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The Association Between a Detectable HIV Viral Load and Non-Communicable Diseases Comorbidity in HIV Positive Adults on Antiretr

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The Association Between a Detectable HIV Viral Load and Non-Communicable Diseases Comorbidity in HIV Positive Adults on Antiretr George et al. BMC Infectious Diseases (2019) 19:348 https://doi.org/10.1186/s12879-019-3956-9 RESEARCHARTICLE Open Access The association between a detectable HIV viral load and non-communicable diseases comorbidity in HIV positive adults on antiretroviral therapy in Western Cape, South Africa S. George1, N. McGrath2,3,4 and T. Oni5,6* Abstract Background: Past studies have found a relationship between detectable HIV viral load and non-communicable diseases (NCDs) in HIV-infected individuals on antiretroviral therapy in high-income settings, however there is little research in South Africa. Our objective was to investigate the association between detectable HIV viral load and prevalent NCDs in a primary health centre in peri-urban South Africa. Methods: HIV-infected adults (aged ≥25) who had been on antiretroviral therapy for ≥ six months and attended the HIV clinic within a primary health centre in Khayelitsha, Cape Town, were recruited. We recorded participants’ demographics, HIV characteristics, the presence of NCDs via self-report, from clinic folders and from measurement of their blood pressure on the day of interview. We used logistic regression to estimate the association between a detectable HIV viral load and NCD comorbidity. Results: We recruited 330 adults. We found no association between a detectable HIV viral load and NCD comorbidity. Within our multivariable model, female gender (OR3·26; p = 0·02) age > 35 (OR 0·40; p = 0·02) low CD4 count (compared to CD4 < 300 (reference category): CD4:300–449 OR 0·28; CD4:450–599 OR 0·12, CD4:≥600 OR 0·12; p = < 0·001), and ever smoking (OR 3·95; p = < 0·001) were associated with a detectable HIV viral load. We found a lower prevalence of non-communicable disease in clinic folders than was self-reported. Furthermore the prevalence of hypertension measured on the day of interview was greater than that reported on self-report or in the clinic folders. Conclusions: The lack of association between detectable viral load and NCDs in this setting is consistent with previous investigation in South Africa but differs from studies in high-income countries. Lower NCD prevalence in clinic records than self-report and a higher level of hypertension on the day than self-reported or recorded in clinic folders suggest under-diagnosis of NCDs in this population. This potential under-detection of NCDs may differ from a high-income setting and have contributed to our finding of a null association. Our findings also highlight the importance of the integration of HIV and primary care systems to facilitate routine monitoring for non- communicable diseases in HIV-infected patients. Keywords: HIV, Viral load control, Non-communicable disease, South Africa * Correspondence: [email protected] 5Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town 7925, South Africa 6MRC Epidemiology Unit, Institute of Metabolic Science Building, Cambridge Biomedical Campus, University of Cambridge, Cambridge CB2 0QQ, UK Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. George et al. BMC Infectious Diseases (2019) 19:348 Page 2 of 11 Background Methods The rollout of antiretroviral therapy (ART) across The study was conducted in Ubuntu ART clinic, in Sub-Saharan Africa (SSA) has dramatically increased the Khayelitsha, the largest township on the outskirts of life expectancy of those initiated on ART. As this popu- Cape Town, SA with approximately 500,000 predomin- lation ages, they become increasingly susceptible to antly black Africans and over 8000 HIV-infected individ- age-related comorbidity. An “accelerated ageing” syn- uals registered on ART [9, 10]. While Ubuntu clinic is drome has been described where deleterious features as- located in a healthcare delivery complex that provides sociated with ageing emerge decades earlier in outpatient primary care services for NCDs, these facil- HIV-infected individuals [1, 2]. Contributing factors are ities have separate buildings, staff and separate pharma- thought to be HIV itself and the effect of long term cies; and represent non-integrated health systems. As a ART [2, 3]. result, each HIV-infected patient at Ubuntu clinic has a To ensure optimal care for aging HIV-infected individ- clinic folder for ART only and (if diagnosis known) a uals, there is a need to recognize the association be- separate folder for other primary health care services, in- tween comorbidity and HIV. Studies on ART patients cluding NCDs. There was no routine screening for have demonstrated the association between a detectable NCDs in the ART clinic. Any recording of NCDs or at- HIV viral load and a greater risk of developing comor- tempt at screening was entirely based on the clinician’s bidities [4–6]. However, these studies were based in decision at the time of consultation. As a result, there high-income settings where the HIV epidemic is not were no NCD data in many of the HIV clinic folders re- generalised. The rising prevalence of non-communicable gardless of on-going care for NCDs in the primary diseases (NCDs) in SSA, combined with high levels of healthcare clinic. The NCDs routinely managed in the chronic infectious diseases such as HIV is resulting in a primary care outpatient clinic and in routine NCD ad- different pattern of multimorbidity than is seen in herence clubs are diabetes, hypertension, CRD and epi- high-income countries [3]. Low-income groups in South lepsy, in line with Western Cape Department of Health Africa (SA) have seen a dramatic increase in prevalence policy which annually audits these specific conditions of NCDs and have the highest burden of HIV, a chronic [10]. infectious disease resulting in concurrent epidemics [7]. Recruitment was from 13th January 2015 until 14th The new ART initiation guidelines in SA will increase February 2015. During this period, as patients arrived at the numbers of patients on ART [8]. However, little is the clinic, staff transferred their HIV clinic folder to the known about the impact of comorbid chronic diseases clinic reception, where SG would screen the folders of on long-term HIV management and care necessitating the first ten patients for eligibility, and all those eligible further research to better understand the association be- were invited to participate. Once those eligible had par- tween NCD comorbidity and HIV control. In SA, NCD ticipated, the next available ten folders were screened, management is largely in primary care clinics, with treat- this system was continued until the sample size was ment freely available. In the Western Cape province, pri- reached. Eligibility criteria were aged 25 years and older, mary care clinics are organised into disease-specific on ART for at least 6 months and not knowingly preg- clubs, with a focus on four diseases (based on prevalence nant at the time of interview. All participants gave writ- and importance as determined by contribution to dis- ten informed consent and interviews were conducted in ability adjusted life years, and the need for specialist ex- a private clinic room on the same day. During the inter- pertise input in the primary care setting): diabetes, view, data on the patient’s age, sex, current and past hypertension, asthma/chronic obstructive pulmonary smoking habit, self-reported previously diagnosed co- disease, and epilepsy. The province-wide annual chronic morbidities: hypertension, diabetes, chronic respiratory disease audit conducted by the provincial government disease (CRD), and epilepsy were collected through ad- department of health, focuses on these diseases with the ministration of a questionnaire. These NCDs were se- aim of improving management and disease outcomes. lected as a priority due to their high prevalence in this Yet, despite the increasing co-morbidity of NCDs with population. In addition, these conditions represent HIV in SA and an increasing body of research in health system priorities for the Western Cape province, high-income countries on the association between a de- as evidenced by the fact that NCD weekly outpatient tectable HIV load and NCDs, there is little known about clinics and adherence clubs exist for these conditions, the association between HIV and these diseases in low and that the Department of Health annual audit for and middle-income settings [3–6]. The objective of this NCDs focuses on these conditions as a part of primary study was therefore to examine the association between care service provision [4, 6, 10, 11]. The diagnosis of prevalent NCDs of importance in this setting (hyperten- these NCDs is in line with guidelines set out by the sion, diabetes, epilepsy or chronic respiratory disease South African government for primary care [12]. Specif- (CRD)) and a current detectable HIV viral load. ically hypertension was diagnosed based on two elevated George et al. BMC Infectious Diseases (2019) 19:348 Page 3 of 11 2 (> 140/90) blood pressure readings, diabetes diagnosed using χ tests for categorical variables and Wilcoxon rank on the basis of a random blood glucose measurement > sum tests for continuous variables. Logistic regression 11 and fasting blood glucose > 7, CRD was a clinical models were used to examine the association between a diagnosis based on symptoms and risk factors as set out detectable viral load and comorbidity, the number of co- in the primary care guidelines [12], and epilepsy diag- morbidities, and the four comorbidity indicators de- nosed by a physician with specialist expertise based on scribed above.
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