Assessment of Prevalence and Associated Factors of Oral Lesions among HIV/Aids Patients Attending in Jimma University Medical Center, ART Clinic, Jimma, Oromia, South Western of Ethiopia

Introduction

Human immunodeficiency virus (HIV), the lentivirus that causes acquired immunodeficiency syndrome (AIDS), has become one of the most important health and social problem. HIV infection is a major global health problem affecting developing and developed countries alike. More than 1.5 million People globally became newly infected with HIV in 2020 [1]. The WHO African region is the most affected region, accounting for more than two-thirds of people living with HIV worldwide [2].

Our country Ethiopia is the second most popular country in sub- Saharan Africa suffering from the burden of HIV/AIDS. The burden of HIV/AIDS remains high in Ethiopia despite a considerable scale up of comprehensive HIV/AIDS interventions during the (Millennium Development Goals) MDG period. In 2016, there were about 718,500 people living with HIV/AIDS [3]. The 2017 UNAID global AIDS report revealed that the number of new HIV infections in Ethiopia were higher in 2016 than in 2010. The reemergence of HIV/ AIDS in Ethiopia could be due to the low coverage of high impact interventions [4]. Oral lesions are common in patients infected with HIV/AIDS and are often the presenting feature. The fact that HIV is not a notifiable disease emphasizes the clinical importance of oral HIV lesions to both physician &the patients [5]. Oral lesions that are associated with this disease are important, because they affect the quality of life of the patient and are useful markers of disease progression and immunosuppression. Oral lesions in HIV infection have been well documented in developed countries, but there are fewer reports on oral lesions from developing countries [6]. Oral lesion is an integral part of overall health and it is strongly associated with systemic conditions [7]. The prevalence of oral lesion is higher among HIV-positive people (HIV+) than among the general population [8].

The oral cavity is the mirror of the overall health of an individual. Among HIV‑associated infections, oral lesion manifestations have been documented as one of the most prevalent morbidities since the beginning of the epidemic. Oral lesions are the earliest clinical manifestations among people living with human immunodeficiency virus (PLHIV) predicting the progression of HIV to AIDS [9]. Oral lesions can not only indicate infection with human immunodeficiency virus (HIV), but they are also among the early clinical features of the infection and can predict progression of HIV disease to acquired immune deficiency syndrome (AIDS). Seven types of oral lesions manifestation are strongly associated with HIV infection and also most commonly found globally, i.e., oral candidiasis, hairy leukoplakia, “acute necrotizing ulcerative gingivitis” (ANUG), “acute necrotizing ulcerative periodontitis” (ANUP), Kaposi sarcoma, linear gingival erythema, and nonHodgkin lymphoma [10]. These oral lesions may be present in up to 50% of the PLHIV and up to 80% of those with a diagnosis of AIDS. The severity of lesions depends on a low CD4+ cell count [11].

The oral lesions of HIV infection can be categorized into infections, neoplasms, immune mediated, other diseases (parotid disease, nutritional, xerostomia), and oral manifestations as adverse effects of anti-retroviral therapy. Oral or pharyngeal candidiasis are the commonest fungal infections observed as the initial manifestation of symptomatic HIV infection. Oral hairy leukoplakia has been shown to be associated with Epstein–Barr virus (EBV) infection. Oral candidiasis and oral hairy leukoplakia are associated very frequently and are considered AIDS defining disease and have also been included in the clinical classification of HIV by Centers for Disease Control and Prevention CDC [12].

Other infectious diseases commonly occurring in HIV patients are herpes simplex and varicella zoster virus infection, Cytomegalovirus-related ulcerations, oral warts associated with human papilloma virus, linear erythematous gingivitis, necrotizing ulcerative gingivitis, necrotizing ulcerative periodontitis, and syphilis. Kaposi’s sarcoma and non-Hodgkin’s lymphoma are the most common neoplasms occur in HIV patients. The disorders of the immune system also led to various oral manifestations, such as aphthous ulcers, xerostomia and necrotizing stomatitis [12, 13].

Oral manifestations such as adverse effect of anti- retroviral therapy can also be found they are oral hyperpigmentation, erythema multiform, xerostomia, paresthesia, lip edema, cheilitis, and taste disturbances [13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32]. Significance of the Study The study contributes on the usefulness of oral cavity lesions finding as markers of disease progression and screening those populations at risk. It will u t i l i z e to make recommendation to the responsible body for the advancement of better care for HIV positive patient with oral lesions. It is believed that the result of this study will be used as a base line data and information for further study or intervention.

Result

In this study, out of the 96 HIV/AIDS patients examined, 43 (44.8%) were males and 53 (55.2%) were females. Most of them (33 (34.4%)) were in the age group of 20-29 followed by age group of 30-39 which is 23 (24%). Regarding marital status, most of them were Divorced (32.3%), followed by single (30.2%). According to Religion most of them were Muslim 35 (36.5%) followed by Orthodox 33 (34.4%) and the least were wakefata 3 (3.1%). Regarding occupation 34 (35.4%) of them were Private worker followed by merchant 23 (24%) and the least were NGO employer 2(2.1%). Regarding the educational levels 23 (24%) were attended elementary school, followed by 22 (23%) high school while 15.6% were can read and write only. The demographics characteristics of patients are summarized in Table 1.

From a total of 96 studied population, 45(46.9.%) has HIV/AIDS associated oral lesions, according to the oral lesions identified in this study, fungal lesions constituted the highest and the pseudo membranous candidiasis was the most common type 11(11.5%), followed by Erythematous candidiasis and Hyperplastic candidiasis 2(2.1%), and the least was Angular cheilitis 1(1%) The second most common oral lesion was viral lesions from that Oral hairy leukoplakia

8(8.3%), accounts highest followed Herpes simplex virus 2(2.1%), and Human papilloma virus (2.1%). The third most common oral lesions were bacterial lesions accounts 6(6.2%) Necrotizing ulcerative periodontitis and necrotizing ulcerative gingivitis 5 (5.2%). The fourth most common oral lesions were neoplasm, from this Kaposis sarcoma 3 (3.1%) other nonspecific etiology were aphthous ulcers 3(3.1%) was found in this study (Table 2).

Click to enlarge

Regarding to frequency distribution and Association of oral lesions with oral hygiene status, most of the Patients with poor oral hygiene status has oral lesions 25 (55.60%), followed by fair oral hygiene status 15 (33.3%), Good oral hygiene status 3 (6.67%) and excellent oral hygiene status 2(4.4%). The result of Chi-square showed that there is statistically significant association between oral hygiene status and oral lesion at 5% (p=0.020) significance level (Figure 1).

Regarding to frequency distribution and association of oral lesions with oral hygiene practice in HIV/AIDS patients, most of patients using mouth rinse technique 31 (32.3%) has oral lesions followed by those using Mefakia 9 (9.4% ) and, tooth brush 5 (5.2% ) with high statistically significant association p-value (0.02) (Figure 2).

Click to enlarge

Discussion

This study describes the prevalence and associated factors of oral lesions in HIV/AIDS patients attending in Jimma university medical center at ART Clinic, Jimma, Oromia, South-western Ethiopia. The overall prevalence of oral lesions in this study was found to be in 45(46.9%), Which was highly in agreement with the research findings that were conducted in Arero Health Center at ART clinic, Arero town, Borena Zone, Oromia Regional State, South Ethiopia with prevalence of 48.8%. Prevalence of oral lesion in the other studies show that their occurrence was approximately 35.7% to 73.1 % The high prevalence could be because the HIV patients visited the health institution at later stages of the infection when the appearance of oral lesions is common [33].

The distribution of the studied population by gender demonstrated that 43(44.8%) of the individuals HIV/ AIDS corresponding to male and 53(55.2%) females, with Male to female ratio in this study is 1:1.5 which is roughly representative of the HIV disease burden in Ethiopia. The great prevalence in female suggests that due to being reinforced further by the fact that older men date or marry younger women. The most affected age group was young and active age groups,2029 2nd decades 33 (34.4%) and majority are within the 3rd decades of life 30-39(24%) and 4th decades of life40-49(20.8%) as confirmed by these findings of study. This marked prevalence of HIV/AIDS infection in 2nd decade’s age group may be due to early starting of sexual contact and having more than one partners.

The most common HIV/AIDS associated oral lesion in this study was pseudomembranous candidiasis 11(11.5%) followed by Oral hairy leukoplakia 8(8.3%) necrotizing ulcerative periodontitis 6(6.2%). Candida is commensal, but in immune compromised conditions, it can become pathogenic. Oral candidiasis (pseudomembranous 11(11.5%), erythematous and Hyperplastic candidiasis 2(2.1%) and angular cheilitis 1(1%) were found. Prevalence of Candidiasis was the most common oral manifestation as these studies. Other studies show similar result, the occurrence of pseudomembranous candidiasis was found to be 23% in Nigeria [33] and 20.1% in Ethiopia [31] erythematous candidiasis 10% % and angular cheilitis 7.5% % in Ethiopia [32].

Viral infection was second common oral lesion Oral hairy leukoplakia 8(8.3%), Herpes simplex virus 2(2.1%) were seen in this study. Also, prevalence bacterial lesions accounts

6(6.2%) necrotizing ulcerative periodontitis, necrotizing ulcerative gingivitis 5(5.2%), Other oral lesions like, neoplasm were Kaposis sarcoma 3 (3.1%) and nonspecific etiology were aphthous ulcers 3(3.1%) was found in this study although; the results of this investigation are disagreed with other previous investigations.

According to this study associated factors with the occurrence of oral lesions was highly observed in patients with alcohol drinking around 36(80%) followed by smoking and patient with chat chewer in 31(65.96%) was oral lesion was seen in patient with not use any substance, with statistically significant association at 1% significant level. Oral lesion was highly observed in CD4 count category <200 cells /µL (62.22%) which is followed by 200-499 cell/NL (31.11%) and only (6.67%) of lesions is in patient with > 500 cell/NL each category, was statistically significant association with oral lesions. Prevalence of oral lesion was highly observed in patients with HAART in 27(60%) while without HAART 18(40%) were observed, with statistically significant association with oral lesions. Moreover, the smaller sample size and most of the patients admitted in Jimma university medical center ART clinic were CD4 cell count <200 cells /µL (62.22%) with highest participant due to this reason study might have missed to pick up any significant association of prevalence of oral lesion with the CD4 count and HAART patients.

Among 45(46.9%) oral lesion prevalence, most of the patients uses month rinse technique 31 (32.3%) followed by mefakia 9(9.4%) and tooth brush 5(5.2%) has high statistically significant association with oral lesions, In associations of oral lesions with oral hygiene practice most of the patients with poor oral hygiene status has oral lesions 25 (55.60%), followed by fair oral hygiene status 15 (33.3%), Good oral hygiene status 3 (6.7 % ) excellent oral hygiene status 2 (4.4% ) These variables have significant association with oral hygiene practice ,The significant factors associated with the occurrence of oral lesions in our study were higher tobacco use and alcohol consumption and poor oral hygienic practices and maximum participants were from lower socioeconomic class. Higher tobacco uses and poor oral hygienic practices were also found among the HIV/AIDS patients of another study conducted in India [34]. Limitations There was shortage of time to get more patients, and low flow of patient during data collection time, and also most of patients were involuntary for interview and oral examination. There was no laboratory examination (testing) material to differentiate one lesion from the other that may be wrongly diagnosed by clinical feature only.

Conclusion and Recommendation

This study reveals that nearly half participants of the HIV/AIDS patients’ suffered from oral lesions. The most prevalent oral lesions among HIV/AIDS patients were pseudomembranous candidiasis 11(11.5%) followed by Oral hairy leukoplakia 8(8.3%) and necrotizing ulcerative periodontitis 6(6.2%). The significant factors associated with the occurrence of oral lesions in this study were higher in chat chewer, alcohol consumer, Smoking cigarettes and patients those use mouth rinse technique oral hygienic practices and has poor oral hygienic status. This may be because of the intensification of infectious lesions and the possibility of secondary infection in poor oral hygiene

Acknowledgment

First of all I would like to thank God for helping me in every aspect of my life, then I would like to give my heart full thank to my advisors Dr. Kefen Yirda (OMFS surgeon) & Dr. Fetene Humne (DMD) for your constructive comments, and also, I would like to forward my special thanks to my family and peoples beside me that give me unforgettable support to reach at this stage. Finally, I want to thank Jimma University for internet access, ART Staff members and my friends for you encourage and professional support on this research.