Since the initial epidemic of HIV, the overall incidence of new HIV case where declining globally, however new cases were more in the Middle East. New HIV infections have been reduced by 47% since the peak in 1996. In 2017, there were 1.8 million new HIV infection and 9400000 died from AIDS related illness worldwide. ALSO 59% OF all people living with HIV were accessing the treatment. (8)
Qatar is a small country in the gulf area with increasing number of populations growing fast over the last 10 years, current population around 2.5 million, 25% were Qataris. We notice from our study the declining number of newly diagnosed HIV infected cases despite the raising in population, which can be explained with the overall declining of HIV incidence. (2).
Also, the incidence of HIV related OIs is decaling, explained by the use of antiretrovirals medication and prophylaxis (3).
In Qatar the use of HIV screening program for all premarital individual, antenatal screening and pre-employment screening for selected jobs, has contributed to early diagnosis of HIV infection and less rate of OIS. In addition, HIV screening test is done for all new comers who will stay more than one month in the country.
HIV treatment is available for all our patients, which also contributing in lower incidence of opportunistic infections among them.
In our study, Patients with OIS have significant decrease in CD4 count and CD4/CD8 ratio with high HIV viral load compared to patients without infection, same observation has been documented in other studies (10, 11, 12).
We also notice a smaller number of hepatitis B or C combined infection among HIV cases, this could be explained by blood donation screening program, along with low incidence of drug abusers among our HIV infected patients.
We notice the presence of comorbidities among our HIV cases, mainly due to diabetes, which may be related to overall high incidence of diabetes among Qatari population (9).
PCP remains the most common type of OIS, accounting for 25% (42 cases) of all diagnosed OIs in our study. Studies from other regional countries show similar prevalence; Oman 25% and Bahrain 15.1% (6, 10). A definitive diagnosis of PCP with a demonstration of organisms in induced sputum samples or BAL fluid was made in most of our studied cases. A total of 16 patients (9.6%) with HIV/AIDS had PCP as an AIDS-defining OI at their first presentation.
CMV disease/retinitis was the 2nd common OIs in our study representing 7.2% (12 cases of infected HIV/AIDS patients). Diagnosis of the disease mainly clinical based on positive CMV serology (IgM,IgG) ,high PCR titer and fundoscopic finding. In contrast to data from Oman where 17% of HIV patients had CMV retinitis. (6).
Although tuberculosis is common in the region due to high number of workers from high endemic area, combined HIV and TB cases were low,5.4% (9 cases). This maybe explained that all new comers to the country will be screened and treated for latent TB infection. We also noticed none of the studied case had MDR TB as overall prevalence of MDR TB in Qatar is low and few associations between it and HIV (13).
Toxoplasmosis, caused by Toxoplasma gondii, is one of the major OIs afflicting HIV patients. Cerebral toxoplasmosis is the most common cause of focal neurological disorders in HIV patients. In our cohort, cerebral toxoplasmosis accounted for 4.2% (7 out of 167) of HIV infected patients. In a study from Oman, cerebral toxoplasmosis was reported in 12% of the HIV-infected patients. (6)
Cryptococcus neoformans is one of the causes of invasive fungal disease in patients with HIV worldwide. Meningitis is the commonest clinical manifestation of invasive cryptococcosis infection. In our study, Cryptococcus meningitis accounted for only 1.2% of all HIV patients. As a result, primary prophylaxis for invasive cryptococcal disease is not practice in Qatar.
Similar low incidence was seen in Indian reports show 6–8%, whereas it is about 5–11% in the USA, 33% in Africa, and 28.5% in Thailand. (14) Interestingly, in Oman reports incidence of cryptococcal meningitis was high as 21% of all HIV infected patients. The exact explanation for such high incidence in Oman is unclear. (6).
Cryptosporidium infection was observed in only 2% in our study. Regional data showed similar low incidence, in Oman 3%. (6). This is in contrast to data from Ethiopia where 21% of HIV patients had Cryptosporidium parvum infection. (15). In patients with HIV, cryptosporidiosis usually causes chronic diarrhea however, it may cause potentially fatal complications, like bile duct perforation. (16). The rate of cryptosporidiosis has subsided in many countries because of the use of ART. (17)
Kaposi sarcoma and PML were rare opportunistic infections in our study group and worldwide. We have smaller of patients with cryptococcal meningitis in comparison to patients in Omani study (6). I n our study none of the patient had MAC infection out of 167 HIV infected patients. This can be explained to routine use of primary prophylaxis in patients with CD4 count less than 50.
The proportion of treatment success among OIs patients in our study is 59.3%, however, one third of patients lost follow up as they left the country.
Conclusion: Qatar has a low prevalence rate for HIV infection and related opportunistic illness. Early diagnosis and use of antiretroviral therapy are important measures to decrease the rate of opportunistic illness.