Skin Manifestation among HIV Patients and Its Correlation with CD4 Count and WHO Clinical staging in Jimma University Specialized Hospital, Southwest Ethiopia

Dermatologic problems occur in >90% of patients with Human Immunodeficiency Virus (HIV) infection. Several skin diseases have proved to be sensitive and useful indicators of progression of HIV infection. Although these conditions may be seen in general healthy population, their occurrence in patients with acquired immunodeficiency syndrome is often atypical, more sever, explosive, extensive or resistant to therapy. Cutaneous manifestations of HIV disease can be seen throughout the course of HIV infection. Among the more common nonneoplastic problems are seborrheic dermatitis, folliculitis and opportunistic infections [1].

Problems with the skin are among the main reasons for seeking care, accounting for up to 24% of primary care visits, and are one of the most common causes of morbidity [2]. Transmissible processes, including infections and infestations, make up the majority of skin disease in many Sub-Saharan African countries accounting for 85% of skin disease in Tanzania, 78% in Malawi, 71.5% in Ethiopia and 40.1% in Uganda [3]. However, primary care providers may have difficulty diagnosing and treating other important skin diseases which often need referrals to specialized dermatology centers [4].
Patient infected with HIV are significantly more likely to develop any of 17 of 20 most common infectious or inflammatory skin conditions .HIV infected patients may experience a variety of dermatologic manifestation. Many of these are readily treatable. HIV infected persons have higher than normal frequency of cutaneous and systemic reactions to a variety of medications [5].
The magnitude and the prevalence of the problem are helpful in early detection and management of the problem.HIV infection predisposes patients to a variety of opportunistic infection as well as reactivation of latent infections. Especially those who have progressed to the acquired immunodeficiency syndrome (AIDS). Skin Disorder and mucosa are among the most common and earliest clinical manifestation of HIV infection [6].
A prospective observational study of 2-year duration carried out in the Department of Pathology of a tertiary referral center [8]. A total of 110 known HIV positive patients of all ages with symptomatic skin lesions attending skin and venereal disease outpatient department and Anti-Retroviral Therapy Clinic at this center were included in the study. Out of total 110 known HIV infected patients, 74 were males and 36 were female patients. Maximum numbers of cases were seen between 31 and 40 years of age group. Average age in the study was 34 years. CD4+ cell count was correlated in 70 cases. Out of 70 HIV+ patients ,42 (59%) patients had CD4+ cell count <200 cell/mm 3 . 10 (15%) patients showed CD4+ cell counts between 200 and 350 cell/mm 3 , 11 patients had CD4+ cell count counts from 350 to 500 cell/mm 3 and 7 (10%) patients had CD4+ cell count >500 cell/mm 3 [9].
The smallest percentage of African HIV positive patients reported else were as developing herpes Zoster is 7% (Namibia Hospital, Kampala, Uganda) and the largest is 23%. But the larger the number of patients in the series, the closer the percentage approximates to 15% [10].

Study design and setting
This was a retrospective cross sectional study using data available as employed from March 20, to April 27, 2016 in Jimma University Specialized Hospital. The hospital (JUSH) is located in Jimma City, 357 km away from Addis Ababa to southwest Ethiopia. The hospital is a referral centre for the Southwestern part of Ethiopia. Currently it became the only teaching and referral hospital in the southwestern part of the country. It provides services for approximately 9000 inpatient and 80000 outpatient attendances a year coming to hospital from the catchment population of about 15,000 million people.

Study sample
The study sample included all 220 medical records of patients who visit JUSH ART Clinic for the first time after diagnosis during the study period and those have full information were included. However, incomplete records were excluded.

Study variables
The outcome variables for this study were Skin manifestation, WHO Clinical Staging, type of skin lesion were extracted as variable from the record. The predictor variables like demographic variables were extracted from records.

Data processing, analysis, interpretation and presentation
Te data were entered in double EpiData software, checked for missing values and outliers and analyzed using SPSS version 20. Descriptive statistics were used to describe the study population in relation to relevant variables. To identify association of skin manifestation with CD4+ cell count and WHO staging the negative binomial regression model was used to control the effect of confounders. Test was two-sided and P<0.05 was considered statistically significant.

Socio-demographic characteristics
The study involved 268 HIV+ patients who were having followup to JUSH ART Clinic. From the study population 163 (60.8%) were female and 105 (39.2%) were males. Most of the patients 149 (55.6%) were within the age group of 15-30 years while 3 (1.1%) were in the age group of >50 years. One hundred and forty three (53.4%) were from rural area (Table 1).
From the study population 137 (51.1%) of them were having skin manifestations. 84 (31.3%) were female and 53 (19.8%) were males. Most of the patients 67 (25%) were in the age group 15-30 years and 60 (22.4%) were in the age group of 31-50 years.
Appropriate diagnosis and management of drug hypersensitivity reactions are essential, especially in patients with very low CD4+ T-cell count and multiple opportunistic infections. In our study 3 (2.2%) the HIV+ patient had showed hypersensitivity reaction. The female to male ratio regarding hypersensitivity reactions was 2:1 ( Table 2).

Discussion
Most studies done on the prevalence of skin manifestation among HIV/AIDS patients are population based; those conducted using a hospitalized population are scarce, which limites comparison of the study.
In this study, among HIV/AIDS patients who were already antiretroviral therapy and the data retrieved from January to December showed that the overall prevalence of skin manifestation was 137 (51.1%). The result is comparable with study done in Ethiopia in the sero-epidimilogical survey that was 55.4%. However, the study conducted in India on HIV+ patients, skin manifestation was 110 (87.6%) which is significantly higher [13].
This variation in the prevalence of skin manifestation in this study and the above study could be due to the variation in the geographic location, socioeconomic status and method of determination of the sample size. The alternative explanation for this variation could be this study is done among patients who have follow-up.
The prevalence of the problem in HIV/AIDS positive patients is likely to be a combined result of the presence of other opportunistic infection which further cause decreases the immunity.
In this study, the most common type of skin lesion is Herpes Zoster 74 (54.0%). This value is higher than the study done in Ethiopia from January 1986 to October 1993, which were Herpes Zoster skin lesion (17%) in Ethiopia and (23%) in Uganda. This higher value could be because most of the patients have low CD4+ cell count, which is significantly associated with skin manifestation.
In general, in the study the overall prevalence of skin manifestation was high. The most common type of skin lesion was Herpes Zoster. Skin manifestation is associated with CD4+ cell counts and with WHO stage of HIV/AIDS positive patients' . Health professionals should give attention on the early detection of skin manifestations among HIV/AIDS positive patients to prevent severity and its complication.