Journal of Investigative and Clinical Dentistry (2016), 7, 158–167
ORIGINAL ARTICLE Oral Microbiology
Highly-active antiretroviral therapy and oral opportunistic microorganisms in HIV-positive individuals of Thailand n4 Pratanporn Arirachakaran1,2, Yong Poovorawan3 & Gunnar Dahle 1 2 3 4
Department of Oral Medicine, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand Infectious Diseases Clinic and Dental Hospital, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand Center of Excellence in Clinical Virology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Keywords aerobic Gram-negative bacilli, Candida, highly-active antiretroviral therapy, HIV, Staphylococcus aureus. Correspondence Pratanporn Arirachakaran, Department of Oral Medicine, Faculty of Dentistry, Chulalongkorn University, 34 Henri-Dunant Road, Pathumwan, Bangkok 10330, Thailand. Tel: +662-218-8725 Fax: +662-218-8941 Email: [email protected] Received 9 April 2014; accepted 25 October 2014. doi: 10.1111/jicd.12142
Abstract Aim: Oral mucosal lesions and opportunistic microorganisms in HIV-positive Thais treated with highly-active antiretroviral therapy (HAART) for more than 5 years were investigated. Methods: A total of 221 HIV-infected patients, comprising 148 HIV patients undergoing HAART for more than 5 years, 20 non-HAART HIV patients, 53 vertically-transmitted (VT) HAART HIV patients, and 30 HIV-negative controls, were examined for CD4+ counts, viral load, saliva secretion rate, and oral mucosal lesions. Samples from the tongue, gingival crevices, and mucosal lesions when present were cultured for the amounts of Candida, staphylococci, enterococci, and aerobic Gram-negative bacilli. Results: HAART (including HIV–VT) maintained oral microbial homeostasis predominated by alpha-hemolytic streptococci similar to the non-HIV controls and with a low prevalence of mucosal lesions. The HAART group had a reduced saliva secretion rate. The frequency and load of opportunistic microorganisms in the HAART group were similar to the non-HAART group, which was significantly higher than the HIV-negative controls. Candida spp. was found significantly more frequently on the tongue in HIV-infected individuals with CD4+ counts 500 (n = 11)d
52a,b 19 12 18 3 120
25a 14 13 14 2 101
3b 1 2 5 0 30
42 7 13 9 0 120
29 4 4c 2 0 101
5 1 0 2 1 30
5 1 1 2 0 30
0 1 1 1 0 11
(43)** (16) (10) (15) (3) (100)
(25) (14) (13) (14) (2) (100)
(10) (3) (7) (17) (0) (100)
(35) (6) (11)c* (8) (0) (100)
(29) (4) (4) (2) (0) (100)
(17) (3) (0) (7) (3) (100)
(17) (3) (3) (7) (0) (100)
(0) (9) (9) (9) (0) (100)
HAART, highly-active antiretroviral therapy; S. aureus, Staphylococcus aureus; VT, vertically transmitted. *P < 0.05, **P < 0.005. Same letter in the same line indicates significant difference between the groups. Values in parentheses are expressed as percentages.
CD4+ ≤500 cell/mm3 had a significantly higher frequency of moderate/heavy loads of S. aureus than the group with CD4+ >500 cells/mm3 (P < 0.05). In contrast, Pseudomonas spp. was found in significantly higher moderate/heavy loads in the CD4+ >500 cells/mm3 group in comparison to the CD4+ ≤500 cell/mm3 group (P < 0.05).
which we had available data). A significantly higher percentage of the non-HAART HIV group had detectable viral loads compared to those of the HAART and HIV– VT groups (P < 0.0001). No significant correlation was found between a detectable viral load and the presence of mucosal lesions or change in microflora.
Viral load, mucosal lesions, and microbiology
Saliva secretion rate, mucosal lesions, and microbiology
A detectable viral load (>50 copies/mL) was found primarily in the non-HAART HIV group (in all 8, for
The HAART group showed a significantly lower unstimulated and stimulated saliva secretion rate than
ª 2014 Wiley Publishing Asia Pty Ltd
163
HAART and oral opportunistic microorganisms
the non-HAART HIV and the control groups (P < 0.001) (Table 1). No data on the saliva secretion rate were available for the HIV–VT group. We found no significant correlation between a low saliva secretion rate and the presence of mucosal lesions or any of the investigated bacterial species or fungi. Ethical standards The Ethics Committee at the Faculty of Dentistry, Chulalongkorn University approved the study protocols, and all the participants signed an informed consent agreement prior to their inclusion in the study. All individuals in the study were in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments (as revised in Seoul 2008). Discussion The present study primarily focused on the clinical and microbiological profile of HIV-infected patients treated with HAART for more than 5 years, and the findings are summarized as follows. Significantly lower viral load and saliva secretion rates between the HAART and the nonHAART groups were found; however, the frequency of mucosal lesions in the HAART and non-HAART groups was low compared to the rates reported in the literature. A high prevalence and load of opportunistic oral pathogens (Candida spp., coliforms, Pseudomonas spp., and S. aureus) were frequently found in the HIV-positive individuals (HAART and non-HAART groups); however, only Candida spp. and coliforms were found significantly more frequently compared with HIV-negative controls. Candida spp. was the only opportunist that was significantly higher in the HAART group compared to the nonHAART group, and when the HAART and non-HAART HIV groups were compared separately with the non-HIV controls. The HIV–VT group had a similar microbiological pattern to the adult HAART HIV group. Both HAART, as well as non-HAART HIV groups, maintained an oral microbial homeostasis predominated by alpha-hemolytic streptococci that was similar to the non-HIV patients. We found that the non-HAART HIV group exhibited few oral lesions and a low prevalence of opportunistic infections (25%), which was unexpected considering that many studies reported a high prevalence (range: 53–90%) of mucosal lesions and opportunistic infections in HIVpositive individuals.8,27–31 These studies demonstrated the presence of oral lesions when the immune system is compromised, because lesions are inversely related to CD4+ cell counts. The presence of oral manifestations is well established as a good indicator of immune dysfunction in 164
P. Arirachakaran et al.
HIV infection.4 It is noteworthy that the mean CD4+ level in our non-HAART group was 439 207 cells/ mm3. HIV-positive patients begin receiving HAART when their CD4+ levels drop below the AIDS-defining value of 200 cells/mm3. Therefore, the HAART individuals in our study previously had CD4+ levels below 200 cells/mm3, which had been restored by HAART to 452 202 cells/ mm3. The similar CD4+ profiles between the HAART and non-HARRT groups likely explain why the number of lesions and opportunistic pathogens was not significantly different. AGNB and yeasts were found in significantly higher amounts from the tongue and gingival crevice in all three groups of HIV-positive individuals than those in the non-HIV group. These organisms also occurred frequently in relatively high amounts, which could indicate that they are not transient, but colonized the oral cavity and were still in a carriage state in these individuals without them developing symptoms and infection. This common carriage condition among HIV patients could be explained by numerous hospital visits and antibiotic exposure. The presence of opportunistic microorganisms, such as S. aureus, E. faecalis, and AGNB, must therefore be interpreted cautiously, even if the high load is considered. In the present study, moderate and heavy growth of opportunistic microorganisms were found in 45% and 7% of the tongue samples from all of HIVand non-HIV-infected patients, respectively. A significantly higher load of S. aureus was also found in the group with CD4+ 500 cells/mm3 is significantly lower than the group with CD4+
ORIGINAL ARTICLE Oral Microbiology
Highly-active antiretroviral therapy and oral opportunistic microorganisms in HIV-positive individuals of Thailand n4 Pratanporn Arirachakaran1,2, Yong Poovorawan3 & Gunnar Dahle 1 2 3 4
Department of Oral Medicine, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand Infectious Diseases Clinic and Dental Hospital, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand Center of Excellence in Clinical Virology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Keywords aerobic Gram-negative bacilli, Candida, highly-active antiretroviral therapy, HIV, Staphylococcus aureus. Correspondence Pratanporn Arirachakaran, Department of Oral Medicine, Faculty of Dentistry, Chulalongkorn University, 34 Henri-Dunant Road, Pathumwan, Bangkok 10330, Thailand. Tel: +662-218-8725 Fax: +662-218-8941 Email: [email protected] Received 9 April 2014; accepted 25 October 2014. doi: 10.1111/jicd.12142
Abstract Aim: Oral mucosal lesions and opportunistic microorganisms in HIV-positive Thais treated with highly-active antiretroviral therapy (HAART) for more than 5 years were investigated. Methods: A total of 221 HIV-infected patients, comprising 148 HIV patients undergoing HAART for more than 5 years, 20 non-HAART HIV patients, 53 vertically-transmitted (VT) HAART HIV patients, and 30 HIV-negative controls, were examined for CD4+ counts, viral load, saliva secretion rate, and oral mucosal lesions. Samples from the tongue, gingival crevices, and mucosal lesions when present were cultured for the amounts of Candida, staphylococci, enterococci, and aerobic Gram-negative bacilli. Results: HAART (including HIV–VT) maintained oral microbial homeostasis predominated by alpha-hemolytic streptococci similar to the non-HIV controls and with a low prevalence of mucosal lesions. The HAART group had a reduced saliva secretion rate. The frequency and load of opportunistic microorganisms in the HAART group were similar to the non-HAART group, which was significantly higher than the HIV-negative controls. Candida spp. was found significantly more frequently on the tongue in HIV-infected individuals with CD4+ counts 500 (n = 11)d
52a,b 19 12 18 3 120
25a 14 13 14 2 101
3b 1 2 5 0 30
42 7 13 9 0 120
29 4 4c 2 0 101
5 1 0 2 1 30
5 1 1 2 0 30
0 1 1 1 0 11
(43)** (16) (10) (15) (3) (100)
(25) (14) (13) (14) (2) (100)
(10) (3) (7) (17) (0) (100)
(35) (6) (11)c* (8) (0) (100)
(29) (4) (4) (2) (0) (100)
(17) (3) (0) (7) (3) (100)
(17) (3) (3) (7) (0) (100)
(0) (9) (9) (9) (0) (100)
HAART, highly-active antiretroviral therapy; S. aureus, Staphylococcus aureus; VT, vertically transmitted. *P < 0.05, **P < 0.005. Same letter in the same line indicates significant difference between the groups. Values in parentheses are expressed as percentages.
CD4+ ≤500 cell/mm3 had a significantly higher frequency of moderate/heavy loads of S. aureus than the group with CD4+ >500 cells/mm3 (P < 0.05). In contrast, Pseudomonas spp. was found in significantly higher moderate/heavy loads in the CD4+ >500 cells/mm3 group in comparison to the CD4+ ≤500 cell/mm3 group (P < 0.05).
which we had available data). A significantly higher percentage of the non-HAART HIV group had detectable viral loads compared to those of the HAART and HIV– VT groups (P < 0.0001). No significant correlation was found between a detectable viral load and the presence of mucosal lesions or change in microflora.
Viral load, mucosal lesions, and microbiology
Saliva secretion rate, mucosal lesions, and microbiology
A detectable viral load (>50 copies/mL) was found primarily in the non-HAART HIV group (in all 8, for
The HAART group showed a significantly lower unstimulated and stimulated saliva secretion rate than
ª 2014 Wiley Publishing Asia Pty Ltd
163
HAART and oral opportunistic microorganisms
the non-HAART HIV and the control groups (P < 0.001) (Table 1). No data on the saliva secretion rate were available for the HIV–VT group. We found no significant correlation between a low saliva secretion rate and the presence of mucosal lesions or any of the investigated bacterial species or fungi. Ethical standards The Ethics Committee at the Faculty of Dentistry, Chulalongkorn University approved the study protocols, and all the participants signed an informed consent agreement prior to their inclusion in the study. All individuals in the study were in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments (as revised in Seoul 2008). Discussion The present study primarily focused on the clinical and microbiological profile of HIV-infected patients treated with HAART for more than 5 years, and the findings are summarized as follows. Significantly lower viral load and saliva secretion rates between the HAART and the nonHAART groups were found; however, the frequency of mucosal lesions in the HAART and non-HAART groups was low compared to the rates reported in the literature. A high prevalence and load of opportunistic oral pathogens (Candida spp., coliforms, Pseudomonas spp., and S. aureus) were frequently found in the HIV-positive individuals (HAART and non-HAART groups); however, only Candida spp. and coliforms were found significantly more frequently compared with HIV-negative controls. Candida spp. was the only opportunist that was significantly higher in the HAART group compared to the nonHAART group, and when the HAART and non-HAART HIV groups were compared separately with the non-HIV controls. The HIV–VT group had a similar microbiological pattern to the adult HAART HIV group. Both HAART, as well as non-HAART HIV groups, maintained an oral microbial homeostasis predominated by alpha-hemolytic streptococci that was similar to the non-HIV patients. We found that the non-HAART HIV group exhibited few oral lesions and a low prevalence of opportunistic infections (25%), which was unexpected considering that many studies reported a high prevalence (range: 53–90%) of mucosal lesions and opportunistic infections in HIVpositive individuals.8,27–31 These studies demonstrated the presence of oral lesions when the immune system is compromised, because lesions are inversely related to CD4+ cell counts. The presence of oral manifestations is well established as a good indicator of immune dysfunction in 164
P. Arirachakaran et al.
HIV infection.4 It is noteworthy that the mean CD4+ level in our non-HAART group was 439 207 cells/ mm3. HIV-positive patients begin receiving HAART when their CD4+ levels drop below the AIDS-defining value of 200 cells/mm3. Therefore, the HAART individuals in our study previously had CD4+ levels below 200 cells/mm3, which had been restored by HAART to 452 202 cells/ mm3. The similar CD4+ profiles between the HAART and non-HARRT groups likely explain why the number of lesions and opportunistic pathogens was not significantly different. AGNB and yeasts were found in significantly higher amounts from the tongue and gingival crevice in all three groups of HIV-positive individuals than those in the non-HIV group. These organisms also occurred frequently in relatively high amounts, which could indicate that they are not transient, but colonized the oral cavity and were still in a carriage state in these individuals without them developing symptoms and infection. This common carriage condition among HIV patients could be explained by numerous hospital visits and antibiotic exposure. The presence of opportunistic microorganisms, such as S. aureus, E. faecalis, and AGNB, must therefore be interpreted cautiously, even if the high load is considered. In the present study, moderate and heavy growth of opportunistic microorganisms were found in 45% and 7% of the tongue samples from all of HIVand non-HIV-infected patients, respectively. A significantly higher load of S. aureus was also found in the group with CD4+ 500 cells/mm3 is significantly lower than the group with CD4+
