Atherosclerotic cardiovascular disease screening and management protocols among adult HIV clinics in Asia.

OBJECTIVES: Integration of HIV and non-communicable disease services improves the quality and efficiency of care in low- and middle-income countries (LMICs). We aimed to describe current practices for the screening and management of atherosclerotic cardiovascular disease (ASCVD) among adult HIV clinics in Asia. METHODS: Sixteen LMIC sites included in the International Epidemiology Databases to Evaluate AIDS - Asia-Pacific network were surveyed. RESULTS: Sites were mostly (81%) based in urban public referral hospitals. Half had protocols to assess tobacco and alcohol use. Protocols for assessing physical inactivity and obesity were in place at 31% and 38% of sites, respectively. Most sites provided educational material on ASCVD risk factors (between 56% and 75% depending on risk factors). A total of 94% reported performing routine screening for hypertension, 100% for hyperlipidaemia and 88% for diabetes. Routine ASCVD risk assessment was reported by 94% of sites. Protocols for the management of hypertension, hyperlipidaemia, diabetes, high ASCVD risk and chronic ischaemic stroke were in place at 50%, 69%, 56%, 19% and 38% of sites, respectively. Blood pressure monitoring was free for patients at 69% of sites; however, most required patients to pay some or all the costs for other ASCVD-related procedures. Medications available in the clinic or within the same facility included angiotensin-converting enzyme inhibitors (81%), statins (94%) and sulphonylureas (94%). CONCLUSION: The consistent availability of clinical screening, diagnostic testing and procedures and the availability of ASCVD medications in the Asian LMIC clinics surveyed are strengths that should be leveraged to improve the implementation of cardiovascular care protocols.

Insulin Resistance is Associated with Higher Plasma Viral Load Among HIV-Positive Adults Receiving Longer-Term (1 Year) Combination Antiretroviral Therapy (ART).

Background: As HIV-positive persons survive longer due to the success of combination antiretroviral therapy (ART) in decreasing mortality, the burden of non-communicable diseases including diabetes mellitus (DM) is anticipated to rise. HIV is characterized by systemic inflammations, markers of which decrease quickly following ART initiation, but typically do not completely normalize. Inflammation may be accompanied by insulin resistance (IR), and both are implicated in the pathogenesis of DM in HIV-positive individuals. Sub-Saharan Africa accounts for almost two-thirds of the global HIV burden but there are few reports of IR, DM and HIV in this region. We assessed the relationship between IR and viral suppression among HIV-positive adults in the Zambian national ART program. Methods: We conducted a cross-sectional survey evaluating HIV-positive adults that had received first line ART (usually TDF/FTC/EFV) for 12 months (± 3 months). Twenty clinics were sampled systematically based on the random starting-point, sampling interval and cumulative population size. Eligible patients had plasma viral load (VL), fasting insulin, and glucose performed. Insulin resistance was determined using Homeostatic model assessment (HOMA). We determined proportions for each outcome using linearized standard error 95% confidence intervals and summary estimates. Viral suppression was defined according to the detection threshold of<20 copies/mL and treatment failure was defined as VL>1,000 copies/mL. Results: Of 473 patients enrolled, 46.8% were male and 53.2% were female. 142 (30%) [95% CI: 0.26-0.34] had IR. Among those with IR, 55 (38.7%) were male whereas 87 (61.3%) were female (p value=0.104). 19% of individuals with IR had treatment failure compared to 5.7% without IR (p value<0.0001). 427 (90.3%) participants had treatment success (VL<1,000 copies/mL), and this was associated with a lower likelihood of IR (odds ratio (OR)=0.26 [0.14, 0.48], p value<0.0001). In addition, a significantly lower proportion of patients with IR were virologically suppressed at one-year compared to individuals without IR, 58% [0.54-0.70] versus 70% [0.65-0.75], respectively (p value=0.042). Conclusion: In Zambian adults on ART for a year, the development of insulin resistance was strongly associated with suboptimal HIV outcomes, specifically non-viral suppression and treatment failure. Further investigations are warranted to determine if this positive association between IR and VL is causally related, and if so in which direction.

Body mass index and the risk of incident noncommunicable diseases after starting antiretroviral therapy.

OBJECTIVES: Obesity and HIV infection are associated with an increased incidence of noninfectious comorbid medical conditions, but the relationship between body mass index (BMI) and the development of noncommunicable diseases (NCDs) among individuals on antiretroviral therapy (ART) has not been well characterized. METHODS: A cohort study of adults initiating ART between 1998 and 2010 at an academic centre with systematic laboratory and clinical data collection, including AIDS and NCD diagnoses, was carried out. The relationship between BMI at ART initiation and the risk of incident cardiovascular, hepatic, renal or oncological NCDs was assessed using Cox proportional hazard models. BMI was fitted using restricted cubic splines and models adjusted for age, sex, race, CD4 count, protease inhibitor use, year of initiation, and prior AIDS-defining illness. RESULTS: Among 1089 patients in the analysis cohort, 54% had normal BMI, 28% were overweight, and 18% were obese. Baseline BMI was associated with developing an incident NCD (P<0.01), but the relationship was nonlinear. Compared with a BMI of 25 kg/m(2) , a BMI of 30 kg/m(2) conferred a lower risk of an incident NCD diagnosis [adjusted hazard ratio (AHR) 0.59; 95% confidence interval (CI) 0.40, 0.87]. This protective effect was attenuated at a BMI of 35 kg/m(2) (AHR 0.78; 95% CI 0.49, 1.23). Results were similar in sensitivity analyses incorporating tobacco, alcohol and illicit drug use, statin and antihypertensive exposure, and virological suppression. CONCLUSIONS: Overweight individuals starting ART have a lower risk of developing NCDs compared with normal BMI individuals, which may reflect a biological effect of adipose tissue or differences in patient or provider behaviours.

Overcoming the perceived barriers to health care access among single mothers in coastal Kenya.

OBJECTIVES: This study assesses the effects of a comprehensive empowerment intervention on barriers to health care access for single mothers in coastal Kenya. METHODS: We surveyed 41 single mothers who completed a pilot empowerment program and 60 single mothers who had not yet initiated the program. Comparisons were made using bivariate tests of association and logistic regression. RESULTS: Women in the pilot program were less likely to report transportation costs (OR = 0.26; 95 % CI [0.11-0.59], p = 0.001) and hospital fees (OR = 0.22 [0.10-0.49], p < 0.001) as barriers. Pilot program mothers were more likely to visit a public hospital for their children (OR = 4.38; [1.58-12.1], p = 0.004) and self (OR = 4.70; [1.54-14.4], p = 0.007) when ill. CONCLUSIONS: Empowerment programs can alleviate perceived barriers to health care among vulnerable populations.

Safety and efficacy of nevirapine- and efavirenz-based antiretroviral treatment in adults treated for TB-HIV co-infection in Botswana.

BACKGROUND: The safety and efficacy of nevirapine (NVP) and efavirenz (EFV) based highly active antiretroviral treatment (ART) with concurrent anti-tuberculosis treatment in sub-Saharan Africa has not been well established. METHODS: We performed a retrospective study comparing human immunodeficiency virus (HIV) infected adults exposed and not exposed to tuberculosis (TB) treatment with similar baseline HIV-1 RNA levels who were started on ART as part of Botswana's ART Programme. ART regimens, HIV-1 RNA, CD4+ cell count, and liver function tests were reviewed for 12 months following ART initiation. RESULTS: Among 155 patients on ART only and 155 exposed to TB treatment, there was no difference in virologic or immunologic response throughout the first year of ART. Furthermore, there remained no differences in virologic or immunologic outcomes when NVP and EFV groups were stratified by TB treatment exposure status. While more hepatotoxic events occurred in the group exposed to TB treatment than in those not exposed (9% vs. 3%, P = 0.05), there was no difference between patients treated with NVP and those treated with EFV. CONCLUSIONS: Patients co-infected with HIV and TB in Botswana can be treated effectively with either NVP- or EFV-based ART and TB treatment. As hepatotoxic events were more common in the group exposed to TB treatment, liver function tests should be monitored closely.