1
|
Bantie B, Gebeyehu NA, Adella GA, Kassie GA, Mengstie MA, Abebe EC, Seid MA, Gesese MM, Tegegne KD, Anley DT, Zemene MA, Dessie AM, Feleke SF, Dejenie TA, Kebede YS, Chanie ES, Kerebeh G, Bayih WA, Moges N. Trends of Body Mass Index changes among adults on antiretroviral therapy in Northwest Ethiopia: a longitudinal data analysis. Sci Rep 2024; 14:5265. [PMID: 38438418 PMCID: PMC10912088 DOI: 10.1038/s41598-024-53701-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 02/03/2024] [Indexed: 03/06/2024] Open
Abstract
Nutritional status is considered a major diagnostic and prognostic indicator of HIV/AIDS in adults. In this aspect, current HIV-treatment guidelines, particularly in low-income countries, recommend the regular monitoring of body mass index (BMI) to determine patients' clinical response to antiretroviral therapy (ART). However, data regarding the change in BMI status of HIV-positive adults on ART following the implementation of the test and treat strategy were limited in Ethiopia. Hence, this study is aimed at investigating the trends of BMI change over time and its associated factors among HIV-positive adults in Northwest Ethiopia. A retrospective longitudinal study was conducted among 404 randomly selected HIV-positive adults receiving ART in Felegehiwot Comprehensive Specialized Hospital (FHCSH), Northern Ethiopia. Data were extracted from the medical record charts of study participants, entered into Epi-data 4.6 software, and exported to Stata 14.2 software for analysis. A generalized estimating equation (GEE) model was fitted to determine the change in BMI status over time and its predictors in HIV-positive adults. The level of significance was declared at a p-value of < 0.05. More than half (201, or 51.73%) of the total 404 participants were female. In the cohort, both the baseline and follow-up mean body mass index levels of the participants fell in the normal range and increased from 20.34 (standard deviation/SD ± 2.8) to 21.41 (SD ± 3.13). The individual profile plots of 50 participants indicated that there is considerable variability in weight change across individuals. Duration of ART follow-up (β = 0.203, 95% confidence interval (CI) 0.16 to 0.24), unemployment (β = - 0.96, 95% CI 1.67 to - 0.25), WHO stage III/IV HIV disease (β = - 0.92, 95% CI - 1.57 to - 0.35),and Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG)ART regimen (β = 0.95, 95% CI 0.32 to 1.57) were identified as significant predictors of change in the BMI status of participants. Likewise, the interaction of TDF/3TC/DTG ART regimen * follow-up duration (β = 2.16, 95% CI 1.84 to 2.84), WHO stage III/IV clinical disease * follow-up duration (β = - 1.43, 95% CI - 1.71 to - 1.15) and TB/HIV co-infection * follow-up duration (β = 1.89, 95% CI 1.57 to 2.87) significantly affects the trend in BMI change status of HIV-positive adults. In this study, the BMI status of HIV-positive adults receiving ART increased with a linear trend. Unemployment, stage III/IV HIV diseases, and Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) ART-drug regimen decreases the mean BMI status of HIV-positive adults. Special consideration and strict follow-up need to be given to those individuals with advanced HIV/AIDS diseases and other identified risk group.
Collapse
Affiliation(s)
- Berihun Bantie
- Department of Comprehensive Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia.
| | - Natnael Atnafu Gebeyehu
- Department of Midwifery, College of Medicine and Health Science, Wolaita Sodo University, Wolaita, Ethiopia
| | - Getachew Asmare Adella
- Department of Reproductive Health and Nutrition, School of Public Health, Woliata Sodo University, Sodo, Ethiopia
| | - Gizachew Ambaw Kassie
- Department of Epidemiology and Biostatistics, School of Public Health, Woliata Sodo University, Sodo, Ethiopia
| | - Misganaw Asmamaw Mengstie
- Department of Biochemistry, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Endeshaw Chekol Abebe
- Department of Biochemistry, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mohammed Abdu Seid
- Unit of Physiology, Department of Biomedical Science, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Molalegn Mesele Gesese
- Department of Midwifery, College of Medicine and Health Science, Wolaita Sodo University, Wolaita, Ethiopia
| | - Kirubel Dagnaw Tegegne
- Department of Nursing, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Denekew Tenaw Anley
- Department of Public Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Melkamu Aderajew Zemene
- Department of Public Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Anteneh Mengist Dessie
- Department of Public Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Sefineh Fenta Feleke
- Department of Public Health, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Tadesse Asmamaw Dejenie
- Department of Medical Biochemistry, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yenealem Solomon Kebede
- Department of Medical Laboratory Science, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Ermias Sisay Chanie
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Gashaw Kerebeh
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Wubet Alebachew Bayih
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Natnael Moges
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| |
Collapse
|
2
|
Jumare J, Dakum P, Sam-Agudu N, Memiah P, Nowak R, Bada F, Oguama U, Odonye G, Adebiyi R, Cairo C, Kwaghe V, Adebamowo C, Abimiku A, Charurat M. Prevalence and characteristics of metabolic syndrome and its components among adults living with and without HIV in Nigeria: a single-center study. BMC Endocr Disord 2023; 23:160. [PMID: 37507703 PMCID: PMC10375691 DOI: 10.1186/s12902-023-01419-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Persons living with HIV (PLHIV) now live longer due to effective combination antiretroviral therapy. However, emerging evidence indicates that they may be at increased risk for some cardiometabolic disorders. We compared the prevalence of metabolic syndrome (MetS) and its component disorders between persons living with and without HIV in Nigeria. METHODS This was a cross-sectional analysis of baseline data from a prospective cohort study of non-communicable diseases among PLHIV along with age- and sex-matched persons without HIV (PWoH) at the University of Abuja Teaching Hospital Nigeria. We collected sociodemographic and clinical data, including anthropometric measures and results of relevant laboratory tests. MetS was defined using a modification of the third report of the National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III) criteria. RESULTS Of the 440 PLHIV and 232 PWoH, women constituted 50.5% and 51.3% respectively. The median age of the PLHIV was 45 years while that of the PWoH was 40 years. The prevalence of MetS was 30.7% (95% CI: 26.4%, 35.2%) and 22.8% (95% CI: 17.6%, 28.8%) among the PLHIV and PWoH respectively (P = 0.026). Independent associations were found for older age (P < 0.001), female sex (P < 0.001), family history of diabetes (P < 0.001), family history of hypertension (P = 0.013) and alcohol use (P = 0.015). The prevalence of component disorders for PLHIV versus PWoH were as follows: high blood pressure (22.3% vs 20.3%), prediabetes (33.8% vs 21.1%), diabetes (20.5% vs 8.2%), high triglycerides (24.5% vs 17.2%), low HDL-Cholesterol (51.1% vs 41.4%), and abdominal obesity (38.4% vs 37.1%). Adjusting for age and sex, prediabetes, diabetes, and low HDL-Cholesterol were significantly associated with HIV status. Duration on antiretroviral therapy, protease inhibitor-based regimen, CD4 count, and viral load were associated with some of the disorders mostly in unadjusted analyses. CONCLUSION We found a high burden of MetS and its component disorders, with significantly higher prevalence of dysglycemia and dyslipidemia among PLHIV as compared to PWoH. Integration of strategies for the prevention and management of MetS disorders is needed in HIV treatment settings.
Collapse
Affiliation(s)
- Jibreel Jumare
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
- International Research Center of Excellence, Institute of Human Virology Nigeria, Federal Capital Territory, Abuja, Nigeria.
| | - Patrick Dakum
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
- International Research Center of Excellence, Institute of Human Virology Nigeria, Federal Capital Territory, Abuja, Nigeria
| | - Nadia Sam-Agudu
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
- International Research Center of Excellence, Institute of Human Virology Nigeria, Federal Capital Territory, Abuja, Nigeria
| | - Peter Memiah
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Rebecca Nowak
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Florence Bada
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Uzoamaka Oguama
- International Research Center of Excellence, Institute of Human Virology Nigeria, Federal Capital Territory, Abuja, Nigeria
| | - George Odonye
- International Research Center of Excellence, Institute of Human Virology Nigeria, Federal Capital Territory, Abuja, Nigeria
| | - Ruxton Adebiyi
- International Research Center of Excellence, Institute of Human Virology Nigeria, Federal Capital Territory, Abuja, Nigeria
| | - Cristiana Cairo
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Vivian Kwaghe
- University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Clement Adebamowo
- Department of Epidemiology and Public Health, and Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Alash'le Abimiku
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
- International Research Center of Excellence, Institute of Human Virology Nigeria, Federal Capital Territory, Abuja, Nigeria
| | - Man Charurat
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| |
Collapse
|
3
|
Hyle EP, Martey EB, Bekker LG, Xu A, Parker RA, Walensky RP, Middelkoop K. Diet, physical activity, and obesity among ART-experienced people with HIV in South Africa. AIDS Care 2023; 35:71-77. [PMID: 34913762 PMCID: PMC9200895 DOI: 10.1080/09540121.2021.2012556] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
The prevalence of non-communicable diseases (NCDs) is increasing in South Africa, in part due to poor nutrition, physical inactivity, and obesity. We characterized the habits and understanding of diet, exercise, and obesity among people with HIV (PWH) taking antiretroviral therapy (ART). We conducted a cross-sectional study of ART-experienced PWH attending an HIV community health center near Cape Town, South Africa. We included PWH currently prescribed ART, older than 21y, and not pregnant. We collected demographic and clinical information and interviewed participants regarding their behaviors and knowledge related to diet, physical activity, and obesity. From March 2015 - February 2016, we enrolled 458 participants. Self-reported diets were low in nutritional diversity: 202 reported eating only starch and protein without vegetable/fruit in the prior 24 h. Although most participants (96%) acknowledged that exercise had health benefits, only 215 participants engaged in daily 30-minute walking or exercise. One quarter of participants recognized nocontributors to obesity, and almost 20% identified no health problems associated with obesity. Participants had diets low in nutritional diversity, modest exercise habits, and limited understanding of the impact of obesity on health. Further understanding of barriers to improving diet and exercise and reducing obesity are essential, especially as PWH age.
Collapse
Affiliation(s)
- Emily P. Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Emily B. Martey
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute of Infectious Disease & Molecular Medicine and Department of Medicine Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ai Xu
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Robert A. Parker
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Rochelle P. Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Keren Middelkoop
- Desmond Tutu HIV Centre, Institute of Infectious Disease & Molecular Medicine and Department of Medicine Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
4
|
Abstract
OBJECTIVE Both obesity and HIV infection are characterized by a state of chronic inflammation associated with increased morbidity and mortality. This review aims to assess the available literature on immune dysregulation in obesity and people with HIV infection (PWH). DESIGN A systematic review of peer-reviewed literature. METHODS We conducted a systematic literature search of PubMed, Embase, Scopus, and international conference abstracts for articles on the epidemiology of obesity in the general population and in PWH and the pathogenesis of obesity with a focus on inflammation and immune activation. RESULTS Of the 631 articles selected after title review, 490 met the inclusion criteria and 90 were included in the final selection. The selected studies highlight the increasing prevalence of obesity in PWH and a substantial role for antiretroviral treatment (ART) in its development. Pathogenesis of obesity and its associated inflammation derives from disturbances in adipose tissue (AT) immune function, focused on T-cell and macrophage function, with a switch to pro-inflammatory immune phenotype and resulting increases in pro-inflammatory chemokines, which contribute to the development of metabolic syndrome. Although dysregulation of these pathways is seen in both obesity and HIV, there remains a lack of human studies on AT inflammation in HIV. CONCLUSION Obesity is an emerging comorbidity in PWH, with a substantial overlap in immune dysregulation patterns seen in both conditions. How this immune dysfunction impacts on development of metabolic complications for both obesity and HIV infection, and whether targeting of AT-derived inflammation will improve outcomes in PWH requires further study.
Collapse
|
5
|
Barré T, Sogni P, Zaegel-Faucher O, Wittkop L, Marcellin F, Carrieri P, Gervais A, Levier A, Rosenthal E, Salmon-Céron D, Protopopescu C. Cannabis Use as a Protective Factor Against Overweight in HIV-Hepatitis C Virus Co-Infected People (ANRS CO13 HEPAVIH Cohort). AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2022; 34:272-290. [PMID: 35994579 DOI: 10.1521/aeap.2022.34.4.272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Overweight is increasingly prevalent in people living with HIV (PLWH), and is a high risk factor for metabolic disorders in this population. PLWH co-infected with hepatitis C virus (HCV) have a higher risk of metabolic disorders than their mono-infected counterparts. The putative relationship between cannabis use and body weight found in the general population has never been documented in HIV-HCV co-infected people. We tested whether cannabis use is associated with body mass index (BMI), overweight, and underweight in HCV co-infected PLWH (N = 992). Mixed-effects linear and logistic regression models were used to study the association between cannabis use and the three outcomes over time. After multivariable adjustment, cannabis use was inversely associated with BMI. Cannabis use was associated with a lower and higher risk of overweight and underweight, respectively. Cannabis use should be assessed and taken into account in the clinical management of the HIV-HCV co-infected population.
Collapse
Affiliation(s)
- Tangui Barré
- Aix Marseille University, Inserm, IRD, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale (SESSTIM), and Institut Sciences de la Santé Publique d'Aix-Marseille (ISSPAM), Marseille, France
| | - Philippe Sogni
- Université Paris Descartes, Paris, France, INSERM U1223, Institut Pasteur, Paris, France, and Service d'Hépatologie, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, France
| | - Olivia Zaegel-Faucher
- Clinical Immuno-Hematology Department, Aix-Marseille University, and Sainte-Marguerite University Hospital, Marseille, France
| | - Linda Wittkop
- ISPED, Inserm, Bordeaux Population Health Research Center, Team MORPH3EUS, UMR 1219, CIC-EC 1401, Université de Bordeaux, Bordeaux, France, and Service D'information Médicale, CHU de Bordeaux, Pôle de Santé Publique, Bordeaux, France
| | - Fabienne Marcellin
- Aix Marseille University, Inserm, IRD, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale (SESSTIM), and Institut Sciences de la Santé Publique d'Aix-Marseille (ISSPAM), Marseille, France
| | - Patrizia Carrieri
- Aix Marseille University, Inserm, IRD, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale (SESSTIM), and Institut Sciences de la Santé Publique d'Aix-Marseille (ISSPAM), Marseille, France
| | - Anne Gervais
- Assistance Publique des Hôpitaux de Paris, Hôpital Bichat Claude Bernard, Service des Maladies Infectieuses et Tropicales, Paris, France
| | - Axel Levier
- ANRS I Emerging Infectious Diseases, Department of Clinical Research, Paris, France
| | - Eric Rosenthal
- Aix Marseille University, Inserm, IRD, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale (SESSTIM), and Institut Sciences de la Santé Publique d'Aix-Marseille (ISSPAM), Marseille, France
- ANRS I Emerging Infectious Diseases, Department of Clinical Research, Paris, France
- Université Côte d'Azur, Nice, France
| | - Dominique Salmon-Céron
- Service Maladies Infectieuses et Tropicales, AP-HP, Hôpital Cochin, Paris, France, and Université Paris Descartes, Paris, France
| | - Camelia Protopopescu
- Aix Marseille University, Inserm, IRD, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale (SESSTIM), and Institut Sciences de la Santé Publique d'Aix-Marseille (ISSPAM), Marseille, France
| |
Collapse
|
6
|
Jia D, Zhou J, Xu Y. Effectiveness of Traditional Chinese Health-Promoting Exercise as an Adjunct Therapy for Drug Use Disorders: A Systematic Review and Meta-Analysis. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2022; 28:294-308. [PMID: 35426734 DOI: 10.1089/jicm.2021.0285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective: Meta-analysis was used to quantitatively examine the effectiveness of Traditional Chinese Health-Promoting Exercise (TCE) as an adjuvant therapy for drug use disorders and rehabilitation based on previously published studies. Methods: Potential literature was retrieved by searching eight electronic databases (China National Knowledge Infrastructure [CNKI], Wanfang, Chinese Scientific Journal Database, China Biology Medicine [CBM], PubMed, Embase, Cochrane Library, and EBSCOhost) from January 2000 to May 2021, as well as through manual searches, including email. These literature reports comprised randomized, controlled trial studies and nonrandomized, controlled trial studies assessing the effects of TCE intervention on the physical and psychological (mental) health of drug addicts. The quality and bias risk of each study were assessed using the Cochrane bias risk assessment tool. The RevMan5.3 statistical software was employed to evaluate the methodological quality of the included studies, and sensitivity and subgroup analyses using the Stata16.0 MP software were performed to explore the sources of heterogeneity among the data. This study is registered on PROSPERO (CRD42021254124). Results: Data from 14 studies (1094 individuals with drug abuse) meeting the inclusion criteria were extracted for meta-analysis. Compared to the control group, TCE intervention induced significant improvements in the systolic blood pressure (standardized mean difference [SMD] = -0.42, p < 0.05), diastolic blood pressure (SMD = -0.34, p < 0.05), one-leg stand with eyes closed (SMD = 0.74, p < 0.05), Symptom Check List (SMD = -0.42, p < 0.05), anxiety scale (self-rating anxiety scale/STI) (SMD = -0.49, p < 0.05), and depression scale (self-rating depression scale/Beck Depression Inventory/Hamilton Depression Rating Scale for Depression) (SMD = -0.37, p < 0.05). Sensitivity and subgroup analyses of the individual outcome indicators with high heterogeneity (I2 ≥ 50%, p < 0.10) were performed to further explore the source of heterogeneity. The results of the sensitivity analysis showed that, after removing studies one by one, the heterogeneity of the data remained high (I2 > 50), and the difference of synthetic overall effect did not change (p < 0.05), indicating that the sensitivity was low and that the results were robust and reliable. The results of the subgroup analysis results indicated that the gender of the participants and the drug type were the sources of heterogeneity. Conclusion: As an effective mind-body movement intervention, long-term TCE is beneficial to improving the physical and mental health of drug addicts. The specific intervention methods are dependent on the gender of the addict and the drug type, and longer intervention times yielded greater impacts on their physical health.
Collapse
Affiliation(s)
- Dongming Jia
- School of Public Health, Hangzhou Normal University, Hangzhou, China
- Zhejiang Police Vocational College, Hangzhou, China
| | - Jiaxin Zhou
- School of Physical Education, Hangzhou Normal University, Hangzhou, China
- The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Yuming Xu
- School of Physical Education, Hangzhou Normal University, Hangzhou, China
- The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| |
Collapse
|
7
|
The Nutritional Status of Adult Antiretroviral Therapy Recipients with a Recent HIV Diagnosis; A Cross-Sectional Study in Primary Health Facilities in Gauteng, South Africa. Healthcare (Basel) 2020; 8:healthcare8030290. [PMID: 32846888 PMCID: PMC7551417 DOI: 10.3390/healthcare8030290] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/10/2020] [Accepted: 08/15/2020] [Indexed: 01/08/2023] Open
Abstract
The study determined the nutritional status of adult antiretroviral therapy (ART) recipients, and investigated the association between the duration on ART and the nutritional status. This study was based in primary health facilities in Gauteng, South Africa. The data collected included sociodemographic variables; the duration of the treatment; and the body mass index (BMI), classified as undernutrition (<18.5 kg/m2), normal (18.5–24.9 kg/m2), or overweight/obesity (≥25 kg/m2). ART recipients (n = 480) had a mean age of 35 (± 8.4SD) years. All had taken ART for six months or more (range 6–48 months). The data were analyzed using STATA 13.0. The overall prevalence of overweight/obesity was 39%, it was higher in females (46%) than in males (30%), 26% were overweight, and 13% were obese. Underweight was 13%, and was higher in males (18%) than females (9%). Being overweight was more likely in those aged ≥35 years and those in smaller households. Being obese was less likely in males, in the employed, and in those with a higher income, but was more likely in those with a longer duration on ART. Abdominal obesity was high, but less likely in males. Interventions to prevent overweight/obesity should be integrated into routine HIV care, while at the same time addressing the burden of undernutrition among ART recipients.
Collapse
|
8
|
Savinelli S, De Francesco D, Feeney ER, Babalis D, Bagkeris E, Post FA, Boffito M, Williams I, Vera J, Johnson M, Anderson J, Sachikonye M, Winston A, Sabin C, Mallon P. Factors associated with obesity in the Pharmacokinetic and Clinical Observations in People over Fifty (POPPY) cohort: an observational cross-sectional analysis. HIV Med 2020; 21:441-452. [PMID: 32311831 DOI: 10.1111/hiv.12857] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/09/2019] [Accepted: 03/11/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aims of the study were to describe the prevalence of obesity in the Pharmacokinetic and Clinical Observations in People over Fifty (POPPY) cohort, to identify demographic, clinical and HIV-specific factors associated with obesity, and to characterize the association between obesity and sociodemographic, clinical and HIV-specific factors and quality of life (QoL). METHODS A cross-sectional analysis was carried out of baseline data from the three groups ["older" people with HIV infection (PWH) aged ≥ 50 years, "younger" PWH aged < 50 years and HIV-negative controls aged ≥ 50 years] within the POPPY cohort. Obesity was defined as a body mass index (BMI) > 30 kg/m2 . RESULTS A total of 1361 subjects were included in the study, of whom 335 (24.6%) were obese. The prevalence of obesity was higher in controls (22.3%) than in older (16.8%) and younger (14.2%) PWH, with no differences between the two groups of PWH. Factors associated with obesity were older age, female gender, black African ethnicity and alcohol consumption. Recreational drug use and a higher current CD4 T-cell count (in PWH) were associated with lower and higher odds of being obese, respectively. The presence of obesity was associated with worse physical health QoL scores, higher odds of having cardiovascular disease, type 2 diabetes and hypertension, but lower odds of having osteopenia/osteoporosis, irrespective of HIV status. CONCLUSIONS Despite a lower prevalence of obesity in PWH, specific subgroups (women, people of black African origin and older people) were more likely to be obese, and negative health consequences of obesity were evident, regardless of HIV status. Whether targeted preventive strategies can reduce the burden of obesity and its complications in PWH remains to be determined.
Collapse
Affiliation(s)
- S Savinelli
- Centre for Experimental Pathogen Host Research (CEPHR), University College Dublin, Dublin, Ireland
| | | | - E R Feeney
- Centre for Experimental Pathogen Host Research (CEPHR), University College Dublin, Dublin, Ireland
| | - D Babalis
- Imperial Clinical Trial Unit (ICTU), Imperial College London, London, UK
| | | | - F A Post
- King's College Hospital NHS Foundation Trust, London, UK
| | - M Boffito
- Chelsea and Westminster Hospital, Imperial College London, London, UK
| | | | - J Vera
- Brighton and Sussex Medical School, Brighton, UK
| | | | - J Anderson
- Homerton University Hospital, London, UK
| | - M Sachikonye
- UK Community Advisory Board (UK-CAB), London, UK
| | | | - C Sabin
- University College London, London, UK
| | - Pwg Mallon
- Centre for Experimental Pathogen Host Research (CEPHR), University College Dublin, Dublin, Ireland
| |
Collapse
|
9
|
Growth curve modelling to determine distinct BMI trajectory groups in HIV-positive adults on antiretroviral therapy in South Africa. AIDS 2019; 33:2049-2059. [PMID: 31577571 DOI: 10.1097/qad.0000000000002302] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Obesity is a major long-term concern in HIV-positive patients due to the pathogenic link between obesity and noncommunicable chronic diseases (NCDs). We aim to characterize changes in BMI over time on antiretroviral therapy (ART) and investigate the association between weight gain and survival in South Africa. DESIGN AND METHODS A prospective cohort study among HIV-positive adults on first-line ART between April 2004 and 2015 in Johannesburg, South Africa. We used latent-class growth modelling (adjusted for age, sex and CD4 cell count) to identify groups of individuals with similar patterns of change in BMI over time. RESULTS Eleven thousand, two hundred and sixty-three patients were included. The best fit model involved two linear and two quadratic trajectories. Thirty-five percent of patients were categorized into group one (mean BMI at ART initiation, 20.4 kg/m; mean BMI after 8 years of follow-up, 20.9 kg/m), 38% into group two (24.5-26.2 kg/m), 21% into group three (29.5-32.6 kg/m) and 6% into group four (36.5-40.0 kg/m). Over the 8 years of follow-up, 6% of our cohort went down in BMI standard category, while 45% went up. The largest increase occurred in the first 12 months on ART. In years 2 through 8, we saw a more gradual increase in BMI. CONCLUSION The largest gain in BMI in HIV patients occurred in the first year on ART. During follow-up, over 50% of our population changed BMI categories putting them at an increased risk for NCDs. Consistent counselling on nutritional and lifestyle changes could help improve ART patients' long-term health outcomes.
Collapse
|
10
|
Baraki AG, Gezie LD, Zeleke EG, Awoke T, Tsegaye AT. Body mass index variation over time and associated factors among HIV-positive adults on second-line ART in north-west Ethiopia: a retrospective follow-up study. BMJ Open 2019; 9:e033393. [PMID: 31551394 PMCID: PMC6773344 DOI: 10.1136/bmjopen-2019-033393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES This study aimed to assess the evolution of body mass index (BMI) of HIV-positive adults on second-line antiretroviral therapy (ART) over time and factors affecting it in north-west Ethiopia. DESIGN An institution-based retrospective follow-up study was conducted using data extracted from 1016 patient cards from February 2008 to February 2016. SETTING Eight referral hospitals from Amhara region, Ethiopia were included. PARTICIPANTS HIV patients who started second-line ART. OUTCOME MEASURES Change in BMI since starting second-line ART. RESULTS Five hundred and thirty-eight (52.95%) participants were males and the median age of the participants was 33 years (IQR: 28; 39). The median follow-up time was 18 months (IQR: 5.2; 32.2). The average change of BMI showed linear increase over time. The amount of BMI increment or decrement according to each variable was shown as β coefficients. Treatment duration (β=0.013, 95% CI 0.004 to 0.022), isoniazid prophylaxis (β=0.87, 95% CI 0.32 to 1.42), cotrimoxazole prophylaxis (β=0.63, 95% CI 0.08 to 1.19), ambulatory functional status (β=-1.16, 95% CI -1.95 to 1.31), bedridden functional status (β=-1.83, 95% CI -2.47 to 1.21), WHO stage III (β=-0.42, 95% CI -0.65 to 0.20), WHO stage IV (β=-0.62, 95% CI -1.02 to 0.22), CD4 count (β=0.001, 95% CI 0.0008 to 0.0015), and time interaction of variables like tertiary educational status (β=0.02, 95% CI 0.01 to 0.04), ambulatory functional status (β=0.03, 95% CI 0.01 to 0.05) and WHO stages III (β=0.01, 95% CI 0.007 to 0.02) were found to be significant predictors. CONCLUSION The BMI of patients has shown linear increment over the treatment time. Factors affecting it have been identified but its effect on cardiovascular disease needs further study.
Collapse
Affiliation(s)
- Adhanom Gebreegziabher Baraki
- Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Lemma Derseh Gezie
- Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Ejigu Gebeye Zeleke
- Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tadesse Awoke
- Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Adino Tesfahun Tsegaye
- Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| |
Collapse
|
11
|
Mosepele M, Botsile E. Role of Noncommunicable Diseases (NCDs) in Resource-Limited Settings (RLS). Curr HIV/AIDS Rep 2019; 15:120-126. [PMID: 29435953 DOI: 10.1007/s11904-018-0381-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW As access to effective antiretroviral therapy (ART) expands globally, a decline in AIDS-related morbidity and mortality has been complicated by rising rates of noncommunicable diseases (NCDs). This review provides a brief description of NCDs and existing gaps on knowledge about NCDs among HIV-infected adults mostly in Africa. RECENT FINDINGS Recent reports show that one in every five persons living with HIV has a chronic illness, predominantly diabetes and/or hypertension, depression, and most of these conditions are either not diagnosed or not being managed. Human papilloma virus-associated anal dysplasia occurs among 70% of HIV-infected women in RLS. Recognizing risk factors for NCDs and providing effective screening and optimal care remains challenging. Research is urgently needed to carefully characterize HIV-associated NCDs in RLS. Such studies should provide a framework for high-priority NCDs that the limited resources can be focused on in these settings.
Collapse
Affiliation(s)
- Mosepele Mosepele
- Department of Internal Medicine, Office F4069 Faculty of Medicine, University of Botswana, Gaborone, Botswana.
| | - Elizabeth Botsile
- Department of Internal Medicine, Office F4069 Faculty of Medicine, University of Botswana, Gaborone, Botswana
| |
Collapse
|
12
|
Pengpid S, Huis in ‘t Veld D, Peltzer K. Effects of tobacco use on non-adherence to antiretroviral therapy among HIV-positive patients in South Africa. JOURNAL OF PSYCHOLOGY IN AFRICA 2019. [DOI: 10.1080/14330237.2019.1616421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Supa Pengpid
- ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom, Thailand; Office of the Deputy Vice Chancellor, Research and Innovation, North West University, Potchestroom, South Africa
| | - Diana Huis in ‘t Veld
- Department of Internal Medicine and Infectious Diseases, UZ Ghent, Gent, Belgium; Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium; FWO Research Foundation Flanders, Brussels, Belgium
| | - Karl Peltzer
- Department for Management of Science and Technology Development, Ton Duc Thang University, Ho Chi Minh City, Vietnam; Faculty of Pharmacy, Ton Duc Thang University, Ho Chi Minh City, Vietnam
| |
Collapse
|
13
|
Todowede OO, Mianda SZ, Sartorius B. Prevalence of metabolic syndrome among HIV-positive and HIV-negative populations in sub-Saharan Africa-a systematic review and meta-analysis. Syst Rev 2019; 8:4. [PMID: 30606249 PMCID: PMC6317235 DOI: 10.1186/s13643-018-0927-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 12/19/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Metabolic syndrome (MetS) is a constellation of conditions that increase the risk of cardiovascular diseases. It is an emerging concern in sub-Saharan African (SSA) countries, particularly because of an increasingly aging population and lifestyle changes. There is an increased risk of MetS and its components among people living with Human immune deficiency syndrome (HIV) individuals; however, the prevalence of metabolic syndrome in the SSA population and its differential contribution by HIV status is not yet established. This systematic review and meta-analysis were conducted to estimate the pooled prevalence of metabolic syndrome in people living with HIV and uninfected populations, its variation by sub-components. METHODS We performed a comprehensive search on major databases-MEDLINE (PubMed), EBSCOhost, and Cochrane Database of Systematic Reviews and Web of sciences for original epidemiological research articles that compared proportions of the MetS and its subcomponents between people living with HIV and uninfected patients and published between January 1990-December 2017. The inclusion criteria were adults aged ≥ 18 years, with confirmed HIV status. We assessed the risk of bias using a prevalence studies tool, and random effect meta-analyses were used to compute the pooled overall prevalence. RESULTS A total of four cross-sectional studies comprising 496 HIV uninfected and 731 infected participants were included in the meta-analysis. The overall prevalence of MetS among people living with HIV was 21.5% (95% CI 15.09-26.86) versus uninfected 12.0% (95% CI 5.00-21.00%), with substantial heterogeneity. The reported relative risk estimate for MetS among the two groups was twofold (RR 1.83, 95% CI 0.98-3.41), with an estimated predictive interval of 0.15 to 22.43 and P = 0.055 higher for the infected population. Hypertension was the most prevalent MetS sub-components, with diverse proportions of people living with HIV (5.2-50.0%) and uninfected (10.0-59.0%) populations. CONCLUSIONS The high range of MetS prevalence in the HIV-infected population compared to the uninfected population highlights the possible presence of HIV related drivers of MetS. Also, the reported high rate of MetS, irrespective of HIV status, indicates a major metabolic disorder epidemic that requires urgent prevention and management programs in SSA. Similarly, in the era of universal test and treat strategy among people living with HIV cohorts, routine check-up of MetS sub-components is required in HIV management as biomarkers. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016045727.
Collapse
Affiliation(s)
- Olamide O Todowede
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa.
| | - Solange Z Mianda
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa
| | - Benn Sartorius
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa.,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, USA
| |
Collapse
|
14
|
van Heerden A, Barnabas RV, Norris SA, Micklesfield LK, van Rooyen H, Celum C. High prevalence of HIV and non-communicable disease (NCD) risk factors in rural KwaZulu-Natal, South Africa. J Int AIDS Soc 2018; 20. [PMID: 29064168 PMCID: PMC5810314 DOI: 10.1002/jia2.25012] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 09/25/2017] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION South Africa faces epidemics of HIV and non-communicable diseases (NCDs). The aim of this study was to characterize the prevalence of non-communicable disease risk factors and depression, stratified by HIV status, in a community with a high burden of HIV. METHODS We conducted a home-based HIV counselling and testing study in KwaZulu-Natal, South Africa between November 2011 and June 2012. Contiguous households were approached and all adults ≥18 years old were offered an HIV test. During follow-up visits in January 2015, screening for HIV, depression, obesity, blood glucose, cholesterol and blood pressure were conducted using point-of-care tests. RESULTS Of the 570 participants located and screened; 69% were female and 33% were HIV-positive. NCD risk factor prevalence was high in this sample; 71% were overweight (body mass index (BMI) 25 to 29.9 kg/m2 ) or obese (BMI≥30 kg/m2 ), 4% had hyperglycaemia (plasma glucose >11.0 mmol/l/200 mg/dl), 33% had hypertension (HTN, >140/90 mmHg), 20% had hyperlipidaemia (low density cholesterol >5.2 mmol/l/193.6 mg/dl) and 12% had major depressive symptoms (nine item Patient Health Questionnaire ≥10). Of the 570 participants, 87% had one or more of HIV, hyperglycaemia, HTN, hyperlipidaemia and/or depression. Over half (56%) had two or more. Older age and female gender were significantly associated with the prevalence of both HIV infection and NCD risk factors. Around 80% of both HIV-positive and negative persons had one of the measured risk factors (i.e. obesity, hyperglycaemia, hyperlipidaemia, HTN), or depression. CONCLUSIONS In a community-based sample of adults in KwaZulu-Natal, South Africa, the prevalence of both HIV infection and NCD risk factors were high. This study is among the first to quantify the substantial burden of NCD risk factors and depression in this non-clinic based population.
Collapse
Affiliation(s)
- Alastair van Heerden
- Human and Social Development (HSD), Human Sciences Research Council, Pietermaritzburg, South Africa.,MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ruanne V Barnabas
- Departments of Global Health and Medicine, University of Washington, Seattle, WA, USA
| | - Shane A Norris
- MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lisa K Micklesfield
- MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Heidi van Rooyen
- Human and Social Development (HSD), Human Sciences Research Council, Pietermaritzburg, South Africa
| | - Connie Celum
- Departments of Global Health and Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
15
|
Samad F, Harris M, Puskas CM, Ye M, Chia J, Chacko S, Bondy GP, Lima VD, Montaner JS, Guillemi SA. Incidence of diabetes mellitus and factors associated with its development in HIV-positive patients over the age of 50. BMJ Open Diabetes Res Care 2017; 5:e000457. [PMID: 29225896 PMCID: PMC5717418 DOI: 10.1136/bmjdrc-2017-000457] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/19/2017] [Accepted: 10/31/2017] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE We sought to determine the incidence and factors associated with development of diabetes mellitus (DM) in older HIV-infected individuals. RESEARCH DESIGN AND METHODS We analyzed data from people living with HIV (PLWH) ≥50 years of age enrolled in a large urban HIV outpatient clinic in Vancouver, British Columbia. Patients were categorized as having DM if they had random blood sugar ≥11.1 mmol/L, fasting blood sugar ≥7 mmol/L, HbA1C ≥6.5%, antidiabetic medication use during the follow-up period, or medical chart review confirming diagnosis of DM. We estimated the probability of developing DM, adjusting for demographic and clinical factors, using a logistic regression model. RESULTS Among 1065 PLWH followed for a median of 13 years (25th and 75th percentile (Q1-Q3): 9-18), the incidence of DM was 1.61/100 person-years follow-up. In the analysis of factors associated with new-onset DM (n=703), 88% were male, 38% had a history of injection drug use, 43% were hepatitis C coinfected, and median body mass index was 24 kg/m2 (Q1-Q3: 21-27). Median age at antiretroviral therapy (ART) initiation was 48 years (Q1-Q3: 43-53) and at DM diagnosis was 55 years (Q1-Q3: 50-61). Patients who started ART in 1997-1999 and had a longer exposure to older ART were at the highest risk of developing DM. CONCLUSIONS Among PLWH aged ≥50 years, the incidence of DM was 1.39 times higher than men in the general Canadian population of similar age. ART initiated in the early years of the epidemic and exposure to older ART appeared to be the main drivers of the development of DM.
Collapse
Affiliation(s)
- Faizal Samad
- AIDS Research Program, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Marianne Harris
- John Ruedy Immunodeficiency Clinic, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Cathy M Puskas
- Clinical Education and Training Program, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Monica Ye
- Epidemiology and Population Health, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Jason Chia
- Epidemiology and Population Health, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Sarah Chacko
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Gregory P Bondy
- Departments of Medicine and Pathology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Viviane D Lima
- Epidemiology and Population Health, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julio Sg Montaner
- John Ruedy Immunodeficiency Clinic, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Silvia A Guillemi
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Clinical Education and Training Program, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| |
Collapse
|