New-onset type 2 diabetes mellitus among patients receiving HIV care at Newlands Clinic, Harare, Zimbabwe: retrospective cohort analysis

Interventions for Type 2 Diabetes reduction among older people living with HIV in Harare

BACKGROUND

Interventions for Type 2 Diabetes reduction among older people aged more than 50 years living with HIV (PLWH) are pertinent as they face excess risks amid a growing population of ageing PLWH.

AIM

To describe interventions for Type 2 Diabetes reduction among older people living with HIV in Harare Urban DistrictSetting: The study was conducted in a low socio-economic setting from five primary health care clinics in Harare urban District.

METHODS

A qualitative multi-method approach was applied using an exploratory descriptive design and an integrative review literature. The exploratory descriptive study collected data from two purposively selected samples; (1) older PLWH and (2) nurses. Whittemore and Knafl's framework was used for the integrative literature review with articles from 2013 to 2023 selected. Data source triangulation was applied using Braun and Clark's content analysis framework. Ethical approval was obtained (14056739_CREC_CHS_2022).

RESULTS

23 older PLWH with mean age, 62 years, 9 nurses with an average of 6 years' experience and 12 articles comprised the three data sources.  Key themes that emerged were that, screening should include; assessment from a younger age; assessment of HIV and ART-specific risks; diagnostic testing of Type 2 diabetes tests at ART initiation and routinely. Health education should provide information on adequate physical activity parameters and increased consumption of fruits and vegetables. Metformin may be considered as a pharmacological intervention where lifestyle interventions fail.

CONCLUSION

The proposed interventions suggest measures to reduce Type 2 Diabetes and mitigate excess risks faced by older PLWH.Contribution: Improved screening, health education and pharmacological interventions for older PLWH in primary health care settings enable Type 2 Diabetes reduction.

The burden of non-communicable diseases among people living with HIV in Sub-Saharan Africa: a systematic review and meta-analysis

Background

Non-communicable diseases (NCDs) are increasing among people living with HIV (PLHIV), especially in Sub-Saharan Africa (SSA). We determined the prevalence of NCDs and NCD risk factors among PLHIV in SSA to inform health policy makers.

Methods

We conducted a systematic review and meta-analysis on the prevalence of NCDs and risk factors among PLHIV in SSA. We comprehensively searched PubMed/MEDLINE, Scopus, and EBSCOhost (CINAHL) electronic databases for sources published from 2010 to July 2023. We applied the random effects meta-analysis model to pool the results using STATA. The systematic review protocol was registered on PROSPERO (registration number: CRD42021258769).

Findings

We included 188 studies from 21 countries in this meta-analysis. Our findings indicate pooled prevalence estimates for hypertension (20.1% [95% CI:17.5-22.7]), depression (30.4% [25.3-35.4]), diabetes (5.4% [4.4-6.4]), cervical cancer (1.5% [0.1-2.9]), chronic respiratory diseases (7.1% [4.0-10.3]), overweight/obesity (32.2% [29.7-34.7]), hypercholesterolemia (21.3% [16.6-26.0]), metabolic syndrome (23.9% [19.5-28.7]), alcohol consumption (21.3% [17.9-24.6]), and smoking (6.4% [5.2-7.7]).

Interpretation

People living with HIV have a high prevalence of NCDs and their risk factors including hypertension, depression, overweight/obesity, hypercholesterolemia, metabolic syndrome and alcohol consumption. We recommend strengthening of health systems to allow for improved integration of NCDs and HIV services in public health facilities in SSA. NCD risk factors such as obesity, hypercholesterolemia, and alcohol consumption can be addressed through health promotion campaigns. There is a need for further research on the burden of NCDs among PLHIV in most of SSA.

Funding

This study did not receive any funding.

BMI as a predictor of high fasting blood glucose among people living with HIV in the Asia-Pacific region

BACKGROUND

Non-Asian body mass index (BMI) classifications are commonly used as a risk factor for high fasting blood glucose (FBG). We investigated the incidence and factors associated with high FBG among people living with HIV in the Asia-Pacific region, using a World Health Organization BMI classification specific to Asian populations.

METHODS

This study included people living with HIV enrolled in a longitudinal cohort study from 2003 to 2019, receiving antiretroviral therapy (ART), and without prior tuberculosis. BMI at ART initiation was categorized using Asian BMI classifications: underweight (<18.5 kg/m2 ), normal (18.5-22.9 kg/m2 ), overweight (23-24.9 kg/m2 ), and obese (≥25 kg/m2 ). High FBG was defined as a single post-ART FBG measurement ≥126 mg/dL. Factors associated with high FBG were analyzed using Cox regression models stratified by site.

RESULTS

A total of 3939 people living with HIV (63% male) were included. In total, 50% had a BMI in the normal weight range, 23% were underweight, 13% were overweight, and 14% were obese. Median age at ART initiation was 34 years (interquartile range 29-41). Overall, 8% had a high FBG, with an incidence rate of 1.14 per 100 person-years. Factors associated with an increased hazard of high FBG included being obese (≥25 kg/m2 ) compared with normal weight (hazard ratio [HR] = 1.79; 95% confidence interval [CI] 1.31-2.44; p < 0.001) and older age compared with those aged ≤30 years (31-40 years: HR = 1.47; 95% CI 1.08-2.01; 41-50 years: HR = 2.03; 95% CI 1.42-2.90; ≥51 years: HR = 3.19; 95% CI 2.17-4.69; p < 0.001).

CONCLUSION

People living with HIV with BMI >25 kg/m2 were at increased risk of high FBG. This indicates that regular assessments should be performed in those with high BMI, irrespective of the classification used.

Prevalence and predictors of glucose metabolism disorders among People Living with HIV on combination antiretroviral therapy

Objective

We investigated prevalence and predictors of glucose metabolism disorders (GMDs) among People Living with HIV (PLWH) on efavirenz- and atazanavir/ritonavir-based combination antiretroviral therapy (cART).

Methods

This cross-sectional study involved adult PLWH on efavirenz- (n = 240) and atazanavir/ritonavir-based (n = 111) cART. The prevalence of GMDs was determined by fasting serum glucose, insulin, and homeostasis model assessment. A logistic regression model was used to determine predictors.

Results

The overall prevalence of GMDs for all regimens was 27.6% (97/351) [95% CI 23.0–32.6%] s, with 31.1% (75/240) [95% CI 25.4–37.5%] for efavirenz-based and 19.8% (22/111) [95% CI 12.9–28.5%)] for atazanavir/ritonavir-based cART group. The prevalence of impaired fasting glycemia was significantly higher (p = 0.026) in the efavirenz- [(15.4%) (37/240); 95%CI (11.1–20.6%)] than atazanavir/ritonavir-based [(7.2%) (8/111), (95%CI (3.2–13.7%)] cART. However, no significant difference was observed in the prevalence of diabetes mellitus and insulin resistance between the two regimens. Age ≥46 years old and specific type of ARV contained in cART, such as TDF, were independent predictors of GMD in both groups. Whereas the male gender and BMI category were predictors of GMDs among EFV-based cART group, AZT- and ABC- containing regimens and triglyceride levels were predictors in the ATV/r-based group.

Conclusions

GMDs were highly prevalent among adults on EFV- than ATV/r-based cARTs. Age ≥46 years and TDF-containing cARTs are common predictors in both regimens. Close monitoring for impaired fasting glucose during long-term EFV-based cART is recommended for early diagnosis of type-2 diabetes and management.

Distinct patterns of fasting plasma glucose and lipid profile levels over time in adults tested positive for HIV on HAART in Shanghai, China, revealed using growth mixture models

Objectives

This study sought to identify potential change patterns and predictors of fasting plasma glucose (FPG) and lipid levels after initiating highly active antiretroviral therapy (HAART).

Methods

A retrospective cohort study was conducted on 1,572 patients tested positive for HIV who initiated HAART between January 2010 and October 2020 in Shanghai, China. The growth mixture models (GMM) were used for capturing subgroups of FPG trajectories as well as triglyceride (TG) and total cholesterol (TC) dual-trajectories. Multinomial logistic regression models identified correlates of given trajectories.

Results

The median follow-up time was 2.0 years (IQR 1.0-4.7). Three FPG trajectory subgroups were identified as FPG low-stable (62.3%), medium-stable (30.5%), and high-increasing (7.2%). Furthermore, three subgroups of TG and TC dual-trajectories were identified as TG and TC high-slight increasing (13.7%), low-rapid increasing (27.6%), and a subgroup of medium-stable TC and slight-decreasing TG (58.7%). Older age, high TG, FPG, BMI, CD4 count of <200 at baseline, and initial use of zidovudine (AZT) and protease inhibitors (PIs) helped to identify the class with increasing glucose or lipid metabolism trajectories.

Conclusion

The change patterns of plasma glucose and lipid in patients tested positive for HIV were heterogeneous and tailored interventions should be considered in specific subgroups.

HIV and cardiovascular disease in sub-Saharan Africa: Demographic and Health Survey data for 4 countries

Background

Investigate the relationship between two common cardiovascular diseases and HIV in adults living in sub-Saharan Africa using population data provided through the Demographic and Health Survey.

Methods

Data for four sub-Saharan countries were used. All adults asked questions regarding diagnosis of HIV, diabetes, and hypertension were included in the sample totaling 5356 in Lesotho, 3294 in Namibia, 9917 in Senegal, and 1051 in South Africa. Logistic models were run for each country separately, with self-reported diabetes as the first outcome and self-reported hypertension as the second outcome and HIV status as the primary independent variable. Models were adjusted for age, gender, rural/urban residence and BMI. Complex survey design allowed weighting to the population.

Results

Prevalence of self-reported diabetes ranged from 3.8% in Namibia to 0.5% in Senegal. Prevalence of self-reported hypertension ranged from 22.9% in Namibia to 0.6% in Senegal. In unadjusted models, individuals with HIV in Lesotho were 2 times more likely to have self-reported diabetes (OR = 2.01, 95% CI 1.08–3.73), however the relationship lost significance after adjustment. Individuals with HIV were less likely to have self-reported diabetes after adjustment in Namibia (OR = 0.29, 95% CI 0.12–0.72) and less likely to have self-reported hypertension after adjustment in Lesotho (OR = 0.63, 95% CI 0.47–0.83). Relationships were not significant for Senegal or South Africa.

Discussion

HIV did not serve as a risk factor for self-reported cardiovascular disease in sub-Saharan Africa during the years included in this study. However, given the growing prevalence of diabetes and hypertension in the region, and the high prevalence of undiagnosed cardiovascular disease, it will be important to continue to track and monitor cardiovascular disease at the population level and in individuals with and without HIV.

Conclusions

The odds of self-reported diabetes in individuals with HIV was high in Lesotho and low in Namibia, while the odds of self-reported hypertension in individuals with HIV was low across all 4 countries included in this study. Programs are needed to target individuals that need to manage multiple diseases at once and should consider increasing access to cardiovascular disease management programs for older adults, individuals with high BMI, women, and those living in urban settings.

Is age and not antiretroviral therapy the strongest risk factor for chronic pain in HIV-infected population?

Background

Chronic pain in HIV-infected patients on effective antiretroviral therapy (ART) limits patients’ normal functioning both somatically and psychologically. The current state of knowledge on the topic is insufficient, with the underlying causes of this pain unexplained. Therefore we analyzed the frequency and factors associated with chronic pain in HIV-infected patients on ART.

Methods

We conducted a prospective, survey study, including consecutive HIV-infected patients under specialist care at the HIV Outpatient Clinic of the Hospital for Infectious Disease in Warsaw between February 2014 and December 2016. During their routine visit all patients who agreed to participate in the study were surveyed using a study questionnaire. For all patients reporting any pain the Brief Pain Inventory (BPI) form and Douleur Neuropathique 4 Questions form (DN4) were completed. Data on history and current ART and laboratory measurements were obtained from electronical database. Chi-squared and Kruskal-Wallis tests were used for group comparison. The potential factors associated with chronic pain were identified via logistic regression models.

Results

In total 196 HIV-infected patients were included in the study, 57 (29,1%) of them reported chronic pain. The reported pain was mostly (75%) limited to a single area of the body. In univariable logistic regression model the odds of chronic pain were significantly higher with increasing age (OR 1.36 [95%CI:1.17–1.58]), time under specialist care (OR 2.25 [95%CI:1.42–35.7]), time on ART (OR2.96 [95%CI:1.60–5.49]), previous ART with zidovudine (OR 2.00[95%CI:1.06–1.55]) and previous treatment with ddI, ddC or d4T (OR4.13 [95%CI:1.92–8.91]). Homosexual route of HIV infection as compared to injecting drug use was decreasing the odds of chronic pain (OR0.33 [95%CI: 014–0.75]). In multivariable analyses, adjusting for all above the only factor associated with chronic pain was age (OR1.28 [95%CI:1.06–1.55]).

Conclusions

The prevalence of chronic pain in the studied population of HIV-infected Polish patients was high. The only risk factor for chronic pain identified was age. With ageing HIV population it is therefore imperative to develop cooperation protocols for specialist HIV treatment clinics, pain treatment clinics, and rehabilitation units.

Prevalence and incidence of pre-diabetes and diabetes mellitus among people living with HIV in Ghana: Evidence from the EVERLAST Study

BACKGROUND

Available data from high-income countries suggest that people living with HIV (PLWH) have a four-fold higher risk of diabetes compared with HIV-negative people. In sub-Saharan Africa, with 80% of the global burden of HIV, there is a relative paucity of data on the burden and determinants of prevalent and incident dysglycaemia.

OBJECTIVES

To assess the prevalence and incidence of pre-diabetes (pre-DM) and overt diabetes mellitus (DM) among PLWH in a Ghanaian tertiary medical centre.

METHODS

We first performed a cross-sectional comparative analytical study involving PLWH on combination antiretroviral therapy (cART) (n = 258), PLWH not on cART (n = 244) and HIV-negative individuals (n = 242). Diabetes, pre-DM and normoglycaemia were defined as haemoglobin A1C (HBA1c) > 6.5%, in the range 5.7-6.4% and < 5.7% respectively. We then prospectively followed up the PLWH for 12 months to assess rates of new-onset DM, and composite of new-onset DM and pre-DM. Multivariate logistic regression models were fitted to identify factors associated with dysglycaemia among PLWH.

RESULTS

The frequencies of DM among PLWH on cART, PLWH not on cART and HIV-negative individuals were 7.4%, 6.6% and 7.4% (P = 0.91), respectively, while pre-DM prevalence rates were 13.2%, 27.9% and 27.3%, respectively (P < 0.0001). Prevalent DM was independently associated with increasing age [adjusted odds ratio (95% confidence interval) (aOR, 95% CI) = 1.82 (1.20-2.77) for each 10-year rise], male sex [aOR = 2.64 (1.20-5.80)] and log(triglyceride/HDL cholesterol) [aOR = 8.54 (2.53-28.83)]. Prevalent pre-DM was independently associated with being on cART [aOR (95% CI) = 0.35 (0.18-0.69)]. There were a total of 12 cases of incident DM over 359.25 person-years, giving 33.4/1000 person-years of follow-up (PYFU) (95% CI: 18.1-56.8/1000), and an rate of incident pre-DM of 212.7/1000 PYFU (95 CI: 164.5-270.9/1000). The two independent factors associated with new-onset DM were having pre-DM at enrolment [aOR = 6.27 (1.89-20.81)] and being established on cART at enrolment [aOR = 12.02 (1.48-97.70)].

CONCLUSIONS

Incidence rates of pre-DM and overt DM among Ghanaian PLWH on cART ranks among the highest in the literature. There is an urgent need for routine screening and a multidisciplinary approach to cardiovascular disease risk reduction among PLWH to reduce morbidity and mortality from the detrimental effects of dysglycaemia.

Body mass index and noninfectious comorbidity in HIV-positive patients commencing antiretroviral therapy in Zimbabwe

OBJECTIVES

The aim of the study was to describe the prevalence of elevated body mass index (BMI) in a cohort of treatment-naïve people living with HIV (PLWH) and to investigate the association of BMI with CD4 count and noninfectious comorbidities including hypertension and renal impairment.

METHODS

A retrospective cohort study of 1598 PLWH at the Newlands Clinic in Harare, Zimbabwe was carried out. Data were extracted from the medical records at baseline and 6 months after initiation of treatment. The univariate association between BMI and CD4 count was assessed and multiple regression models were used to predict factors associated with loss of renal function and change in CD4 count at 6 months.

RESULTS

Overweight and obesity (BMI ≥ 25 kg/m² ) were prevalent in this cohort (34%), as was the presence of hypertension (18%). Higher BMI was associated with a higher CD4 count at baseline and 6 months (B = 0.28 and 0.24, respectively; P < 0.001 for both), adjusted for age and sex. The presence of hypertension independently predicted loss of renal function at 6 months (B = -15.31; P < 0.001), adjusted for BMI, CD4 count and sex. High BMI itself was also independently associated with a decline in renal function (B = -0.41; P = 0.003), adjusted for other significant variables.

CONCLUSIONS

We demonstrate a high prevalence of overweight/obesity and hypertension in an urban cohort of PLWH in Zimbabwe. Higher BMI was associated with a higher CD4 count, both before and 6 months after commencing antiretroviral therapy; it was also associated with loss of renal function in this cohort.

Diabetes prevalence by HbA1c and oral glucose tolerance test among HIV-infected and uninfected Tanzanian adults

BACKGROUND

The burden of diabetes is increasing in sub-Saharan Africa, including among people living with HIV. We assessed the prevalence of diabetes and the roles of HIV, antiretroviral therapy (ART) and traditional risk factors among adults in Tanzania.

METHODS

We analysed diabetes-relevant baseline data from 1,947 adult participants in the CICADA study in Mwanza, Tanzania: 655 HIV-uninfected, 956 HIV-infected ART-naïve, and 336 HIV-infected persons on ART. WHO guidelines for haemoglobin A1c (HbA1c) and oral glucose tolerance test (OGTT) were used to define diabetes and prediabetes. Risk factors were evaluated using multinomial logistic regression analysis. Relative risk ratios (RRR) were generated comparing participants with diabetes and prediabetes against the reference of those with no diabetes.

RESULTS

Mean age was 41 (SD 12) years; 59% were women. The prevalence of diabetes was 13% by HbA1c and 6% by OGTT, with partial overlap among participants identified by the two tests. Relative to HIV-uninfected, HIV-infected ART-naïve persons had increased relative risks of diabetes (HbA1c: RRR = 1.95, 95% CI 1.25-3.03; OGTT: RRR = 1.90, 95% CI 0.96-3.73) and prediabetes (HbA1c: RRR = 2.89, 95% CI 1.93-4.34; OGTT: RRR = 1.61, 95% CI 1.22-2.13). HIV-infected participants on ART showed increased risk of prediabetes (RRR 1.80, 95% CI 1.09, 2.94) by HbA1c, but not diabetes. CD4 count < 200 cell/μL at recruitment increased risk and physical activity decreased risk of diabetes by both HbA1c and OGTT.

CONCLUSIONS

The prevalence of diabetes was high, especially among HIV-infected ART-naïve adults. Being more physically active was associated with lower risk of diabetes. HbA1c and OGTT identified different participants as having diabetes or prediabetes. Overall, the finding of high burden of diabetes among HIV-infected persons suggests that health systems should consider integrating diabetes screening and treatment in HIV clinics to optimize the care of HIV patients and improve their health outcomes.

C - reactive protein and interleukin - 6 levels among human immunodeficiency virus -infected patients with dysglycemia in Tanzania

BACKGROUND

Chronic inflammation has been associated with dysglycemia among people living with HIV (PLHIV). There is however, limited data regarding this phenomenon in sub-Sahara Africa (SSA). Therefore we assessed the levels of C-reactive protein (CRP) and Interleukin 6 (IL-6) on a cohort of PLHIV and its associations with dysglycemia in Tanzania.

METHODS

We conducted a cross-sectional study at the Infectious Disease Clinic (IDC) in Tanzania from March to May 2018. Purposive sampling was used to identify participants who had an undetectable viral load, were on 1st line anti-retroviral therapy (ART) and had an overnight fast. The WHO stepwise approach for non-communicable disease (NCD) surveillance was used to collect data. Fasting blood glucose and blood glucose after 75 g oral glucose load was measured, and Enzyme-linked immunosorbent assay (ELISA) was used to test for inflammatory markers (IL-6 and CRP). Associations were explored using the Chi square test and binary logistic regression was performed to estimate the odds ratios. A p-value less than 0.05 was considered statistically significant.

RESULTS

A total of 240 participants were enrolled. Forty two percent were overweight/obese (> 25 kg/m²), 89% had a high waist to height ratio. The median ART duration was 8(5-10) years. The prevalence of dysglycemia among our cohort of PLHIV was 32%. High CRP was associated with a 2.05 increased odds of having dysglycemia OR 2.05 (1.15-3.65) (p = 0.01). Taking stavudine was associated with a 1.99 odds of having dysglycemia OR 1.99 (1.04-3.82) (p = 0.03).We did not find a significant association between IL-6 and dysglycemia.

CONCLUSION

High CRP and taking stavudine were significantly associated with dysglycemia among PLHIV with undetectable viral load.

Prevalence, Risk Factors, and Pathophysiology of Dysglycemia among People Living with HIV in Sub-Saharan Africa

OBJECTIVE

To review available literature on the prevalence, risk factors, pathophysiology, and clinical outcomes of dysglycemia among people living with HIV (PLHIV) in sub-Saharan Africa (SSA).

METHODS

Database search on PUBMED for eligible studies describing the prevalence, risk factors, pathophysiology, or clinical outcomes of dysglycemia in SSA PLHIV.

RESULTS

Prevalence of diabetes mellitus (DM) and pre-DM among SSA PLHIV ranged from 1% to 26% and 19% to 47%, respectively, in 15 identified studies. Older age and an elevated body mass index (BMI) were common risk factors for dysglycemia. Risk factors potentially more specific to PLHIV in SSA included exposure to older-generation thymidine analogues or protease inhibitors, malnutrition at ART initiation, a failure to gain fat mass on treatment, and elevated serum lipids. There is evidence of higher nephropathy and neuropathy rates among PLHIV in SSA with comorbid DM compared to HIV-negative individuals with DM.

CONCLUSION

There is a need for longitudinal studies to enhance understanding of the risk factors for dysglycemia among PLHIV in SSA, further research into optimal therapies to reduce pre-DM progression to DM among SSA PLHIV, and studies of the burden and phenotype of diabetic complications and other health outcomes among PLHIV with comorbid DM in SSA.