European Journal of Cardiovascular Medicine

Research from the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates around 38 million people with HIV/AIDS in 2019, with an additional 1.7 million newly infected.[1] The presence of HIV/AIDS results in a reduction of immune defenses, which leads to immunosuppression. This condition renders the patient susceptible to various complications, including potential organ damage and metabolic disorders.[2] In Asia, there are approximately 4.8 million individuals living with HIV, with nearly half (49%) of this population residing in India.[3] The expansion of antiretroviral therapy (ART) services in India has been substantial since the initiation of ART centers by the National AIDS Control Organization (NACO) in 2004, which provide free AR medications.[3] Patients who are suspected of treatment failure on first-line regimens based on WHO-defined immunologic or clinical criteria are submitted to viral load testing, and only patients who have definite virologic failure are eligible to move to second-line ART. The only available second-line ART comprises a boosted protease inhibitor (BPI) in conjunction with two nucleoside reverse transcriptase inhibitors (NRTIs), much like other variants of RLS. Studies on the effectiveness and survival of patients on second-line regimens are available for the RLS, with the majority of these studies coming from Africa.[4-6] The second-line ART treatment is well tolerated; nevertheless, dyslipidemia and anemia should be monitored closely.[7] Several studies have found that the risk of dyslipidemia with protease inhibitors (PIs) is over 60%. The risk is higher when more than one PI is used together than when only one is used.[8,9] In order to lessen future mortality rates among second-line patients, NACO has taken steps such as decreasing the cut-off level for starting viral load for second-line patients to 1000 copies/ml and ensuring early referral via medical officer training. Making viral load testing more widely available, as is now recommended by the WHO, would go a long way toward strengthening the second-line program. Therefore, NACO will soon implement third-line antiretroviral therapy (ART) and strengthen the first and second lines of treatment.[10] Chronic hypothyroidism and isolated low free T4 (fT4) levels are all different types of thyroid dysfunction that can happen in people with HIV.[11]  In a study thyroid dysfunction was seen in 225 newly diagnosed HIV-positive patients to be as high as 75.5%, compared to only 16% in the control group. More than 50% of patients had subclinical hypothyroidism, which was the most commonly observed abnormality.[12] There have been reports of conflicting information concerning the relationship between thyroid dysfunction and HAART. A limited number of studies conducted in India have investigated thyroid dysfunction among HIV-positive individuals undergoing treatment. Moreover, most of the available data from India do not adequately examine the impact of antiretroviral medications on thyroid function in adults. The discrepancies in findings and the limited data available from various regions of India necessitated the initiation of this study [13].

Henceforth, the goal of our study was to evaluate & compare the effects of 2nd line ART on thyroid profile (TP) among HIV positive(+ve)  patients & correlate the severity with CD4 level.

The current prospective study was conducted from October 2022 to September 2023 in ART center,  JLN Medical College and Hospital, Ajmer among HIV infected 102 patients who are on 2^nd line HAART & registered after ethical approval and informed consent.

Study Design: Observational Study

Inclusion Criteria:

1. Age greater than 18 years.
2. HIV patients failed on st line ART.
3. Those who switched to 2^nd line from October 2022 to September 2023.
4. Adherence>95%

Exclusion Criteria:

1. Pregnant women
2. Age <18 years
3. Any severe illness within 2 months of evaluation
4. Hypothyroid or hyperthyroid treatment
5. Previous history of thyroid surgery

Methodology

In our study, we have recorded baseline data in pre-test case records [CD4 level & plasma viral load (PVL)] then at 6 & 12 months after switching to 2^nd line ART. If the patient failed to show viral suppression (<400 copies/ml) at 6^th month, PVL was repeated after 12 th month. Additionally, patients were also asked to follow up after every 3 months for thyroid function (TY-F) test till the study completion. Furthermore, patients recieved counselling at every visit & adherence to 2^nd line ART by pill count and the levels of FT3, FT4 and TSH was measure by chemiluminescence assay using UniCeL DxI 600 analyzer. Data was expressed in precentage using SPSS version 21 software and the p value was considered as significant when it is equal to or less than 0.05.

TABLE 1: TDF

Table 1 shows that, only 38.2% patients (41) showed TDF presence.

TABLE 2: PT of TDF

Table 2 shows that, majority of the patients were normal ( no TDF) with 61 in number (59.80%), followed by SC-HPT with 34 in number (33.33%) , then overt HPT was seen in 5 patients (4.90%) , isolated low free T4 seen in 2 patients (1.96%) respectively.

TABLE 3A: TDF

Table 3A shows that, the average age of the patients in the study was 34.22 ± 9.35 years. Thus, the age varied from 20 years to 72 years and found non-statistically significant difference between them as the p-value was 0.453.

TABLE 3B: TDF (SEX DISTRIBUTION)

Chi-square = 2.089 with 2 degrees of freedom;   P = 0.352

Table 4A shows that, majority patients were TL+ATV+RTV with 22 in number (56.4%) followed by AL+ATV+RTV with 12 in number (30.8%) then, TL+LPV+RTV with 5 in number (12.8%) respectively. Thus , found non significant difference as the p value was 0.352.

TABLE 4B: TDF (drug)

                                 Chi-square = 2.512 with 5 degrees of freedom;   P = 0.947

Table 4B shows that, patients who were taking L & RTV were maximum in number with 39 (38.24%) followed by ATV with 34 in number(40%), then T with 27 in number (34.62%), ABC with 12 in number (50%) and APV with 5 in number (29.41%) respectively to have TDF.

TABLE 4C: DIFFERENT LEVELS

Table 4c shows that, at baseline, after 6^th month & 12^th month (AL+ATV+RTV) found non-significant difference as the p value was 0.746, 0.267,0.396,0.219,0.189,0.642,0.789,0.430 and 0.585 respectively at 2^nd line of ART initiation.

TABLE 5: TDF (CD4 count)

Table 5 shows that, at baseline , after 6^th month & 12^th month showed statistically significant difference as the p value was <0.001 respectively.

TABLE 6: BASELINE (CD4 count)

Table 6 shows that, there was non-significant difference as the p value was >0.05 for FT3 & FT4 while significant difference was seen for TSH as the p value was <0.05 respectively.

TABLE 8: AFTER 12^th Month (CD4)

Table 8 shows that, there was non-significant difference as the p value was >0.05 for FT3 & FT4 while significant difference was seen for TSH as the p value was <0.01 respectively.

TABLE 9: VL

Table 9 shows that, MVL was decreased after 6 months and after 12 months in both outcome groups but there was statistically significant higher VL in TDF group after 6 months as the p value was 0.049. No correlation was observed at baseline and after 12 months as the p value was 0.523 & 0.112 respectively.

TABLE 10: BASELINE (VL)

Table 10 shows that, there was non-significant difference as the p value was >0.05 for FT4 & TSH while significant difference was seen for FT3 as the p value was <0.05 respectively.

TABLE 11: AFTER 6^th Month (VL)

Table 11 shows that, there was non-significant difference as the p value was >0.05 for FT4 & TSH , while significant difference was seen for FT3 as the p value was <0.01 respectively.

TABLE 12: AFTER 12^th Month (VL)

Table 12 shows that, there was non-significant difference as the p value was >0.05 for FT3,  FT4 &  TSH respectively.

An in-depth cross-sectional population study done by Menon et al. in 2009 in southern India found that 19.6% of adults have thyroid dysfunction, with 9.4% having subclinical thyroid dysfunction [6]. The reported prevalence of thyroid dysfunction among individuals with HIV in India varies between 23% and 75.5%, while our study found it to be 38.2% [7]. A study conducted in Western nations have shown that the prevalence of thyroid dysfunction varies between 10% and 18% [11]. It's possible that the big differences in incidence rates between studies are because the people who were included in the studies had different levels of immunodeficiency, different types of

HAART, and different lengths of time they were sick. Documented variations in the frequency of thyroid disorders exist among different ethnic groupings in the West [12].

The results in our study suggest that a potential disparity may be present between individuals of Indian descent and those from Western populations. Hence, we can link the observed disparities to reduced immunity and an increased prevalence of iodine deficiency within our community. The current investigation identified 34 out of 41 abnormal thyroid functions as subclinical hypothyroidism, while 5 cases presented with overt hypothyroidism. Nevertheless, two subjects exhibited isolated low levels of free T4. The mean age of research participants was 34.22 years, with a standard deviation of 9.35 years. The age range in this study was between 20 and 72 years. We observed no statistically significant difference (p-value > 0.05) between the group with thyroid dysfunction and the group without thyroid dysfunction. While 67.7% of the participants were male, the ratio of females to males in our study was 1:2. Males made up the majority (79.5%) of the group with thyroid problems. There was less than a statistically significant difference in the distribution of sexes across the result groups (p > 0.05).

A significant proportion (59.8%) of participants in this investigation received the TL+ATV+RTV regimen. In the cohort with thyroid dysfunction, 56.4% were administered a combination of TL+ATV+RTV, whereas this figure was 62.0% in the cohort without thyroid dysfunction. The distribution did not reach statistical significance (p-value > 0.05). There was a statistically significant drop in the baseline CD4 cell count in the group whose thyroid function was not working properly (p-value less than 0.001). At both the 6 and 12 month points, the mean CD4 cell count went up in both result groups. However, there was a statistically significant drop in the count in the aberrant outcome group.We looked at the links between CD4 cell count and thyroid function parameters, namely FT3, FT4, and TSH, at the start of the study, after 6 months, and again after 12 months. At baseline, FT3 (r=0.011) and FT4 (r=-0.009) did not exhibit any statistically significant correlation (P>0.05), whereas TSH (r=-0.252) demonstrated a statistically significant inverse correlation (P<0.05). After 6 months, we found no significant correlation with FT3 (r=-0.129) and FT4 (r=0.125) (P>0.05). Conversely, a statistically significant inverse correlation was noted with TSH levels at the 6-month mark (r=-0.458; P<0.01). After 12 months, we detected no significant correlation with FT3 (r = -0.174) and FT4 (r = -0.194) (P > 0.05). Conversely, a statistically significant inverse correlation was identified with TSH levels at the 12-month mark (r = -0.578; P < 0.01).

Sebastian et al. conducted a study in 2018 that identified thyroid dysfunction in 47 participants. Subclinical hypothyroidism was the most frequently observed thyroid function abnormality, impacting 29 individuals. Of the 30 individuals diagnosed with hypothyroidism, only 4 exhibited elevated TPO-Ab titres. TSH levels demonstrated an inverse relationship with the duration of antiretroviral therapy and CD4 counts. Age demonstrated a negative correlation with CD4 counts. We observed a negative correlation between TSH levels and CD4 counts after adjusting for age and the duration of antiretroviral therapy. We compared the median TSH levels of patients who received a specific medication to those of individuals who did not receive the treatment [13].

In our study, the mean viral load demonstrated a decline at both the 6-month and 12-month intervals across all result groups. Notably, the group without thyroid dysfunction showed a statistically significant reduction in viral load after 6 months, with a p-value of less than 0.05. In this study, the correlations between viral load and thyroid function parameters (FT3, FT4, and TSH) were computed and analyzed at baseline, 6 months, and 12 months.

At baseline, no statistically significant correlation was established in comparison with FT4 (r=0.165) and TSH (r=0.171) (P>0.05). Conversely, a statistically significant direct correlation was noted when compared with FT3 (r=0.195; P<0.05). At 6 months, there was no statistically significant correlation observed in relation to FT4 and TSH (P > 0.05); however, a statistically strong direct correlation was noted with FT3 (P < 0.01). At the 12-month mark, no statistically significant correlation was observed in comparison to FT3, FT4, and TSH (P > 0.05). The negative connection between baseline CD4 count and anti-TPO antibody titers suggests that early immunodeficiency in the course of the illness may be linked to a heightened risk of autoimmunity in the future. Past research have shown that HIV-infected individuals with low CD4+ cell counts often exhibit elevated autoantibody expression. It is thought that this is because the virus directly impacts the endothelium, hematopoietic stem cells, and other tissues, making immune cells more effective at killing cells and increasing the expression of autoantigens [13].

LIMITATION

1. There was no comparing group who not recieve ART.
2. Anti-thyroid peroxidase antibodies (TPO) & imaging investigations were not conducted in our study.

The results of our study support the ongoing development of a second-line antiretroviral therapy regimen that is more effective and less toxic, with a significantly shorter treatment duration. This should be a top priority for the HIV community. Until that time, it is essential to reduce the occurrence of severe adverse events in HIV patients through thorough screening to promptly identify any adverse events, such as sub clinical hypothyroidism and follow up the patient and treat when indicated. Thorough investigations are crucial to evaluate the health status of individuals with HIV and moderate thyroid dysfunction, along with the pharmacoeconomic implications of screening, in order to improve the development of clinical guidelines.

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