Incidence of non-communicable diseases (NCDs) in HIV patients on ART in a developing country: Case of Zimbabwe's Chitungwiza Central Hospital-A retrospective cohort study (2010-2019)

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.

Cardiovascular disease in Sub-Saharan African prisons: a scoping review

PURPOSE

The dual epidemic of non-communicable diseases (NCDs) and human immuno-deficiency virus (HIV) in Sub-Saharan Africa has increased substantially in recent years, with cardiovascular disease representing a significant contributor to the regional burden of disease. Very little is known about the cardiovascular health of people deprived of their liberty in the region. The purpose of this study was to collate extant literature on the topic.

DESIGN/METHODOLOGY/APPROACH

A scoping review mapped and described what is known about cardiovascular disease in prison populations in Sub-Saharan Africa. A systematic search of empirical literature with no date limitation was conducted in English. Sixteen studies representing six Sub-Saharan African countries (Cameroon, Nigeria, Guinea, Burkina Faso, Ghana and Ethiopia) were charted, categorised and thematically analysed.

FINDINGS

Seven key themes were identified: custodial deaths and autopsy; cardiorespiratory fitness and exercise; cardiovascular disease and elderly people in prison; cardiovascular disease and women in prison; dietary deficiencies; influence of sleep patterns on cardiovascular disease; and other associated risk factors. Most natural deaths at autopsy of custodial deaths were due to cardiovascular disease. Cardiorespiratory fitness was low in prisons, and poor sleep patterns and dietary deficiencies are likely contributors to the burden of cardiovascular disease in prisons. The needs of elderly and female prison populations are ill-considered.

ORIGINALITY/VALUE

To the best of the authors' knowledge, this is the first known attempt to scope extant literature on cardiovascular disease in Sub-Saharan African prisons. A strategic focus on the cardiovascular health of people in prison is warranted. Routine monitoring and expansion of existing prison health-care services and integration of NCD services with infectious disease (HIV and tuberculosis) programmes in prisons are required.

Factors influencing left ventricular diastolic dysfunction on echocardiography of people living with HIV in Kunming, China

BACKGROUND

The widespread use of antiretroviral therapy has prolonged the survival of people living with HIV (PLWH). Among these patients, co-existing cardiovascular diseases, particularly left ventricular diastolic dysfunction (LVDD), are receiving increasing attention.

METHODS

We recruited 386 patients in the PLWH group and 386 sex- and age (± 3 years)-matched individuals in the HIV-negative group, and used logistic regression to determine the risk factors of LVDD.

RESULTS

Compared to the HIV-negative group, PLWH had a significantly higher prevalence of smoking (p < .001), alcohol consumption (p < .001), hypertension (p = .002), diabetes (p = .020), and hyperlipidemia (p < .001) and a lower prevalence of body mass index (BMI) ≥ 24.0 kg/m2 (p < .001). The prevalence of LVDD on echocardiography was significantly higher in PLWH than in the HIV-negative group (25.9% vs 16.1%, p = .001). The multivariate analysis showed that non-youth (OR = 8.666; 95%CI = 4.310-17.459; p < .001), BMI ≥ 24.0 kg/m2 (OR = 1.992; 95% CI = 1.007-3.939; p = .048), hypertension (OR = 1.888; 95% CI = 1.044-3.415; p = .036), hyperlipidemia (OR = 1.911; 95% CI = 1.068-3.418; p = .029), and HIV infection (OR = 2.003; 95%CI = 1.341-2.992; p = .001) were risk factors for LVDD.

CONCLUSION

The rate of echocardiographic abnormalities was higher in PLWH. LVDD was associated with non-youth, BMI ≥ 24.0 kg/m2, hypertension, hyperlipidemia, and living with HIV.

Diabetes mellitus and associated factors among HIV-positive patients at primary health care facilities in Harare, Zimbabwe: a descriptive cross-sectional study

BACKGROUND

Highly active antiretroviral therapy (HAART) has improved the life expectancy of people living with HIV (PLWH) and has increased the risk of chronic non-communicable diseases. Comorbid HIV and diabetes mellitus (DM) significantly increase cardiovascular disease and mortality risk. This study aimed to determine the prevalence of type 2 diabetes mellitus among HIV-positive patients receiving HAART in Zimbabwe and its associated risk factors.

METHODS

This cross-sectional study was conducted at eight primary healthcare facilities in Harare, Zimbabwe, between January 2022 and March 2023. Non-probability convenience sampling was used to recruit adult HIV-positive patients undergoing HAART attending the facilities. Data were captured on clinical history and socio-demographic and behavioral characteristics, and analyzed using descriptive statistics to determine DM prevalence rates. Additionally, bivariate and multivariate logistic regression models were employed to examine factors associated with HIV and DM comorbidities.

RESULTS

A total of 450 participants were included in this study, of which 57.6% (n = 259) were female. The majority were married (73.8%) and older than 35 years (80.2%). Most participants had completed high school (87.6%) and 68.9% were employed either formally or self-employed. The prevalence of diabetes mellitus (DM) was 14.9%. HIV/DM comorbidity was more prevalent in patients who were female, self-employed, and smoked (p < 0.05). Multivariate logistic regression analysis revealed that the factors associated with DM-HIV comorbidity were gender, age, education, marital status, employment status, smoking, physical activities, duration of HAART, and diet. Age, level of education, marital status, and occupation were not associated with HIV-DM comorbidity. Obesity (body mass index > 30 kg/m2), smoking, and alcohol consumption were associated with an increased risk of DM. Regular physical activity is associated with a reduced risk of DM.

CONCLUSION

A substantial burden of DM was found in PLWH. The intersectoral integration approach is advocated, and active screening for DM is recommended. Gender-specific interventions are necessary to target diseases and health behaviors that differ between men and women. These interventions should be customized to the specific diseases and behaviors of each group.

Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial

BACKGROUND

Sub-Saharan Africa is experiencing a dual burden of chronic human immunodeficiency virus and non-communicable diseases. A pragmatic parallel arm cluster randomised trial (INTE-AFRICA) scaled up 'one-stop' integrated care clinics for HIV-infection, diabetes and hypertension at selected facilities in Uganda. These clinics operated integrated health education and concurrent management of HIV, hypertension and diabetes. A process evaluation (PE) aimed to explore the experiences, attitudes and practices of a wide variety of stakeholders during implementation and to develop an understanding of the impact of broader structural and contextual factors on the process of service integration.

METHODS

The PE was conducted in one integrated care clinic, and consisted of 48 in-depth interviews with stakeholders (patients, healthcare providers, policy-makers, international organisation, and clinical researchers); three focus group discussions with community leaders and members (n = 15); and 8 h of clinic-based observation. An inductive analytical approach collected and analysed the data using the Empirical Phenomenological Psychological five-step method. Bronfenbrenner's ecological framework was subsequently used to conceptualise integrated care across multiple contextual levels (macro, meso, micro).

RESULTS

Four main themes emerged; Implementing the integrated care model within healthcare facilities enhances detection of NCDs and comprehensive co-morbid care; Challenges of NCD drug supply chains; HIV stigma reduction over time, and Health education talks as a mechanism for change. Positive aspects of integrated care centred on the avoidance of duplication of care processes; increased capacity for screening, diagnosis and treatment of previously undiagnosed comorbid conditions; and broadening of skills of health workers to manage multiple conditions. Patients were motivated to continue receiving integrated care, despite frequent NCD drug stock-outs; and development of peer initiatives to purchase NCD drugs. Initial concerns about potential disruption of HIV care were overcome, leading to staff motivation to continue delivering integrated care.

CONCLUSIONS

Implementing integrated care has the potential to sustainably reduce duplication of services, improve retention in care and treatment adherence for co/multi-morbid patients, encourage knowledge-sharing between patients and providers, and reduce HIV stigma.

TRIAL REGISTRATION NUMBER

ISRCTN43896688.

Serum E-selectin and endothelial cell-specific Molecule-1 levels among people living with HIV on long term ART in Uganda: a pilot cross-sectional study

BACKGROUND

Prolonged exposure to HIV and anti-retroviral therapy (ART) has been linked with endothelial cell activation which subsequently predisposes people living with HIV (PLWH) to cardiovascular diseases. Serum biomarkers of endothelial cell activation such as E-Selectin and endothelial cell-specific molecule-1 (ESM-1) could aid in early detection of PLWH at a risk of cardiovascular diseases. However, there is a paucity of data on these biomarkers like E-selectin and endothelial cell-specific molecule-1 (ESM-1) among PLWH on long term ART (≥ 10 years) in Uganda. The aim of this study is to determine the serum levels of these biomarkers in this population.

METHODS

This was a cross-sectional study where we randomly sampled 73 stored serum samples of PLWH who were enrolled in the Infectious Diseases Institute (IDI) ART long term (ALT cohort). We measured serum levels of E-selectin and ESM-1 by ELISA. Data was summarized using median and interquartile range. Inferential statistics were performed to determine predictors of elevated levels of E-selectin.

RESULTS

Of the 73 samples analyzed, 38 (52.1%) were from female participants. The mean age was 54 ± 9.0 years. Twenty participants (27.4%) had a history of smoking while 52 (71.2%) had a history of alcohol intake. Twenty-five (34.3%) of the participants were overweight whereas 4 (5.6%) were obese. Fifty-four (74%) had an undetectable viral load (≤ 0 copies/ml) and the mean duration of ART at the time of sampling (2014/2015) was 10.4 ± 0.4 years. While serum levels of ESM-1 were not detectable in any of our samples, the median E-selectin levels was 147.6 μm/L ranging from 8.44 μm/L and 1,979.36 μm/L. Sixty-seven participants (91.8%) had elevated levels of E-selectin (> 39 μm/L). CD4 count > 500 cells/µl compared to lower counts was a predictor of elevated levels of E-Selectin (adjusted Odd Ratio 12.5, 95% CI (1.03 - 149.95, p < 0.05).

CONCLUSIONS

The majority (91.8%) of PLWH on long term ART had elevated levels of E-selectin. Having high CD4 count (> 500 cells/µl) was predictive of elevated levels of E-Selectin. Future work should longitudinally assess the trend of levels of E-selectin and ESM-1 while assessing for cardiovascular diseases endpoint.

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.

Development of Hypertension and Diabetes Mellitus, and Associated Factors, Among Adult HIV Patients in Ethiopia

Background

Medical improvements and increased access to treatment have turned HIV from a highly fatal disease into a treatable and controllable disease. With the improvement in lifespan, HIV patients face increasing morbidity and mortality from chronic comorbidities (hypertension and diabetes mellitus). There is, nevertheless, a paucity of information on the scale of HIV noncommunicable disease comorbidity and its associated factors. This study aimed to investigate the incidence and predictors of chronic comorbidity in HIV patients in a resource-limited setting.

Methods

A prospective cohort study was conducted from 2019 to 2021. We included 520 HIV patients at baseline. Patients without hypertension or diabetes were followed for two years to determine the incidence of developing comorbidities. Nine trained nurses used a pre-tested structured questionnaire to collect data during routine care consultations in three hospitals in southern Ethiopia. To find predictors of these chronic comorbidities, a multivariable logistic regression analysis was used.

Results

After two years, 54 out of 377 participants, or 14%, had chronic comorbidity, which is defined as having diabetes and/or hypertension. Hypertension (12%) and diabetes (4%), respectively, were observed. When compared to those who were not overweight, the risk of developing chronic comorbidity was three times higher in overweight people [AOR = 3.45, 95% CI: (1.04, 11.45), P = 0.045]. Older participants were about 6 times more likely than younger participants to have chronic comorbidity [AOR = 4.93, 95% CI: (1.56, 15.57), P = 0.007]. Those who did not engage in regular physical activity were twice as likely to develop chronic comorbidity [AOR = 2.16, 95% CI: (1.09, 4.29), P = 0.027].

Conclusion

The incidence of chronic comorbidity was high in the study population. Targeted screening for early signs of chronic comorbidity, nutritional counseling, and awareness creation in regular physical activity programs should be integrated into HIV care to prevent and control chronic comorbidity in resource-limited settings.

Associations between HIV status and self-reported hypertension in a high HIV prevalence sub-Saharan African population: a cross-sectional study

OBJECTIVES

This study examined whether HIV status and antiretroviral therapy (ART) exposure were associated with self-reported hypertension in Zimbabwe.

DESIGN

Study data were taken from a cross-sectional, general population survey, which included HIV testing (July 2018-December 2019).

SETTING

The data were collected in Manicaland Province, Zimbabwe.

PARTICIPANTS

9780 people aged 15 years and above were included.

OUTCOME MEASURE

Self-reported hypertension was the outcome measure. This was defined as reporting a previous diagnosis of hypertension by a doctor or nurse. After weighting of survey responses by age and sex using household census data, χ² tests and logistic regression were used to explore whether HIV status and ART exposure were associated with self-reported hypertension.

RESULTS

The weighted prevalence of self-reported hypertension was 13.6% (95% CI 12.9% to 14.2%) and the weighted prevalence of HIV was 11.1% (10.4% to 11.7%). In univariable analyses, there was no evidence of a difference in the weighted prevalence of self-reported hypertension between people living with HIV (PLHIV) and HIV-negative people (14.1%, 11.9% to 16.3% vs 13.3%, 12.6% to 14.0%; p=0.503) or between ART-exposed and ART-naive PLHIV (14.8%, 12.0% to 17.7% vs 12.8%, 9.1% to 16.4%,p=0.388). Adjusting for socio-demographic variables in logistic regression did not alter this finding (ORs:HIV status:0.88, 0.70 to 1.10, p=0.261; ART exposure:0.83, 0.53 to 1.30, p=0.411).

CONCLUSIONS

Approximately one in seven PLHIV self-reported having hypertension, highlighting an important burden of disease. However, no associations were found between HIV status or ART exposure and self-reported hypertension, suggesting that it will be valuable to focus on managing other risk factors for hypertension in this population. These findings should be fully accounted for as Zimbabwe reorients its health system towards non-communicable disease control and management.

The risk of hyperglycemia associated with use of dolutegravir among adults living with HIV in Kampala, Uganda: A case-control study

Emerging evidence suggests a possible association between hyperglycemia and dolutegravir (DTG), a preferred first-line antiretroviral agent in sub-Saharan Africa (SSA). There is need for rigorous studies to validate this association in the face of increasing DTG use and burden of non-communicable diseases among people living with HIV (PLHIV). We conducted a case-control study to assess the risk of hyperglycemia associated with use of DTG among PLHIV attending Mulago ISS Clinic in Kampala. Cases had hyperglycemia while controls had no hyperglycemia as confirmed by fasting plasma glucose and oral glucose tolerance tests. Demographic, laboratory, and clinical data were collected using interviewer-administered questionnaires and medical record abstraction. Analysis compared cases and controls on DTG use prior to diagnosis of hyperglycemia while controlling for potential confounders using multivariable logistic regression. We included 204 cases and 231 controls. In multivariable analysis, patients with prior DTG use had seven times greater odds of subsequent diagnosis of hyperglycemia compared to those who had non-DTG-based regimens (adjusted odds ratio [aOR] 7.01, 95% CI 1.96-25.09). The odds of hyperglycemia also increased with age (56 years and above vs. 18-35, aOR 12.38, 95% CI 3.79-40.50) and hypertension (aOR 5.78, 95% CI 2.53-13.21). Our study demonstrates a strong association between prior DTG exposure and subsequent diagnosis of hyperglycemia. Given the benefits of DTG, wide-scale use, and the growing burden of diabetes mellitus (DM) in SSA, there is need for systematic screening for hyperglycemia and consideration of alternate regimens for those at risk for DM.