Missed Opportunities to Address Cardiovascular Disease Risk Factors amongst Adults Attending an Urban HIV Clinic in South Africa

Self-reported cardiovascular disease risk factor screening among people living with HIV vs. members of the general population in Botswana: a community-based study

BACKGROUND

Morbidity and mortality due to cardiovascular diseases (CVDs) are high and increasing in low- and middle-income countries. People living with HIV (PLWH) are more likely to experience CVD than members of the general population. Therefore, we aimed to assess whether PLWH were more likely to have previously been screened for cardiovascular disease risk factors (CVDRFs) than people without HIV.

METHODS

A population-based, cross-sectional study was conducted among individuals aged 16 to 68 years across 22 communities in Botswana from February to August 2017 as part of a larger community-based cluster randomized HIV treatment-as-prevention trial. Participants were asked if they had been screened for and counselled on cardiovascular disease risk factors (history of hypertension or blood pressure check, blood glucose and cholesterol measurements, weight check and weight control, tobacco smoking and cessation, alcohol use and physical activity) in the preceding 3 years. HIV testing was offered to those with an unknown HIV status. Multiple logistic regression analysis controlling for age and sex was used to assess the relationship between CVDRF screening and HIV status.

RESULTS

Of the 3981 participants enrolled, 2547 (64%) were female, and 1196 (30%) were PLWH (93% already on antiretroviral therapy [ART]). PLWH were more likely to report previous screening for diabetes (25% vs. 19%, p < 0.001), elevated cholesterol (17% vs. 12%, p < 0.001) and to have had their weight checked (76% vs. 55%, p < 0.001) than HIV-uninfected participants. PLWH were also more likely to have received counselling on salt intake (42% vs. 33%, p < 0.001), smoking cessation (66% vs. 46%, p < 0.001), weight control (38% vs. 29%, p < 0.001), physical activity (46% vs. 34%, p < 0.001) and alcohol consumption (35% vs. 23%, p < 0.001) than their HIV-uninfected counterparts. Overall, PLWH were more likely to have received screening for and/or counselling on CVDRFs (adjusted odds ratio 1.84, 95% CI: 1.46-2.32, p < 0.001).

CONCLUSION

PLWH were almost two times more likely to have been previously screened for CVDRFs than those without HIV, indicating a need for universal scale-up of integrated management and prevention of CVDs in the HIV-uninfected population.

Prevalence of obesity, hypertension and diabetes among people living with HIV in South Africa: a systematic review and meta-analysis

BACKGROUND

HIV has become a manageable chronic condition due to the success and scale-up of antiretroviral therapy (ART). Globally, South Africa has the highest number of people living with HIV (PLHIV) and research evidence indicates that countries with the highest burden of PLHIV have a substantial burden of obesity, hypertension (HPT) and type 2 diabetes (T2D). We sought to summarize the burden of these three common NCDs among PLHIV in South Africa.

METHODS

In this systematic review, multiple databases were searched for articles reporting on the prevalence of obesity, HPT, and T2D among PLHIV in South Africa published since journal inception until March 2022. A meta-analysis was conducted using random-effects models to obtain pooled prevalence estimates of the three NCDs. Heterogeneity was assessed using X2 test on Cochran's Q statistic.

RESULTS

We included 32 studies, with 19, 22 and 18 studies reporting the prevalence of obesity, HPT, and T2D among PLHIV, respectively. The overall prevalence of obesity, HPT, and T2D was 23.2% [95% CI 17.6; 29.9], 25.5% [95% CI 15.6; 38.7], and 6.1% [95% CI 3.8; 9.7] respectively. The prevalence of obesity was significantly higher among women (P = 0.034) compared to men, however the prevalence of HPT and T2D did not differ by sex. The prevalence of each of the three NCDs did not differ significantly between rural, urban, and peri-urban areas. The prevalence of obesity and T2D was higher in studies conducted between 2013 and 2022 compared to studies conducted between 2000 and 2012, while the prevalence of HPT was higher between 2000 and 2012 compared to between 2013 and 2022.

CONCLUSIONS

These findings suggest that South Africa is experiencing a syndemic of NCDs among people PLHIV highlighting the need to increase cost-effective interventions and management strategies that involve integrated HIV and NCD care in the South African setting.

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.

Six-month incidence of hypertension and diabetes among adults with HIV in Tanzania: A prospective cohort study

Data describing the incidence of hypertension and diabetes among people with HIV in sub-Saharan Africa remain sparse. In this study, adults with HIV were enrolled from a public clinic in Moshi, Tanzania (September 2020-March 2021). At enrollment, a survey was administered to collect information on comorbidities and medication use. Each participant's blood pressure and point-of-care glucose were measured. Baseline hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension at enrollment. Baseline diabetes was defined by self-reported diabetes or hyperglycemia (fasting glucose ≥126 mg/dl or random glucose ≥200 mg/dl) at enrollment. At 6-month follow-up, participants' blood pressure and point-of-care glucose were again measured. Incident hypertension was defined by self-report of new hypertension diagnosis or blood pressure ≥140/90 mmHg at follow-up in a participant without baseline hypertension. Incident diabetes was defined as self-report of new diabetes diagnosis or measured hyperglycemia at follow-up in a participant without baseline diabetes. During the study period, 477 participants were enrolled, of whom 310 did not have baseline hypertension and 457 did not have baseline diabetes. At six-month follow-up, 51 participants (95% CI: 38, 67) had new-onset hypertension, corresponding to an incidence of 33 new cases of hypertension per 100 person-years. Participants with incident hypertension at 6-month follow-up were more likely to have a history of alcohol use (90.2% vs. 73.7%, OR = 3.18, 95% CI:1.32-9.62, p = 0.008) and were older (mean age = 46.5 vs. 42.3, p = 0.027). At six-month follow-up, 8 participants (95% CI: 3, 16) had new-onset diabetes, corresponding to an incidence of 3 new cases of diabetes per 100 person-years. In conclusion, the incidence of elevated blood pressure and diabetes among Tanzanians with HIV is higher than what has been reported in high-income settings.

Prevalence and influences of diabetes and prediabetes among adults living with HIV in Africa: a systematic review and meta-analysis

INTRODUCTION

In people living with human immunodeficiency virus (PLHIV), traditional cardiovascular risk factors, exposure to HIV per se and antiretroviral therapy (ART) are assumed to contribute to cardiometabolic diseases. Nevertheless, controversy exists on the relationship of HIV and ART with diabetes. To clarify the relationship between HIV and type 2 diabetes, this review determined, in PLHIV in Africa, diabetes and prediabetes prevalence, and the extent to which their relationship was modified by socio-demographic characteristics, body mass index (BMI), diagnostic definitions used for diabetes and prediabetes, and HIV-related characteristics, including CD4 count, and use and duration of ART.

METHODS

For this systematic review and meta-analysis (PROSPERO registration CRD42021231547), a comprehensive search of major databases (PubMed-MEDLINE, Scopus, Web of Science, Google Scholar and WHO Global Health Library) was conducted. Original research articles published between 2000 and 2021 in English and French were included, irrespective of study design, data collection techniques and diagnostic definitions used. Observational studies comprising at least 30 PLHIV and reporting on diabetes and/or prediabetes prevalence in Africa were included. Study-specific estimates were pooled using random effects models to generate the overall prevalence for each diagnostic definition. Data analyses used R statistical software and "meta" package.

RESULTS

Of the 2614 records initially screened, 366 full-text articles were assessed for eligibility and 61 were selected. In the systematic review, all studies were cross-sectional by design and clinic-based, except for five population-based studies. Across studies included in the meta-analysis, the proportion of men was 16-84%. Mean/median age was 30-62 years. Among 86,412 and 7976 participants, diabetes and prediabetes prevalence rates were 5.1% (95% CI: 4.3-5.9) and 15.1% (9.7-21.5). Self-reported diabetes (3.5%) was lower than when combined with biochemical assessments (6.2%; 7.2%).

DISCUSSION

While not statistically significant, diabetes and prediabetes were higher with greater BMI, in older participants, urban residents and more recent publications. Diabetes and prediabetes were not significantly different by HIV-related factors, including CD4 count and ART.

CONCLUSIONS

Although HIV-related factors did not modify prevalence, the diabetes burden in African PLHIV was considerable with suboptimal detection, and likely influenced by traditional risk factors. Furthermore, high prediabetes prevalence foreshadows substantial increases in future diabetes in African PLHIV.

Factors influencing treatment adherence in hypertension and HIV management in South Africa: A comparative literature review

BACKGROUND

Hypertension (HTN) is the most significant risk factor for cardiovascular disease (CVD) in South Africa (SA), with one in three people over the age of 25 suffering from HTN. Whilst human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) are the leading causes of death in South Africa, CVD is in the top 10 causes of death, demonstrating the importance of detecting and controlling blood pressure early on. This study aimed to review adherence factors to antihypertensive medication and antiretroviral therapy (ART) and evaluate the resulting factors influencing adherence discrepancies within the South African population.

METHODS

A comprehensive literature review was carried out. PubMed, ScienceDirect, Cochrane and Embase were searched for English publications between 2000 and 2021.

RESULTS

A total of 50 articles covering quantitative and qualitative studies were included. Many studies identified poor adherence levels to antihypertensive treatment, reaching a substandard adherence rate of 41.9%, whilst most studies on the HIV-positive population reported good levels of adherence, with adherence rates of more than 90%. Being of the male gender, advanced age, low socioeconomic status and a low level of education were associated with unsatisfactory adherence rates in both groups. Within the HIV group, more participants had better knowledge concerning the extent of their disease and its required treatments.

CONCLUSION

The results present substandard adherence levels to antihypertensives compared with antiretroviral (ARV) adherence, despite the influence of more non-adherence factors in the HIV group. The authors recommend better adherence counselling for patients with HTN during every clinic visit, regular healthcare worker training and the implementation of ART adherence programmes in patients with hypertension.

Financial burdens of HIV and chronic disease on people living with HIV in Côte d'Ivoire: A cross-sectional out-of-pocket expenditure study

BACKGROUND

Although people living with HIV in Côte d'Ivoire receive antiretroviral therapy (ART) at no cost, other out-of-pocket (OOP) spending related to health can still create a barrier to care.

METHODS

A convenience sample of 400 adults living with HIV for at least 1 year in Côte d'Ivoire completed a survey on their health spending for HIV and chronic non-communicable diseases (NCDs). In addition to descriptive statistics, we performed simple linear regression analyses with bootstrapped 95% confidence intervals.

FINDINGS

365 participants (91%) reported OOP spending for HIV care, with a median of $16/year (IQR 5-48). 34% of participants reported direct costs with a median of $2/year (IQR 1-41). No participants reported user fees for HIV services. 87% of participants reported indirect costs, with a median of $17/year (IQR 7-41). 102 participants (26%) reported at least 1 NCD. Of these, 80 (78%) reported OOP spending for NCD care, with a median of $50/year (IQR 6-107). 76 participants (95%) with both HIV and NCDs reported direct costs, and 48% reported paying user fees for NCD services. Participants had missed a median of 2 HIV appointments in the past year (IQR 2-3). Higher OOP costs were not associated with the number of HIV appointments missed. 21% of participants reported spending over 10% of household income on HIV and/or NCD care.

DISCUSSION AND CONCLUSIONS

Despite the availability of free ART, most participants reported OOP spending. OOP costs were much higher for participants with co-morbid NCDs.

Expanding the Vision for Differentiated Service Delivery: A Call for More Inclusive and Truly Patient-Centered Care for People Living With HIV

BACKGROUND

Simplifying antiretroviral therapy for clinically stable people living with HIV (PLHIV) is important but insufficient to meet their health care needs, including prevention and treatment of tuberculosis and noncommunicable diseases, routine primary care, and family planning. Integrating these services into differentiated service delivery (DSD) platforms is a promising avenue to achieve such coverage. We propose a transition from an HIV-focused "DSD 1.0" to a patient-centered "DSD 2.0" that is inclusive of additional chronic care services for PLHIV.

DISCUSSION

The lack of coordination between HIV programs and these critical services puts a burden on both PLHIV and health systems. For individual patients, fractionated services increase cost and time, diminish the actual and perceived quality of care, and increase the risk that they will disengage from health care altogether. The burden on the health system is one of inefficiency and suboptimal outcomes resulting from the parallel systems required to manage multiple vertical programs.

CONCLUSIONS

DSD 2.0 provides an opportunity for the HIV and Universal Health Coverage agendas-which can seem to be at odds-to achieve greater collective impact for patients and health systems by integrating strong vertical HIV, tuberculosis and family planning programs, and relatively weaker noncommunicable disease programs. Increasing coordination of care for PLHIV will increase the likelihood of achieving and sustaining UNAIDS' goals of retention on antiretroviral therapy and viral suppression. Eventually, this shift to DSD 2.0 for PLHIV could evolve to a more person-centered vision of chronic care services that would also serve the general population.

High Prevalence of AH in HIV Patients on ART, in Bahia, Brazil

INTRODUCTION

The prevalence of arterial hypertension (AH) in HIV-patients is highly variable and its association with antiretroviral therapy (ART) is controversial.

OBJECTIVE

To estimate the prevalence of AH and associated factors in HIV-patients on ART.

METHODS

This cross-sectional study was conducted in HIV-patients attended in a referral center in Salvador, Brazil. We evaluated clinical, socio-demographic and anthropometric data. Student's ttests or Mann-Whitney's and Pearson's chi-square tests were used to compare the groups. Values of p <0.05 were considered significant. The variables that presented a value of p <0.20 were included in a logistic regression model.

RESULTS

We evaluated 196 patients (60.7% male) with a mean age of 46.8 ± 11.7 years and a mean body mass index of 24.9 ± 5.3 kg / m2. The median elapsed time since HIV diagnosis and ART use was 11.8 (4.4 - 18.1) and 7.2 (2.7 - 15.3) years, respectively. The prevalence of AH was 41.8%. For individuals > 50 years old, there was a significant association between the increased abdominal circumference and AH and patients ≤ 50 years old presented significant association between AH and overweight, increased abdominal circumference and number of previous ART regimens. After multivariate analysis, age [OR:1.085; 95% CI 1,039 - 1,133], overweight [OR: 4.205; 95% CI 1,841 - 9,606], family history of AH [OR: 2.938; 95% CI 1,253 - 6.885], increased abdominal circumference [OR: 2.774; 95% CI 1.116 - 6.897] and life-time number of ART regimens used [OR: 3.842; 95% CI 1.307 - 11.299] remained associated with AH.

CONCLUSION

AH was highly prevalent and was associated not only with classical risk factors for arterial hypertension, but also with specific ART regimens.

Cost of Integrating Noncommunicable Disease Screening Into Home-Based HIV Testing and Counseling in South Africa

INTRODUCTION

Integrated HIV-noncommunicable disease (NCD) services have the potential to avert death and disability but require data on program costs to assess the impact of integrated services on affordability.

METHODS

We estimated the incremental costs of NCD screening as part of home-based HIV testing and counseling (HTC) and referral to care in KwaZulu-Natal, South Africa. All adults in the households were offered integrated HIV-NCD screening (for HIV, diabetes, hypertension, hypercholesterolemia, obesity, depression, tobacco, and alcohol use), counseling, and linkage to care. We conducted comprehensive program microcosting including ingredient-based and activity-based costing, staff interviews, and time assessment studies. Sensitivity analyses varied cost inputs and screening efficiency.

RESULTS

Integrating all-inclusive NCD screening as part of home-based HTC in a high HIV prevalence setting increased program costs by $3.95 (42%) per person screened (from $9.36 to $13.31 per person). Integrated NCD screening, excluding point-of-care cholesterol testing, increased program costs by $2.24 (24%). Furthermore, NCD screening integrated into HTC services reduced the number of persons tested by 15%-20% per day.

CONCLUSIONS

Integrated HIV-NCD screening has the potential to efficiently use resources compared with stand-alone services. Although all-inclusive NCD screening could increase the incremental cost per person screened for integrated HIV-NCD services over 40%, a less costly lipid assay or targeted screening would result in a modest increase in costs with the potential to avert NCD death and disability. Our analysis highlights the need for implementation science studies to estimate the cost-effectiveness of integrated HIV-NCD screening and linkage per disability-adjusted life year and death averted.

Cardiovascular risk factors among ART-experienced people with HIV in South Africa

INTRODUCTION

People with HIV (PWH) are at increased risk for atherosclerotic cardiovascular disease (CVD). Screening for CVD risk factors is recommended but not routine in South African HIV clinics. We sought to describe the prevalence of CVD risk factors among antiretroviral treatment (ART)-experienced patients in South Africa.

METHODS

We performed a prospective, observational cross-sectional study of PWH (>21 years, excluding pregnant women) on ART in South Africa. We interviewed patients regarding CVD risk factors, and obtained two blood pressure (BP) measurements and random/fasting glucose via a point-of-care glucometer. Standardized chart reviews provided individuals' HIV-specific data. We defined hypertension as: self-reported use of antihypertensives or mean systolic BP (SBP) ≥140 mmHg or diastolic BP (DBP) ≥90 mmHg (Stage 1) or SBP ≥160 mmHg or DBP ≥100 mmHg (Stage 2). We defined diabetes as self-reported use of insulin/oral hypoglycaemics or fasting (random) glucose ≥7.0 (≥11.1) mmol. We obtained risk ratios (RR) for hypertension from a multivariable log-binomial regression model, adjusting for age, sex and diabetes.

RESULTS

From March 2015 to February 2016, 458 participants enrolled with median age 38 years (interquartile range (IQR) 33 to 44 years) and median CD4 466/μL (IQR 317 to 638/μL); 78% were women. Participants were on ART for a median of four years, with 33% on ART ≥6 years. Almost a quarter (106/458) met the study definition for hypertension, of whom 45/106 (42%) were previously diagnosed, 23/45 (51%) were on medication and 4/23 (17%) were controlled. Eight participants had asymptomatic hypertensive urgency (BP≥180/110 mmHg). Of the 458 participants, 26 (6%) met the study definition for diabetes, half of whom (13/26) were already diagnosed; 11/13 (85%) were on treatment, of whom 4/11 (36%) had normal glucose. Age was the only significant predictor of hypertension (RR, 1.04; 95% CI, 1.03 to 1.06, p < 0.0001) in the multivariable model.

CONCLUSIONS

Hypertension and diabetes were prevalent among PWH prescribed ART in South Africa with less than half diagnosed, and still fewer treated and controlled. Hypertension was independently associated with age but not with HIV-specific factors. Screening for and treatment of CVD risk factors could decrease future morbidity and mortality, especially as this population ages.

Doye I, Toure M, Sy MP, Kiviat NB, Sow PS, Gottlieb GS, Hawes SE. Increasing prevalence of hypertension among HIV-positive and negative adults in Senegal, West Africa, 1994-2015

BACKGROUND

Non-communicable diseases, including hypertension (HTN), are increasingly recognized as important causes of morbidity and mortality among people living with HIV (PLHIV) in resource-limited settings. The goals of this study were to determine the prevalence of HTN among PLHIV in Senegal over time and to identify predictors of HTN among HIV-positive versus HIV-negative adults.

METHODS

We conducted a retrospective study using data from individuals enrolled in previous studies in Senegal from 1994-2015. Blood pressure (BP) measurements taken during study visits were used for analysis. HTN was defined as systolic BP≥140 or diastolic BP≥90. We used logistic regression to identify predictors of HTN.

RESULTS

We analyzed data from 2848 adults (1687 HIV-positive, 1161 HIV-negative). Among PLHIV, the prevalence of HTN increased from 11% during 1994-1999 to 22% during 2010-2015. Among HIV-negative individuals, the prevalence of HTN increased from 16% to 32%. Among both groups, the odds of HTN more than doubled from 1994-1999 to 2010-2015 (HIV-positive OR 2·4, 95% CI 1·1-5·0; HIV-negative OR 2·6, 95% CI 1·5-4·6). One quarter of all individuals with HTN had stage 2 HTN. The strongest risk factor for HTN was obesity (HIV-positive OR 3·2, 95% CI 1·7-5·8; p<0·01; HIV-negative OR 7·8, 95% CI 4·5-13·6; p<0·01). Male sex and age ≥50 were also predictive of HTN among both groups. Among HIV-positive subjects, WHO stage 1 or 2 disease was predictive of HTN and among HIV-negative subjects, having no formal education was predictive.

CONCLUSION

Over the past 20 years, the prevalence of HTN has doubled among both HIV-positive and HIV-negative adults in Senegal. Our study indicates that there is an increasing need for the integration of chronic disease management into HIV programs in Senegal. Furthermore, our findings highlight the need for enhanced prevention, recognition, and management of non-communicable diseases, including hypertension and obesity, among both HIV-positive and HIV-negative individuals in Senegal.

Awareness and management of elevated blood pressure among human immunodeficiency virus-infected adults receiving antiretroviral therapy in urban Zambia: a call to action

The prevalence of high blood pressure (HBP) and hypertension (HTN), awareness of the diagnoses, and use of anti-hypertensive drugs were examined among human immunodeficiency virus (HIV)-infected individuals on antiretroviral therapy (ART) in Zambia's capital Lusaka. Within a prospective cohort based at two public sector ART clinics, BP was measured at ART initiation and every 6 months thereafter as a routine clinic procedure. Predictors of HBP (systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg) during one year on ART were analyzed using logistic regression, and the proportion with HTN (2+ episodes of HBP >3 months apart) described. A phone survey was used to understand patient awareness of HBP, use of anti-hypertensive drugs, and history of cardiovascular events (CVE; myocardial infarction or stroke). Among 896 cohort participants, 887 (99.0%) had at least one BP measurement, 98 (10.9%) had HBP, and 57 (6.4%) had HTN. Increasing age (10-year increase in age: adjusted odds ratio [AOR] = 1.50; 95% confidence interval [CI] 1.20-1.93), male sex (AOR = 2.33, 95% CI 1.43-3.80), and overweight/obesity (AOR = 4.07; 95% CI 1.94-8.53) were associated with HBP. Among 66 patients with HBP, 35 (53.0%) reported awareness of the condition, and nine (25.7%) of these reported having had a CVE. Only 14 (21.2%) of those reached reported ever taking an anti-hypertensive drug, and one (1.5%) was currently on treatment. These data suggest that major improvements are needed in the management of HBP among HIV-infected individuals in settings such as Zambia.

Models of integration of HIV and noncommunicable disease care in sub-Saharan Africa: lessons learned and evidence gaps

OBJECTIVE

To describe available models of HIV and noncommunicable disease (NCD) care integration in sub-Saharan Africa (SSA).

DESIGN

Narrative review of published articles describing various models of HIV and NCD care integration in SSA.

RESULTS

We identified five models of care integration across various SSA countries. These were integrated community-based screening for HIV and NCDs in the general population; screening for NCDs and NCD risk factors among HIV patients enrolled in care; integration of HIV and NCD care within clinics; differentiated care for patients with HIV and/or NCDs; and population healthcare for all. We illustrated these models with descriptive case studies highlighting the lessons learned and evidence gaps from the various models.

CONCLUSION

Leveraging existing HIV infrastructure for NCD care is feasible with various approaches possible depending on available program capacity. Process and clinical outcomes for existing models of care integration are not yet described but are urgently required to further advise policy decisions on HIV/NCD care integration.

Integrating cardiovascular disease risk factor screening into HIV services in Swaziland: lessons from an implementation science study

OBJECTIVE

To study the feasibility of cardiovascular disease risk factor (CVDRF) screening at an HIV clinic in Swaziland.

METHODS

A sample of HIV-positive patients at least 40 years on antiretroviral treatment was screened for hypertension, diabetes, hyperlipidemia, and tobacco smoking.

RESULTS

A total of 1826 patients were screened; 684 (39%) had at least one CVDRF. Screening volume varied markedly, and was limited by staffing, space, and supplies.

DISCUSSION

CVDRF screening was feasible and prevalence of risk factors in people living with HIV at least 40 years was high.

Noncommunicable diseases among HIV-infected persons in low-income and middle-income countries: a systematic review and meta-analysis

OBJECTIVE

To appropriately identify and treat noncommunicable diseases (NCDs) among persons living with HIV (PLHIV) in low-and-middle-income countries (LMICs), it is imperative to understand the burden of NCDs among PLHIV in LMICs and the current management of the diseases.

DESIGN

Systematic review and meta-analysis.

METHODS

We examined peer-reviewed literature published between 1 January 2010 and 31 December 2016 to assess currently available evidence regarding HIV and four selected NCDs (cardiovascular disease, cervical cancer, depression, and diabetes) in LMICs with a focus on sub-Saharan Africa. The databases, PubMed/MEDLINE, Cochrane Review, and Scopus, were searched to identify relevant literature. For conditions with adequate data available, pooled estimates for prevalence were generated using random fixed effects models.

RESULTS

Six thousand one hundred and forty-three abstracts were reviewed, 377 had potentially relevant prevalence data and 141 were included in the summary; 57 were selected for quantitative analysis. Pooled estimates for NCD prevalence were hypertension 21.2% (95% CI 16.3-27.1), hypercholesterolemia 22.2% (95% CI 14.7-32.1), elevated low-density lipoprotein 23.2% (95% CI 15.2-33.6), hypertriglyceridemia 27.2% (95% CI 20.7-34.8), low high-density lipoprotein 52.3% (95% CI 35.6-62.8), obesity 7.8% (95% CI 4.3-13.9), and depression 24.4% (95% CI 12.5-42.1). Invasive cervical cancer and diabetes prevalence were 1.3-1.7 and 1.3-18%, respectively. Few NCD-HIV integrated programs with screening and management approaches that are contextually appropriate for resource-limited settings exist.

CONCLUSION

Improved data collection and surveillance of NCDs among PLHIV in LMICs are necessary to inform integrated HIV/NCD care models. Although efforts to integrate care exist, further research is needed to optimize the efficacy of these programs.

A time-motion study of cardiovascular disease risk factor screening integrated into HIV clinic visits in Swaziland

INTRODUCTION

Screening of modifiable cardiovascular disease (CVD) risk factors is recommended but not routinely provided for HIV-infected patients, especially in low-resource settings. Potential concerns include limited staff time and low patient acceptability, but little empirical data exists. As part of a pilot study of screening in a large urban HIV clinic in Swaziland, we conducted a time-motion study to assess the impact of screening on patient flow and HIV service delivery and exit interviews to assess patient acceptability.

METHODS

A convenience sample of patients ≥40 years of age attending routine HIV clinic visits was screened for hypertension, diabetes, hyperlipidemia and tobacco smoking. We observed HIV visits with and without screening and measured time spent on HIV and CVD risk factor screening activities. We compared screened and unscreened patients on total visit time and time spent receiving HIV services using Wilcoxon rank-sum tests. A separate convenience sample of screened patients participated in exit interviews to assess their satisfaction with screening.

RESULTS

We observed 172 patient visits (122 with CVD risk factor screening and 50 without). Screening increased total visit time from a median (range) of 4 minutes (2 to 11) to 15 minutes (9 to 30) (p < 0.01). Time spent on HIV care was not affected: 4 (2 to 10) versus 4 (2 to 11) (p = 0.57). We recruited 126 patients for exit interviews, all of whom indicated that they would recommend screening to others.

CONCLUSION

Provision of CVD risk factor screening more than tripled the length of routine HIV clinic visits but did not reduce the time spent on HIV services. Programme managers need to take longer visit duration into account in order to effectively integrate CVD risk factor screening and counselling into HIV programmes.

The association between HIV and atherosclerotic cardiovascular disease in sub-Saharan Africa: a systematic review

Background

Sub-Saharan Africa (SSA) has confronted decades of the HIV epidemic with substantial improvements in access to life-saving antiretroviral therapy (ART). Now, with improved survival, people living with HIV (PLWH) are at increased risk for non-communicable diseases (NCDs), including atherosclerotic cardiovascular disease (CVD). We assessed the existing literature regarding the association of CVD outcomes and HIV in SSA.

Methods

We used the PRISMA guidelines to perform a systematic review of the published literature regarding the association of CVD and HIV in SSA with a focus on CVD surrogate and clinical outcomes in PLWH.

Results

From January 2000 until March 2017, 31 articles were published regarding CVD outcomes among PLWH in SSA. Data from surrogate CVD outcomes (n = 13) suggest an increased risk of CVD events among PLWH in SSA. Although acute coronary syndrome is reported infrequently in SSA among PLWH, limited data from five studies suggest extensive thrombus and hypercoagulability as contributing factors. Additional studies suggest an increased risk of stroke among PLWH (n = 13); however, most data are from immunosuppressed ART-naïve PLWH and thus are potentially confounded by the possibility of central nervous system infections.

Conclusions

Given ongoing gaps in our current understanding of CVD and other NCDs in PLWH in SSA, it is imperative to ascertain the burden of CVD outcomes, and to examine strategies for intervention and best practices to enhance the health of this vulnerable population.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4940-1) contains supplementary material, which is available to authorized users.

Cholesterol Screening and Statin Prescription is Low Among HIV-Infected Patients on Protease-Inhibitor Regimens in Botswana

Background:

Little is known about the use of statin for cardiovascular disease (CVD) risk reduction among HIV-infected patients on protease inhibitors (PI`s) in sub-Saharan Africa (SSA).

Objective:

Cholesterol screening and statin use were retrospectively assessed among HIV-infected participants on PI`s between 2008 and 2012 at a large urban HIV clinic in Botswana.

Methods:

Proportion of participants screened per year was calculated and statin indication was assessed using atherosclerosis CVD (ASCVD) and Framingham risk (FRS) scores as of the year 2012 guidelines.

Results:

Cholesterol screening ranged between 19% and 30% per year (2008-2011) but increased to 80% after study enrollment. The rate of hypercholesterolemia (> 5.0 mmol/L) was 31% in 2012. Fewer than 1% participants were on statin therapy but 14.3% and 9.4% had statins indicated by ASCVD and FRS respectively.

Conclusion:

The high proportion of participants indicated for, but not prescribed statins highlights a substantial gap in the care to reduce CVD risk among these patients.

Cardiovascular disease risk among Chinese antiretroviral-naïve adults with advanced HIV disease

BACKGROUND

Cardiovascular disease (CVD) is an important cause of mortality among HIV-infected patients, however little is known about the burden of CVD among this population in Asia. We sought to quantify prevalence of CVD risk factors, 10-year CVD risk, and patterns of CVD risk factor treatment in a group of individuals with HIV in China.

METHODS

We retrospectively analyzed baseline data from treatment-naïve HIV-infected adults enrolled in two multicenter clinical trials in China. Data regarding CVD risk factors such as smoking, hypertension, diabetes, dyslipidemia and obesity were assessed. The Framingham Risk Score (FRS) and Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) risk scores were calculated to estimate 10-year CVD risk. The American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score was used to identify individuals meeting criteria for lipid-lowering therapy.

RESULTS

In total, 973 patients were included in the analysis. Mean age was 36.0 ± 10.2 years and 74.2% were men. The most common CVD risk factors were dyslipidemia (51.7%) and smoking (23.7%). Prevalence of hypertension, diabetes and obesity were 8.4%, 4.6% and 1.0%, respectively. Over 65% of patients had at least one CVD risk factor. The prevalence of 10-year risk of CVD ≥10% was 4.5% based upon FRS and was 3.3% based upon D:A:D risk score. Few patients with dyslipidemia, hypertension or diabetes were on treatment.

CONCLUSIONS

CVD risk factors are common but under-treated among Chinese treatment-naïve individuals with HIV. Future interventions should focus on training HIV providers to appropriately recognize and manage CVD risk factors during routine clinical assessments.

The burden of hypertension, diabetes mellitus, and cardiovascular risk factors among adult Malawians in HIV care: consequences for integrated services

Background

Hypertension and diabetes prevalence is high in Africans. Data from HIV infected populations are limited, especially from Malawi. Integrating care for chronic non-communicable co-morbidities in well-established HIV services may provide benefit for patients by preventing multiple hospital visits but will increase the burden of care for busy HIV clinics.

Methods

Cross-sectional study of adults (≥18 years) at an urban and a rural HIV clinic in Zomba district, Malawi, during 2014. Hypertension and diabetes were diagnosed according to stringent criteria. Proteinuria, non-fasting lipids and cardio/cerebro-vascular disease (CVD) risk scores (Framingham and World Health Organization/International Society for Hypertension) were determined. The association of patient characteristics with diagnoses of hypertension and diabetes was studied using multivariable analyses. We explored the additional burden of care for integrated drug treatment of hypertension and diabetes in HIV clinics. We defined that burden as patients with diabetes and/or stage II and III hypertension, but not with stage I hypertension unless they had proteinuria, previous stroke or high Framingham CVD risk.

Results

Nine hundred fifty-two patients were enrolled, 71.7% female, median age 43.0 years, 95.9% on antiretroviral therapy (ART), median duration 47.7 months. Rural and urban patients’ characteristics differed substantially. Hypertension prevalence was 23.7% (95%-confidence interval 21.1–26.6; rural 21.0% vs. urban 26.5%; p = 0.047), of whom 59.9% had stage I (mild) hypertension. Diabetes prevalence was 4.1% (95%-confidence interval 3.0–5.6) without significant difference between rural and urban settings. Prevalence of proteinuria, elevated total/high-density lipoprotein-cholesterol ratio and high CVD risk score was low. Hypertension diagnosis was associated with increasing age, higher body mass index, presence of proteinuria, being on regimen zidovudine/lamivudine/nevirapine and inversely with World Health Organization clinical stage at ART initiation. Diabetes diagnosis was associated with higher age and being on non-standard first-line or second-line ART regimens.

Conclusion

Among patients in HIV care 26.6% had hypertension and/or diabetes. Close to two-thirds of hypertension diagnoses was stage I and of those few had an indication for antihypertensive pharmacotherapy. According to our criteria, 13.0% of HIV patients in care required drug treatment for hypertension and/or diabetes.