Abstract
Background:
Zinc status is suboptimal, and requirements are known to be increased in human immunodeficiency virus (HIV) infected individuals. Some aspects of the association between zinc status and HIV disease severity in African children still constitute a knowledge gap.
Objectives:
The objective of this study was to compare serum zinc levels with the disease severity in HIV infected Nigerian children.
Materials and Methods:
Fifty-three randomly selected HIV infected children attending pediatric anti-retroviral clinics in Ogbomosho, Nigeria, were studied. Data from their social demographics, the WHO disease stages and zinc levels were determined and analyzed to test associations.
Results:
The mean age of the 53 participants was 9 ± 1.3 years with, male-to-female ratio of 2.1:1. Of the 53 children, 32 (60.4%), 13 (24.5%) and 8 (15.1%) were from WHO clinical stage I, II and III. Zinc levels in the subjects ranged from 0.017 to 3.18 ng/ml. Nine (17.0%) children had deficient zinc levels below 0.05 ng/ml. The mean serum zinc level was 1.959 (±0.95), 1.607 (±1.28), and 1.435 (±1.36).ng/ml in the subjects from WHO clinical HIV stage I, II and III, respectively. P = 0.05. Four (50.0%) of the 8 children with advanced HIV stages were zinc deficient compared with the 5 (20.0%) of the 40 in the nonadvanced HIV class, P < 0.01.
Conclusion:
Zinc deficiency is a significant challenge of HIV infected children with advanced disease. Screening of children with advanced HIV disease for zinc deficiency should be routine, and deficiencies should be corrected.
Keywords: Advanced disease, micronutrient, retroviral infection, zinc
Introduction
Micronutrients are chemical elements essential in minute quantities for the physiological growth and development of living organisms.[1] They play a crucial role in enhancing immunity and facilitating proper development in children.[2] Imbalances in micronutrients, whether deficiencies or excesses, can adversely affect the health of growing children.[2] Its deficiency is associated with deranged immune system function and diseases such as diarrhea and pneumonia.[3,4,5] Results from previous studies on zinc in human immunodeficiency virus (HIV) show that zinc deficiency is prevalent among HIV infected individuals.[6,7,8,9]
Zinc plays a critical role in inhibiting HIV-1 protease, essential for viral replication, thereby potentially reducing morbidity associated with HIV infection.[10,11] Zinc deficiency has been associated with decreased CD4 cell production,[12,13] it has also been shown to inhibit HIV-ribonucleic acid transcription, further underscoring its therapeutic relevance.[10] HIV infection, caused by HIV-1 and HIV-2, is a systemic illness affecting multiple organs as it progresses through various clinical stages.[14]
Global studies suggest zinc deficiency among HIV-infected children, and the association between the disease severity and nutritional indices is indistinct. Thus, there is a need for local studies as the prevalence of poverty and nutritional spectrum differs across the developed and developing world. Furthermore, results from local studies are expected to better inform nutritional policies aimed at improving the well-being of infected children.[5,15,16,17] These reasons informed our desire to measure and compare serum zinc levels of HIV infected children and determine the association between serum zinc levels and HIV-disease severity.
Materials and Methods
This study was carried out in the pediatrics antiretroviral clinics of three HIV treatment centres in Ogbomoso, Nigeria, namely, State Hospital (SH), LAUTECH Teaching Hospital (LTH) and Bowen University Teaching Hospital (BUTH) from March 3, 2023 to August 4, 2023. Ethical clearances were obtained from the Research and Ethics Committees of LTH, BUTH, and Oyo State Ministries of Health and education, with protocol numbers/reference numbers of LTH/OGB/EC 2020/222; BUTH/REC-352 and AD/13/474/44340, respectively. Approvals from school administrators were also obtained. Permission and written informed consent were obtained from the parents/caregivers of all study participants, and assent was obtained from subjects above 7 years old.
This is a cross-sectional study. Sample size was calculated by the formula
Where Zα is the (critical value of the normal distribution at α) = 1.96
Zβ is the (critical value of the Normal distribution at β) = 0.84,
σ2 is the population variance = 33.3
δ is the difference in the mean of the serum zinc levels between HIV-infected children and controls (86.1 and 65.8.) from a from a previous study.[16] Therefore,
Adding 10% attrition (4.219) = 4.219 + 42.19 = 46.4,
From the minimum sample size calculation, we decided to study 53 cases and samples to increase the significance of findings.
The studied children were randomly selected HIV-infected children receiving care at LTH, BUTH and SH antiretroviral clinics, aged 2–12 years. It was ensured that the subjects did not have zinc supplements in the last 6 months or conditions such as diarrhea or pneumonia that could deplete their zinc status in the last 6 months before inclusion in this study. All children receiving steroids, diuretics or iron-containing drugs, were also excluded, as this affects the serum zinc levels.
Information was obtained using a proforma designed for the study from all recruited subjects and controls. Some of the information obtained includes age, sex, tribe, and domicile. The socioeconomic status was also ascertained according to Oyedeji’s social classification method.[18] General and systemic examination was done for all subjects, and the World Health Organization revised clinical staging was used to stage each HIV infected subject.[19] HIV screening and confirmation were done using rapid test kits.[20] HIV testing was done with the Alere Determine TM HIV 1/2 kits (Abbot, Japan).[21] The samples for serum zinc estimation were collected in the morning before 12:00 noon in an ice-packed cooler and sent to the laboratory within 2 h of collection for further analysis. Furthermore, samples were analyzed using a human zinc transporter 1 enzyme-linked immunosorbent assay kit manufactured by BioAssay Technology Laboratory.[22] Serum zinc deficiency was defined as a zinc level <0.05 ng/ml.
The results were determined by measures of central tendency and dispersion. The data was analyzed using SPSS version 2,3 (IBM Corporation, Armonk, New York, USA).[23] Descriptive statistics were employed to summarize categorical variables such as age, sex, religion, tribe. Descriptive statistics were used to summarize continuous variables, including weight, height, and body mass index (BMI). Normal weight, over weight, underweight and normal height, stunting and tall stature were classified and based on the World Health Organization growth standards. The World Health Organization BMI for age for boys and girls was used to classify the BMI. Differences in these variables between the control group and the study subjects were presented using two-sample comparisons. The Student’s t-test was applied to assess significant differences in the mean serum zinc levels of normally distributed variables. The level of significance was set at P < 0.05.
Results
Facilities where the studied children were selected from
A total number of 53HIV infected patients were studied. Eleven (20.8%) subjects were recruited from BUTH, 16 (30.1%) from LTH Ogbomoso, and 26 (49.1%) from SH Sunsun.
Sociodemographic characteristics of the study population
The 53 HIV infected children studied were aged between 2 and 12 years, with a mean age of 9.13 years, as shown in Table 1. There was a male preponderance with a male-to-female ratio of 2:1. According to the type of family, more than half of the children were from the monogamous family setting and the middle and lower socioeconomic strata class III, IV and V. Full details of the findings are found in Table 1.
Table 1.
Sociodemographic characteristics of study participants
| Variable | Charactheristics | n (%) |
|---|---|---|
| Age (years) | 2–3 (Toddler) | 2 (3.8) |
| 4–5 (Preschool) | 5 (9.4) | |
| 6–12 (School age) | 46 (86.8) | |
| Mean age | 9±1.3 | |
| Sex | Female | 17 (32.1) |
| Male | 36 (67.9) | |
| Social class | Class I | 3 (5.7) |
| Class II | 4 (7.6) | |
| Class III | 30 (56.6) | |
| Class IV | 13 (24.5) | |
| Class V | 3 (5.7) | |
| Type of family | Monogamous | 31 (58.5) |
| Polygamous | 8 (15.1) | |
| Related caregiver | 1 (1.9) | |
| Single parent | 13 (24.5) | |
| Family size | <4 | 13 (24.5) |
| 4–≤7 | 37 (69.8) | |
| ≥7 | 3 (5.7) |
Range of serum zinc values in children studied across age and gender
The serum zinc levels ranged between 0.02 and 3.18 ng/ml. The mean serum zinc level was 1.67 (±1.15) ng/ml. The mean serum zinc level in the 2–3 year, 4–5 years, and 6–12 year age categories was 0.81, 1.11, and 1.76 ng/m, respectively. The mean serum zinc for boys and girls was 1.62 ng/ml and 1.76 ng/ml, respectively. Of the 53 studied children, 44 (83.0%) had normal serum zinc levels, and 9 (17.0%) were deficient.
World Health Organization clinical stages of the studied children
Of the 53 studied children, 32 (60.4%) belonged to stage I of the World Health Organization clinical classification of HIV/AIDS, whereas 13 (24.5%) belonged to stage clinical II and 8 (15.1%) belonged to clinical stage III. None of the children had evidence of clinical stage IV disease or AIDS.
Comparison of the serum zinc levels in the different stages of human immunodeficiency virus disease
The mean serum zinc levels of the subjects declined with the WHO clinical stage of the children; however, this decrease was almost significant statistically, P = 0.05. However, comparison of the number of subjects that had normal serum zinc levels with those that were zinc deficient was statistically significant P < 0.01. Table 2 displays the association between the zinc levels and the WHO clinical stages.
Table 2.
Mean serum zinc levels and status across the World Health Organization clinical stages of the human immunodeficiency virus disease among subjects
| Variable | WHO clinical HIV staging |
F | P | |||
|---|---|---|---|---|---|---|
| Stage 1 | Stage 2 | Stage 3 | Stage 4 | |||
| Mean serum zinc level (ng/mL) | 1.959±0.95 | 1.607±1.28 | 1.435±1.36 | - | 3.813 | 0.052 |
| Zinc status deficient, n (%) | 1 (1.88) | 4 (7.55) | 4 (7.55) | - | - | 0.002 |
| Normal, n (%) | 31 (58.49) | 9 (16.98) | 4 (7.55) | - | - | - |
F: F-test, WHO: World Health Organization; HIV: Human immunodeficiency virus
Comparison of the serum zinc levels by sociodemographic characteristics of children studied
Zinc deficiency was more common in the 6–12 year age category and the male gender. Zinc deficiency rates were also higher among monogamous family setting and children from social class III. These differences were not statistically significant. The associations are shown in Table 3.
Table 3.
Association between serum zinc levels and sociodemographic characteristics
| Variable | Category | Zinc status |
P | |
|---|---|---|---|---|
| Deficient, n (%) | Zinc level, n (%) | |||
| Age (years) | 1–3 (Toddler) | 1 (1.89) | 1 (1.89) | 0.47 |
| 4–5 (Preschool) | 1 (18.89) | 4 (7.55) | ||
| 6–12 (School age) | 7 (13.20) | 39 (73.58) | ||
| Sex | Female | 4 (7.55) | 13 (24.53) | 0.45 |
| Male | 5 (9.43) | 31 (58.49) | ||
| Birth order | 1 | 1 (1.89) | 10 (18.86) | 0.51 |
| 2 | 3 (5.66) | 14 (26.42) | ||
| 3 | 2 (3.77) | 9 (17.0) | ||
| 4 and above | 3 (5.66) | 11 (20.8) | ||
| Social class | Class I | 0 | 3 (5.66) | 0.96 |
| Class II | 0 | 4 (7.55) | ||
| Class III | 6 (11.32) | 24 (45.28) | ||
| Class IV | 3 (5.66 | 10 (18.86) | ||
| Class V | 0 | 3 (5.66) | ||
| Type of family | Monogamous | 7 (13.20) | 24 (45.3) | 0.50 |
| Polygamous | 0 | 8 (15.09) | ||
| Related caregiver | 0 | 1 (1.89) | ||
| Single parent | 2 (3.77) | 11 (20.76) | ||
| Family size | <4 | 3 (5.66) | 10 (18.89) | 1.00 |
| 4–≤7 | 5 (9.4) | 32 (60.4) | ||
| ≥7 | 1 (1.89) | 2 (3.77) | ||
Anthropometric Indices of studied children and comparison of the mean serum zinc levels with anthropometric indices
Of the 53 children, by weight, 11 (20.8%) were underweight, and 42 (79.2%) were of normal weight. None was overweight. By height, 46 (86.8%) were of normal height, 6 (11.3%) stunted and 1 (1.9%) tall stature. Forty-four (83.0%) had a normal BMI, and 9 (17.0%) were wasted. None was obese. Subjects with poor anthropometric indices had lower serum zinc levels than those who had normal anthropometric indices. Details of the mean zinc levels across the anthropometric indices are shown in Table 4.
Table 4.
Mean serum zinc levels compared with the anthropometric indices of the studied children
| Variable | Anthropometry | Subjects (ng/mL), mean±SD |
|---|---|---|
| Height | Stunted | 1.08±1.82 |
| Normal | 1.65±1.08 | |
| Tall stature | 2.06±1.40 | |
| Weight | Underweight | 1.02±1.47 |
| Normal | 1.68±1.00 | |
| Overweight | - | |
| BMI | Wasted | 1.06±0.79 |
| Normal | 1.84±1.19 |
BMI: Body mass index; SD: Standard deviation
Discussion
The serum zinc levels in HIV-infected Ogbomosho children across the WHO clinical stages have been documented in this study. Our prevalence estimate is significantly lower than the reports from previous studies. Previous studies have reported regional variations in the prevalence of serum zinc deficiencies among HIV-infected children in Nigeria. Specifically, Asemota et al. reported a 56% prevalence in Calabar, Chukwu et al. documented a 72% prevalence in Enugu, and Anyabolu et al. reported a 77% prevalence in Ile-Ife.[5,13,16] The differences in the prevalence estimates in the different studies may be attributed to some methodological differences in the studies, such as age group, nutritional status, and the WHO clinical groups of the children studied.
The majority of the children studied had mild symptoms of HIV clinical stages and did not have zinc deficiency whereas the minority were predominantly deficient. Our study showed that the mean serum zinc levels in the subjects decreased with the progression of WHO clinical stages, though the difference was not statistically significant. It is expected that asymptomatic subjects and those who have not experienced either single episodes or recurrent episodes of diarrhea or respiratory tract illnesses should not have decreased serum zinc levels if their nutrition is optimal. This finding may be attributed to the dual role of zinc in viral replication and immune function. As viral load increases, both the virus and the immune system have increased zinc requirements, potentially leading to a depletion of serum zinc levels.
A higher prevalence of zinc deficiency was observed among males compared to females. This finding is consistent with the results of Asemota et al.[14] who also reported a higher prevalence of zinc deficiency in males, with female participants having greater mean serum zinc levels than their male counterparts. We do not have any plausible reasons to explain this finding.
The nutritional spectrum of the studied children in terms of weight, height and BMI compare similarly to previous studies on the same subject.[24,25,26,27] Children with HIV disease are expected to have declining weight/height for age as they progress across the HIV disease spectrum categories. Thus, the correlation of anthropometric indices with clinical staging was expected, however the correlation of zinc status with the severity or progression of HIV disease or the anthropometric status is the science requiring research.
Our study recorded a decline in the mean serum zinc levels across the WHO clinical staging of the studied children from mild to advanced, however this finding was not significant. Based on the correlation between anthropometrics and WHO clinical staging, a similar decline would be expected for zinc across the nutritional indices from normal to abnormal. The lack of significance in findings may, however, be due to our small sample size and the absence of children with AIDS in our study.
The lack of significant association between zinc status and the socioeconomic factors in the present study suggests that the socioeconomic characteristics may not be strongly responsible for the zinc status deficiency in our study. This result is not consistent with most other reports in Africa, which associate a low socioeconomic status with Zinc deficiency in HIV infected children.[27,28] The differences in our report may be explained by the differences in study methodology, as most of our participants did not have advanced disease and were from the middle class. Our submission on these differences is that there is a need for further research on this subject.
Some of the strengths of this study include it being a multicenter study and the random selection of subjects. However, the small sample size and the fact that none of the patients in our series had AIDS limit the extent to which our results can be generalized.
Conclusion
Zinc deficiency is more common among children with advanced HIV disease, although this association is not significant. Supplementation of zinc is, however, suggested in those deficient. We recommend further research of zinc status among children with advanced HIV progression and the mode of supplementation of zinc viz a viz whether prophylactic or therapeutic modality.
Ethical statement
Research and Ethics Committees of Ladoke Akintola University Teaching Hospital (LTH/OGB/EC 2020/222). Research and Ethics Committees, Bowen University Teaching Hospital, (BUTH/ REC 352) and Ministries of Health and education, Oyo State (AD/13/474/44340).
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
Our gratitude to all our patients and their caregivers for their cooperation. We also appreciate the health workers managing all the patients in the various health facilities.
Funding Statement
Nil.
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