Volume 8, Issue 6, June – 2023 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Sociodemographic Characteristics of Patients with

Advanced HIV Disease in Enugu, South-east Nigeria:
A Retrospective Analysis of Program Data
1.
Chukwudi Kennedy Okwor, Elizabeth Marcus, Charles Onyegbado,
Fabian Bassey, Eugene Onu, Amana Effiong, John Oko Okpanachi.
HIV Care and Treatment, Caritas Nigeria,
Abuja, Nigeria.

2. 3.
Okenwa Joel Uchechukwu. Ezema Godian Chibueze.
State AIDS/STI Control Programme, National Clinical Mentorship Programme,
Enugu State Ministry of Health, Enugu. Federal Ministry of Health, Nigeria, Abuja. Nigeria

Abstract:- I. INTRODUCTION
Background: Advanced Human Immunodeficiency Virus
disease is militating against the gains made in HIV care Advanced HIV disease (AHD) is defined as HIV in
and treatment programs, especially in sub-Africa. Even under-five children, a CD4 cell count < 200 cells/mm3, or
with broadened access to antiretroviral therapy, HIV stage three and four diseases in adults and adolescents with
patients develop advanced HIV disease due to re- HIV1. Globally, TB, severe bacterial infections, cryptococcal
emerging opportunistic infections. This study x-rayed the disease, histoplasmosis, toxoplasmosis, and Pneumocystis
sociodemographic characteristics of patients with jirovecii pneumonia are the opportunistic infections (OIs)
advanced HIV disease in order to facilitate HIV program commonly implicated in morbidity and mortality among
designs that focus on the prevention, care, and treatment people living with HIV (PLHIV)2. In 2016, the Ministry of
of advanced HIV disease. Health of Nigeria adopted the Treat-All approach, which is
Methods: This was a retrospective analysis of program the immediate commencement of antiretroviral therapy for all
data of patients diagnosed with advanced HIV disease, adults and children diagnosed with HIV infection 3. Even with
based on their CD4 cell counts, between April 2022 and the introduction of tests and treat-all, the risk of death is high
March 2023. A descriptive statistical analysis of their in patients with AHD even after ART initiation, especially at
sociodemographic variables was done using SPSS version low CD4 count level4. Tuberculosis (TB) is the leading cause
22. The statistical correlations between the socioeconomic of morbidity and mortality among people living with HIV,
status and results of the Lateral Flow- while severe bacterial infection is responsible for a third of
Lipoarabinomannan and cryptococcal antigens tests, hospitalization among PLHIV worldwide5-6. The use of
ART adherence, and patients living status were prophylactic antimicrobial agents with judicious use of
computed. The observations were presented with tables antiretroviral drugs in patients diagnosed with advanced HIV
and charts. disease resulted in clinical improvement in patients in the first
Results: Advanced HIV disease concentrated in the 31 to week of therapeutic intervention7. Although there have been
45-year age group with observable preponderance for significant advances in the design of care around PLHIV and
female patients and people of lower socioeconomic status. breakthroughs in the development of novel antiretroviral
There was no significant association between patients’ medications, AIDS-related death is rising due to AHD5.
socioeconomic status and results of tuberculosis screening Worldwide, over 38 million people are living with HIV and
tests (95% CI; p = 0.425) and ART adherence (95% CI; p about 28 million patients are continuing with treatment.
= 0.847); patients’ gender and CD4 cell count at the time However, over 680, 000 AIDS-related deaths were recorded
of AHD diagnosis. in 2021 alone8. In Nigeria, the prevalence of AHD is not
Conclusion: The findings that advanced HIV disease is known. However, a data review from the National Data
common among female HIV-positive patients and people Repository (NDR) in 2019 showed that 1 in 3 had
from lower socioeconomic status signal the design of the immunologic AHD and an AIDS-related death rate of 0.22
AHD package of care around these vulnerable per 1000 deaths9. Over a quarter of patients diagnosed with
populations. HIV have severe outcomes after admission, highlighting the
significance of post-discharge referral of patients for ART
Keywords:- Militating; Gains; Re-Emerging; Retrospective; interventions10.
Lower Socioeconomic Status; Vulnerable Population.

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Volume 8, Issue 6, June – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Recognizing AHD requires astute clinical review, CD4 that would need an AHD care package. This study x-rayed the
cell estimation, and screening for notorious opportunistic socio-demographic characteristics of people living with
infections. CD4 cell testing is a good predictor of AHD as advanced HIV disease.
these cells proportionately decline with HIV disease
progression. Measuring CD4 cell counts is critical in the II. METHODOLOGY
diagnosis and periodic assessment of patients, as it provides
information about the status of immune function. Periodic This is a retrospective descriptive study on patients
measurement of CD4 cells guides healthcare workers in diagnosed with AHD between April 2022 to March 2023 in
determining the need for screening for and prophylaxis for ART centers in Enugu state, southeast Nigeria. We extracted
common opportunistic infections. It is recommended that data from the electronic medical records (EMR) for 342
CD4 cell counts be monitored at the initiation of therapy, patients who were diagnosed with and received care for AHD
three months after therapy has started, and every 12 months, during the period. The patients’ data extracted were
depending on the patient’s clinical status11. sociodemographic variables (age, gender, education, and
occupation), CD4 cell count at AHD diagnosis, TB LF-LAM,
The AHD package of care is recommended for people CrAg screening test results, and OIs treatment status. For
presenting with advanced HIV disease and it includes children and adolescents, the SES of the parents or caregivers
screening, prophylaxis, and/or treatment for the commonly was ascertained. The information on participants' education
implicated opportunistic infections, rapid ART initiation, and and occupation was collected during clinic visits and via
patient-centered adherence support12. In order to successfully phone calls. Patients’ ART adherence was calculated using
implement the AHD package of care to bend the mortality patients’ self-report validated by EMR entries. The ART
curve due to AHD, there needs to be a widespread in-country adherence rate was calculated by: Number of pills doses taken
supply of AHD commodities, training of healthcare staff on ÷ number of pills doses prescribed x 100 (where the number
the management of AHD, and an efficient AHD surveillance of pills taken = the number of pills prescribed – number of
system. The Federal Ministry of Health, Nigeria rolled out the pills missed). The adherence was classified as optimal and
first phase of the AHD package of care interventions in 28 suboptimal if ART adherence was above and below 95%
high-volume healthcare facilities across four priority states, respectively. The patients’ socioeconomic status was
adopting the hub–and–spoke model to ensure that patients calculated using the revised Scoring Scheme for the
diagnosed with AHD in a peripheral healthcare facility are Classification of Socioeconomic Status in Nigeria20. The tool
referred to the tertiary facilities that have the capacity to classified socioeconomic status into upper, medium, and
manage the patients’ complications13. The unavailability of lower based on the average educational attainment and
diagnostic tests for OIs like Lateral Flow-lipoarabinomannan occupation score of both parents and caregivers. It is graded
(TB LF-LAM), and Cryptococcal antigen (CrAg) in addition on a score of 1 to 6; 1 being the highest and 6 being the
to healthcare capacity gaps militate against the rapid lowest. The average score of the two variables is calculated. A
implementation of the AHD package of care14. Experts have person with a score of 1 to 2 belongs to the upper
also called for the integration of the three work streams socioeconomic class, and a score of 3 to 4, and 5 to 6 belong
necessary for a better quality of life among PLHIVs: scale-up to the middle, and lower socioeconomic classes, respectively.
of antiretroviral treatment through outpatient programs15, The data were coded and inputted in the Statistical Package
intentional implementation of the WHO-recommended AHD for Social Sciences (SPSS) version 22 for analysis.
package of care to reduce mortality16 and institutionalization Descriptive statistics were used to describe patients’
of comprehensive patient-centered palliative care model for sociodemographic characteristics while inferential statistics
people living with HIV8. Although the effectiveness of were used to determine the association between
palliative care has been demonstrated in the management of sociodemographic variables and AHD diagnosis. The
patients with chronic conditions, its use in the care of AHD observations were presented in tables and charts.
patients is unpopular. The evolution in HIV therapeutics has
replaced high mortality associated with HIV leading to III. RESULTS
improved life expectancy and a high disease burden on
patients, families, and healthcare17. There were 342 patients diagnosed with advanced HIV
disease between April 2022 to March 2023 in Enugu. The
Several pieces of literature have documented that mean age of the AHD patients was 38 years (SD ±12.8). The
caregivers’ socioeconomic status (SES) impacts health modal age was 41 years while the minimum and maximum
outcomes, especially in chronic illnesses like HIV/AIDS18. ages were 2 years and 83 years respectively (Table 1). The
The SES of caregivers impacts the health outcomes of patient ages were further categorized into five-year age
children19. There are myriads of literature on AHD, however, groups. Laboratory parameters for advanced HIV disease
there is a paucity of information on the sociodemographic were common among the 30-40, 41-45, and 31- 35-year age
identities of patients diagnosed with AHD in our clime. There groups and less common among the extreme age groups (Fig
is a need to characterize patients with AHD in our setting to 1).
facilitate future risk stratification and planning for patients

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Volume 8, Issue 6, June – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165

Fig 1: Chart distribution of the age groups of AHD patients based on CD4 cell counts between April 2022 to March 2023.

Table 1: Sociodemographic variables of AHD patients.

Variable Frequency(n)
Age group (years) [N=342] (%)
1-5years 3 1
6-10 years 4 1.2
11-15 years 4 1.2
16-20 years 6 1.8
21-25 years 24 7.0
26-30 years 36 10.5
31-35 years 54 15.8
36-40 years 64 18.7
41-45 years 56 16.4
46-50 years 36 10.5
51-55 years 22 6.4
56-60 years 13 3.8
>60 years 20 5.8
Mean ± SD 38.9±12.75 years
Median 38 years
Maximum 83 years
Minimum 2 years
Gender
Male 133 39
Female 209 61
Socioeconomic status
Upper 13 4
Middle 70 20
Lower 259 76
Survival Status
Alive 321 94
Dead 21 6

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Volume 8, Issue 6, June – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
There were 209 (61%) and 133 (39%) female and male AHD patients respectively between April 2022 and March 2023 (Table
1). Two hundred and fifty-nine (76%) were from the lower socioeconomic class, while 70 (20%) and 13 (4%) were from the middle
and upper socioeconomic classes (Table 1). The mortality rate among AHD patients was 6% (Table 1). A total of three hundred
(88%) and 217 (64%) AHD patients underwent CrAg and TB LAM tests respectively during the period under review while
Tuberculosis and Cryptococcal antigen positivity rates among those that had the tests were 39% and 5% respectively (Table 2). A
negative Pearson’s association was observed between SES and TB LF-LAM (N =342; r = -0.004) and ART adherence (N =342; r =
-0.007); TB LF-LAM results and ART adherence (N =342; r = -0.013) (Table 3). The Pearson’s Chi-Square tests did not reveal any
significant association between patients’ SES and the TB LF- LAM test (95% CI; p = 0.425); ART adherence and TB LAM result
(95% CI; p = 0.796); patients’ gender and TB LF-LAM results (95% CI; p = 0.793) (Table 4).

Table 2: Uptake and positivity rates of CrAg and TB LAM tests among AHD patients between April 2022 and March 2023.
Tests Frequency % Positivity %
CrAg Test
CrAg test (done) 217 64
Valid CrAg test (not done) 125 36 5
Total 342 100
TB LF-LAM Test
TB LAM (done) 300 88
Valid TB LAM (not done) 42 12 39
Total 342 100

Table 3: Correlations between SES, TB LAM result, and ART Adherence status.
Variables Socioeconomic TB LAM result ART Adherence
status of AHD status
patients
Pearson Correlation 1 -.004 -.007
Socioeconomic status of AHD
Sig. (2-tailed) .942 .900
patients
N 342 342 342
Pearson Correlation -.004 1 -.013
TB LAM result Sig. (2-tailed) .942 .806
N 342 342 342
Pearson Correlation -.007 -.013 1
ART Adherence status Sig. (2-tailed) .900 .806
N 342 342 342

Table 4: Chi-Square Test

Variables Value df Likelihood ratio X2 (2-sided)
ART Adherence and TB LF- 0.457 2 0.448 0.796
LAM Result
SES and ART Adherence rate 0.332 2 0.332 0.847

IV. DISCUSSION health coverage and enable patients and families to live a
quality life.
This study found that, in our setting, advanced HIV
disease concentrated in the middle age group (35 to 45 years) In our study, the uptake of TB LF-LAM and CrAg tests
while the younger (1 to 20 years) and older age (51 to 60 were 88% and 64% respectively for the AHD patient
years) categories were comparatively less affected by AHD. population. It showed that a worrisome number of patients
Several studies have reported a high rate of HIV missed the opportunity to access the package of care for the
transmission among the middle age groups21-23. A significant diagnosis of commonly implicated OIs like TB and
number of HIV-positive people live into old age and it Cryptococcal infections. One reason for the suboptimal
signals the design of an HIV intervention program that will uptake is that the AHD package of care is newly
focus on the aging population. The HIV-positive patients in implemented in Nigeria with few tertiary health institutions
the lower socioeconomic class were worst hit by AHD and it involved in the first phase of its implementation14.
validated the findings from other studies that poverty hastens Furthermore, there is no sustained supply of the AHD
the progression of HIV disease24. The HIV package of care package of care commodities to the healthcare facilities. The
ought to include social health protection packages designed diagnostic positivity rates for TB and Cryptococcal infections
to mitigate the impact of advanced HIV disease on patients. among HIV patients using TB LF-LAM and CrAG were 39%
Affordable health insurance policies guarantee universal and 5%. These findings were in tandem with the global

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Volume 8, Issue 6, June – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
understanding that TB is the commonest opportunistic [5]. Hakim J, Musiime V, Szubert AJ, Mallewa J, Siika A,
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outcome of the TB LF-LAM test and it calls for proactive TB Walker AS, Gibb DM; REALITY Trial Team.
preventive measures among HIV-positive patients from Enhanced Prophylaxis plus Antiretroviral Therapy for
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The authors have no competing interest to declare. Guidelines. Open Forum Infect Dis. 2022 Dec
16;9(12):ofac611. doi: 10.1093/ofid/ofac611. PMID:
AUTHOR RESPONSIBILITIES. 36540386; PMCID: PMC9757676.
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