Noncommunicable disease burden among HIV patients in care: a national retrospective longitudinal analysis of HIV-treatment outcomes in Kenya, 2003-2013

Abstract

Background Over the last decade, the Kenyan HIV treatment program has grown exponentially, with improved survival among people living with HIV (PLHIV). In the same period, noncommunicable diseases (NCDs) have become a leading contributor to disease burden. We sought to characterize the burden of four major NCDs (cardiovascular diseases, cancer, chronic respiratory diseases and diabetes mellitus) among adult PLHIV in Kenya. Methods We conducted a nationally representative retrospective medical chart review of HIV-infected adults aged ≥15 years enrolled in HIV care in Kenya from October 1, 2003 through September 30, 2013. We estimated proportions of four NCD categories among PLHIV at enrollment into HIV care, and during subsequent HIV care visits. We compared proportions and assessed distributions of co-morbidities using the Chi-Square test. We calculated NCD incidence rates and their confidence intervals in assessing cofactors for developing NCDs. Results We analyzed 3170 records of HIV-infected patients; 2115 (66.3%) were from women. Slightly over half (51.1%) of patient records were from PLHIVs aged above 35 years. Close to two-thirds (63.9%) of PLHIVs were on ART. Proportion of any documented NCD among PLHIV was 11.5% (95% confidence interval [CI] 9.3, 14.1), with elevated blood pressure as the most common NCD 343 (87.5%) among PLHIV with a diagnosed NCD. Despite this observation, only 17 (4.9%) patients had a corresponding documented diagnosis of hypertension in their medical record. Overall NCD incidence rates for men and women were (42.3 per 1000 person years [95% CI 35.8, 50.1] and 31.6 [95% CI 27.7, 36.1], respectively. Compared to women, the incidence rate ratio for men developing an NCD was 1.3 [95% CI 1.1, 1.7], p = 0.0082). No differences in NCD incidence rates were seen by marital or employment status. At one year of follow up 43.8% of PLHIV not on ART had been diagnosed with an NCD compared to 3.7% of patients on ART; at five years the proportions with a diagnosed NCD were 88.8 and 39.2% ( p < 0.001), respectively. Conclusions PLHIV in Kenya have a high prevalence of NCD diagnoses. In the absence of systematic, effective screening, NCD burden is likely underestimated in this population. Systematic screening and treatment for NCDs using standard guidelines should be integrated into HIV care and treatment programs in sub-Saharan Africa.

Understanding implementation barriers in the national scale-up of Differentiated ART delivery in Uganda

“…There is need for deepening the capacity of suppliers for managing the dramatic increase in demand or the sheer volumes of ART medicines to be dispensed occasioned by DSD implementations such as multimonth scripting [7]. Our findings point to the need for harmonizing appointment spacing in HIV care with the management of other co-morbidities such as diabetes and hypertension [36], [37]. We found that older patients (50 years and above) who had well-controlled sugar levels or blood pressure and were also stable on ART were still required to make monthly clinic visits regardless of the DSD provision of 3-monthly visits.…”

“…We found that older patients (50 years and above) who had well-controlled sugar levels or blood pressure and were also stable on ART were still required to make monthly clinic visits regardless of the DSD provision of 3-monthly visits. This calls for the integrated management of HIV and other comorbidities that is becoming increasingly important priority due to ageing cohorts of clients and the need to revisit treatment guidelines even in non-HIV services [36], [37], [45].…”

Understanding implementation barriers in the national scale-up of differentiated ART delivery in Uganda

“…There is need for deepening the capacity of suppliers for managing the dramatic increase in demand or the sheer volumes of ART medicines to be dispensed occasioned by DSD implementations such as multi-month scripting [7,41]. Our findings point to the need for harmonizing appointment spacing in HIV care with the management of other co-morbidities such as diabetes and hypertension [42,43]. We found that older patients (50 years and above) who had well-controlled sugar levels or blood pressure and were also stable on ART were still required to make monthly clinic visits regardless of the DSD provision of 3-monthly visits.…”

Missed opportunities for NCD multimorbidity prevention in adolescents and youth living with HIV in urban South Africa

“…A study in the United States reported that HIV-infected adults had a 1.5 fold increased risk of having a heart attack [33] and were nearly 50% more likely to have received a diagnosis of chronic obstructive pulmonary disease (COPD) compared to demographically and behaviourally similar uninfected controls [34]. Other NCDs more commonly reported in HIV-infected compared to uninfected persons include cardiovascular events [35], hypertension [36,37], osteoporosis [38], renal impairment [39], diabetes mellitus [40], and depression and neurocognitive disorders [41].…”