INTRODUCTION:

AIDS (Acquired Immune Deficiency Syndrome), caused by the Human Immune Deficiency Virus (HIV-1, HIV-2), is a chronic, potentially life-threatening condition which has been considered also as the disease of poverty ^1,2 In this era 35 million people are living with HIV and 2 million people are becoming infected every year.This condition destroys the immune system also has great probability of making the body more prone to infections and diseases^2,3. Non-communicable diseases (NCDs) are becoming a major public health challenge³. Non communicable diseases are chronic conditions that require long-term care and treatment resulting in lifelong health consequences^4,5NCDs play a major role in the number of deaths and disabilities in the world.⁴As AIDS is a collection of symptoms and opportunistic infections from the specific damage to the immune system caused by the HIV there is a need to study the NCDS associated with it.^5,6.

With the increase in lifespan that antiretroviral therapy programs have made possible⁷, NCDs are prevailing due to a mix of factors like chronic immune activation, medication side effects, co-infections, and the aging process itself this may also result from the interaction of other multiple risk factors, such as smoking, nutrition, physical activity, and genetics. These non-communicable diseases are now common and found to be preventable. There are only limited studies done in this area in Indian population.

In our study we tried to evaluate the prevalence of non communicable diseases (hypertension/CAD/ Diabetes Mellitus/ Chronic kidney disease/dyslipidemia/cancer/ malnutrition/stroke) in HIV patients.

METHODOLOGY:

This study was conducted on patients who presented to the Emergency Medicine and Critical Care Department of a tertiary care centre for various HIV related acute problems. This was a Cross sectional, Retrospective study completed over 24 months. Sample size was calculated with a prevalence rate of 12%² to get the confidence level of 95+5% at a 0.05 significance level. The minimum sample size worked out was 163. All the 191 patients who satisfied the inclusion and exclusion criteria were selected for the study.

Inclusion Criteria:

Patients who came with positive status for HIV ELISA.

Exclusion Criteria:

Patients who are not having HIV.

Patients with incomplete data.

Age <18yrs

Data Collection Tools

1. The Who Step - wise approach to NCD risk factor surveillance:

It is a data collection tool for identifying the patient’s lifestyle.

2. Atherosclerotic Cardiovascular Disease scale (ASCVD scale)⁸:

This Risk Estimator, based on the Pooled Cohort Equations and lifetime risk prediction tools, enables health care providers and patients to estimate 10-year and lifetime risks associated with atherosclerotic cardiovascular disease

3. Framingham Risk Score⁹:

Prediction variables used in Framingham CHD risk score (1998) are Age, Gender, Total or LDL cholesterol (mg/dl), HDL cholesterol (mg/dl), Systolic blood pressure (mmHg), Diabetes Mellitus (yes/no), Current smoking (yes/no)

Method:

A cross sectional study was done for evaluating the prevalence of non-communicable disease among HIV. Patients who satisfied the inclusion and exclusion criteria were selected. Patient’s data relevant to study was collected from Hospital Healthcare Information System and patient treatment chart using standard data collection form /questionnaires. 2 data collection forms are used. First data collection form contains demographic details of the patient, social history, behavioral measurement, physical measurement; biochemical measurement etc. Cardiovascular risk assessment was done by using ASCVD risk score and Framingham risk score.

Statistical Analysis:

The collected data were compiled using the Microsoft excel and were presented in the graphical format using bar diagrams. Chi-square test was used to find significance of association of qualitative variables. Percentage or proportion is used for categorical variables. Statistical Package for Social Sciences (SPSS version 20) was used.

RESULTS:

191 Patients were applied in the study.

Socio Demographic Characteristics of The Patients:

Age Distribution of patients:

The age range of study patients is 20-80 years and most of the patients were in the age group of 40-60 years. This is shown in Table 1.

Table1. Age distribution of patients (n=191)

Age	Number	Percentage (%)
20-40	43	22.51
40-60	125	65.45
60-80	23	12.04

Figure 1. Gender distribution of patients (%)

Smoking habits of the patient

Smoking habits of the patient is illustrated in Figure 2. Within the study population 7.85% was smokers.

Figure 2. Smoking status of the patients

Prevalence of NCDs in HIV patients

From the total number of HIV patients, 64.92% (123) of patients were affected by NCDs. The prevalence rate of each NCD is depicted in Table 2. The prevalence rate of dyslipidemia 49 (25.7%) was found to be high, followed by hypertension 48 (25.1%) and diabetes 36 (18.8%).

Table 2: Prevalence of NCDs in HIV patients

NCDs	No: of patients (n= 191)	Prevalence
Spondylosis	1	0.5
Gastritis	1	0.5
Uterine Fibroids	2	1
Peripheral Neuropathy	3	1.6
Pancreatitis	4	2.1
COPD	4	2.1
Asthma	4	2.1
Psychological Effect	4	2.1
Bone disorders	5	2.6
Stroke	6	3.1
Renal Failure	7	3.7
Thyroid Dysfunction	7	3.7
CAD	10	5.2
CLD with PHTN	11	5.8
Cancer	12	6.3
Diabetes	36	18.8
Hypertension (HTN)	48	25.1
DLP	49	25.7

Association between Framingham score and CAD:

An association between Framingham score and CAD is depicted in Table 3 which shows significant (p value < 0.001) increase in the rate of CAD along with increase in Framingham score. The score is categorized based on its mean value (> 8.8, < 8.8). The percentage incidence of CAD increased from 1.5 to 14.3 in the group whose mean value of the score is > 8.8.

Table 3. Association between Framingham score and CAD

Framingham score

No CAD

CAD

P value

< 8.8

98.5

1.5

< 0.001

> 8.8

85.7

14.3

Association between ASCVD score and CAD:

A border line significant (p = 0.093) increase between ASCVD score and CAD shows that ASCVD lifetime – optimal risk score increases with incidence of CAD with all the patients with CAD falling in high-risk category.

Association between CD4 count and Dyslipidemia:

In our study, out of the 49 patients with DLP, we could find 33 with initial CD4 count < 200 and we found that there is no association between DLP and CD4 count (p = 0.617).

Association between CD4 count and CAD:

In our study, 82 (66.67%) patients with NCD were having CD4 count < 200. Out of this, we observed 10 patients with CAD (8.1%) with CD4 count < 200. Table 4 depicts the significant relationship (p=0.038) between low CD4 count and CAD.

Table 4. Association between CD4 count and CAD

Initial CD4 count	No CAD	CAD	P value
>200	100	0	0.038
< 200	91.9	8.1	0.038

Association between CD4 count and hypertension:

Table 5 depicts that there is a significance (p=0.047) between low CD4 count and Hypertension.

Table 5. Association between CD4 count and hypertension

CD4 count

Without HTN

With HTN

P value

>200

0.047

< 200

Management of high prevalent NCDs:

The most prevalent NCD seen were dyslipidemia (DLP), hypertension (HTN) and diabetes (DM) which were either treated with lifestyle modification or therapy. The prevalence rate of which are shown below in Table 6.

Table 6. Management of high prevalent NCDs

Management

DLP (%)

HTN (%)

DM (%)

Therapy

(59.18%)

(70.83 %)

(77.78 %)

Lifestyle modification

(40.82%)

(29.17 %)

(22.22 %)

DISCUSSION:

A total of 191 Human Immune deficiency Virus (HIV) patients were enrolled in the study, out of which most of the patients were in the age group of 40-60 years which is similar to the study done by Gibson B Kagaruki et al ¹⁰. The reason for the increase in NCD in this age group is probably due to the advanced age, which results in NCDs and also emergence of various risk factors. This is also suggested according to the previous study as well. Various other studies conducted on the People Living with HIV (PLWHIV) have reported that age is a traditional and remerging risk factor even after initiation of ART and they are seen to survive longer up to the NCD risk age level.

This study also shows that 68.06% were males and 31.94% were females which are contrast to the study of Gibson B Kagaruki et al¹⁰ where the percentage of females (70.5%) was higher than that of the males (29.5%). In our study the probable reason for increased incidence among men would be due of the better awareness among men regarding NCDs and HIV, better reporting of cases among men, extensive labour migration among men, and also better survival.

The study also took into account the smoking status of the patient as it is an inevitable risk factor for cardiovascular disease. Accordingly, patients were graded as smokers, non-smokers and ex- smokers (patients who had stop smoking for at least 1 year prior to inclusion in the study) and it was found that majority of the patients were non-smokers. This parameter was taken into consideration because based on the study of Sylvie Lang et al¹¹ smoking was associated with higher risk of cardiovascular disease in HIV patients and it is also a parameter in risk scoring. This finding is supported by Reinsch N et al¹² in which they state that one of the most common risk factors they founded were smoking. Smoking is prevalent in various parts of India irrespective of the social economic status. Studies have revealed that several infectious and non-infectious complications such as malignancies and cardiovascular events, may be added risk for HIV-infected smokers. Also tuberculosis is also prevalent in India. Tuberculosis is a serious health threat for people living with HIV. Patients tested positive for HIV are more likely than others to become unwell with TB. TB & HIV co-infection is a combination which we need to tackle and smoking can be indeed produces a negative impact on their health status. We were also able to ascertain through our study that even among non-smokers HIV, the burden of NCD’s are high which is another hurdle that we will have to handle.

In 2008, non-communicable diseases accounted for 51% of the global burden of disease which increased to 56% by 201¹³. Further, in an estimate in Kenya, the prevalence of hypertension among HIV negative individuals was projected to grow from 19.9% in 2018 to 23% in 2035. This was in bare comparison to a growth from 29.9% to 37.4% among PLHIV over a similar period of time¹⁴,These findings articulate the excess NCDs burden among key populations and identify the need for routine active screening to increase early identification. In this study, the prevalence rate of NCD in HIV patients was found to be 64.92% and the NCDs observed include dyslipidemia, hypertension, diabetes mellitus, cancer, chronic liver disease with portal hypertension, coronary artery diseases, thyroid dysfunction, renal failure, stroke, arthritis. The prevalence rate of dyslipidemia, hypertension and diabetes were found to be high. Probably because of the sedentary lifestyle, work style and reduced medical follow up. Demographic changes, changes in the lifestyle along with increased rates of urbanization, lack of monitoring, lack of routine health check-up would be the major reasons responsible for the tilt towards the non-communicable diseases in our study. Retro positive patients are even more reluctant to opt for health check-up and monitoring of their condition including NCDs, this could also be a major reason for the high incidence of NCD’s in our study. These patients are treated with anti-hyperlipidemic agents, antihypertensive, anti- diabetics respectively and others are managed by proper diet.

Out of the total population considered in our study, 87.4% patients took Highly Active Anti Retroviral Therapy (HAART) of which 59.6% were diagnosed with Non communicable Diseases (NCD). These findings show that NCDs are more prevalent in people taking HAART. Gibson B Kagaruki et al ^[9] also discussed about the same in his study. This could be partly due to the ART itself, because some of the ART drugs, for example, stavudine has been associated with incidence of dyslipidemia. The most commonly prescribed HAART regimen is Lamivudine + Zidovudine + Efavirenz. Prevalence rate of NCD in our study was higher when compared to other studies, which may be because the standard of living and quality of life is similar to normal population.

In the study, based on the cut off range we have taken for Framingham score (i.e., mean value = 8.8) we found that 29.32% patients were having greater than the mean value. From these 56 patients we could find that 14.2% patients showed already CAD screening positive. Therefore, an association between Framingham score and CAD was estimated and showed the risk of CAD increase with increase in the Framingham score (p<0.05). This is similar to the study conducted by Reinsch N et al¹⁰ where Framingham score was used for evaluating 10 year risk of Coronary Heart Disease (CHD). Also, ASCVD showed borderline significance (p<0.05) that implicates the same. Chronic inflammation and immune activation are the HIV specific factors that increase the risk of HIV associated with CAD. Good adherence to combination antiretroviral therapy (ART) regimens has also been a possible factor for this increased incidence. Introduction of ART has improved the life expectancy of patients with HIV infection, allowing them to live longer even with this chronic medical condition and consequently experiencing conditions such as cardiovascular diseases (CVDs). Also, increased incidence of NCDs could be contributed by the prevalence of conventional CVD risk factors and side effects of ART to be involved in the increased CVD risk in people living with HIV (PLWH). Our observations hold the need for randomized controlled trials to assess whether earlier introduction of ART and avoidance of treatment interruptions will reduce the incidence of cardiovascular events.

The severity of HIV is measured by an important diagnostic parameter, the CD4 count. Patients whose CD4 counts < 200 cells/mm³ are more prone to different types of infections and the chance for development of NCDs in these patients are found to be high. In our study population (191) we could see that 64.39% patients were having CD4 count less than or equal to 200. Out of this, we observed 8.1% patients with CAD. Thereby a significant relation between low CD4 count and Coronary Artery Disease (p=0.038, p<0.05) is showed. Virginia A.Triant et al¹⁵ found that CD4 cell count which indicates the level of viremia have been correlated with CHD risk. This could also be due to the fact that low count of CD4+ T-cell posing as the most robust risk factor for increased subclinical carotid atherosclerosis in HIV-infected people.

A large study among newly infected Chinese found that 10% had diabetes and these were associated with low CD4 count ^[16] which was found not statistically significant in our study. While our analysis showed a significance (p=0.047) between hypertension and low CD4 count. In addition to the traditional causes of hypertension, chronic inflammation, immune reconstitution, and lipodystrophy could also be contributing factors for the pathophysiology of hypertension in HIV infection.

CONCLUSION:

The prevalence rate of non-communicable diseases (NCD’s) among retro positive patients is high and should be screened in the same manner as done for routine patients. Retro positive patients present to the Emergency room with disease related deteriorations and also with NCD associated complications. When managing in the emergency room it is always essential to think of these NCDs in retro positive patients and the complication it can produce. This will help in early diagnosis, evaluate the complication in more organized manner and provide effective management. In this context, we also counsel the initiation and intensification of awareness through various health education programs on non-communicable diseases among HIV patients and their risk factors, so that we could help in reducing the morbidity and mortality among such patients.

LIMITATION:

This study was conducted at a single centre. A multicentric RCT would help in ascertain the data.

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Received on 15.09.2021 Modified on 11.03.2022

Research J. Pharm. and Tech 2023; 16(4):1743-1748.

DOI: 10.52711/0974-360X.2023.00287

Prevalence of Non-Communicable Disease in HIV Infected patients coming to Emergency Medicine and Critical Care Department in A Tertiary Care Centre in South India