Comparison of total antioxidant capacity level in patients with HIV/AIDS and healthy individuals

Dewi Zakiawati; Irna Sufiawati; Herry Herman

doi:10.4103/jioh.jioh_261_21

ORIGINAL RESEARCH

Year : 2023 | Volume : 15 | Issue : 4 | Page : 367-371

Comparison of total antioxidant capacity level in patients with HIV/AIDS and healthy individuals

Dewi Zakiawati¹, Irna Sufiawati², Herry Herman³
¹ Oral Medicine Residency Program, Faculty of Dentistry, Universitas Padjadjaran, Bandung, West Java, Indonesia
² Department of Oral Medicine, Faculty of Dentistry, Universitas Padjadjaran, Bandung, West Java, Indonesia
³ Department of Orthopaedics and Traumatology, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia

Date of Submission	23-Sep-2021
Date of Decision	06-Jun-2023
Date of Acceptance	08-Jun-2023
Date of Web Publication	31-Aug-2023

Correspondence Address:
Dr. Irna Sufiawati
Department of Oral Medicine, Faculty of Dentistry, Universitas Padjadjaran, J. Sekeloa No.1 Bandung, West Java 40132
Indonesia

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jioh.jioh_261_21

Abstract

Aim: The primary aim of this study was to analyze differences in total antioxidant capacity (TAOC) levels in patients with HIV/AIDS compared with healthy individuals. The secondary aim of this study was to investigate factors that may contribute to the TAOC level in patients with HIV/AIDS including viral load, CD4 counts, and oral lesions. Materials and Methods: This research was a cross-sectional study. Fifty-eight samples from patients with HIV/AIDS and healthy individuals were calculated using the purposive sampling method. The TAOC level from the stored biological material was measured using enzyme-linked immunosorbent assay (ELISA) with the colorimetric method. The data were analyzed statistically using the chi-square to see the difference in TAOC levels between HIV and healthy individuals. Spearman’s correlation test was used to analyze the correlation between TAOC and other contributing factors. Results: The serum samples were collected from 35 patients with HIV/AIDS (74.3% men and 25.7% women) and 23 healthy individuals (65.2% men and 34.8% women). The samples were mostly obtained from healthy individuals aged 25–34 and 35–44 years old with a 47.8% and 37.1%, consecutively. Similarly, the HIV/AIDS samples are also dominated by the same age group which shares the exact percentage of both groups (37.1%). The TAOC level in patients with HIV/AIDS was lower significantly than the healthy individuals (P < 0.05). However, the TAOC level had a very weak statistical correlation with viral load (P = 0.03), CD4 (P = 0.46), and oral lesions (P = 0.44). Conclusions: In this study, the TAOC level in patients with HIV/AIDS was lower than the healthy individuals, and did not correlate to the number of viral loads, CD4 cell count, and oral lesions of patients with HIV/AIDS.

Keywords: Acquired Immune Deficiency Syndrome, Antioxidant Activity, HIV Infections, Oral Lesions

How to cite this article:
Zakiawati D, Sufiawati I, Herman H. Comparison of total antioxidant capacity level in patients with HIV/AIDS and healthy individuals. J Int Oral Health 2023;15:367-71

How to cite this URL:
Zakiawati D, Sufiawati I, Herman H. Comparison of total antioxidant capacity level in patients with HIV/AIDS and healthy individuals. J Int Oral Health [serial online] 2023 [cited 2023 Sep 25];15:367-71. Available from: https://www.jioh.org/text.asp?2023/15/4/367/384658

Introduction

Human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) has been a global health burden.^[1] In 2020, World Health Organization (WHO) and The Joint United Nations Programme on HIV and AIDS (UNAIDS) recorded not less than 38 million people worldwide have suffered from the disease,^[2],[3],[4] whereas Indonesia has a prevalence rate of 394,769 people, with an estimated 108,000–135,403 people receiving treatment.^[2],[4],[5]

HIV progression can be evaluated from several parameters,^[6],[7],[8] such as viral loads and CD4 T cells as immunological indicators,^[7],[9],[10] the presence of oral lesions,^[11] and the production of reactive oxygen species (ROS) or oxidants by viruses that trigger oxidative stress (OS).^[12],[13]

Oxidative stress is an imbalance between oxidant and antioxidant systems from the production of cellular ROS from cytokines and/or activation of polymorphonuclear leukocytes (PMN) causing the enzymatic and non-enzymatic antioxidants in the serum are failed to prevent viral replication.^[12],[14] An early sign of OS is a decrease in the total antioxidant capacity (TAOC), which is the total accumulation of antioxidants in the serum and other body fluids.^{[12],[14],[15],[16],[17],[18]} Considering the advancement of HIV/AIDS can be assessed from the number of viral loads, CD4, and oral clinical signs, it is plausible that these indicators may also be interconnected with the TAOC level.

In healthy individuals, the cells also produce natural antioxidants as part of the homeostasis in response to an OS.^[19] However, the level of TAOC in cells infected by HIV may not be similar to normal conditions due to the extra production of ROS as a result of DNA damage from the virus and/or the use of antiretroviral agents.^[20] This study aimed to analyze the difference of TAOC levels in patients with HIV/AIDS and healthy individuals, as well as investigate the correlation between viral load, CD4 counts, and oral lesions with TAOC levels in patients with HIV/AIDS.

Materials and Methods

Setting and design

A cross-sectional study was conducted to measure the TAOC level of a stored serum collected from patients with HIV/AIDS and healthy subjects at –80°C. The study was done in Klinik Teratai, Clinical Pathology Laboratory Dr. Hasan Sadikin General Hospital Bandung, and Central Laboratory Universitas Padjadjaran from Mei-June 2021. The observers were recruited by the project leader according to their expertise (oral medicine residents).

Sampling criteria

Out of 92 stored blood, we calculated the sample using a purposive sampling method. The inclusion criteria were sample has complete data of viral load, CD4, and oral lesion from patients with HIV/AIDS taken within a range of 6 months to 1 year before or after the sample was taken. Whereas samples were excluded if the sample was under unfavorable storage conditions (not stored in the refrigerator below 80^OC, and if there was discoloration/cloudy after thawing. Meanwhile, for inclusion and exclusion criteria from previous studies which were obtained from direct patients were HIV-positive patients >18 years old with ARV duration > 6 months for patients on ARV therapy, and patients without ARVs were new HIV-positive patients who have not received ARV therapy and agreed to participate in the study by giving written consent. The patients who were not compliant with ARV therapy were excluded from the study. The criteria from healthy individual control were subjects >18 years old and HIV-negative. The final number of samples was 35 serums from patients with HIV/AIDS and 23 serums from healthy individuals.

Ethical approval and informed consent

The serum was previously collected under part of the same project led by the corresponding author (ethical clearance number 1425/UN6.KEP/ECO/2019). Whereas the current ethical approval was obtained from Universitas Padjadjaran Research Ethic Committee No. 434/UN6.KEP/EC/2021 on 19 Mei 2021. Since the research was done in vitro, the written consent was exempted.

Methodology

The TAOC level was measured using ELISA with a colorimetric method and read at 520 nm (Elabscience Catalog number E-BC-K219). To further analyze the factors that might correlate to the TAOC level in patients with HIV/AIDS, we collected several recent data from the medical record, including viral load, CD4 T Cell, and oral lesions.

Observational parameters

This research observed whether the TAOC level in HIV/AIDS samples was lower, higher, or similar compared to healthy individuals. Furthermore, the study investigated whether the viral load, CD4 counts, and oral lesions in patients with HIV/AIDS were correlated to the level of TAOC.

Statistical analysis

The study used Chi-Square to analyze the difference in the TAOC level between patients with HIV/AIDS and healthy subjects. Subsequently, correlation analysis was conducted to determine the possible contributions of viral loads, CD4 T cells, and oral lesions in patients with HIV/AIDS. The correlation between TAOC level and other factors is denoted by the P-value < 0.05, df = 2, confidence level 95%, and power 0.95. How the variables correlate to each other is indicated by the Spearman Correlation (SPSS v.22, Indonesia) value from zero (0) to one (1), with 0 given no correlation at all, 0 < 0.25 means the correlation is very weak, 0.25 < r 0.5 means the correlation is sufficient, 0.5 < 0.75 means the correlation is strong, and 0.75 < 0.99 means the correlation is very strong, and lastly, correlation coefficient 1 means that the correlation is perfect.

Results

Sample characteristics

More than 70% of the serum samples came from male subjects (70.7%) and the rest were female (29.3%). The HIV/AIDS-positive group was mostly male (74.3%), as well as healthy individuals also dominated by males (65.2%) [Figure 1].

Figure 1: Gender distribution between HIV/AIDS samples and healthy individuals

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In healthy individuals, the age distribution of the sample was mostly from the group of 35–44 years old (47.8%), and the least was from the age of 0–24 (11.4%). Whereas on HIV-positive individuals had the most common age group of 35–44 and 25–34 years old with both groups at a percentage of 37.1%, and the age group of 45–54 years old was the least one (4.3%) [Figure 2].

Figure 2: Age distribution between HIV/AIDS samples and healthy individuals

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Total antioxidant level between HIV/AIDS and healthy individuals

The median and mean value of TAOC level in patients with HIV/AIDS were 10.10 U/mL and 11.44 U/mL (SD ±5.87927), respectively, and in healthy subjects was 11.74 U/mL and 11, 94 U/mL (SD ±3.495262), consecutively [Table 1]. Chi-Square analysis was conducted to determine whether there was a difference between the TAOC level distribution in patients with HIV/AIDS and healthy individuals. We found a significant difference between the distribution of TAOC levels in HIV patients and healthy individuals. Low TAOC level is prevalent in HIV/AIDS patients with P < 0.03 [Table 2].

Table 1: Median and mean values of the TAOC level in HIV/AIDS patients and healthy individuals

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Table 2: Association between TAOC level in HIV/AIDS patients and healthy individuals

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TAOC level and other factors in patients with HIV/AIDS

To investigate if the lower TAOC level in patients with HIV/AIDS may have anything to do with viral load, CD4 level, and occurrence of oral lesions, a correlation study was conducted utilizing Spearman rank analysis to compensate for the non-normally distributed data. The analysis of the correlation between TAOC level and other factors were presented in [Table 3]. We detected no correlation between TAOC level and all three variables, which was denoted by each significant value (P) exceeding 0.05, indicating that low TAOC may not be affected by the variables, but other yet unidentified factors may.

Table 3: Analysis of correlations between TAOC values and other variables

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The viral load data were grouped into two categories: <40 copies/mm³ and undetected viral load (n = 30), and viral load > 40 copies/mm³ (n = 5). Similarly, the CD4 T cells data was also categorized into two groups, <200 cell/mm³ (n = 12), and more than 200 cells/mm³ (n = 23). These details are presented in [Table 4].

Table 4: Viral load and CD4 T cells categories

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An oral lesion recorded in the medical records was presented in [Table 5]. Overall, there were 16 oral lesions found: Acute pseudomembranous candidiasis (31.25%), hyperpigmentation (31.25%), Oral hairy leukoplakia (12.5%), Herpes zoster (6.25%), Oropharyngeal candidiasis (6.25%), Angular cheilitis (6.25%), and Linear gingival erythematous (6.25%).

Table 5: Oral lesions distribution in HIV/AID patients

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Discussion

HIV/AIDS infection causes an imbalance of oxidants and antioxidants, thus worsening the prognosis of the disease.^[14] Other complications that happen in patients are also an effect of increased ROS in the tissues.^[21] Recent studies conducted by Quaye et al., 2019 reported an increase in oxidative stress or decreased antioxidant activity in HIV-infected patients who did not receive therapy compared to healthy individuals.^[21] It is in line with this study, where low TAOC levels in patients with HIV/AIDS were more prevalent. The comparative analysis of TAOC level in this study was done from two groups, healthy individuals and patients with HIV/AIDS, where most patients were under treatment. A study done by Abduljalil, et al., 2015 showed that Highly Active Antiretroviral Therapy (HAART) was able to trigger the formation of ROS in HIV patients.^[22] This could be the explanation for why the TAOC level of patients with HIV/AIDS in this study was lower compared to healthy individuals. Although viral load can be suppressed by therapy, HAART can still cause an elevation of ROS that activate HIV transcription and cell death.^[21] However, the degree of damage is relatively low compared to the direct viral effect.

Viral load describes the amount of virus in the blood, which marks the disease progression and is an indicator of treatment success,^[23],[24] while CD4 testing is used to assess the disease status and risk of death.^[7],[9] Oftentimes, HIV/AIDS can be detected from the oral cavity, and the symptoms are mostly coming from oral complaints.^[11] These theoretical backgrounds indicated there is a possible relationship among those variables with TAOC level. Nevertheless, this study revealed no correlation between TAOC level in HIV/AIDS patients with viral load, CD4 cell count, or the incidence of oral lesions, with all of the correlation scores being statistically very weak. This is in contrast to the study conducted by Suresh, et al., 2009 which showed a significantly increased oxidative stress in HIV-1 seropositive patients compared to controls.^[12] The study suggested that TAOC level could be an early biochemical marker in HIV-infected patients and helps to monitor and optimize antioxidant therapy in patients. The results differ from our research due to differences in the groups of samples where in their study all samples came from untreated patients with HIV/AIDS. Additionally, there are also differences in the TAOC measurement used. This study used ELISA, while the study previously mentioned was using the ferric-reducing antioxidant power (FRAP) method.

A decrease in CD4 number was closely associated with a high viral load.^[21] ARV therapy in combination with antioxidant administration has been shown to prevent neurocognitive impairment, opportunistic infections, and reduce viral loads.^[14] However, the low viral load in this study was not associated with high antioxidant status. Another study conducted by Jalil, et al., 2017 showed a correlation between CD4 and the antioxidant status of patients with HIV/AIDS, with the higher the CD4 count, the better the patient’s antioxidant status.^[18] The difference might occur due to the method used, which is ABTS, and also a complete record of the CD4 number and clinical stage of the patient. We found difficulties to collect CD4 counts data, clinical stages, and oral lesions, especially in untreated patients with HIV/AIDS due to incomplete medical records. Moreover, the study by Jalil, et al., 2017 did not provide information on whether the sample came from treated or untreated patients.

HIV infection is characterized by a progressive decrease in the absolute number of CD4 T cells which is significantly correlated with the incidence of oral lesions.^[25] A research done by Jalil, et al., 2017 found a correlation between the antioxidant status of HIV patients and the clinical stage (stages I and IV).^[18] Similar to this study, the results showed no correlation. This study came from samples who were mostly had been treated, so the number of people who had oral lesions was also minimal. In contrast, the prevalence of oral lesions found in a study conducted by Berberi and Aoun in 2017 reached up to 100%.^[25]

To summarize, our study showed that the level of TAOC in patients with HIV/AIDS was lower compared to healthy individuals, which suggests the essential use of antioxidant intake for patients with HIV/AIDS. Nonetheless, the TAOC level did not correspond to the number of viral loads, CD4 cell count, and oral lesions in the HIV/AIDS patient. One of the reasons behind this limitation is that our study was done during the COVID-19 pandemic era when there was a restriction to use human subjects. Therefore, we only obtained the information from medical records. Furthermore, this study suggested that all clinicians, especially those who work in the HIV/AIDS unit should ensure to input the viral loads, CD4 cell counts, and oral lesions data in the patient’s medical record from the first to the last visit.

Conclusion

In conclusion, the proportion of low TAOC is prominent in patients with HIV/AIDS compared to those of healthy individuals. However, within the HIV/AIDS group, we have not found a correlation between TAOC level with the level of viral load, CD4, and the presence of oral lesions.

Future scope/clinical significance

The study implied that antioxidant supplements may add benefits to the management of patients with HIV/AIDS. Moreover, clinical studies are required to observe the effect of antioxidants on oral lesions in patients with HIV/AIDS in Indonesia. Further research is also needed to measure the level of salivary TAOC in patients with HIV/AIDS and its relation to oral lesions, both before and after HAART.

Acknowledgement

We would like to thank the Directorate General of Higher Education, Ministry of National Education Indonesia for funding this research. We also would like to thank the staff of the Klinik Teratai and Clinical Pathology Laboratory Dr. Hasan Sadikin General Hospital Bandung, and Central Laboratory Universitas Padjadjaran for their excellent technical assistance.

Financial support and sponsorship

This work was supported by Directorate General of Higher Education, Ministry of National Education Indonesia, grant number 4I6/UN6.F/LT/2019.

Conflict of interest

All authors have no conflicting interest to declare.

Authors’ contribution

DZ: data curation, formal analysis, investigation, methodology, project administration, and writing—preparation, review and editing. IS: conceptualization, resources, validation, visualization, supervision, and writing—review and editing. HH: conceptualization, formal analysis, methodology, validation, visualization, supervision, and editing. All the authors approved the final version of the article for publication.

Ethical policy and institutional review board statement

The study has been approved by the Research Ethics Committee of Universitas Padjadjaran No. 434/UN6.KEP/EC/2021.

Patient declaration of consent

Not applicable.

Data availability statement

The data are available from the corresponding author upon plausible request.

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