Human Immunodeficiency Virus (HIV) remains a major global health challenge, gradually weakening the immune system and, if untreated, leading to acquired immunodeficiency syndrome (AIDS) (1). Antiretroviral therapy (ART) has revolutionized HIV treatment, significantly advancing management in recent decades. However, patients still face side effects like anemia, hepatotoxicity, and fluctuations in CD4 levels, which can impact both health and ART effectiveness. In HIV-positive tuberculosis (TB) patients, Immune Reconstitution Inflammatory Syndrome (IRIS) complicates treatment, characterized by an enhanced immune response to TB antigens after starting ART. IRIS can manifest as either unmasking TB-IRIS, where subclinical TB becomes symptomatic, or paradoxical TB-IRIS, where existing TB worsens post-ART initiation (2).

Anemia is frequently made worse in individuals with IRIS and is a common comorbidity of TB and HIV infections (3). In HIV, anemia can have multiple causes, including long-term inflammation, iron, vitamin B12, folate, and dietary deficiencies, as well as direct effects of the virus on haematopoiesis. Multifactorial factors, including dietary inadequacies, ART-related toxicities, chronic inflammation, and bone marrow suppression, contribute to the pathogenesis of anemia in TB-IRIS (4). Anemia may deteriorate these individuals' quality of life and clinical results.

Hepatotoxicity, often known as liver toxicity, is a serious issue in HIV patient care. ART treatments can damage the liver and worsen pre-existing liver disorders, especially when they involve medications that the liver metabolises (5). Hepatotoxicity has been linked to medications including isoniazid, rifampicin, and protease inhibitors. Because of the increased inflammatory response in the context of IRIS, there is an increased risk of liver injury (6). The treatment of individuals with co-infections with HIV and TB is greatly influenced by the selection of ART regimen. But in order to prevent side effects and drug-drug interactions, the interaction between various ART treatments and anti-TB therapies needs to be carefully considered.

For those living with HIV, the CD4 count is a vital indicator of immunological function. An increased risk of getting IRIS is linked to low baseline CD4 counts (7). IRIS is a manifestation of an inflammatory response against latent TB antigens that can arise from the restoration of immunological function after ART. For the purpose of anticipating and controlling IRIS, tracking the fluctuations of CD4 count is crucial. Furthermore, the assessment of the importance of CD4 count can be complicated by anemia and hepatotoxicity. Due to its effects on immune response and bone marrow function, anemia can lower CD4 count (8). By changing the metabolism and efficacy of antiretroviral medications, hepatotoxicity from ART can also have an indirect impact on CD4 count.

Recent research has focused on improving our understanding of the mechanisms and predictors of TB-IRIS in order to develop better management strategies. In an effort to lessen toxicity and improve patient outcomes, research on optimising ART regimens is also ongoing. To elucidate the relationship between ART regimens, anemia, hepatotoxicity, and CD4 count in patients with TB-related immune suppression. Our goal is to provide a comprehensive overview of the variables influencing the onset and treatment of disease due to TB infection by integrating clinical data and recent research discoveries. To enhance treatment plans and results for individuals who co-infect HIV and TB, it is imperative to understand these relationships.

This prospective cohort study enrolled 400 HIV-positive patients from the ART Centre at King George's Medical University (KGMU), Lucknow, India. The participants were selected based on the following inclusion criteria: (i) diagnosed with HIV infection, (ii) eligible for ART according to National AIDS Control Organization (NACO) guidelines, (iii) ART-naive, (iv) HIV-positive patients currently on anti-tuberculosis therapy (ATT), and (v) willing to participate in the study. Patients were excluded if they (1) did not consent to participate, or (2) were already receiving ART.

Diagnosis of Active TB

Active TB diagnosis required either two positive sputum smears for acid-fast bacilli (AFB), Participants were categorized into two groups: (1) HIV patients with active TB on ATT, and (2) HIV patients without active TB evidence.

Laboratory Methods

Blood samples for CD4 cell count measurement were collected at baseline and again at the six-month follow-up. CD4 cell counts were analysed using standard three-color flow cytometry (FACScan; Becton Dickinson, San Jose, CA).

Data Collection

All participants were confirmed HIV-positive using the Enzyme linked immunosorbent assay (ELISA) method. A pre-designed structured questionnaire was used to gather socio-demographic data, clinical characteristics, and information on risk factors for IRIS. Detailed clinical histories and thorough examinations were conducted for all patients.

Ethical Approval

This study was approved by the Institutional ethical committee of King George’s Medical University, Lucknow, India (Ref. Code: - XXXV ECM/B-P3, No.694-R. Cell-09). Written informed consent for the participation in the study was obtained prior to enrolment from all the participants. Only participants who had consented were enrolled in the study and all information including their HIV status was kept confidential.

Statistical Analysis

Continuous variables such as age, Hb and CD₄ cell count were summarized into means and medians as appropriate with t test, paired and unpaired as appropriate. The 95% confidence intervals were constructed around the estimates and the p-values used as a measure of statistical significance. A p-value of 0.05 or less was considered significant. Data analysis was done using SPSS 15.0 version statistical software.

Pattern of Opportunistic Infection

Opportunistic infections (OIs) are prevalent among HIV patients due to their compromised immune systems. The predominant OIs observed in the patients were TB: 20.25%, Oral candidiasis: 16.5%, Cryptococcal meningitis: 2.5%, Diarrhoea: 1.5%, Scabies and sexually transmitted diseases (STDs): 1.25%, Carcinoma cervix, herpes zoster, non-Hodgkin’s lymphoma (NHL), and Progressive Multifocal Leukoencephalopathy (PML): 0.5% each, HIV neuropathy and molluscum contagiosum: 0.25% each. Over half of the patients (54.25%) did not present with any of these OIs at the time of the study (Table 1).

Table 1: Distribution of patients by OIs.

HIV, a condition marked by immune system compromise and increased vulnerability to opportunistic infections (OIs), remains a critical global health concern. While antiretroviral therapy (ART) has significantly improved the prognosis for HIV patients, complications such as hepatotoxicity, anemia, and the development of immune reconstitution inflammatory syndrome (IRIS) continue to present challenges. This discussion explores the relationship between OIs, ART regimens, and biochemical markers influencing patient outcomes.

In our study, tuberculosis (TB) emerged as the most prevalent OI, affecting 20.25% of the cohort. According to the World Health Organization (1), TB remains one of the leading causes of illness and death among people living with HIV, consistent with our findings and previous literature. Oral candidiasis was the second most common OI, affecting 16.5% of the cohort, aligning with earlier studies that underscore the high incidence of mucosal infections in HIV patients (9). Less common OIs, such as herpes zoster (0.5%) and cryptococcal meningitis (2.5%), followed epidemiological patterns reported in earlier research. Notably, more than half of the patients (54.25%) did not present with OIs at the time of investigation, indicating that ART may have effectively reduced the prevalence of these infections. This supports existing evidence that modern ART regimens enhance immune function and reduce the risk of OIs (10).

Anemia, a common condition in the general population and particularly among HIV patients attending ART Centres (11), was prevalent in our cohort, affecting 85% of the patients. This finding is in line with Kaudha et al. study (12), which associated anemia with low hemoglobin (Hb) levels, and decreased CD4 counts, a well-established marker of poor clinical outcomes in HIV patients. The correlation between anemia and advanced HIV stages further emphasizes its prognostic importance.

Anemia is also independently linked to higher mortality rates in HIV patients. Our study observed an association between anemia and an increased incidence of IRIS. Although the underlying mechanisms remain unclear, factors contributing to anemia, such as poor nutrition, low CD4 counts, high viral loads, and inflammatory cytokines, may impair erythropoietin production and red blood cell formation. These factors could potentially serve as predictors for a rapid immune recovery (i.e., IRIS) following ART initiation. Thus, early diagnosis and treatment of anemia may mitigate the risk of IRIS.

We examined the association between ART regimens and IRIS, focusing on patients receiving one of four combinations: two Nucleoside Reverse Transcriptase Inhibitors (NRTI) and one Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI). No specific ART regimen was found to be associated with a higher incidence of IRIS, corroborating previous studies (13,14). The distribution of ART regimens was as follows: 32.5% received Stavudine + Lamivudine + Efavirenz (STV+LMV+EFV), 32% received Zidovudine + Lamivudine + Nevirapine (ZDV+LMV+NVP), 23.3% received Stavudine + Lamivudine + Nevirapine (STV+LMV+NPV), and 12.3% received Zidovudine + Lamivudine + Efavirenz (ZDV+LMV+EFV). These regimens are commonly selected for their effectiveness and tolerability, reflecting the need for personalized treatment approaches (15).

Our findings indicated that patients with positive tuberculin skin test (TST) results had a higher incidence of IRIS (20.6%) compared to those with negative TST results (7.4%). This supports previous research showing that latent TB increases the risk of IRIS after ART initiation (13,16). Additionally, hepatomegaly and abdominal lymphadenopathy were associated with a higher risk of IRIS, consistent with earlier studies (17). However, no significant associations were found between IRIS and markers such as VDRL, HBsAg, and HCV, in line with recent research suggesting that these markers may not be critical in predicting IRIS.

During the one-year follow-up, no cases of IRIS-associated hepatitis were reported. However, a significant increase in serum transaminases (SGOT, SGPT) was observed at the onset of IRIS, consistent with previous findings (18). Although nevirapine is commonly associated with hepatotoxicity, our data did not point to a drug-induced cause, as similar increases were observed in patients on efavirenz. Elevated transaminases can impair liver function, indicating that caution is needed when initiating ART in patients with pre-existing liver conditions.

The rapid PCR method has become the preferred diagnostic tool for TB detection, and enhancing the development of rapid molecular diagnostics for subclinical HIV co-infections could aid in controlling the TB epidemic (19). Misdiagnosis of smear-negative TB based solely on clinical presentation can lead to inappropriate treatment, increasing the risk of adverse treatment reactions and drug resistance due to the overlapping clinical features of various OIs (20).

Effective ART administration and high adherence rates are critical in managing HIV and preventing TB, particularly in co-infected individuals (21). Lastly, our study identified a strong association between IRIS and elevated levels of serum creatinine, total cholesterol, and total lymphocyte count (TLC). These findings highlight the complex interactions between lipid metabolism, renal function, and systemic inflammation in HIV patients. Elevated cholesterol may signal metabolic abnormalities related to HIV or ART, while increased serum creatinine and TLC could indicate ongoing inflammation or renal impairment.

This study highlights the complexities of managing HIV in patients co-infected with tuberculosis (TB). While antiretroviral therapy (ART) improves outcomes, challenges such as Immune Reconstitution Inflammatory Syndrome (IRIS), anemia, and hepatotoxicity persist. TB, the most common opportunistic infection, increases the risk of IRIS, particularly in patients with low baseline CD4 counts, positive tuberculin skin tests, hepatomegaly, and abdominal lymphadenopathy. Anemia and liver dysfunction further contribute to poorer outcomes. These findings emphasize the importance of monitoring ART regimens and patient-specific risk factors to enhance management of HIV and TB.

Acknowledgements

The patients' participation in the study is greatly appreciated by the authors. The contributing

physicians and residents from KGMU, Lucknow's Department of Clinical Hematology and Medical Oncology for their kind assistance.

Author Contributions Statement

P Gupta: study conception, design and execution, study follow up, analysis and interpretation of data, critical review, drafting and editing of the paper. AK Tripathi: study conception, design and execution, study follow up, analysis and interpretation of data and critical review of the paper. S Gupta: study execution, study follow up, critical review, writing and editing of the paper. A Gupta: study analysis and interpretation of data, and draft editing. All the authors agreed to take responsibility for every part of the work and gave their approval for the submission version.

Declaration of interest statement: The authors report no conflict of interest.

Data Availability Statement

The study's supporting data are not publicly available due to potential privacy concerns regarding study participants. The data will be sent to the appropriate author upon reasonable request.

Funding:

The Indian Council of Medical Research (ICMR), New Delhi provided funding for this study work (Grant no. 80/619/2009-ECD-I). In preparation of the manuscript, no extramural funding was received.

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