients belonging to older age-group, in practice. They pose a challenge as they might present with advanced forms and comorbid conditions. We aimed to describe the clinicoepidemiological profile of elderly people living with HIV.

METHODOLOGY

We conducted a cross-sectional study at Kasturba Medical College, Mangalore. We analyzed the record of 120 patients from 2009 to 2014. Descriptive statistics were used to describe sociodemographic and clinical profile of patients.

RESULTS

Of 786 HIV-positive patients, 120 were elderly. Mean age was 55.9 ± 6.1 years. Majority 68% were male. In all, 63.33% were male. Commonest route of transmission was heterosexual intercourse, most presented at World Health Organization (WHO) stage 1 (64.17%). In all, 77.5% had hypertension and 26.6% had tuberculosis. The median CD4 count at presentation was 245 cells/mm³ (145-426 cells/mm³). Forty-two percent were late presenters (CD4 <200 cells/mm³).

CONCLUSION

Treating physician should have a high index of suspicion in diagnosing HIV among elderly age-group.

Cervical cytological abnormalities and human papilloma virus infection in women infected with HIV in Southern India

AIM

The aim of this study was to examine the association between CD4 count, human papilloma virus (HPV) infection, and the risk of cervical intraepithelial neoplasia among HIV-infected women.

METHODS

A cross-sectional study was conducted among 104 HIV-infected women attending an antiretroviral therapy clinic. They underwent Pap smear and cervical HPV DNA testing.

RESULTS

The overall prevalence of HPV infection was 57.7%. HPV 16 was the commonest genotype found (38.5%); HPV 16 and 18 put together contributed to 73.3% of HPV infection; 27.5% of HIV-infected women had squamous cell abnormalities. Cervical intraepithelial neoplasia was less likely among women with CD4 count > 500/mm³ (12%) and in those without opportunistic infections (17.8%). The prevalence of high-risk HPV infection was higher in women with high-grade squamous intraepithelial lesions or greater lesions (85.7%) as compared to women with normal cytology (52.1%).

CONCLUSION

The high prevalence of HPV infection and cervical intraepithelial neoplasia in HIV-infected women warrants the need for regular Pap smear screening in these women and routine HPV vaccination for adolescents to reduce the burden of cervical cancer in India.

Fertility Desires and Intentions among People Living with HIV/AIDS (PLWHA) in Southern India

INTRODUCTION

The desire of people living with HIV/AIDS (PLWHA) to have children can have significant public health implications. Combination Antiretroviral Therapy (cART) has increased the life expectancy of PLWHA as a result of which they may consider child bearing. There are hardly any studies from India addressing the fertility desires among PLWHA.

AIM

This study was done to assess the fertility desires of PLWHA in Southern India.

MATERIALS AND METHODS

It was a cross-sectional study conducted among 230 HIV-positive men and women who presented to Kasturba Medical College (KMC), Mangalore, India. Study was conducted between October 2012 and October 2014. Statistical analysis was performed using SPSS software version 11.5. Chi-square test, Fisher's exact test and student t-test was used to find out the association of various factors affecting fertility desire. A p-value of less than 0.05 was considered statistically significant.

RESULTS

The mean age of our study population was 36.3±5.5 years. The mean age of males was 37.3±6 years and for female 34.9±5 years. In our study 132 (57.4%) were males. Majority were literate 229 (99%). Majority of patients were employed 166 (72%). In our study 195 (84.7%) were on cART. Out of 230 PLWHA 39 (16.95%) were unmarried and 151(65.5%) married PLHIV were living with partners at the time of study. In our study 77 (33.5%) patients had fertility desire. Age, gender, marital status, number of children, partner's fertility desire and HIV status of partner had an association with fertility desire.

CONCLUSION

Providing universal access to cART is the main aim of national programs. It is high time that these programs focus on fertility issues of PLWHA. Reproductive rights of PLWHA need to be respected. Physicians and HIV counselors should proactively discuss and address reproductive issues of PLWHA.

Caregiver Burden among Adults Caring for People Living with HIV/AIDS (PLWHA) in Southern India

INTRODUCTION

In India, family caregivers provide bulk of care to People Living With HIV/AIDS (PLWHA). Caregiver burden refers to the physical, emotional and financial hardships associated with providing care to a diseased individual. Attending to the needs of PLWHA can place a significant burden on family members. This may adversely affect their Quality of Life (QOL).

AIM

The main aim of our study was to assess the caregiver burden and QOL among the family members of PLWHA in Southern India. We also determined the impact of caregiver burden on QOL.

MATERIALS AND METHODS

This facility based cross-sectional study was carried out at Kasturba Medical College (KMC) Mangalore. The study was conducted over a period of 18 months starting from October 2013. A total of 360 caregivers participated in our study. The data were collected by face-to-face interview. Caregiver burden was assessed using the Zarit Burden scale & WHOQOL-BREF scale was used to assess the QOL of caregivers. The collected data was entered and analysed using SPSS version 11.5. A p-value of less than 0.05 was considered statistically significant.

RESULTS

The mean age of caregivers was 36.09± 10.18 years. Most of the caregivers were females 279 (77.5%). Majority of caregivers 184 (51.1%) belonged to Middle/Lower Middle socioeconomic class (Kuppuswamy class III). Majority of PLWHA 155 (43.1%) had Stage 2 disease. Mean CD4 count of the patients was 405.2± 240 cells/μL. In our study 88(24.4%) caregivers had moderate to severe burden and 36(10%) had very severe burden. Physical domain of QOL showed maximum score of 60.28±13.08, while a minimum score of 51.88 ± 14.20 was seen in social domain. With increase in caregiver burden, the mean QOL scores decreased which was statistically significant.

CONCLUSION

Our study highlights the need to counsel the caregivers on how to deal with PLWHA in the family. Family care plays a major role in the general wellbeing of PLWHA. Majority of national HIV programmes all over the world focus mainly on PLWHA. National programmes should immediately address the mental health issues of caregivers thereby reducing caregiver burden. More studies on this topic have to be conducted in developing countries.

Level of Satisfaction Among People Living with HIV (PLHIV) Attending the HIV Clinic of Tertiary Care Center in Southern India

INTRODUCTION

Patient satisfaction is an important issue for the health care sector. Hospitals routinely collect patient satisfaction data so that they can improve the quality of their services. There is a dearth of research in the field of satisfaction among people living with HIV (PLHIV) in India.

AIM

The aim of our study was to determine the level of satisfaction among PLHIV attending the HIV clinic of tertiary health centre in Southern India.

MATERIALS AND METHODS

This descriptive cross-sectional study was done in the HIV clinic attached to Kasturba Medical College (KMC) Hospital, Mangalore, India from August 2012 - August 2013. PLHIV of age more than 18 years were included. During the study period 422 consecutive patients who consented for the study were enrolled. To determine patient satisfaction towards healthcare service, we used the Short Form Patient Satisfaction Questionnaire (PSQ-18). Data was analysed using SPSS Version 11.5 statistical software.

RESULTS

A total of 422 patients were included in the study out of whom 253(60%) were males and 169(40%) were females. Mean age of the patients was 37.08±7.2 years. The median CD4 count was 345 cells/mm(3) (IQR 245-451.2). The mean score for general satisfaction was 4.43±0.48, for technical quality 4.77±0.26, for interpersonal manner 4.59±0.4, for communication 4.64±0.42, for financial aspects 3.20±0.78), for accessibility and convenience 4.50±0.72 and for time spent with the doctor was 4.59±0.45. Subscale scores for general satisfaction, technical quality, accessibility, interpersonal manner, finance and communication were higher in females when compared to males which were found to be statistically significant. Younger PLHIV (≤ 35 years) had significantly higher scores in technical quality, interpersonal manner and time spent with the doctor when compared to older PLHIV.

CONCLUSION

Patient satisfaction was highest for technical quality and it was lowest for financial aspects. If hospitals wish to improve the quality of health services they should give priority to decreasing costs and improving accessibility.

Successful Treatment of Chromobacterium violaceum Sepsis in a South Indian Adult

Infection due to Chromobacterium violaceum is rare. Diagnosis may be delayed since Chromobacterium sepsis may mimic melioidosis, especially in melioidosis-endemic areas. Management of Chromobacterium infection is challenging given the propensity of this pathogen to cause visceral abscesses, drug resistance, and relapse. Mortality rates are high despite treatment. We report a case of C. violaceum septicemia in an immunocompetent adult from south India, who was successfully treated with combination antibiotic therapy. Physicians in tropical and subtropical regions must be aware of C. violaceum infection as it can mimic melioidosis.

Oral Cytology for HIV

Aim:

To asses morphological and morphometrical alterations of oral squamous epithelial cells in HIV infected individuals, and determine its diagnostic significance for HIV infection.

Materials and Methods:

Informed Consent was obtained from all study subjects. 40 adult HIV infected patients (experimental group) and 40 adult non-infected volunteers (control group) participated. Age, occupation, and relevant medical history were recorded. The following laboratory tests reports were recorded: complete blood cell counts, blood glucose levels, serum iron and erythrocyte sedimentation rate. Oral smears were collected from normal appearing tongue and buccal mucosa of the individuals by exfoliative cytology. The cells were morphologically analysed and the nuclear area (NA), the cytoplasmic area (CA) and the nucleus-to-cytoplasm area ratio (NA/CA) were calculated. Cell yield, cell cohesion, presence/absence of inflammatory cells and candida were observed.

Results:

The cytological smears of HIV patients showed abundant cell yield and the epithelial cells were found to be in close cohesive clusters and both findings were found to be statistically significant. Nuclear cytoplasmic ratio was seen to be increased in 93.8% of HIV positive patientsand Mild to moderate pleomorphism was observed in 17.9% of HIV positive patients. HIV positive patients had a diminished inflammatory response and this was found to be statistically significant.

Conclusion:

Statistically significant deviations from normal oral epithelium were found in the study conducted. With further research, oral exfoliative cytology may form a new, painless, inexpensive diagnostic method for HIV infections.

Carbamzepine-induced toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN), also known as Lyell's syndrome, is a widespread life-threatening mucocutaneous disease where there is extensive detachment of the skin and mucous membrane. Many factors involved in the etiology of TEN including adverse drug reactions. Here we are reporting a case of toxic epidermal necrolysis in an adult male patient after receiving carbamazepine in a 38 year old male. On the 18^th day of carbamazepine, patient developed blisters which first appeared on the trunk, chest and arms. The erythematous rash was covering almost all over the body with epidermal detachment of 70% body surface area. There was loss of eye lashes, congestion of conjunctiva with mucopurulent discharge and exposure keratitis. The clinical impression was TEN induced by carbamazepine. Carbamazepine was stopped immediately. He was treated with high dose intravenous betamethasone and systemic and topical antibiotics. After one month, the progression of the skin lesions halted and he was discharged.

Profiles of attendees in voluntary counseling and testing centers of a medical college hospital in coastal karnataka

RESEARCH QUESTION

What are the socio-demographic profile and risk behavior pattern of seropositive attendees in the voluntary counseling and testing center (VCTC)?

STUDY DESIGN

Retrospective study.

SETTING

VCTC in the outpatient complex of Kasturba Medical College Hospital, Mangalore, Karnataka.

SUBJECTS

Records pertaining to all the 539 and 330 seropositive attendees during the years 2005 and 2006, respectively, were included in the study besides data from 2001 onwards in order to assess the time trend of human immunodeficiency virus (HIV).

STUDY VARIABLES

Age, sex, marital status, religion, educational status, occupation, place of residence and pattern of risk behavior in relation to HIV/AIDS.

STATISTICAL ANALYSIS

Analysis was done with SPSS version 11. Statistical test and Chi-square was done, and P < 0.05 was considered statistically significant.

RESULTS

The time trend of VCTC attendees reveals a gradual increase except in 2006 showing a sharp decline. Seropositives were around 20% between 2001 and April 2007 with a sharp increase in 2006, i.e., 33.64%. Male seropositivity constituted 60-63%; 81-91% of seropositive attendees belonged to the age group of 15-50 years; 58-70% were married. Only about 3% were illiterates and 20-25% constituted 6(th)-12(th) pass-outs. With regard to occupational profile, about 17-27% were housewives, 19-21% were laborers/hotel workers and 7% were entrepreneurs. About 45% were from urban area and nearly one-third hailing from other districts in the border of Karnataka. About 25% were exposed to commercial sex workers; another 21-23% were involved in premarital sex and nearly 38% were indulging in heterosexual activities.

Periodontal status of HIV-positive patients

OBJECTIVE

To assess the periodontal status of HIV positive individuals and to compare it with age-and gender-matched controls.

MATERIALS AND METHODS

The cross-sectional study comprised fifty-two HIV positive individuals and fifty-two controls. OHI-S and PI were recorded by a single pre-trained and pre-calibrated examiner.

RESULTS

Based on antiretroviral therapy use, mean OHI-S was higher among HIV positive females undergoing therapy. A significant gender difference was observed in the PI score among those on antiretroviral therapy, with females having a lower score (p = 0.04). Also, significant gender difference was observed in the mean PI score among HIV positive individuals, with males having a higher score.

CONCLUSION

There was a significant difference in the overall mean OHI-S score among HIV positive individuals and controls (p = 0.03). However, no significant difference was observed when the overall PI score was calculated for both groups (p = 0.95).