salivary gland disease which include xerostomia , cysts and sjogren 's syndrome - like condition with persistent glandular enlargement and secretory hypofunction have been reported in hiv - infected individuals.[13 ] hiv - salivary gland disease ( sgd ) includes lymphoepithelial lesions and cysts involving the salivary gland tissue and/or intra - glandular lymph nodes , sjogren 's syndrome - like condition and diffuse infiltrative cd8 lymphocytosis syndrome ( dils ) . the introduction of highly active antiretroviral therapy ( haart ) which includes a combination of antiretroviral drugs in the treatment of hiv infected has led to a significant decrease in oral manifestations.[57 ] however , adverse effects like xerostomia and an increase in salivary gland disease have been reported with haart .
the present study was done to ascertain and compare between haart and non - haart patients , the occurrence of salivary gland disease , unstimulated salivary flow rates and stimulated salivary flow rates ( usfr and ssfr ) and their relationship to cd4 count and the perception of xerostomia .
the study was carried out on 100 confirmed hiv seropositive patients attending ragas - yrg care , chennai , india .
the patients were divided into two groups , haart group comprising 50 patients initiated on haart .
the patients were on a combination of two nucleotide reverse transcriptase inhibitors and one non - nucleotide reverse transcriptase inhibitor .
after the baseline ( 0 ) examination , they were followed - up in the consecutive 3 , 6 , and 9 month . at the baseline visit ,
subsequently , 44 , 35 , and 20 patients were followed - up at 3 , 6 , and 9 months respectively as patients were lost to follow - up . during each visit , clinical oral examination , collection of unstimulated and stimulated
multi - item  xerostomia inventory comprising a set of 19 questions was used to assess salivary gland function during each visit .
the  spitting method  proposed by navazesh et al . , was used for the collection of unstimulated saliva .
stimulated saliva was collected by applying 2% citric acid on the dorsolateral surface and tip of the tongue every 30 seconds and the patient was asked to spit saliva into a sterile graduated container .
this was done for 10 min and the total volume of saliva was recorded and expressed in ml / min .
fifty patients not on haart ( with age and cd4 count matched as closely as possible with those in the haart group ) comprised the non - haart group .
data entry , database management , and all statistical analysis were performed with the aid of the statistical package for the social sciences ( spss version 10.05 ) software .
student t - test was carried out to compare the mean differences in normally distributed data .
mann - whitney u test was applied to assess the statistical differences between the groups of patients when the data were non - normal .
anova ( one - way ) test was used to compare the mean unstimulated salivary flow rate and stimulated salivary flow rate within the haart group at 0 , 3 , 6 , and 9 months .
data entry , database management , and all statistical analysis were performed with the aid of the statistical package for the social sciences ( spss version 10.05 ) software .
student t - test was carried out to compare the mean differences in normally distributed data .
mann - whitney u test was applied to assess the statistical differences between the groups of patients when the data were non - normal .
anova ( one - way ) test was used to compare the mean unstimulated salivary flow rate and stimulated salivary flow rate within the haart group at 0 , 3 , 6 , and 9 months .
the study population comprised 100 hiv seropositives , 50 in the haart group and 50 in the non - haart group .
there were 76 males ( haart group = 36 , non haart group = 40 ) and 24 females ( haart group = 14 , non - haart group = 10 ) .
the mean age in the haart group was 34  6.3 ( males = 35.1  5.9 ; females = 30.7  6.5 ) .
the mean age in non - haart group was 35.2  7.6 ( males = 36.3  7.5 ; females = 30.7  6.2 ) [ table 1 ] .
the mean cd4 count in haart and non - haart groups were 255  110 and 200  90 respectively .
forty one patients had a cd4 count  200 ( haart group = 36% and non - haart group = 46% ) and 59 had a cd4 count > 200 ( haart group = 64% and non - haart group = 46% ) [ table 2 ] .
when the salivary flow rates between the two groups were compared , the mean unstimulated salivary flow rate in haart group at baseline was 0.61  0.18 and in the non - haart group was 0.65  0.29 . [ table 3 ; figure 1 ] .
the mean stimulated salivary flow rate in haart group at baseline and non - haart groups was 1.24  0.50 and 1.37  0.53 respectively .
the mean unstimulated salivary flow rate in the haart group at baseline ( 0 ) , 3 , 6 , and 9 months was 0.61  0.18 , 0.62  0.27 , 0.69  0.25 , and 0.68  0.27 respectively [ table 4 ; figure 1 ] .
the mean stimulated salivary flow rate at baseline was 1.24  0.50 at 3 months 1.57  0.51 , at 6 months 1.49  0.73 , and at 9 months 1.23  0.57 ( p = 0.02 ) [ table 4 ; figure 2 ] .
age and gender distribution cd4 count in the study population mean unstimulated and stimulated salivary flow rates in highly active antiretroviral therapy ( at baseline ) and non - haart groups mean and 95% confidence interval for mean unstimulated salivary flow rate in highly active antiretroviral therapy at baseline ( 0 ) , 3 , 6 , and 9 months and non - haart groups mean and 95% confidence interval for mean stimulated salivary flow rate in highly active antiretroviral therapy at baseline ( 0 ) , 3 , 6 , and 9 months and non - haart groups mean unstimulated and stimulated salivary flow rates in highly active antiretroviral therapy group at baseline ( 0 ) 3 , 6 , 9 months the mean unstimulated salivary flow rate in haart patients with a cd4 count  200 at baseline ( 0 ) was 0.56  0.13 ml / min , whereas in patients with a cd4 count > 200 , the mean unstimulated salivary flow rate was 0.64  0.1 ml / min . at 3 months , the mean unstimulated salivary flow rate in patients with a cd4 count
 200 was 0.61  0.27 ml / min and 0.63  0.27 ml / min in patients with a cd4 count > 200 .
the mean unstimulated salivary flow rate in patients with a cd4  200 at 6 months and 9 months was 0.86  0.38 ml / min and 0.68  0.28 ml / min respectively , whereas in patients with a cd4 > 200 , the mean un - stimulated salivary flow rate was 0.66  0.23 ml / min at 6 months and 0.68  0.28 ml / min at 9 months .
the mean stimulated salivary flow rate in haart patients with a cd4 count  200 at baseline ( 0 ) was 1.06  0.26 ml / min and those with a cd4 count > 200 had a mean stimulated salivary flow rate of 1.34  0.59 ml / min . at 3 months , the mean stimulated salivary flow rate in patients with a cd4  200 and cd4 > 200 was 1.54  0.49 ml / min and 1.6  0.54 ml / min respectively .
the mean stimulated salivary flow rate at 6 months in patients with a cd4  200 was 2.25  0.98 ml / min and in those with a cd4 count > 200 was 1.39  0.64 ml / min ( p = 0.02 ) . at 9 months
, the mean stimulated salivary flow rate in haart patients with a cd4 count  200 was 1.15  0.19 ml / min and 1.25  0.64 ml / min in those with a cd4 count > 200 [ table 5 ; figure 3 ] .
mean salivary flow rates in highly active antiretroviral therapy patients with cd4200 and cd4>200 at baseline ( 0 ) , 3 , 6 , 9 months mean salivary flow rates in highly active antiretroviral therapy group with cd4200 and cd4>200 at baseline ( 0 ) , 3 , 6 , and 9 months the mean unstimulated salivary flow rate in non - haart patients with a cd4 count  200 was 0.60  0.26 ml / min and 0.69  0.31 ml / min in patients with a cd4 count > 200 .
in patients with a cd4 count  200 , the mean stimulated salivary flow rate was 1.24  0.40 ml / min and in patients with a cd4 > 200 , the mean stimulated salivary flow rate was 1.48  0.6 ml / min [ table 6 ; figure 4 ] .
mean salivary flow rates in non.highly active antiretroviral therapy patients with cd4200 and cd4>200 mean salivary flow rates in non - highly active antiretroviral therapy group with cd4200 and cd4>200 the results of the subjective symptoms of dry mouth perceived by haart and non - haart patients are listed in [ table 7 ] .
subjective symptoms of dry mouth perceived by highly active antiretroviral therapy and non - haart patients ( % of patients who gave a positive response )
xerostomia with a sjogren 's syndrome - like condition with persistent glandular enlargement and secretory hypofunction have been reported .
hiv - sgd includes lymphoepithelial lesions and cysts involving the salivary gland tissue and/or intra - glandular lymph nodes , sjogren 's syndrome - like condition , and dils . in the present study , the mean usfr and ssfr in haart and non - haart
groups were compared . the  spitting method  , proposed by navazesh , was used for collecting saliva as it is an inexpensive , simple , and an easily reproducible procedure .
there was no significant difference in the salivary flow rates between the two groups at baseline .
when the mean unstimulated salivary flow rate in haart group at baseline ( 0 ) , 3 , 6 , and 9 months was compared , there was no statistically significant difference .
the mean stimulated salivary flow rate increased from baseline to 3 months and this increase was statistically significant ( p = 0.02 ) .
this is in contrast to that reported by navazesh et al . , who identified haart as a significant risk factor for low unstimulated ( 0.1 ml / min ) and low stimulated ( 0.7 ml / min ) salivary flow rate .
in the present study , neither the haart nor non - haart patients had an unstimulated salivary flow rate 0.1 ml / min and a stimulated salivary flow rate 0.7 ml / min .
and patton et al . , observed an increase in hiv salivary gland disease following haart and attributed this increase to lympho - proliferative reactivation stimulated by haart .
this was not seen in this study . in hiv salivary gland disease , the infiltrate is composed predominantly of lymphocytes of the cd8 ( suppressor ) subtype .
the increased numbers of circulating cd8 t - cells that infiltrate salivary glands in hiv infection is designated dils .
the increase in mean stimulated salivary flow rate observed in patients on haart during follow up may be attributed to the immune reconstitution following haart , which probably reduces the cd8 lymphocytosis in salivary glands . to ascertain
if immune suppression influences salivary flow rate , the mean usfr and ssfr in haart and non - haart patients with a cd4  200 and cd4 > 200 were compared .
the mean usfr and ssfr in non - haart patients with a cd4  200 and cd4 > 200 were not statistically significant . in the haart group at baseline ( 0 ) ,
patients with cd4  200 had a lower mean stimulated salivary flow rate when compared with patients with cd4 > 200 ( p = 0.07 ) .
in their study on 733 hiv - positive and at risk hiv - negative women observed that hiv - positive women with a cd4  200 had a higher prevalence of zero unstimulated saliva , suggesting that immunosuppression affects salivary gland function . in yet another study , mulligan et al .
, found that hiv - positive women had higher rates of salivary gland tenderness and absence of saliva on palpation that was significantly associated with a low cd4 count . in the haart group at 6 months ,
patients with cd4 count  200 had a higher mean stimulated salivary flow rate when compared with patients with cd4 > 200 and this was statistically significant ( p = 0.02 ) . since there were only four patients with cd4  200 out of the 35 patients followed - up at 6 months , these results will have to be confirmed with larger samples .
antiretroviral drugs like didanosine , zidovudine , lamivudine , and protease inhibitors ( indinavir , nelfinavir , ritonavir and saquinavir ) have been reported to cause xerostomia . in this study xerostomia
was evaluated using a  multi - item " inventory comprising a set of 19 questions proposed by thomson et al
. a greater number of patients in the non - haart group perceived dryness of lips when compared with haart patients at baseline and this was statistically significant ( p = 0.02 ) . out of the 19 questions , only 3 questions  does your mouth feel dry ?  ( p = 0.00 ) ,  do you get up in the night to drink water ?  ( p = 0.00 ) , and 
( p = 0.01 ) were statistically significant in the haart group at baseline ( 0 ) , 3 , 6 , and 9 months . in the haart group ,
the percentage of patients who perceived xerostomia at 3 , 6 , and 9 months was less than the percentage of patients who perceived xerostomia at baseline ( 0 ) .
this correlates with the increase in mean stimulated salivary flow rate observed from baseline to 3 months which was maintained at 6 months and 9 months . in this study population haart
sreebny et al . , classified usfr that were 0.1 ml / min as  abnormal  , between 0.11 ml / min and 0.2 ml / min as  low normal ,  and greater than 0.2 ml / min as  normal .  in their study , subjects who complained of dry mouth had usfr  0.1 ml / min and hence they concluded that the subjective feeling of xerostomia is usually associated with a marked decrease in the rate of whole saliva . in the present study ,
the haart and non - haart patients had  low normal  to  normal  salivary flow rates .
fox suggested that dry mouth symptoms are not reliable indicators of diminished salivary flow rates .
narhi et al . , stated that not all patients who complain of dry mouth have salivary gland hypo - function .
although some of the haart and non - haart patients perceived xerostomia , their salivary flow rates were normal in the present study . in the present study
, there was no difference in the salivary flow rates ( unstimulated and stimulated ) between the two groups .
in the haart group , there was an increase in the mean stimulated salivary flow rate from baseline ( 0 ) to 3 months and this increase was maintained at 6 months and 9 months . as the salivary flow rates were within normal limits , the xerostomia questionnaire did not reveal any difference between the two groups . since many patients were lost to follow up in the haart group in the present study , a long - term follow - up study with a larger sample is required for conclusive evidence on salivary flow rates
 aims : to ascertain and compare between highly active antiretroviral therapy ( haart ) and non - haart patients , the stimulated salivary flow rates and unstimulated salivary flow rates ( usfr and ssfr ) and to correlate the salivary flow rates with immune suppression.materials and methods : one hundred human - immuno deficiency virus seropositive patients attending ragas - yrg care were examined and divided into two groups , a haart group ( patients on combination antiretroviral therapy ) comprising 50 patients and a non - haart group comprising 50 patients . 
 the haart group was followed every 3 months after the baseline visit ( 0 ) for a period of 9 months , during which a clinical oral examination and collection of unstimulated and stimulated saliva was done . 
 their salivary gland function was assessed using a xerostomia inventory during each visit . 
 the study on non - haart group was cross-sectional.statistical analysis : statistical analysis were performed with the aid of the statistical package for the social sciences ( spss version 10.05 ) software.results:there was no significant difference in mean ssfr and usfr between the two groups at baseline . in the haart group , 
 the mean stimulated salivary flow rate increased from baseline to 3 months ( p = 0.02 ) , with the increase being maintained at 6 months and 9 months . when salivary flow rates were correlated with cluster of differentiation , cd4 counts , patients in the haart group with a cd4  200 at 6 months visit had a higher mean stimulated salivary flow rate when compared with patients with cd4  200 ( p = 0.02 ) . 
 the xerostomia inventory did not reveal any significant difference between the two groups and haart was not significantly associated with xerostomia.conclusion:in our study haart was neither associated with xerostomia nor a reduction in salivary flow rate and immune suppression was not a significant factor for decreasing the salivary flow rate . 
INTRODUCTION
MATERIALS AND METHODS
Statistical analysis
RESULTS
DISCUSSION