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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 1  |  Page : 36-40

Hematological profile of human immunodeficiency virus-infected children


1 Department of Paediatrics, Dalhatu Araf Specialist Hospital, Lafia, Nasarawa State, Nigeria
2 Department of Medical Microbiology, Dalhatu Araf Specialist Hospital, Lafia, Nasarawa State, Nigeria
3 Public Health, Dalhatu Araf Specialist Hospital, Lafia, Nasarawa State, Nigeria

Date of Submission08-Jul-2019
Date of Decision18-Sep-2019
Date of Acceptance30-Nov-2019
Date of Web Publication18-Mar-2020

Correspondence Address:
Dr. Surajudeen Oyeleke Bello
Department of Paediatrics, Dalhatu Araf Specialist Hospital, Lafia, Nasarawa State
Nigeria
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DOI: 10.4103/smj.smj_32_19

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  Abstract 


Background: Hematological disorder has been shown to be one of the leading manifestations of human immunodeficiency virus (HIV) infection. This could be from the virus itself or the accompanying opportunistic infections including malignancies. The manifestations include among others, anemia, leukopenia and thrombocytopenia. Objectives: The objective of this study is to determine the prevalence of anemia, leukopenia, and thrombocytopenia as well as assessing the relationship between antiretroviral therapy (ART) regimen and anemia. Materials and Methods: The study was a prospective study among HIV-infected children and adolescents aged 2 years to <18 years receiving ART at the Dalhatu Araf Specialist Hospital, Lafia Nasarawa State. A total of 263 clients were recruited consecutively. Known sickle-cell disease patients, those with ongoing sepsis and or those recently transfused were excluded from the study. Data were analyzed using the SPSS version 20.0 through a univariate and multivariate analysis, and reporting was done in tables and figure. Results: There are slightly more males than females, with a male-to-female ratio of 1.02:1. Children aged between 2 and 9 years accounted for over two-third of the study population. The prevalence of anemia, leukopenia, and thrombocytopenia was 32.7%, 11.4%, and 3.04%, respectively. More than two-third of the participants was on zidovudine-based regimen, and there is a statistically significant association between anemia and the use of zidovudine-based ART regimen. Conclusion: Anemia is the most common hematological abnormality among HIV-infected children and adolescents. There is an association between the use of zidovudine and occurrence of anemia. The use of alternative drug to zidovudine is advocated.

Keywords: Children, hematological, human immunodeficiency virus infected


How to cite this article:
Bello SO, Audu ES, Hassan I. Hematological profile of human immunodeficiency virus-infected children. Sahel Med J 2020;23:36-40

How to cite this URL:
Bello SO, Audu ES, Hassan I. Hematological profile of human immunodeficiency virus-infected children. Sahel Med J [serial online] 2020 [cited 2020 Jul 4];23:36-40. Available from: http://www.smjonline.org/text.asp?2020/23/1/36/280942




  Introduction Top


Hematological disorder has been shown to be one of the leading manifestations of human immunodeficiency virus (HIV) infection.[1] This could be from the virus itself or the accompanying opportunistic infections including malignancies.[2] Hematological manifestations include anemia, leukopenia, neutropenia, thrombocytopenia, etc.[3],[4] Other potential causes of anemia in HIV-infected participants could be from nutritional deficiency, disorder of absorption, certain medications, infiltration of bone marrow, and or blood malignancies.[5],[6]

A study in Calabar in 2013 among adult HIV-infected individuals revealed 47.4% and 10.3% prevalence of anemia and leukopenia, respectively.[7] Other studies revealed the prevalence of anemia that ranges between 55.2% and 77%.[2],[7] The above (latter) studies were done in Asia among the adult populations.

One of the few studies conducted among children was in India, which reported a 69% prevalence of anemia.[1] Another was a study in Ethiopia that compared the hematological parameters of patient preantiretroviral therapy (ART) and a year post-ART and found 42.8% and 18.9%, respectively.[8] Nyesigire Ruhinda et al. in Uganda reported 57.6% anemia, of which 44.9% were microcytic hypochromic type of anemia.[9] Another study in Lagos Nigeria reported a 54.2% prevalence of anemia among children aged 5–12 years old.[10]

There is a paucity of data on this important subject (hematological manifestations) among Nigerian children let alone the adolescents. This is even more farfetched in the north central region, which is the zone with the second-highest HIV prevalence (after the South-South zone) according to the recently released data of the National AIDS Indicator and Impact Survey.[11]

This study seeks to assess the hematological profile and the possible correlation with highly active antiretroviral therapy (HAART) to bridge this knowledge gap and contribute to the body of knowledge. The study provides an answer to the following research questions:

Research questions

  1. What are the prevalence of anemia, leukopenia, and thrombocytopenia among children and adolescents accessing ART in Dalhatu Araf Specialist Hospital (DASH) Lafia?
  2. What is the correlation between ART regimen and anemia?


Research hypothesis

Null hypothesis; there are no significant hematological abnormalities among HIV-infected children and adolescents at DASH Lafia.

Aim and objectives

General objective

To determine the hematological profiles of HIV-infected children and adolescents as well as assess its relationship with the ART regimen in DASH Lafia.

Specific objectives

  1. To determine the prevalence of anemia, leukopenia, and thrombocytopenia among HIV-infected children and adolescents in DASH Lafia
  2. To assess the relationship of anemia with ART regimen in DASH Lafia.



  Materials and Methods Top


Study area

The study was conducted at the antiretroviral clinic at the Special Treatment Center of the DASH Lafia. The antiretroviral clinic operates from Mondays to Thursdays, with Tuesdays dedicated to the adolescents while Wednesdays are dedicated to children <10 years old. Two consultants, a senior registrar, two registrars, and three medical officers run the center. Nurses, pharmacists, laboratory scientists, psychologists, adherence counselors, among others, ably support them.

Study population

The study population included HIV-infected children/adolescents attending antiretroviral clinic at the DASH, Lafia.

Study design

The design was a cross-sectional analytical hospital-based study among HIV-infected participants aged 6 months to 18 years.

Sample size

The sample size was calculated using the following formula:



n = sample size calculated, P is the prevalence at 18.9%[3]q = 1 − p, Z = standard deviate at 95% confidence level = 1.96, d = level of precision at 5%.



n = 236 allowing for 10% attrition risk, the minimum sample size used was 263.

Inclusion criteria

All children and adolescents receiving care at the ART clinic for at least a year were included in the study.

Exclusion criteria

  1. Children/adolescents with known or features of sickle-cell disorder
  2. Children/adolescents who are newly transfused in the last 1 month
  3. Children/adolescents with ongoing sepsis/malaria (febrile, icteric, etc.) were excluded from the study.


Sampling technique

A consecutive nonprobability sampling technique was used to recruit participants that meet the inclusion criteria as they present to the clinic until the calculated minimum sample size is reached.

Ethical approval

Ethical approval was sought and obtained from the DASH Research Ethics Committee on the April 10, 2019, with protocol number DASH/ADM/0348. Those with moderate-to-severe anemia, leukopenia, or thrombocytopenia were referred to the pediatric hematology clinic for further investigation and care.

Consent

Written informed consent on participation and data publication was obtained after the study was explained to the participants and they fully understand the reasons behind the study. They were made to understand that they can withdraw from the study at any time without suffering any untoward action for refusing to participate. Full confidentiality was guaranteed. All aspects of the study generally was in accordance with guideline of 2013 Helsinki's declaration.

Recruitment procedure

Participants were enrolled into this study after signing informed consent with or without assent. Blood was drawn from the cubital fossa after sterilizing the site with methylated spirit. About 3 ml of venous blood was collected through aseptic technique and 2 ml was kept in an ethylenediaminetetraacetic acid vacutainer. The sample was analyzed using an automated hematology cell counter subjected to regular quality control program. Hemoglobin (Hb) counts, platelets counts, white blood cell (WBC) counts, and differentials were studied. The remaining 1 ml of venous blood was in a plain bottle, and its serum separated and used for viral load analysis. The electronic medical record at the ART clinic was used to get the information such as the biodata and the ART regimen, etc., The above was used to complete the questionnaire. The questionnaire was administered after giving the parents/caregivers adequate information about the study and informed consent with or without assent.

Case definitions

  • Anemia:[3] Hb <11.0 g/dl
  • Mild anemia = Hb of 10.0–10.9 g/dl
  • Moderate anemia = Hb of 7–9.9 g/dl
  • Severe anemia = Hb of <7 g/dl, respectively. Others includes
  • Leukopenia:[12] WBC <4000/mm and
  • Thrombocytopenia:[13] Platelets <150,000/mm.


Data analysis

The data were entered into a Microsoft Excel sheet with the variables coded before transferring into the Statistical Package for Social Sciences SPSS version 20.0 (IBM SPSS statistic Inc.). Categorical variables were presented with the tables of frequency distribution. Mean and standard deviation of continuous variables were calculated. The association between two categorical variables was calculated using the Chi-square test. P < 0.05 considered statistically significant.

Outcome

Hematological profiles (anemia, leukopenia, and thrombocytopenia).


  Results Top


Demographic characteristics of the study population

Of the 263 clients recruited for this study, males were 133 (50.6%), whereas females were 130 (49.4%), with a male-to-female ratio of 1.02:1. Children within the under-five age bracket were 65 (24.7%), those aged 6–9 years were 140 (53.2%), while those aged 10 years and above were 58 (22.1%), respectively [Table 1].
Table 1: Demographic characteristics of the study population

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Hematological parameters of the study population based on gender

Eighty-six (32.7%) of the study population have one form of anemia or the other. There were more females with anemia compared to the males but not statistically significant P = 0.073. All the 3 (3.5%) patients with severe anemia were females [Table 2].
Table 2: Hematological parameters of the study population based on the gender

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Distribution of anemia based on anti-retroviral regimen

There were significantly more anemic patients 73 (84.9%) on Combi-Pak (AZT/3TC/NVP) than on other treatment regimens [Table 3].
Table 3: Distribution of anemia based on anti-retroviral regimen

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As at the time of this study, more than two-third of the study population were on Combi-Pak (AZT/3TC/NVP). Twenty-three (8.7%) of the 263 were on second-line drugs, all others were on first-line drug regimen [Figure 1].
Figure 1: Pattern of anti-retroviral regimen usage

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Relationship between anemia and viral load

There is no significant difference between viral load and the degree of anemia, as shown in [Table 4].
Table 4: Relationship between anemia and viral load

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  Discussion Top


Similar to earlier reports, anemia was the most common hematological abnormality seen among HIV-infected children and adolescents in this study.[2],[8] The prevalence of anemia found in this study was 32.7%. This is similar to the 37.5% reported by De Santis et al.[4] in Sao Paulo Brazil. The similarity may due to the similarity in the study design (prospective cross-sectional). The finding in the present study is in contrast with the finding by Lai et al.[8] in South-East China who reported 55.15% and that by Nyesigire Ruhinda etal.[9] in Uganda who reported 57.6%. The difference may be due to the study population which is HIV-infected children on ART drug refill clinic follow-up compared to the China study which was among hospitalized HIV-infected adults and the Ugandan study among children yet to be commenced on ART. It is equally lower than the 69% reported among Indian children.[1] The discrepancy with our study may be due to the higher sample size in this study compared to the relatively lower sample size of 100 in their study. The finding in the current study is, however, >18.9% reported by Geletaw et al.[3] among Ethiopian children who are at least 6 months on ART. The discrepancy may be due to the nonstratification of our study population based on years on ART.

There was no statistically significant difference in the anemia based on gender; there was, however, more females with anemia compared to the males, similar to earlier findings.[2],[9]

Thrombocytopenia was 11.4% in this study, similar to the 11% reported among children in India.[1] This is lower than the 16.9% reported by Lai et al.[8] using a lower cutoff for thrombocytopenia (<100,000). It is higher than the 5% reported by Raman et al.[2] among adult participants.

More than two-third of the study population were on zidovudine-based regimen as at the time of this study, similar to the earlier studies.[3],[14] There is an association between the use of zidovudine and anemia as reported by Richard et al.[14] in Ekiti.

Most of the participants in this study were on zidovudine-based regimen.

Study limitation

One limitation of the study is that the type of anaemia was not determined.


  Conclusions Top


Anemia remains the most common hematological abnormality among HIV-infected children and adolescents. There is a significant association between anemia and use of zidovudine-based ART. The prevalence of thrombocytopenia and leucopenia in this study was 11.4% and 3.04%, respectively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bhowmik A, Banerjee P. Hematological manifestation in HIV infected children. J Coll Physicians Surg Pak 2015;25:119-23.  Back to cited text no. 1
    
2.
Raman TR, Manimaran D, Hemanathan G, Afroz T, Sagar R. Hematological abnormalities in HIV infected individuals in correlation to CD4 counts and ART status. Asian J Med Sci 2016;7:14-8.  Back to cited text no. 2
    
3.
Geletaw T, Tadesse MZ, Demisse AG. Hematologic abnormalities and associated factors among HIV infected children pre-and post-antiretroviral treatment, North West Ethiopia. J Blood Med 2017;8:99-105.  Back to cited text no. 3
    
4.
De Santis GC, Brunetta DM, Vilar FC, Brandão RA, de Albernaz Muniz RZ, de Lima GM, et al. Hematological abnormalities in HIV-infected patients. Int J Infect Dis 2011;15:e808-11.  Back to cited text no. 4
    
5.
Tsegaye A, Desta K, Oma D, Derseh H, Zeleke Z, Fikadu T, et al. Prevalence of anemia before and after initiation of antiretroviral therapy on HIV infected patients at Ras Desta Damtew memorial Hospital, Addis Ababa, Ethiopia. J Med Health Sci 2018;7:24-31.  Back to cited text no. 5
    
6.
Makubi AN, Mugus F, Magesa PM, Roberts D, Quaresh A. Risk factors for anaemia among HIV infected children attending HIV care and treatment clinic at Muhimbili national hospital in Dar es Salaam, Tanzania. Tanzan J Health Res 2012;14:68-74.  Back to cited text no. 6
    
7.
Ogba OM, Abia-bassey LN, Epoke J, Mandor BI, Akpotuzor J, Iwatt G, et al. Haematological profile of HIV infected patients with opportunistic respiratory mycoses in relation to immune status – A hospital based study. Trop Med Surg 2013;1:122-6.  Back to cited text no. 7
    
8.
Lai JL, Chen YH, Liu YM, Yuan JJ, Lin J, Huang AQ, et al. Prevalence and risk factors of anaemia in hospitalised HIV-infected patients in southeast China: A retrospective study. Epidemiolica Infectious 2019;147:81-6.  Back to cited text no. 8
    
9.
Nyesigire Ruhinda E, Bajunirwe F, Kiwanuka J. Anaemia in HIV-infected children: Severity, types and effect on response to HAART. BMC Pediatr 2012;12:170.  Back to cited text no. 9
    
10.
Ahumareze RE, Rankin J, David A, Wapmuk A, Disu E. Prevalence of anaemia and the relationship between haemoglobin concentration and CD4 Count in HIV positive children on highly active antiretroviral therapy (HAART) in Lagos, Nigeria. Curr Pediatr Res 2016;20:29-36.  Back to cited text no. 10
    
11.
Federal Ministry of Health. Nigeria AIDS Indicator Impact Survey; 2019.  Back to cited text no. 11
    
12.
World Health Organisation. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin Minerals Nutritional Infectious System. Vol. 11. Geneva: World Health Organisation; 2011. p. 1-6.  Back to cited text no. 12
    
13.
Deshpande NS, Karva D, Agarkhedkar S, Deshpande S. Prevalence of anemia in adolescent girls and its co-relation with demographic factors. Int J Med Public Health 2013;3:235-9.  Back to cited text no. 13
  [Full text]  
14.
Richard A, Olayanju AO, Ntuhun BD, Chollom S. Haematological prameters in human immunodeficiency virus positive individuals on different HAART regimen. World J Pharm Res 2015;4:1-13.  Back to cited text no. 14
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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