Intestinal Parasite Infestation in HIV Infected Patients in Tertiary Care Center

Every year, the number of people living with HIV rises as a consequence of advanced infections and the positive effects of highly active antiretroviral therapy (HAART). Gastrointestinal involvement is common, with 90% of patients seeking treatment for gastrointestinal problems as their HIV infection progresses. Nonetheless, identifying and characterization of infectious agents is important for patient management by excluding a clinical diagnosis and determining appropriate treatment, as well as determining public healthcare policy for true pathogen prevalence and yielding epidemiological risk factors for specific infections. The aim of this study is to evaluate the prevalence of symptomatic or asymptomatic intestinal parasitic infection among HIV or AIDS patients. For this study with 80 HIV seropositive patients being recruited from various wards and the Integrated Counseling and Testing Center (ICTC) affiliated to the microbiology department. Patients with acute and chronic diarrhea with abdominal disorder were taken as symptomatic whereas patients without these clinical complaints and who came for routine investigations were taken as asymptomatic. Firstly stool samples were analyzed by macroscopically for the presence of mucus, blood, larvae, segments of tapeworm and adult worms. The consistencies of stool were also recorded such as formed, watery or soft or loose with odor and color. It was examined microscopically after macroscopically for protozoan cysts and trophozoites, helminthic ova and larvae, as wet mount preparation by saline and iodine preparation as well as formal ether concentrated. For the detection of intestinal coccidian parasites, smears were prepared from stool samples and a modified Ziel-Nelseen (MZN) stain was also performed. Stool samples with the detection of parasites were informed for treatment. The prevalence of intestinal parasite was 23.75% with asymptomatic and symptomatic groups having a prevalence of 16.98% and 37.04% respectively. Out of total patients, 56.25% were male and 43.75% were female. Among the male patients, 11 (13.75%) were positive for an intestinal parasitic infection and 8 (10%) were positive among females. The age distribution data revealed that the age group 21-40 years old had the highest number of intestinal parasites, followed by 41-60, 61-80, and 0-20 years old. The most intestinal parasites were found in the young and middle-aged


iNtRODuCtiON
Globally Human Immuno-Deficiency Virus / Acquired Immune Deficiency Syndrome (HIV/AIDS) is a type of common health problem 1 . Superimposed infection, caused by a defect in immunity, is one of the most serious health issues among HIV-positive people 2 .
Every year, the number of people living with HIV rises as a consequence of advance infections and the positive effects of highly active antiretroviral therapy (HAART) 3 . Since the onset of AIDS, clinical changes affecting the gastrointestinal system have been common, particularly diarrhoea caused by parasite infections 4 . Many studies showed that intestinal parasites such as Entamoeba histolytica/dispar, Giardia lamblia, Cryptosporidium species, Cyclospora cayetanensis, Isospora belli and Strongyloides stercoralis are accountable for 60-80% of infestations 5 . These parasitic infections play a significant role in HIV/ AIDS pathogenesis and diarrhoeal disease accept as an important role up to 50% in developing countries 6 . Many studies have shown the impact of socioeconomic status and cultural issues on the onset of intestinal parasite infection in the general population and HIV-positive patients in particular 3 . Immunosuppression caused by HIV infection encourages the occurrence of many opportunistic diseases that cause high mortality, with gastroenteritis occupying a prominent position 7,8 . Gastrointestinal association is common, with 90% of patients seeking treatment for gastrointestinal problems as their HIV infection progresses 9 . Nonetheless, identifying and characterization of infectious agents is important for patient management by excluding a clinical diagnosis and determining appropriate treatment, as well as determining public healthcare policy for true pathogen prevalence and yielding epidemiological risk factors for specific infections 10 . In 2012, the National AIDS Response resulted in the treatment of 2,212 patients in seven facilities with antiretroviral therapy (ART) 11 . The association between intestinal parasite infections and several nutritional markers has been demonstrated in numerous studies involving nutritional status, infection prevalence and intensity 12 . The clinical spectrum of these parasitic protozoa infections ranges from asymptomatic infection to severe infection with chronic diarrhoea, dehydration, and mal-absorption, especially in HIV positive patients 13 . Such co-infections have more severe clinical signs and are more difficult to treat as compared to parasite infections in otherwise healthy people 14 . Due to the high prevalence of parasitic intestinal diseases in people living with HIV or AIDS, many of which are opportunistic in nature and have a severe impact on patients, new research is needed to investigate the relationship between these infections and their immune responses, as well as the nutritional effects of these diseases in this population 3 . In this study we aim to determine the prevalence of intestinal parasite infection in HIV seropositive patients.

MATERIAl AND METHODS
This research was carried out in the parasitological section of laboratory in the department of microbiology at CCMMC, Bhilai; Durg district of Chhattisgarh state situated in Central East India. This cross-sectional study was carried on HIV patients who visit in hospitals from November 2017 to November 2020 after obtaining institutional ethical clearance. HIV seropositive patients were randomly selected for this study irrespective of whether they were symptomatic patients, according to this study. Different parasites were identified as Entamoeba histolytica, Taenia species, Ascaris lumbricoides, Cryptosporidium parvum and Isospora with one protozoan, two coccidian parasites and two helminthes. The most common parasite was Taenia species 6 (7.5%) followed by Entamoeba histolytica 5 (6.3%) and Cryptosporidium parvum 5 (6.3%). Intestinal parasitic infection is not uncommon in HIV seropositive patients. This study underscores the need for early diagnosis and treatment of these intestinal parasites in both symptomatic and asymptomatic HIV patients.
Keywords: HIV/AIDS, parasites, infection or asymptomatic. A sample size of 80 was used based on an ongoing larger work of PhD theses for which this study forms a part of.
Eighty(80) HIV seropositive patients were recruited from various wards and the Integrated Counseling and Testing Center (ICTC) affiliated to the microbiology department. Detail data of patients were obtained from the patients as well as from the medical record department (MRD) during the study period. After giving consent, from all symptomatic and asymptomatic HIV patients stool sample were collected. Each patient's stools were collected in a clean, dry, leak-proof, tight-lidded plastic container. Aside from obtaining the sample, the patient's name, age, sex, occupation, history of clinical manifestations, such as diarrhoea, and antibiotic and antiparasitic drug treatment history were all noted. Stool sample was process as per the standard protocol for detection of parasites by Macroscopic Examination, Microscopic Examination and Concentration technique as Formal ether concentration 15 .
Firstly stool sample were analyzed by macroscopically for presence of mucus, blood, larvae, segments of tapeworm and adult worms. The consistencies of stool were also recorded such as formed, watery or soft or loose with odor and color.
In the microscopic examination after macroscopically, Saline and Iodine wet mount were performed for the presence of parasitic cysts, trophozoites and ova or larva as well as formal ether concentrated were also perform and examined microscopically. Modified Ziehl-Neelsen (MZN) stain was also done for detection and identification of intestinal coccidians like Cryptosporidium parvum and Isospora belli 15 . Stool sample with detection of parasites were informed for treatment.

Result
A total of 80 stool samples were collected and tested for intestinal parasite infection in HIV-positive patients. Out of 80 HIV seropositive patients, 53 were asymptomatic and 27 were symptomatic patients. The prevalence of intestinal parasite in the study subjects was 23.75% while it was 16.98% and 37.04% in the asymptomatic and symptomatic subjects respectively (Table 1).
Among 80 HIV seropositive patients, 56.25% were male and 43.75% were female. Among the male patients, 11 (13.75%) were positive for intestinal parasitic infection and 8 (10%) were positive among females ( Table 2). The positivity ratio between male and female is 1: 1.375.
In this study HIV seropositive patient with age range from 0-80 years old were included with the mean age of 39.2±9.1 years old [Standard Deviation (SD) 13.84]. The age group 21-40 years old had the largest age distribution, while the age group 0-20 years old had the lowest. The age distribution data revealed that the age group 21-40 years old had the highest number of intestinal parasites, followed by 41-60, 61-80 and 0-20 years old. The most intestinal parasites were found in the young and middle-aged patients, according to this studied i.e. Between 21-40 years old age group. In the age group 0-20 years old and 61-80 years old only 2.5% of intestinal parasites were detected ( Table 3).
From the total number of patients, 26 were those patients with CD4 + T cell count less than 200 cells/µl followed by 19 were those patients with CD4 + T cell count 200-499 cells/ µl and 35 were those patients with greater than or equal to 500 cells/µl. In this study among the patient with HIV-positive with CD4 + T cell count <200 cells/µl had higher possibility of infestation with intestinal parasitic as compared to those with CD4 + T cell count of 200-499 and those with CD4 + T cell count >500 (Table 4).

DisCussiON
The advent and spread of AIDS is the biggest threat to public health in modern times. In today's world, HIV infection has become a major issue. Infection is prevalent in many parts of the world, including Southeast Asia. The link between intestinal parasite diseases and the AIDS pandemic is a critical concern 16 . In this study the prevalence rate of intestinal parasites was 23 24 in Lucknow, Uttar Pradesh, India prevalence of intestinal parasitic infection was reported as 57.81%, which was also high when compared to this study. There is a discrepancy in the prevalence of intestinal parasitic infestations in HIV seropositive individuals when compared to studies conducted by different authors from India or elsewhere, which could be related to differences in geographical distribution of parasites, hygienic  23 showed Cryptosporidium as a most commonly observed parasites and followed by Cystoisospora belli, Cyclospora spp. Studies from various parts of the world indicate similar rates of incidence with major regional differences. All HIV-positive patients' stools should be extensively analysed to identify intestinal infections so that adequate management can be implemented. The study showed prevalence of intestinal parasites was highly significant in HIV-positive patients with CD4 + T cell count< 200 cells/µl had high possibility of increased parasitic infection (P < 0.05) as compared to patients with CD4 + T cell count of >200. This report also showed as similar to many other study as carried out by Babatunde et al 13 , Assefa et al 25 and Wiwanitkit et al 26 . Therefore, all these findings suggested that immunity plays an important role in the survival and development of intestinal parasites in HIVpositive individuals.

CONClusiON
This study showed the prevalence of intestinal parasite was 23.75% with asymptomatic and symptomatic groups having a prevalence of 16.98% and 37.04% respectively. Taenia species was the most common parasite found in HIV patients followed by Cryptosporidium parvum and Entamoeba histolytica. The finding from our study underscores the need for early diagnosis and treatment of these intestinal parasites both in symptomatic and asymptomatic HIV patients as early as possible. This will aid clinicians in developing suitable patient treatment methods.

ACKNOwlEDGMENTS
We are grateful to our representative institutes for providing the support to complete this work.