Cardiovascular Journal of Africa: Vol 32 No 6 (NOVEMBER/DECEMBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 6, November/December 2021 AFRICA 323 this study. It has been documented in other studies that HAART is effective in increasing CD4 cell count and decreasing the viral load, with an associated decrease in morbidity and mortality among HIV-infected individuals. 28,29 For the same reason, opportunistic infection was seen less often in the HIV-positive patients on HAART. 10,30-32 The mean weight and BMI were higher in the HIV-positive patients on HAART than in the HAART-naïve group. There was no significant difference in the mean weight and BMI between the HIV-positive patients on HAART and the controls (Table 1). Weight loss is a feature of HIV infection, and weight gain in the HIV patients on HAART could have been due to a HAART- induced decrease in viral burden, 33,34 as well as the metabolic side effects of HAART. In addition, the use of antiretrovirals, such as NRTIs and PIs, has been found to cause an increase in weight and mean BMI of subjects on HAART. 35,36 They are also associated with the metabolic abnormalities of diabetes, dyslipidaemia, altered body fat distribution, especially HIV lipodystrophy syndrome, as well as mitochondrial abnormalities. 37 Weight and BMI of HIV patients on HAART in this study therefore increased and became comparable to that of the controls. A similar finding was documented in a related study between a cohort of HIV/AIDS patients and normal controls, 12,16 but there was no separation, as in our study, of the HIV patients into those on HAART and HAART-naïve groups. In our study, antimicrobials and multivitamins received by the group on HAART helped to control opportunistic infections and diarrhoeal diseases, and improved appetite, weight gain and over-all well-being of the subjects. The mean CD4 cell count in the HIV subjects was higher in the group on HAART (408.43 ± 221.62 cells/mm 3 ) compared to the HAART-naïve group (250.06 ± 154.26 cells/mm 3 ) (Fig. 2), underscoring the benefits of HAART in this patient population. 28 The mean CD4 cell count for the HAART-naïve group was relatively high in this study because HIV patients with clinical features of end-stage AIDS, classified as category C by CDC 1993, 22 were excluded. Cardiac complications of HIV infection such as left ventricular dysfunction and dilated cardiomyopathy have been found to occur more often in patients with low CD4 counts. 38 In a study carried out in the pre-HAART era, global left ventricular hypokinesia was found to be associated with lower CD4 counts. 11 The dimensions of the aortic root, left atrium and left ventricle were within the normal range in the study groups. Although comparable to the controls, they were relatively higher in the HIV-positive patients on HAART than in the HIV-positive, HAART-naïve subjects (Table 6). HAART has been found to induce myocardial toxicity and was believed to be the cause of right ventricular wall impairment and dilatation in a related study in children. 39 In a similar study by Ajala et al ., 24 in which the mean duration of HAART was not stated, no difference in chamber dimension was reported (Table 7). However, HIV disease has been found in some studies to be independently associated with increased left atrial volume in addition to increased left ventricular mass index, 8,12 while other studies have shown no difference. 13 Although the mean thickness of the interventricular septum was within normal limits in all the groups in our study, it was higher in the HIV-positive, HAART-naïve subjects but similar between the HIV-positive, HAART-exposed subjects and the controls (Table 6). Similarly, the posterior wall was higher in this group compared to the HAART-exposed or control groups. However, no difference in wall thickness was found in a recent study done in a similar population. 24 Disparate results have been reported, indicating possible HAART-induced increases in left ventricular wall thickness and mass in some studies, 8,14 while others showed increased thickness of the interventricular septum and posterior wall, 40 and eccentric patterns of LVH, with an increase in left ventricular cavity size in HIV-infected persons who were not on HAART 41,42 (Table 7). Possible causes of a thicker interventricular septum and posterior wall in the HAART-naïve group were higher HIV viraemia and its toxic effect on the myocardial cells, causing local release of cytokines and other factors, leading to subclinical 17 % 83 % HIV+ve, HAART-naive HIV+ve, on HAART CD4 < 200 cells/mm 3 of 17% CD4 > 200 cells/mm 3 of 83% 43 % 57 % CD4 < 200 cells/mm 3 of 43% CD4 > 200 cells/mm 3 of 57% Fig. 2. Percentage of individuals and their mean CD4 counts in HIV-positive groups on HAART and HIV-positive, HAART-naïve groups. Table 6. Comparison of echocardiographic parameters measured across the groups using one-way ANOVA Param- eters HIV+ on HAART HIV+ HAART- naïve Controls F -value p -value AO (cm) 2.71 ± 0.40* 2.41 ± 0.37 2.74 ± 0.42* 21.363 < 0.001 LA (cm) 3.27 ± 0.62 2.68 ± 0.51 3.11 ± 0.47 31.385 < 0.001 EDD (cm) 4.73 ± 0.70* 4.41 ± 0.55 4.75 ± 0.42* 11.240 < 0.001 ESD (cm) 3.01 ± 0.51 2.84 ± 0.57 2.92 ± 0.43 2.616 0.075 IVS (cm) 0.77 ± 0.17* 0.85 ± 0.17 0.78 ± 0.15* 6.098 0.003 PW (cm) 0.82 ± 0.16 0.87 ± 0.17 0.82 ± 0.13 2.878 0.058 EF (%) 68.95 ± 12.43* 72.81 ± 11.70 67.36 ± 9.04* 6.223 0.002 FS (%) 36.77 ± 9.81 36.51 ± 8.64 37.77 ± 6.53 0.623 0.537 LVM (g) 141.94 ± 49.75 138.61 ± 48.53 131.26 ± 31.55 1.540 0.216 LVMI (g/m 2 ) 79.95 ± 26.25 77.55 ± 25.91 72.37 ± 16.52 2.760 0.065 *Duncan’s post hoc multiple comparisons test indicating means for groups in homogenous subsets (means not significantly different). AO: aorta; LA: left atrium; EDD: end-diastolic diameter of left ventricle; ESD: end-systolic diameter of left ventricle; IVS: interventricular septum; PW: poste- rior wall of left ventricle; EF: ejection fraction; FS: fractional shortening; LVM: left ventricular mass; LVMI: left ventricular mass index.