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Table of Contents
Year : 2020  |  Volume : 25  |  Issue : 2  |  Page : 70-76

HIV-related oral lesions in patients on HAART: A preliminary study in Enugu, Southeast Nigeria

Department of Preventive Dentistry, Faculty of Dentistry, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria

Date of Submission23-Dec-2019
Date of Decision12-Mar-2020
Date of Acceptance01-Jun-2020
Date of Web Publication29-Jul-2020

Correspondence Address:
Ezi A Akaji
Department of Preventive Dentistry, Faculty of Dentistry, University of Nigeria, Ituku-Ozalla, Enugu.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_43_19

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Background/Aim: Oral lesions in human immunodeficiency virus (HIV) infections may serve as markers for immune deterioration and disease progression and sometimes be the first indication of the disease. The aim of this study was to assess the prevalence and pattern of HIV-related oral lesions (HIV-ROLs) in people living with the disease in Enugu, Southeast Nigeria. Materials and Methods: A questionnaire was used to obtain data from 208 HIV- infected persons accessing treatment from two centers for acquired immune-deficiency syndrome (AIDS) prevention. Data obtained were demographic details, duration of infection, current cluster of differentiated 4 (CD4) count, and oral complaints. Thereafter, the perioral and oral cavity of the respondents were inspected for HIV-ROLs using disposable items. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software program, version 17. Results: Eighty-four (40.4%) respondents had HIV-ROLs; 44 had more than one lesion yielding 128 combinations. Forty-four of the 84 lesions (52.4%) were seen in those diagnosed over 5 years ago, 28 (33.3%) in those with 2–5 years duration of infection (P = 0.05), and 27 (32.1%) in persons with CD4 counts <200 cells/mm3. Fifty-three (41.4%) were oral candidiasis and 6 (4.7%) were oral hairy leukoplakia. One hundred and nine (52.4%) respondents had oral complaints/concerns, 53 (48.6%) of whom had at least one lesion on examination (P = 0.01). Conclusion: The pattern of oral lesions observed was consistent with those reported in similar studies, though prevalence varied slightly. Lesions correlated positively with self-reported oral concerns. Coordination of healthcare services between the physicians and dentists is vital in improving the well-being of the patients.

Keywords: AIDS, HIV infection, oral lesions

How to cite this article:
Akaji EA, Nwankwo OF, Nwadije JC. HIV-related oral lesions in patients on HAART: A preliminary study in Enugu, Southeast Nigeria. Int J Med Health Dev 2020;25:70-6

How to cite this URL:
Akaji EA, Nwankwo OF, Nwadije JC. HIV-related oral lesions in patients on HAART: A preliminary study in Enugu, Southeast Nigeria. Int J Med Health Dev [serial online] 2020 [cited 2022 Aug 12];25:70-6. Available from: https://www.ijmhdev.com/text.asp?2020/25/2/70/291063

  Introduction Top

Acquired immune-deficiency syndrome (AIDS) is a complex of symptoms and infections caused by the human immunodeficiency virus (HIV) affecting the immune system. It poses as a human and social disaster, particularly in resource-limited settings, constituting a massive and complex challenge for the public health system.[1],[2] The oral cavity acts as a mirror, which reflects the state of health of the body as a large number of systemic diseases including HIV infection manifest in the oral tissues.[1],[3] Factors that predispose to HIV-related oral lesions (HIV-ROLs) include number of cluster of differentiated 4 (CD4) T cells, viral load, malnutrition, innate immunity, and smoking.[4],[5] However, in developing countries, additional factors such as poor access to treatment, poor oral hygiene, and low socioeconomic status act as confounders.[6] Under normal conditions, the number of CD4 T lymphocytes cells ranges from 600 to 1600 cells/mm³, and reduction in the circulating number is the main criterion for assessing the immune-suppressive state of HIV-positive patients with the initial signs occurring when CD4 count is lower than 500 cells/mm3.[4] Oral lesions can be seen in 30%–80% of HIV patients, similar range but with more severe infections were observed in pediatric patients.[7],[8] Frequencies of oral lesions reported in some studies include India (80.6%), South Africa (22%), Iran (57.1%), and Ghana (82.5%), whereas in Lebanon, all the 75 patients enrolled for a study had at least one HIV-ROL.[5],[9],[10],[11],[12] In Nigeria, frequencies of 32.5% and 2.4% were observed in Calabar and Lagos, respectively.[13],[14]

The impact of HIV/AIDS and oral disease on the quality of life (QOL) involves physical and emotional well-being, social support systems, and life roles.[15],[16] The poor QOL is attributable to the effect of the lesions altering facial appearance, speech, and causing pain and difficulty in chewing and swallowing. Poor oral functionality could lead to exacerbation of nutritional problems that may further worsen the QOL particularly in children.[17] Detection and management of HIV-ROLs are therefore important for the health and QOL in affected persons.

Furthermore, in individuals with unknown HIV status, oral lesions may sometimes be the first indication of the disease.[1],[3] Fifty-three of 700 patients seen within a year in an oral medicine clinic in Lagos had lesions which aroused suspicion of HIV infection; patients were offered HIV screening and counseling, but 15 declined. On screening, 35 of the consenting 38 (that is 92.1%) tested positive for HIV.[18] In 2016, it was observed that approximately 1 out of 88 patients attending the dental clinic in Benin, Nigeria with complaints such as toothache and gum disease had an undiagnosed HIV infection. The proposition was that “dental clinic settings may well serve as provider-initiated Voluntary Counselling and Test (VCT) centers for ambulatory patients.” [19] Considering that the number of people living with HIV (PLWH) is on the increase worldwide with an appreciable record of new cases annually,[20] and a steady increase in the prevalence of the infection in Enugu State,[21] the likelihood of an oral health-care worker treating PLWH in this region is almost certain. Therefore, the dental team and all medical professionals charged with treating PLWH need to be aware of the common oral presentations so that care of infected persons geared at improving their overall well-being would be achieved.[15] The aim of this preliminary study was to assess the prevalence and pattern of HIV-ROLs in PLWH in Enugu, Southeast –Nigeria with the view to generate data for further studies in the region.

  Materials and Methods Top

This was a cross-sectional study with participants drawn from patients attending the AIDS Prevention Initiative in Nigeria (APIN) clinic at University of Nigeria Teaching Hospital (Centre A) and HIV clinic at Enugu State University Teaching Hospital, Enugu (Centre B). All the patients were on highly active antiretroviral therapy (HAART). These two centers serve patients from Enugu, Southeast-Nigeria and its environs.

Ethical clearance for the study was obtained from the Health Research Ethics Committee of University of Nigeria Teaching Hospital. Permission was sought from the head of each indexed clinic, whereas individual consent was obtained from the respondents before administering the pretested questionnaire. Patients attending the two centers for treatment within the second quarter of year 2017 and who gave consent were recruited for the study. The patients were assured of confidentiality and made to understand that participation was voluntary and information gotten were solely for research purpose; those who did not want to participate were excluded.

Questions asked reflected the various aspects of the study such as sociodemographic characteristics, duration of the HIV infection, oral complaint if any, or change(s) in the mouth affecting oral functions or otherwise. Thereafter, clinical examination was done using sterile instruments to inspect the perioral and oral cavity of each respondent in a private section of the clinic under bright light. The presumptive criteria adopted for the diagnosis of oral lesions in HIV/AIDS were those described by EC Clearing house and World Health Organization [Table 1].[22] Respondents’ latest CD4 counts were recorded. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software program, version 17.0 (SPSS, Chicago, Illinois). Frequency distribution tables were generated for nominal and ordinal variables and the values of P < 0.05 were accepted as statistically significant.
Table 1: Classification of oral lesions associated with HIV

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  Results Top

Sociodemographic details according to HIV-related oral lesions

A total of 208 respondents with an age range of 17 to 62 years (mean: 41.5± 0.7 years) were recruited for the study. One hundred and fifty-seven (75.5%) were females, and 147 (70.7%) married. Eighty-four (40.4%) of them had HIV-ROLs; females (67 [79.8%]) accounted for a higher number of oral lesions observed in the study, so also age group of 40years and above (37[44%]). Details are summarized in [Table 2].
Table 2: Sociodemographic characteristics of respondents

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Duration of infection and CD4 counts of respondents to HIV-related oral lesions

[Table 3] shows the occurrence of HIV-ROLs which varied significantly with duration of infection: 44(52.4%) were seen in those diagnosed over 5years ago (P = 0.05). Twenty-seven (32.1%) of the respondents with oral lesions had CD4 count lower than 200 cells/mm3, lesions were observed in 13 (15.5%) of those with CD4 >500 cells/mm3 (P = 0.83); some patients had no record of their last cell count.
Table 3: Occurrence of HIV-related oral lesion relative to duration of infection and CD4 counts

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Oral complaints and pattern of HIV-related oral lesions seen on examination of the mouth

One hundred and nine (52.4%) of the participants had oral complaints/concerns. Dry mouth 22(20.2%), oral ulcers 24(22.0%), and bleeding gum 15(14.4%) were the most reported. On examination of the mouth, 44 of the 84 respondents (52.4%) with HIV-ROLs had more than one condition. Lesions strongly associated with HIV infection constituted 71.1% of the total HIV-ROLs seen. Fifty-three (41.4%) were oral candidiasis with the pseudomembranous variant being the most common. Linear gingival erythema (LGE) represented 23.4% of the total lesions. Details of complaints and clinical findings are in [Table 4]. Cross-tabulation of pattern of HIV-ROLs found on examination with respondents’ oral complaints showed that 53 (48.6%) with complaints had presence of at least one oral lesion (P = 0.01). Details are shown in [Table 5].
Table 4: Patients’ complaints and the specific HIV-related oral lesions seen on examination

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Table 5: Relationship between patients’ complaints and HIV-ROLs seen on examination

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  Discussion Top

The oral cavity reflects the state of health of the body as some systemic ailments such as HIV infection manifest in oral tissues. This study shows HIV-related oral findings in PLWH attending two main centers in Enugu. The prevalence of oral lesions was 40.4% in contrast to values reported in similar studies.[5],[9],[10],[11],[12] Observed disparity may be due to sampling variations in the different studies. In this study also, HIV-ROLs were worse with increasing age, and more in females (P > 0.05), although some studies had reported male preponderance or equal presentations.[5],[10],[23],[24] Extra HIV-ROLs in females are linked to their engagement in informal employment which exposes them to higher risk factors for infection.[13] Again, married persons had more oral lesions in this study as had been reported,[10],[25] although the observation was not statistically significant as obtained here. An extrapolation could be made from gender inequalities in prevalence of HIV/AIDS in Sub-Saharan Africa with women being at a disadvantage in terms of socioeconomic status, risky behavioral factors, lack of formal education, and younger age at marriage, hence more females and married persons present with a higher number of HIV-ROLs.[26]

Regarding the types of oral lesions, 71.1% of those observed in this study were Group 1 lesions. Oral candidiasis (with pseudomembranous variant) was the most common, and is consistent with previous reports [Figure 1].[3],[4],[5],[7],[10],[11],[12],[13],[23] Candidiasis is reported to be the most common opportunistic infection in HIV infections; it is caused by the fungus, Candida albicans (but sometimes by nonalbicans species). It is frequently the first recognized oral manifestation and its appearance could also indicate an increased risk of progression to AIDS.[4],[23] On the contrary, oral hairy leukoplakia (OHL) is a viral opportunistic infection caused by Esptein–Barr virus. It is highly characteristic of HIV infection and most often coexist with oral candidiasis.[11] A prevalence of 4.7% OHL in this study is about half that reported in Iran and Ghana[10],[11] and much lower than those from India and Lebanon.[5],[12],[23] Periodontal lesions (LGE and necrotizing ulcerative periodontitis [NUP]) were also observed in this study. LGE is a bacterial infection commonly seen early in the course of HIV infection; it may serve as a precursor to NUP.[11],[27] The prevalence of LGE here (23.4%) is higher than those from a previous Nigerian (7.4%),[4] and South African study (8%),[15] but similar to that from India (21.1%).[5]
Figure 1: Pseudomembranous candidiasis in palate, tongue, and retro-buccal area. Source: Pediatric AIDS Pictoral Atlas, Baylor International Pediatric AIDS Initiative

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It is noteworthy that other Group 1 lesions such as Kaposi sarcoma (KS) and Non-Hodgkin’s lymphoma (NHL) were not observed in this study. Similarly, none was reported in two studies done in Iran.[10],[25] In Lebanon, KS and NHL were, respectively, seen in 8% and 4% of the study populations,[12] whereas only one participant had KS (with no NHL) in Benin, Nigeria, and Johannesburg.[4],[15] Since the advent of HAART, there is a decreased incidence of AIDS-defining cancers in PLWH.[28] HAART is said to lower the circulating HIV in the blood promoting the partial restoration of the immune system which helps in fighting viruses that predispose to many of these cancers.[28],[29] Incidentally, all the participants in this study were on HAART although compliance with treatment was not investigated.

Here also, Group 2 lesions such as melanotic hyperpigmentation (MH) occurred in 14.1% of the participants. Prevalence of MH in similar studies were 20.8%,[11] 3.4%,[10] 18.2%,[25] 22.4%,[l5] 3.75,[23] 10.3%,[4] and 2%.[14] MH may be an outcome of drugs used for treating secondary systemic conditions or the primary HIV infection.[11] Eweka et al.[14] described the process of hyperpigmentation as complex and associated with HIV-induced cytokine dysregulation with the medications normally prescribed for HIV-seropositive persons, and with adrenocortical dysfunction usually seen in patients with AIDS.

Furthermore, some studies had observed the correlation between prevalence of oral lesions and the laboratory parameters such as CD4 cell count and viral load in HIV/AIDS patient’s serum. They described a strong correlation between the oral lesions, lower CD4 cell count, and high viral load which are recognized and widely used as markers of HIV-related disease progression.[4],[11],[14],[23],[24],[25] In this study, HIV-ROLs were greatest in patients with CD4 count less than 200 cells/mm3 and this corroborated with previous reports.[4],[11],[14],[23] Lesions were also seen in those with CD4 count >500 cell/mm3 whereas some with <200 cell/mm3 had none. This may not be unconnected with presence of confounding factors such as poor oral hygiene, smoking, excessive use of alcohol, effect of drugs used in the management of co-morbidities like tuberculosis and auto-immune diseases.[4],[30] It is posited that oral manifestations in HIV infection persist in developing countries even with use of HAART due to many risk factors like the difficulty to access treatment, low socioeconomic status, late diagnosis of the infection in addition to the earlier mentioned confounding factors.[6] All the above, coupled with thriving opportunistic infections in an immune-depressive state, may lead to multiple infections as in the case of oral candidiasis variants occurring in same person, often with OHL.[11],[31]

Lastly, oral complaints such as pain, burning mouth, and/or gum bleeding were reported in this study. These could be symptoms of oral ulcers, gingivitis, dry mouth, or occur as side effects of the antiretroviral therapy and other self-medicated drugs common in many parts of the country.[14] As a result, eating, swallowing, and tooth-brushing may be compromised worsening nutritional, oral hygiene statuses, and encouraging more lesions in some persons.[4] It could be inferred that respondents’ self-reported oral complaints were real as almost half of them [Table 5] had at least one oral lesion consistent with HIV (P < 0.05). Hence, scaling up basic procedures such as home and professional dental care to alleviate the symptoms and halt progression of oral infections is advised.[32]

This study is not without limitations. Compliance and consistency in the use of HAART by the patients were not investigated; neither was the possibility of concurrent self-medication which is common in our environment. These could serve as pointers to management outcomes in relation to the lesions as poor compliance to HIV treatment has severe consequences on disease morbidity and mortality.[33] However, findings from this study enable conclusions as follows: HIV-ROLs in this environment are comparable to those reported in other studies. Their presence significantly correlated with self- reported oral concerns which hindered key oral functions. Hence, referral to the oral physician is important in the patients’ management and will go a long way to improve overall health of PLWH.


We are grateful to patients and staff of both centers for their cooperation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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