Prevalence of oral mucosal lesions in human immunodeficiency virus‐infected children attending the Pediatric Infectious Diseases Clinic in Cape Town

Abstract Objective Investigation of the prevalence of oral mucosal lesions in human immunodeficiency virus (HIV)‐infected children undergoing highly active antiretroviral therapy (HAART). Materials and Methods Cross‐sectional study of 66 HIV seropositive children, comprised of 28 (42.4%) females and 38 (57.6%) males (average age of 6 years). Study participants all required data regarding CD4+ T‐helper cell counts and the viral load. All participants underwent an orofacial clinical examination by calibrated clinicians. Associations between the presence of oral mucosal lesions, CD4+ cell counts, and viral load were analyzed using Poisson regression. Results The prevalence of oral manifestations was detected in 21 children (31.8%). Oral lesions were detected in 16 children with viral load copies <50 cells/mm3 and 22 children with CD4+ counts >500 cells/mm3. Predominant lesions identified included angular cheilitis (36.7%), candidiasis (13.3%) and atypical oral ulcers (13.3%). The presence of one lesion was the most prevalent represented by 19 children. Oral lesions in relation to the CD4+ counts >500 resulted in; 14 children with one oral lesion, 5 with two lesions and 3 with three oral mucosal lesions. The other half of this CD4+ count patient group presented with no oral mucosal lesions. Oral lesions in relation Viral load copies <50 resulted in; 9 children with one oral lesion, 3 with two oral mucosal lesions and 4 with three oral mucosal lesions. The other half of this Viral load patient group presented with no oral mucosal lesions. No significant correlations were established between the presence of oral mucosal lesions and low CD4+ counts (p = 0.715) nor with high viral load counts (p = 0.638). Conclusion HIV‐related oral mucosal lesions still presented in the participants despite management with HAART. Based on the results, CD4+ counts and viral load does not appear to be suitable markers of orofacial involvement in children.


| INTRODUCTION
Human immunodeficiency virus (HIV) infections are characterized by suppressed immune systems. The virus targets CD4+ T-helper cells (CD4+ cells) in the immune system, which are meant to assist the body in fighting infections. The virus replicates within these CD4+ cells until it eventually destroys them (Calles, Evans, & Terlonge, 2010); this results in a decreased amount of CD4+ cells and an increased viral load (Wilson et al., 2008) HIV/AIDS prevalence report, concerning South African children between the ages of 0 and 14 years, stated that 1.25 million children were infected out of a population of 52.8 million people (Shisana et al., 2014). In 2017, the same age group represented 3 million infected children out of a total South African population of 57 million people (Simbayi et al., 2018). Furthermore, a South African study recorded an oral lesion prevalence of 51.8% among children between the ages of 0 and 14 years. Interestingly, the study's statistical analysis found no association between age and the prevalence of oral mucosal lesions (Duggal, Abudiak, Dunn, Tong, & Munyombwe, 2010). Moreover, several cardinal oral lesions are associated with the disease progression of HIV/AIDS, including oral candidiasis, hairy leukoplakia, Kaposi sarcoma, linear gingival erythema, necrotizing ulcerative gingivitis, necrotizing ulcerative periodontitis, and non-Hodgkin's lymphoma (NHL) (Coogan, Greenspan, & Challacombe, 2005). Oral manifestations of HIV/AIDS are among the earliest signs of the disease and may function as markers of disease progression in both adults and children (Coogan et al., 2005;Miziara & Weber, 2008).
Normal CD4+ cell counts for adolescents and adults range between 500 and 1200 cells/mm 3 (Bofill et al., 1992). Furthermore, while infants and young children normally possess higher CD4+ counts than adolescents or adults, they slowly decline to adult values by the age of 6 years (Shearer et al., 1997). Subsequently, this signifies a need to consider age when dealing with the immunological status of children, especially because the percentages of CD4+ cell counts are imperative when determining the immunological staging in children.
The viral load is a blood test that determines the concentration of HIV copies in a person's blood plasma and is expressed as copies/ml or as a log 10 value (Wilson et al., 2008). Clinicians use this test's results to assess the severity of an infection. Ideally, the viral load of a patient on antiretroviral medication should either remain undetectable or manifest below the detection limit of 50 copies/ml (Doyle et al., 2012). A rising viral load is often indicative of drug failure (Bofill et al., 1992). This is alarming because a decrease in CD4+ cells and an increased viral load make the body more susceptible to opportunistic infections (Wilson et al., 2008;Yengopal, Bhayat, & Coogan, 2011).
Some of these infections result from commensal microorganisms that take advantage of the immunosuppression and manifest as different infections, including fungal, viral, and bacterial infections as well as neoplastic lesions (Coogan et al., 2005;Yengopal et al., 2011). These opportunistic infections often manifest in the oral cavity.
Nevertheless, the relevant literature asserts that a CD4+ count on its own is not a reliable marker for HIV progression in pediatric cases (Ramos-Gomez et al., 1996), which has led to the inclusion of oral mucosal lesions. These oral mucosal lesions are determined in the cited Table 1 of the reference article on orofacial lesions associated with pediatric HIV infection (Ramos-Gomez et al., 1999). The inclusion of oral mucosal lesions in the WHO clinical staging of HIV/AIDS has significantly benefited developing countries, especially those with poor resource settings where access to laboratory services is limited and turnaround times for blood tests are longer than usual (Yengopal, Kolisa, Thekiso, & Molete, 2016). Therefore, the presence of these oral mucosal lesions acts as clinical signposts concerning the presence and progression of a patients' immunodeficiency (Baghirath, Krishna, Gannepalli, & Ali, 2013;Yengopal et al., 2016). Additionally, oral manifestations have been reported as the earliest indicative signs of a pediatric HIV infection (Ramos-Gomez et al., 1999); therefore, they aid in determining the prognosis and progression of an HIV infection (Coogan et al., 2005). However, although the utilization of oral lesions as predictors regarding the progression of HIV infections in adults has been thoroughly investigated and documented, there is a dearth of data concerning its efficacy in pediatric populations (dos Santos Pinheiro et al., 2009;Meless et al., 2014;Oladokun, Okoje, Osinusi, & Obimakinde, 2013;Rwenyonyi et al., 2011).
The oral health status and prevalence of oral mucosal lesions among the children living with HIV/AIDS admitted to the Tygerberg Pediatric Infectious Diseases Clinic (Tygerberg PIDC) were unknown (Mohamed, Mathiba, & Mulder, 2020). This study aimed to investigate the array of oral mucosal lesions associated with HIV among children living with the disease.

| MATERIALS AND METHODS
The study was conducted at the Tygerberg PIDC, which conducts antiretroviral therapy. It used a cross-sectional descriptive study design in conjunction with the convenience sampling of candidates who fit certain inclusion criteria. Participant inclusion criteria included the following: children between the ages of 2 and 12 years with a confirmed HIV-positive status; signed consent forms from legal guardians; recorded viral loads or CD4+ count result records at the time of the dental examination; and the ability to comply with a clinical examination conducted by the principal researcher (O. M.). An appropriate sample size was determined with a power calculation, and 50 patients were found to be adequately representative of the study population.
The clinical team consisted of two dentists; the calibration of the prin- Although the data distribution of the CD4+ counts and viral loads was skewed, it was expected as it often occurs in HIV research. Therefore, a statistical calculation was conducted to achieve an informative plot for the collected CD4+/viral load data transformation. A natural log was used as the log of the statistically transformed variables of the CD4+ counts and the viral loads ( Figure 1). The generalized linear models approach of the Poisson family was used to determine the association between oral mucosal lesions with the CD4+ counts ( Figure 2) and oral mucosal lesions with viral load ( Figure 3) that the children exhibited. Additionally, frequency distribution was used to summarize and identify the children's most common oral mucosal lesions and characteristics (Table 1).
The principal researcher (O. M.), who is a qualified dental practitioner, performed a standardized clinical examination on all the participants. A basic examination pack was used for the examination of each child; it consisted of an explorer probe, an intra-oral mirror, gauze, and an LED headlight. All of the patients' oral mucosal lesions were recorded, and a data capture sheet documented the information obtained during the clinical assessment. The enrolled patients' data capture sheets were kept safely in a locked cabinet in the Principal Researcher's office.
While parotid enlargements are rarely seen in adults, parotid-and other salivary gland enlargements are extremely common in children with HIV infections (Ramos-Gomez et al., 1999); a study recorded a prevalence ranging between 0% and 58% (Schiødt et al., 1992). The recorded 1.5% prevalence of parotid enlargements found in this study is analogous with the results of studies conducted in Tanzania, India, Uganda, Nigeria, and West Africa (Hamza et al., 2006;Kaul et al., 2009;Meless et al., 2014;Oladokun et al., 2013;Rwenyonyi et al., 2011).
The only child in this study who did present with a parotid The prevalence of linear gingival erythema (LGE) in children with HIV varies between different populations and can range anywhere between 0% and 48% (Hamza et al., 2006;Kaul et al., 2009;Ramos-Gomez et al., 1999;Rwenyonyi et al., 2011). In this study, 3% of the patients had LGE and exhibited a viral load <50 copies/ml. Studies have linked the occurrence of gingivitis and periodontal disease in HIV-infected individuals to other relevant factors, such as poor oral hygiene (dos Santos Pinheiro et al., 2009;Robinson, 2002). However, several children had poor oral hygiene and increased dental plaque, which made it diagnostically difficult to distinguish between LGE and conventional gingivitis. The low result of 3% is peculiar, as other studies comparing the prevalence of LGE in HIV-infected and HIVnegative participants found that LGE was not only equally common in both groups but was significantly associated with dental plaque in both groups as well (Grbic et al., 1995;Robinson, Sheiham, Challacombe, Wren, & Zakrzewska, 1998). This disparity suggests that LGE may be indistinguishable from conventional gingivitis, which would explain the wide variability of its prevalence (Robinson, 2002).
However, in this study, one child (1.5%) had developed a NHL. This child exhibited an extremely high viral load despite being on HAART medication, thus signifying immune failure. NHL is usually only seen in the late stages of AIDS where CD4+ counts are below 100 cells/mm 3 (Bajpai & Pazare, 2010). In the current population, antiretroviral treatments caused most patients to retain high CD4+ counts and low viral loads. This may explain the low prevalence rate of NHL.
To assess the factors associated with the occurrence of oral lesions among the patients, the level of their immunosuppression was assessed. A study previously hypothesized that the presence of oral lesions in patients with HIV coincides with a deterioration of their immune status-a low CD4+ count and high viral load (Baghirath et al., 2013). Therefore, a lower CD4+ count is expected to lead to a predisposition for oral lesions (Adebola et al., 2012;Sales-Peres et al., 2012). Additionally, a CD4+ count and viral load, although measuring different aspects of immunity, should display an inverse correlation (HIV i-base, 2016). Furthermore, several studies assert that a CD4+ count functions better as an indicator of disease progression than a viral load (Adebola et al., 2012;Bodhade et al., 2011;Rwenyonyi et al., 2011;Sales-Peres et al., 2012). However, this study, along with several others, found little to no correlations between the presence of oral mucosal lesions and CD4+ counts or viral loads (Nabbanja et al., 2013;Shah, 2006) (Oladokun et al., 2013).
Furthermore, a study exploring the factors influencing the distribution of oral mucosal lesions in children with CD4+ counts below 500 cells/mm 3 revealed that they had significantly more oral mucosal lesions than those with CD4+ counts above 500 cells/mm 3 (Rwenyonyi et al., 2011). Conversely, this study reports the same number of patients with and without oral mucosal lesions for CD4+ counts above 500 cells/mm 3 (Table 1). Additionally, another study concerning South African children with HIV discovered an association between viral loads and CD4+ counts with the presence of oral mucosal lesions (Duggal et al., 2010). Therefore, the results of this study verify other findings that state that oral mucosal lesions are independently associated with immunosuppression (Meless et al., 2014). Consequently, these findings suggest that CD4+ counts and viral loads are not indicators of disease progression for children between the ages of 2 and 12.

| CONCLUSION
Several oral manifestations of HIV were observed in a portion of the study population despite the use of HAART medication; the most common of these lesions were candidiasis infections (particularly angular cheilitis). However, the presence of oral mucosal lesions was not significantly correlated with the immunosuppression status of the patients. Based on the results, CD4+ counts and viral load does not appear to be suitable markers of orofacial involvement in children.
Nevertheless, the early recognition of oral mucosal lesions can still facilitate appropriate and early interventions for collaborative health platforms. This can only be accomplished through improved oral screening and referral processes between health practitioners.

| Recommendations
This study highlights the need for oral health awareness and access to oral health services for children living with HIV in South Africa. Most of the patients' caregivers were unaware of services offered at Tygerberg Dental Faculty, UWC, as well as the importance of managing oral mucosal lesions. Therefore, education programs and primary health care screening programs should be implemented by the dental faculty to drive this service.
The research data also stressed the need for a collaborative effort between the PIDC and pediatric dental clinics to provide effective oral health services for children living with HIV.

| Limitations of the study
A potential limitation of this study could be the small sample size at the PIDC, since this clinic is located in one of the nine provinces of South Africa. Larger sample sizes would have been more representative of the overall oral health status of children in South Africa.