Contemporary profile of oral manifestations of HIV/AIDS and associated risk factors in a Southeastern US Clinic

Irene Tamí-Maury, DMD, DrPH, MSc

1

; James Willig, MD, MPH

2

; Sten Vermund, MD, PhD

3

; Pauline Jolly, PhD, MPH

2

; Inmaculada Aban, PhD, MS

2

; Jeff Hill, DMD

2

; Craig Wilson, MD

2

1.The University of Texas MD Anderson Cancer Center, Houston, TX. 2.

University of Alabama at Birmingham, Birmingham, AL. 3. Vanderbilt University, Nashville, TN.

Background

The Southern United States has become the center of the HIV/AIDS epidemic in the nation. Six of the Southern states (Alabama, Georgia, Louisiana, Mississippi, North Carolina, and South Carolina) constitute the Deep South, a region that has “some of the highest levels of poverty and uninsured individuals, factors that complicate the prevention and treatment of HIV infection”.

1 Although Alabama has been designated a moderate morbidity state with regards to HIV infection (15,683 cumulative HIV/AIDS cases as of 6/30/08), new infections are increasingly concentrated in vulnerable populations, such as African-Americans, women, and rural populations.

2,3 The epidemiology and prevalence of oral manifestations (OM) during HIV infection are comprehensively documented in the literature from the United States 4-8 However, the profile and risk factors for OM in those individuals initiating HAART remains understudied in the Southeast of the US, 9 region of increasing HIV prevalence.

Objective

The purpose of this study, was to investigate clinical and socio-demographic factors associated with the presence of OM in persons with HIV infection initiating HAART who were followed for 2 years in Alabama.

Methods

Retrospective review of electronically captured data from patients initiating HAART at a Southeastern US clinic. Prevalence was determined and risk factors for overall OM, oropharyngeal candidiasis (OPC), and all other OM were evaluated using logistic regression.

Results Clinical and socio-demographic factors stratified by presence or absence of oral manifestations(n=744) Characteristics

Insurance Status Uninsured Public Private Death during the Study Period No Yes Mean Baseline CD4 (cell/ul) Baseline CD4 (cell/ul) <50 50 to 199 200 to 349 ≥ 350 Mean Baseline Viral Load (log 10 ) Baseline Viral Load 0-999 copies/mL 1,000-9,999 copies/mL 10,000-49,999 copies/mL 50,000-99,999 copies/mL ≥100,000

Total number of patients All patients n (%)

173 (23.3) 302 (40.6) 269 (36.2)

Without OL n (%) With OL n (%)

p-value

109 (22.8) 180 (37.7) 189 (39.5) 8.9

64 (24.1) 122 (45.9) 80 (30.1) <0.05

708 (95.2) 36 (4.8) 276 ± 264.3

173 (23.9) 170 (23.4) 151 (20.8) 231 (31.9) 4.2 ± 1.36

142 (21.2) 92 (13.7) 132 (19.7) 99 (14.8) 205 (30.6)

744 (100.0)

463 (96.9) 15 (3.1) 331 ± 259.8

65 (14.0) 101 (21.7) 112 (24.1) 187 (40.2) 4.0 ± 1.34

110 (25.2) 73 (16.7) 100 (22.9) 62 (14.2) 92 (21.1)

478 (64.2)

245 (92.1) 21 (7.9) 179 ± 244.3

108 (41.5) 69 (26.5) 39 (15.0) 44 (16.9) 4.6 ± 1.30

<0.01

<0.01

<0.01

<0.01

32 (13.7) 19 (8.2) 32 (13.7) 37 (15.9) 113 (48.5)

266 (35.8)

<0.01

Results (cont.) Clinical and socio demographic determinants of “Oral Lesions”

1

the HIV Cohort in Predictors

Baseline CD4 (cell/ul) <50 50 to 199 200 to 349 ≥ 350 (ref)

Bivariate analyses Crude OR

7.04

2.87

1.46

1.00

1 MODEL: OL vs. No-OL 2 Odd ratios, significant association (

p

<0.05) 3 Confidence Interval 4

p

-trend 0.01

2

Multivariate analyses Adj OR

2

95% CI

3 6.09

4 2.59

1.41

1.00

3.82-9.69

1.63-4.11

0.85-2.32

p-value

<0.01

<0.01

0.18

Clinical and socio demographic determinants of “Oro-pharyngeal Candidiasis”

1

in the HIV Cohort Predictors

Baseline CD4 (cell/ul)

Bivariate analyses Crude OR

2

Multivariate analyses Adj OR

2

95% CI

3

p-value

<50 9.37

50 to 199 3.80

200 to 349 1.58

≥ 350 (ref) 1.00

1 MODEL: OPC vs. No-OL 2 Odd ratios, significant association (

p

<0.05) 3 Confidence Interval 4

p

-trend 0.01

8.19

4 3.45

1.52

1.00

4.92-13.66

2.07-5.73

0.86-2.69

<0.01

<0.01

0.15

Conclusions

 OM were found in 36% of HIV patients entering care at the University of Alabama at Birmingham 1917 Clinic in the 2-year study period.    Low baseline CD4 count and high baseline viral load were significantly associated with OL and OPC.

History of tobacco and alcohol abuse were not significantly associated with OL.

Low baseline CD4 was the most important predictor for OL.

Implications for Practice

Due to their prevalence, especially in those patients with low baseline CD4 counts, training in the detection and treatment of OM are important components to HIV care. The accessibility of the oral cavity and the clinical relevance of oral HIV lesions cannot be overlooked or underestimated. Also, additional studies, preferable prospective cohort studies, are needed to accurately estimate the prevalence of OM associated with HIV infection. HIV infected individuals reporting the occurrence of these OM should be monitored more closely with a team approach between primary care HIV providers and oral health professionals with a more aggressive diagnostic surveillance for these common conditions.

References

1. Reif S, Geonnotti K, Whetten K. HIV infection and AIDS in the Deep South. Am J Public Health 2006;96(6):970-3.

2. Sawires S, Szekeres G, Coates T. Alabama and HIV/AIDS. Los Angeles: University of California; 2007.

3. HIV/AIDS in the South. 2010 [cited 2010 04 November]; Available from: http://www.aidsalabama.org/in-the-south.asp

4. Ledergerber B, Egger M, Erard V, Weber R, Hirschel B, Furrer H, et al. AIDS-related opportunistic illnesses occurring after initiation of potent antiretroviral therapy: the Swiss HIV Cohort Study. JAMA 1999;282(23):2220-26.

5. Greenspan D, Canchola A, MacPhail L, Cheikh B, Greenspan J. Effect of highly active antiretroviral therapy on frequency of oral warts. The Lancet 2001;357(9266):1411-1412.

6. Mercante D, Leigh J, Lilly E, McNulty K, Fidel P. Assessment of the association between HIV viral load and CD4 cell count on the occurrence of oropharyngeal candidiasis in HIV-infected patients. J Acquir Immune Defic Syndr 2006;42(5):578-83.

7. Marcus M, Maida C, Freed J, Younai F, Coulter I, Der-Martirosian C, et al. Oral white patches in a national sample of medical HIV patients in the era of HAART. Community Dent Oral Epidemiol 2005;33(2):99-106.

8. Chattopadhyay A, Caplan D, Slade G, Shugars D, Tien H, Patton L. Risk indicators for oral candidiasis and oral hairy leukoplakia in HIV-infected adults. Community Dent Oral Epidemiol 2005;33(1):35-44. 9. Patton L, McKaig R, Straus R, Rogers D, Eron J. Changing prevalence of oral manifestations of human immuno-deficiency virus in the era of protease therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:299-304.

This study has been published by the Journal of Public Health Dentistry. For more information contact Dr. Tamí-Maury at [email protected]