|Year : 2021 | Volume
| Issue : 4 | Page : 420-424
Non-AIDS comorbidities among people with HIV at a moroccan referral hospital: Prevalence and factors associated with metabolic complications
Hicham Titou, Mohammed Boui, Naoufal Hjira
Department of Dermatology-Venereology, Mohammed V Military Teaching Hospital, Mohammed V University, Rabat, Morocco
|Date of Submission||29-Aug-2021|
|Date of Acceptance||20-Oct-2021|
|Date of Web Publication||14-Dec-2021|
Department of Dermatology-Venereology, Mohammed V Military Teaching Hospital, Mohammed V University, Rabat
Source of Support: None, Conflict of Interest: None
Background: Among people living with HIV receiving antiretroviral therapy, the prevalence of non-AIDS-related comorbidities is increasing. In Morocco, there are limited dataregarding the profile of non-AIDS comorbidities in this population. The prevalence of non-AIDS comorbidities and the factors associated with metabolic complications among HIV-infected patients are described. Materials and Methods: A cross-sectional study was conducted in 2018 and included 269 HIV-infected patients. A medical officer reviewed records for non-AIDS comorbidities. Univariate and multivariate logistic regression analyses were used to assess the association between metabolic complications and interesting potential variables. Results: A total of 269 individuals were inducted into the study. The mean age was 48.9 ± 10.7 years and 75.5% were men. The median current CD4+ T-cell count was 613 cells ml−1 (IQR: 390–784 cells ml− 1). More than a third of the patients (34.8%) had at least two non-AIDS comorbidities. The most prevalent comorbidities were hyperlipidemia in 56 (20.8%) patients. In multivariate analysis, older age (odds ratio [OR] = 1.04, 95% confidence interval [CI] = 1.02–1.07) and obesity (OR = 4.25, 95% CI = 1.54–8.74) were associated with the presence of metabolic complications. Conclusions: The prevalence of comorbidities is high, particularly in older people. Care models for HIV-positive patients should include clinical monitoring and effective management of these comorbidities and metabolic complications to complete long-term survival.
Keywords: Comorbidities, HIV, metabolic, Morocco
|How to cite this article:|
Titou H, Boui M, Hjira N. Non-AIDS comorbidities among people with HIV at a moroccan referral hospital: Prevalence and factors associated with metabolic complications. Biomed Biotechnol Res J 2021;5:420-4
|How to cite this URL:|
Titou H, Boui M, Hjira N. Non-AIDS comorbidities among people with HIV at a moroccan referral hospital: Prevalence and factors associated with metabolic complications. Biomed Biotechnol Res J [serial online] 2021 [cited 2022 Jan 25];5:420-4. Available from: https://www.bmbtrj.org/text.asp?2021/5/4/420/332457
| Introduction|| |
In 2018, the reported prevalence of HIV-infected patients in the adult Moroccan population was 0.1%. Currently, HIV infection has become a manageable chronic health condition. In many parts of the world, HIV-infected individuals now experience longer life expectancy than previously, but with that, also long-term exposure to antiretroviral therapy (ART) toxicities and chronic inflammation. Therefore, there has been a major change in the causes of morbidity and mortality from AIDS-defining complications (infections and AIDS-related malignancies) to non-AIDS-defining conditions, principally cardiovascular diseases, metabolic syndrome, liver-related complications, and non-AIDS malignancies., Like many non-AIDS conditions, the pathogenesis of increased cardiometabolic risk among PLWH is incompletely understood. It likely implicates “traditional” risk factors, direct effects of HIV infection such as HIV-associated inflammation and immune activation, and effects of ART.
The prevalence of metabolic syndrome has increased in all countries around the globe and, thus, metabolic syndrome is considered a clinical and public health crisis. In developing countries, the prevalence of metabolic syndrome ranges from 8.5% to 52% in PLWH., In the general population, metabolic syndrome results in two times the risk to develop cardiovascular disease and five times the risk to develop diabetes mellitus.
Non-AIDS-related comorbidities are correlated with the physiological aging process, but other risk factors have been linked to the long-term use of ART, a low immune status, the use of injected drugs, male gender, and specific drug regimens.,, In addition, management of the chronic health conditions in this aging population is complicated by polypharmacy/drug–drug interactions and toxicity. This raises new treatment challenges that require management of health services and resources to better address the needs of this population. The aims of this study were to describe the prevalence of non-AIDS comorbidities and the factors associated with metabolic complications among PLWH in Moroccan.
| Materials and Methods|| |
A cross-sectional study of patients infected with HIV Type 1 and followed in the Dermatology–Venereology Department of Mohamed V Military Hospital, between February 1, 2018, and January 31, 2019. This regional referral center ensures care and monitoring of HIV-positive military personnel and their families in Morocco.
In this study, the inclusion criteria were age ≥18 years, the presence of HIV-1-positive serology confirmed by the western blot or polymerase chain reaction, and on ART for at least 6 months. The data were extracted by a single investigator from medical records using a preestablished list of the most common conditions among PLWH. All data were retrieved including sociodemographic characteristics (age, sex), addictive behaviors (smoking, alcohol), clinical characteristics (HIV history, duration of receiving TAR, therapeutic regimens), anthropometric data (weight, height), biological data (CD4 counts, viral load). The “metabolic complications” in the study included diabetes mellitus, impaired fasting glucose, hypertension, and hyperlipidemia. We evaluated the prevalence of multimorbidity as described by the presence of two or more chronic health conditions in addition to HIV.
Descriptive statistics (standard deviation, %) was used to describe patients' baseline characteristics and the prevalence of comorbidities. Univariate and multivariate logistic regressions were conducted to determine the association between metabolic complications and interesting potential variables. Multivariable analyses were performed using the variables with P < 0.05 from the univariable analysis to identify risk factors for metabolic complications. Statistical analysis was conducted using the Statistical Package for Social Sciences (IBM SPSS Statistics for Windows, Version 25.0; IBM Corp., Armonk, New York, USA).
| Results|| |
A total of 269 PLWH were recruited into the study with a predominance of male (75.5%) [Table 1]. The mean age was 48.9 ± 10.7 years and the median duration of receiving ART was 11 years (IQR 6–15 years). More than 20% of patients had ever had an AIDS diagnosis. The median current CD4+ T-cell count was 613 cells ml−1 (IQR 390-784 cells ml–1). Additional patient characteristics are summarized in [Table 1].
|Table 1: Relationship of baseline characteristics to comorbidities characteristic|
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More than a third of the patients (34.8%) had multimorbidity, defined as the co-occurrence of more than one chronic health condition in addition to HIV [Table 2]. In patients younger than 40 years, multimorbidity was present in 15.4%. In patients aged 41–50 years, multimorbidity was present in 25.6%. Multimorbidity increased over the age of 50 years, with 45.8% and 51.6% of patients aged 51–60 years and 61 years and older, respectively, developed multimorbidity.
The most prevalent multimorbidity was the metabolic complications diagnosis 107 (39.8%) including hyperlipidemia in 56 (20.8%) patients, diabetes mellitus in 42 (15.6%) patients, impaired fasting glucose in 15 (5.5%) patients, and hypertension in 7 (2.6%) patients. All patients with metabolic complications, renal disease, and stroke had another chronic health condition in addition to HIV and hence had multimorbidity. The prevalence of each individual comorbidity is presented in [Table 3].
In univariate logistic regression analysis, increasing age, obesity, duration of receiving ART, and indinavir-containing antiretroviral regimen were significantly associated with a metabolic complication [Table 4]. In multivariate analysis, a higher risk of metabolic complications was significantly associated with increasing age and obesity [Table 4].
| Discussion|| |
The present study demonstrates that more than a third of the patients (34.8%) had multimorbidity, defined as the co-occurrence of more than one chronic health condition in addition to HIV. A similar finding has been reported in a retrospective study conducted in Thailand (41%). Several previous studies of PLWH in North America have reported multimorbidity rates between 34.4% and 69.0%.,
Metabolic complications are the most prevalent comorbidities in our study, including hyperlipidemia, diabetes mellitus, impair fasting glucose, and hypertension. We observed more than a quarter of patients had dyslipidemia based on total and HDL cholesterol and triglyceride levels. This is comparable to several studies in Taiwan and South Africa.,, However, the prevalence of diabetes mellitus and hypertension was low compared to the findings of the present study., A previous study in Taiwan reported that 20% of patients present hyperglycemia and 10% of those had diabetes mellitus. In South Africa and Nigeria, cross-sectional studies reported a high prevalence of hypertension but a low prevalence of hyperlipidemia., Differences in lifestyle, ART regimens, economic status, and differences in main transmission routes may be factors that contribute to the discord in results between studies.
In regard to HIV-associated neurocognitive disorder, the prevalence rate varies between 20% and 30%.,, This is in contrast to our finding, which showed a low prevalence. However, our finding is comparable to the results of cross-sectional studies in Australia and Thailand., Several previous studies showed that mental health problems had the highest comorbidity prevalence.,, Underestimation could be an explanation to the discord in results between our findings and those studies.
This study shows that every 10-year increase in age was associated with a 1.0-fold risk of having metabolic complications. In fact, several studies found a significant association between metabolic syndrome and age.,, As age increases, there is a physiological tendency for metabolic syndrome to rise, which may be because of an aggravate in stiffness of the arteries and endothelial atherosclerotic complications.
Results from previous studies found that there was a high burden of metabolic syndrome in patients treated with ART., While insulin resistance, lipodystrophy, obesity, and higher cholesterol levels have been reported among patients on ART, studies reported that untreated PLWH have low HDL and hypertriglyceridemia. First-generation protease inhibitors have been implicated in the development of insulin resistance, cardiovascular disease, and dyslipidemia., Surprisingly, no correlation was found between using protease inhibitors and metabolic complications in our study. This result could be explained by the low number of patients in the present study who were treated by protease inhibitors.
In contrast to our study, several studies found a high prevalence of obesity among PLWH on ART.,, Previous studies reported an increased risk of metabolic syndrome with body mass index.,, Growth in overweight/obesity in the general population is being mirrored in the HIV-infected population, at least in part because of restored health. Although pathophysiological mechanisms and complications of obesity in PLWH are not completely understood, it is known that these body composition changes affect long-term health outcomes, in addition to raise the risk of developing cardiovascular problems, chronic kidney diseases, and mortality.
In Morocco, a lower-middle-income country in North Africa, no national community-based prevalence data on metabolic syndrome exist. The health ministry conducted a national survey in 2000 on cardiovascular risks in a population aged 20 years and more. The study revealed a prevalence of 29% for hyperlipidemia, 6.6% for diabetes mellitus, 13.2% for obesity, and 33.6% for hypertension. A previous study of individuals at least 40 years old found the prevalence of diabetes mellitus and obesity and were approximately 10.2% and 25.1%, respectively, in Morocco. This study showed a higher prevalence of diabetes mellitus in PLWH than in the general population. Chronic inflammation as a result of HIV infection could be a possible mechanism of diabetes mellitus in HIV-infected adults, since systemic inflammation result of other causes has been correlated with incident diabetes mellitus in the general population., Both diabetes mellitus and HIV infection are independently associated with an increased risk of atherosclerosis.,
There are some limitations to our study that need to be considered. First, there was no HIV-uninfected control group for comparison. Second, the relatively small sample size in the present study limits the generalizability of the results. Third, this study reviewed medical records over a long period, and data on several antiretrovirals drugs (dose and duration) were missing.
| Conclusions|| |
This study highlights the substantially increased burden of multimorbidity in a middle-income country. Health-care providers caring for PLWH must be knowledgeable not only about HIV but also about other chronic health conditions when treating HIV-infected patients to achieve long-term survival.
Financial support and sponsorship
Conflicts of interest
The authors declare that none of the authors have any competing interests.
| References|| |
Brown TT, Qaqish RB. Antiretroviral therapy and the prevalence of osteopenia and osteoporosis: A meta-analytic review. AIDS 2006;20:2165-74.
Triant VA, Brown TT, Lee H, Grinspoon SK. Fracture prevalence among human immunodeficiency virus (HIV)-infected versus non-HIV-infected patients in a large U.S. healthcare system. J Clin Endocrinol Metab 2008;93:3499-504.
Sierra H, Cordova M, Chen CJ, Rajadhyaksha M. Confocal imaging-guided laser ablation of basal cell carcinomas: An ex vivo
study. J Invest Dermatol 2015;135:612-15.
Bonfanti P, De Socio GV, Ricci E, Antinori A, Martinelli C, Vichi F, et al
. The feature of metabolic syndrome in HIV naive patients is not the same of those treated: Results from a prospective study. Biomed Pharmacother 2012;66:348-53.
Mondy K, Overton ET, Grubb J, Tong S, Seyfried W, Powderly W, et al.
Metabolic syndrome in HIV-infected patients from an urban, Midwestern US outpatient population. Clin Infect Dis 2007;44:726-34.
Grundy SM. Metabolic syndrome pandemic. Arterioscler Thromb Vasc Biol 2008;28:629-36.
Gaur P, Bhattacharya S, Kant S, Kushwaha RA, Pandey S, Sharma S. Review on role of CD4 T-cells in patients with respiratory illness and human immunodeficiency virus infection. Biomed Biotechnol Res J 2020;4:90-4. [Full text]
Kendall CE, Wong J, Taljaard M, Glazier RH, Hogg W, Younger J, et al
. A cross-sectional, population-based study measuring comorbidity among people living with HIV in Ontario. BMC Public Health 2014;14:1-9.
Negin J, Martiniuk A, Cumming RG, Naidoo N, Phaswana-Mafuya N, Madurai L el al. Prevalence of HIV and chronic comorbidities among older adults. AIDS. 2012; 26 Suppl 1(0 1):S55-63.
Simone MJ, Appelbaum J. HIV in older adults. Geriatrics 2008;63:6-12.
Nakaranurack C, Manosuthi W. Prevalence of Non-AIDS Comorbidities and Factors Associated with Metabolic Complications among HIV-Infected Patients at a Thai Referral Hospital. Journal of the International Association of Providers of AIDS Care (JIAPAC). January 2018.
Kim DJ, Westfall AO, Chamot E, Willig AL, Mugavero MJ, Ritchie C, et al.
Multimorbidity patterns in HIV-infected patients: The role of obesity in chronic disease clustering. J Acquir Immune Defic Syndr 2012;61:600-5.
Ramdani N, Vanderpas J, Boutayeb A, Meziane A, Hassani B, Zoheir J, et al. Diabetes and obesity in the eastern Morocco. Mediterr J Nutr Metab 5, 149–155 (2012).
Lo YC, Chen MY, Sheng WH, Hsieh SM, Sun HY, Liu WC, et al
. Risk factors for incident diabetes mellitus among HIV-infected patients receiving combination antiretroviral therapy in Taiwan: A case-control study. HIV Med 2009;10:302-9.
Fettig J, Swaminathan M, Murrill CS, Kaplan JE. Global epidemiology of HIV. Infect Dis Clin North Am 2014;28:323-37.
Bloch M, Kamminga J, Jayewardene A, Bailey M, Carberry A, Vincent T, et al
. A screening strategy for HIV-associated neurocognitive disorders that accurately Identifies patients requiring neurological review. Clin Infect Dis 2016;63:687-93.
De Francesco D, Underwood J, Post FA, Vera JH, Williams I, Boffito M, et al.
Defining cognitive impairment in people-living-with-HIV: The POPPY study. BMC Infect Dis 2016;16:617.
Wright EJ, Grund B, Cysique LA, Robertson KR, Brew BJ, Collins G, et al.
Factors associated with neurocognitive test performance at baseline: A substudy of the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial. HIV Med 2015;16 Suppl 1:97-108.
Edmiston N, Passmore E, Smith DJ, Petoumenos K. Multimorbidity among people with HIV in regional New South Wales, Australia. Sex Health 2015;12:425-32.
Torres TS, Cardoso SW, Velasque Lde S, Marins LM, Oliveira MS, Veloso VG, et al.
Aging with HIV: An overview of an urban cohort in Rio de Janeiro (Brazil) across decades of life. Braz J Infect Dis 2013;17:324-31.
Jantarapakde J, Phanuphak N, Chaturawit C, Pengnonyang S, Mathajittiphan P, Takamtha P, et al.
Prevalence of metabolic syndrome among antiretroviral-naive and antiretroviral-experienced HIV-1 infected Thai adults. AIDS Patient Care STDS 2014;28:331-40.
Tesfaye DY, Kinde S, Medhin G, Megerssa YC, Tadewos A, Tadesse E, et al.
Burden of metabolic syndrome among HIV-infected patients in Southern Ethiopia. Diabetes Metab Syndr 2014;8:102-7.
Alencastro PR, Wolff FH, Oliveira RR, Ikeda ML, Barcellos NT, Brandão AB, et al.
Metabolic syndrome and population attributable risk among HIV/AIDS patients: Comparison between NCEP-ATPIII, IDF and AHA/NHLBI definitions. AIDS Res Ther 2012;9:29.
Wen W, Luo R, Tang X, Tang L, Huang HX, Wen X, et al.
Age-related progression of arterial stiffness and its elevated positive association with blood pressure in healthy people. Atherosclerosis 2015;238:147-52.
Husain NE, Noor SK, Elmadhoun WM, Almobarak AO, Awadalla H, Woodward CL, et al.
Diabetes, metabolic syndrome and dyslipidemia in people living with HIV in Africa: Re-emerging challenges not to be forgotten. HIV AIDS (Auckl) 2017;9:193-202.
Solomon S, Mulugeta W. Disease burden and associated risk factors for metabolic syndrome among adults in Ethiopia. BMC Cardiovasc Disord 2019;19:236.
Scherzer R, Heymsfield SB, Lee D, Powderly WG, Tien PC, Bacchetti P, et al.
Decreased limb muscle and increased central adiposity are associated with 5-year all-cause mortality in HIV infection. AIDS 2011;25:1405-14.
Erlandson KM, Reynolds SM, Cox C, Palella FJ, Witt MD, Kingsley LA, et al.
Self-reported body fat change in HIV-infected men is a marker of decline in physical health-related quality of life with aging, independent of co-morbidity. PLoS One 2014;9:e114166.
Castro Ade C, Silveira EA, Falco Mde O, Nery MW, Turchi MD. Overweight and abdominal obesity in adults living with HIV/AIDS. Rev Assoc Med Bras (1992) 2016;62:353-60.
Report F. Executive summary of the third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III). Vol. 151. Arch Intern Med 2001;285:2486-97.
Naidu S, Ponnampalvanar S, Kamaruzzaman SB, Kamarulzaman A. Prevalence of metabolic syndrome among people living with HIV in developing countries: A systematic review. AIDS Patient Care STDS 2017;31:1-13.
Malangu N. Factors associated with metabolic syndrome among HIV-positive patients at a health facility in Botswana. Br J Med Res 2014;4:2352-61.
Shah K, Alio AP, Hall WJ, Luque AE. The physiological effects of obesity in HIV-infected patients. J AIDS Clinic Res 2012;3:2-6.
Tazi MA, Abir-Khalil S, Chaouki N, Cherqaoui S, Lahmouz F, Sraïri JE, et al.
Prevalence of the main cardiovascular risk factors in Morocco: Results of a national survey, 2000. J Hypertens 2003;21:897-903.
Hu FB, Meigs JB, Li TY, Rifai N, Manson JE. Inflammatory markers and risk of developing type 2 diabetes in women. Diabetes 2004;53:693-700.
Spranger J, Kroke A, Möhlig M, Hoffmann K, Bergmann MM, Ristow M, et al.
Inflammatory cytokines and the risk to develop type 2 diabetes: Results of the prospective population-based European prospective investigation into cancer and nutrition (EPIC)-Potsdam study. Diabetes 2003;52:812-7.
Grunfeld C, Delaney JA, Wanke C, Currier JS, Scherzer R, Biggs ML, et al.
Preclinical atherosclerosis due to HIV infection: Carotid intima-medial thickness measurements from the FRAM study. AIDS 2009;23:1841-9.
Triant VA, Lee H, Hadigan C, Grinspoon SK. Increased acute myocardial infarction rates and cardiovascular risk factors among patients with human immunodeficiency virus disease. J Clin Endocrinol Metab 2007;92:2506-12.
[Table 1], [Table 2], [Table 3], [Table 4]