Skip to main content
Download PDF
  • Research article
  • Open access
  • Published:

Prevalence and associated factors of thrombocytopenia among HAART naive HIV positive patients at Gondar university hospital, northwest Ethiopia

BMC Research Notes volume 7, Article number: 5 (2014) Cite this article

Abstract

Background

Hematological abnormalities are common in HIV positive patients. Of these, thrombocytopenia is a known complication which has been associated with progression of disease. However, its magnitude and associated factors in HAART naive HIV positive patients is not known in Ethiopia. Therefore, the aim of this study was to determine the prevalence and associated factors of thrombocytopenia in HAART naïve HIV positive patients.

Methods

A retrospective study was carried out among HAART naive HIV positive patients at Gondar University Hospital, Northwest Ethiopia, from September 2011 through August 2012. Socio-demographic variables and immunohematological (platelets and CD4+ T cells) values were carefully reviewed from medical records. Associated factors and outcomes were assessed using logistic regression.

Results

A total of 390 HAART naive HIV positive patients with a mean age of 33.65 years and a range of 18–70 years were reviewed. The overall prevalence of thrombocytopenia was 23(5.9%). The mean CD4 count was 288 ± 188.2 cells/μL. HIV patients whose age ≥ 50 years old were 2.5 times more likely to have thrombocytopenia and those patients whose CD4 count < 350 were 2.6 times more likely to have thrombocytopenia than HIV patients whose CD4 count ≥500. However, CD4 count was not statistically associated with prevalence of thrombocytopenia (P > 0.05).

Conclusion

As CD4 counts of HIV patients decreasing, they have more likely to have thrombocytopenia. Therefore, early diagnosis and treatment of thrombocytopenia in these patients are necessary.

Background

Human immunodeficiency virus (HIV) is a retrovirus that infects cells of the immune system, destroying or impairing their function, which leads to the occurrence of opportunistic infections and tumors[1]. Though the malfunction of the immune system and the decrease in the number and activity of CD4+ T cells signify the hallmark of HIV infection, it is notable that HIV can also impede with other cell lineages and tissues[2, 3]. In addition to progressive reduction of CD4+ T cells, peripheral blood cytopenias, such as anaemia, neutropenia and thrombocytopenia, happen in most patients with AIDS[4, 5].

Peripheral blood cytopenias have been showed even in the absence of chemotherapeutic treatment or opportunistic infections and tumours, signifying that HIV infection may be directly associated with the induction of these hematological abnormalities[6]. Intriguingly, identified thrombocytopenia can signify the first clinical manifestation in otherwise asymptomatic HIV positive patients[7] while neutropenia and anaemia are more common in the late stages of HIV disease[8].

Thrombocytopenia is characterized by platelet counts below 125 × 103/mm3, and also frequently occurs in HIV-infected patients[9–11]. Its pathogenesis has not yet been recognized. Possible mechanisms that have been reported are increased platelet destruction, either caused by the non-specific deposition of circulating immune complexes on platelets or by the presence of specific anti-platelet antibodies, as well as direct infection of megakaryocytes by HIV with a resulting ineffective in platelet production[12].

Incidence of thrombocytopenia is around 40% of HIV-infected persons, and in approximately 10% of the patients, it may be the first sign of AIDS[13]. This haematological disorder may represent the first manifestation of HIV infection and it may progress over time and lead to severe bleeding[14]. Mature Megakaryoctes (MKs) can be infected by HIV through binding the CD4 receptor[15], and HIV genomes have been detected in MKs purified from bone marrow (BM) of HIV-positive patients[16].

The infection of MKs is not strain-restricted because both R5- and X4-tropic HIV-1 strains are able to infect MKs thus indicating that the infection may occur early in the development of HIV infection[17]. In addition to these direct effects of HIV on the MK cell lineage, HIV also supports chronic thrombocytopenia through autoimmune mechanisms[14], particularly manifest in early stages of the disease[18]. Autoimmune mechanisms are associated to anti-HIV antibodies cross-reacting with platelet-membrane glycoproteins, supporting the basic role of molecular mimicry in the induction of these antibodies[19].

Thrombocytopenia is associated with increased morbidity and mortality, accelerated deterioration in CD4 counts and accelerated progression to AIDS[20]. The incidence of thrombocytopenia varied according to the definition of thrombocytopenia and the characteristics of the baseline population[21]. There is no such information for HIV-infected individuals in Ethiopia which may help to inform respective bodies for treatment of HIV-infected individuals in this area. We therefore assessed the prevalence of thrombocytopenia in HIV-infected HAART naive patients and also tried to determine the relationship between thrombocytopenia and CD4 cell counts in these patients.

Methods

A retrospective study was carried out among HAART naive HIV positive patients at Gondar University Hospital, Northwest Ethiopia, from September 2011 through August 2012. Gondar University Hospital provides HIV/AIDS interventions including free diagnosis, treatment and monitoring. The center diagnoses new cases and monitors those on therapy. Patients on interferon therapy, chemotherapy, or malignancy were excluded.

Socio-demographic variables and immunohematological (platelets and CD4+ T cells) values were carefully reviewed retrospectively from medical records. Reviewed laboratory data of platelets analyses were done using the automated blood analyzer Cell-Dyn 1800 (Abott Laboratories Diagnostics Division, USA) and CD4 T lymphocyte counts were done using the Becton Dickinson FACS count. Thrombocytopenia was defined as platelets count <125.0 × 103/mm[22, 23].

SPSS version 16 statistical software was used for analysis of the data. Descriptive statistics (minimum, maximum, mean and standard deviation) were used for continuous variables in the course of analysis and categorical data were analyzed using logistic regression. A P-value of < 0.05 was considered to be statistically significant.

Ethical clearance was obtained from the Institutional Ethical Review Board of University of Gondar and Permission for data collection was also obtained from the University Hospital.

Result

A total of 390 HAART naïve HIV positive patient results were reviewed from their medical records. Out of these, 271 (69.5%) were females. The mean age of the patients was 33.65 ± 9.1 years, ranging from 18–70 years. The majority of study participants 328 (84.1%) were urban residents (Table 1).

Table 1 Socio-demographic characteristics of HAART naive HIV positive patients at Gondar university hospital, northwest Ethiopia, 2013
Full size table

The overall prevalence of thrombocytopenia was 23(5.9%). Platelet levels of the study participants were between 29×103 cells/μl and 653×103 cells/μl with the mean of 258×103 ± 100.561 cells/μl. The minimum CD4 count was 9 cells/μL, and the maximum was 1280 cells/μL. The mean CD4 count was 288 ± 188.2 cells/μL. In this study, majority of the thrombocytopenia cases 12 (7.3%) were observed in the age group of 30–39 years. However, the difference was not statistically significant. HIV patients whose age ≥ 50 years old were 2.5 times more likely to have thrombocytopenia and those patients whose CD4 counts < 350 were 2.6 times more likely to have thrombocytopenia than HIV patients whose CD4 count ≥500 (Tables 2 and3).

Table 2 Prevalence of thrombocytopenia among HAART naive HIV positive patients at Gondar university hospital, northwest Ethiopia, 2013
Full size table
Table 3 Association of thrombocytopenia with related factors among HAART naïve HIV positive patients at Gondar university hospital, northwest Ethiopia, 2013
Full size table

Discussion

Increasing the intricacy of HIV infection, varied hematological manifestations can be seen, in which HIV related thrombocytopenia is one of them[24]. We assessed platelet counts in HAART naive HIV infected patients, which showed that 5.9% of the sample population had thrombocytopenia, which was in agreement with previous studies by Denue et al.,[25], Sloand et al.,[21], Sullivan et al.,[26], and Suresh et al.,[27]. However, lower than reported by Erhabor et al.,[28] and Akinsegun et al.,[29]. This problem is truly a medical challenge in vulnerable population, especially by the limited therapeutic options and the absence of intervention protocol for HIV subjects[9].

Results from this study showed that majority of HAART-naïve HIV positive patients were females. The female prevalence in this study confirms the World Health Organization (WHO) report that HIV/AIDS affects females most severely in sub-Saharan Africa[30, 31]. However, thrombocytopenia had not showed statistical significance with sex and age (p > 0.05). This was in agreement with previous study done by Majluf-Cruz[24].

According to the present study, as immunity of a patient decreasing, thrombocytopenia was more prevalent rather than HIV positive patients who have relatively high CD4 count. For example, the prevalence of thrombocytopenia was proportionally high among patients who had a CD4 lymphocyte count of ≤ 350 cells/μL and low among patients with a CD4 count > 500 cells/μL. However, the increase in prevalence of thrombocytopenia with decreased CD4 cell count was not statistically significant (P >0.05). Similar findings have been reported by Elisaphane et al.,[32], Ira and Bhushan[33].

To the best of our knowledge, this is the first study in Ethiopia to determine prevalence of thrombocytopenia in HAART-naïve HIV infected patients. However, this study had limitations such as its retrospective nature which introduces possible biases related to ascertainment, documentation and chart review. In addition, this study was not included HIV infected patients who had on HAART. However, the observed results may still be a good reflection of a true circumstances and this study serve as a reference for additional recommendations to improve care of HIV infected persons and a step for further studies on the pathophysiology of HIV associated thrombocytopenia.

Conclusion

In conclusion, as CD4 counts of HIV patients decreasing, they have more likely to have thrombocytopenia. Based on this finding, it is recommended that physicians giving care for HIV infected individuals should routinely investigate and treat thrombocytopenia.

References

  1. Levy JA: HIV pathogenesis, 25 years of progress and persistent challenges. AIDS. 2009, 23: 147-160.

    Article  PubMed  Google Scholar 

  2. Borderi M, Gibellini D, Vescini F, Crignis De Cimatti E, Biagetti L, Tampellini C: Metabolic bone disease in HIV infection. AIDS. 2009, 23: 1297-1310.

    Article  PubMed  Google Scholar 

  3. Gandhi RT, Sax PE, Grinspoon SK: Metabolic and cardiovascular complications in HIV-infected patients: new challenges for a new age. J Infect Dis. 2012, 3: 353-4.

    Article  Google Scholar 

  4. Zon LI, Arkin C, Groopman JE: Haematologic manifestations of the human immune deficiency virus (HIV). J Haematol. 1987, 66: 251-256.

    Article  CAS  Google Scholar 

  5. Moses A, Nelson J, Bagby GC: The influence of human immunodeficiency virus-1 on hematopoiesis. Blood. 1998, 91: 1479-1495.

    PubMed  CAS  Google Scholar 

  6. Alexaki A, Wigdahl B: HIV-1 infection of bone marrow hematopoietic progenitor cells and their role in trafficking and viral dissemination. PLoS Pathog. 2008, 4: e1000215-

    Article  PubMed  PubMed Central  Google Scholar 

  7. Ratner L: Human immunodeficiency virus-associated autoimmune thrombocytopenic purpura. Am J Med. 1989, 86: 194-198.

    Article  PubMed  CAS  Google Scholar 

  8. Davis BR, Zauli G: Effect of human immunodeficiency virus infection on haematopoiesis. Baillieres Clin Haematol. 1995, 8: 113-130.

    Article  PubMed  CAS  Google Scholar 

  9. Miguez-Burbano MJ, Jackson J, Hadrigan S: Thrombocytopenia in HIV disease: clinical relevance, physiopathology and management. Curr Med Chem Cardiovasc Hematol Agents. 2005, 3: 365-76.

    Article  PubMed  CAS  Google Scholar 

  10. Kirchhoff F, Silvestri G: Is Nef the elusive cause of HIV-associated hematopoietic dysfunction?. J Clin Invest. 2008, 118: 1622-5.

    PubMed  CAS  PubMed Central  Google Scholar 

  11. Dilkshit B, Wanchu A, Sachdeva RK, et al: Profile of hematological abnormalities of Indian HIV infected individuals. BMC Blood Disorders. 2009, 9: 5-

    Article  Google Scholar 

  12. Jost J, Tauber MG, Luthy R, et al: HIV-associated thrombocytopenia. Schweiz Med Wochenschr. 1988, 118: 206-212.

    PubMed  CAS  Google Scholar 

  13. Pechere M, Samii K, Hirschel B: HIV related thrombocytopenia. Engl J Med. 1993, 328: 1785-6.

    Article  CAS  Google Scholar 

  14. Scaradavou A: HIV-related thrombocytopenia. Blood Rev. 2002, 16: 73-76.

    Article  PubMed  CAS  Google Scholar 

  15. Zucker-Franklin D, Cao YZ: Megakaryocytes of human immunodeficiency virus-infected individuals express viral RNA. Proc Natl Acad Sci USA. 1989, 86: 5595-5599.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  16. Zucker-Frankli D, Termin CS, Cooper MC: Structural changes in the megakaryocytes of patients infected with the human immune deficiency virus (HIV-1). Am J Pathol. 1989, 134: 1295-1303.

    Google Scholar 

  17. Voulgaropoulou F, Pontow SE, Ratner L: Productive infection of CD34 + −cell-derived megakaryocytes by X4 and R5 HIV-1 isolates. Virology. 2000, 269: 78-85.

    Article  PubMed  CAS  Google Scholar 

  18. Murphy MF, Metcalfe P, Waters AH, Carne CA, Weller IV, Linch DC, Smith A: Incidence and mechanism of neutropenia and thrombocytopenia in patients with human immunodeficiency virus infection. Br J Haematol. 1987, 66: 337-340.

    Article  PubMed  CAS  Google Scholar 

  19. Karpatkin S, Nardi M, Lennette ET, Byrne B, Poiesz B: Anti-human immunodeficiency virus type 1 antibody complexes on platelets of seropositive thrombocytopenic homosexuals and narcotic addicts. Proc Natl Acad Sci USA. 1988, 85: 9763-9767.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  20. Volberding PA, Baker KR, Levine AM: Human immunodeficiency virus hematology. 2003, American Society of Haemotology Annual Meeting, 294-312.

    Google Scholar 

  21. Sloand EM, Klein HG, Banks SM, Vareldzis B, Merritt S, Pierce P: Epidemiology of thrombocytopenia in HIV infection. Eur J Haematol. 1992, 48: 168-72.

    Article  PubMed  CAS  Google Scholar 

  22. Steinman RM, Granelli-Piperno A, Pope M, et al: The interaction of immunodeficiency viruses with dendritic cells. Curr Top Microbiol Immunol. 2003, 276: 1-30.

    PubMed  CAS  Google Scholar 

  23. World Health Organisation: Nutritional anemia: report of a WHO scientific group. 1968, Geneva, Switzerland: World Health Organisation

    Google Scholar 

  24. Majluf-Cruz A: Changes in blood coagulation in HIV infection. Rev Invest Clin. 1997, 49: 51-66.

    PubMed  CAS  Google Scholar 

  25. Denue BA, Gashau W, Bello HS, Kida M, Bakki B, Ajayi B: Relation between some haematological abnormalities, degree of immunosuppression and viral load in treatment-naïve HIV-infected patients. EMHJ. 2013, 19: 4-

    Google Scholar 

  26. Sullivan PS, Hanson DL, Chu SY, Jones JL, Ciesielski CA: Surveillance for thrombocytopenia in persons infected with HIV: results from the multistate adult and adolescent spectrum of disease project. JAIDS. 1997, 14: 374-379.

    PubMed  CAS  Google Scholar 

  27. Suresh Venkata Satya A, Singh VP, Madhukar R, Datla Vivekananda V, Gulati AK, Shyam S: Hematological profile of HIV patients in relation to immune status - a hospital-based cohort from Varanasi, North India. Turk J Hematol. 2008, 25: 13-19.

    Google Scholar 

  28. Erhabor O: Some haematological parameters in human immunodeficiency virus (HIV) infected Africans: the Nigerian perspective. Niger J Med. 2005, 14: 33-38.

    PubMed  CAS  Google Scholar 

  29. Akinsegun A, Olajumoke O, Titilope A, et al: Hematologic abnormalities in treatment naïve HIV patients. Infectious Diseases Research and Treatment. 2010, 3: 45-49.

    Google Scholar 

  30. Dabis F, Ekpini ER: HIV-1/AIDS and maternal and child health in Africa. Lancet. 2002, 359: 2097-104.

    Article  PubMed  Google Scholar 

  31. Joint United Nations Programme on HIV/AIDS and World Health Organization: AIDS epidemic update: Dec 2004. 2004, Geneva, Switzerland: UNAIDS

    Google Scholar 

  32. Elisaphane M, Ivan E, Eugene M, et al: Assessment of haematological parameters in HIV-infected and uninfected Rwandan women: a cross-sectional study. BMJ Open. 2012, 2: e001600-

    Google Scholar 

  33. Ira S, Bhushan K: Hematological manifestation in haart naive hiv-1 infected children in india in a resource limited setting. PIDC. 2011, 8: 35-

    Google Scholar 

Download references

Acknowledgements

The authors wish to acknowledge Gondar University Hospital staffs for facilitating the data collection.

Author information

Authors and Affiliations

  1. School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, Ethiopia

    Yitayih Wondimeneh, Dagnachew Muluye & Getachew Ferede

Authors
  1. Yitayih Wondimeneh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Dagnachew Muluye
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Getachew Ferede
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Getachew Ferede.

Additional information

Competing interests

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Authors’ contributions

YW: Participated in the conception and design of the study, data collection, analysis and interpretations of the findings, reviewed the manuscript. DM: Participated in the conception and design of the study, analysis and interpretations of the findings, reviewed the manuscript. GF: Participated in the conception and design of the study, data collection, analysis and interpretations of the findings, drafting the manuscript and write up. All authors read and approved the final manuscript.

Rights and permissions

Open Access This article is published under license to BioMed Central Ltd. This is an Open Access article is distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article

Wondimeneh, Y., Muluye, D. & Ferede, G. Prevalence and associated factors of thrombocytopenia among HAART naive HIV positive patients at Gondar university hospital, northwest Ethiopia. BMC Res Notes 7, 5 (2014). https://0-doi-org.brum.beds.ac.uk/10.1186/1756-0500-7-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://0-doi-org.brum.beds.ac.uk/10.1186/1756-0500-7-5

Keywords

BMC Research Notes

ISSN: 1756-0500

Contact us