Missed HIV care appointments and high body mass index predict hypertension risks at diagnosis: a risk identifying opportunity among people living with HIV for global health

INTRODUCTION

The world health organization (WHO) estimates that >75% of people living with HIV (PLWHIV) are susceptible to NCD, among them hypertension and diabetes.¹ Globally, Sub-Saharan Africa (SSA) accounts for 55% of PLWHIV who are at a growing risk of hypertension and diabetes co-morbidities partly due to lifestyles changes and rising life expectancy following long-time antiretroviral therapy (ART) use.^2-4 In Kenya, despite the exponential growth of HIV treatment programs, 21% of PLWHIV currently suffer from NCDs, thus, contributing to half of all hospital admissions and deaths, as well as aiding the sustained HIV-NCD twin burden, especially among women of reproductive age.⁵

Yet, the combined HIV-NCD impacts on the country are still not adequately studied.⁶ Understanding HIV-NCD epidemic dynamics is needed in integrating NCD screening and management services at HIV care and treatment centers.^6,7

Managing hypertension and diabetes by PLWHIV requires long-term regular medication access, treatment adherence, and continuous health status monitoring.⁸ Besides, PLWHIV often miss clinic appointments interrupting their ART care and thus the effectiveness of HIV management programs while compromising the tracking of their conditions, including NCD, consequently promoting poor health outcomes and increasing healthcare costs or other indirect burdens.^8,9 Missed HIV care appointments by PLWHIV indicate limited ART adherence highlighting inconsistencies important for developing defaulter tracing programs.⁹ Nonetheless, patient-related factors and beliefs, facility-level barriers, poor record-keeping, inadequate treatment medication, limited health facility staff capacity, over-burdened healthcare facilities, and long waiting times increase instances of missed appointment schedules among PLWHIV.^9,10 However, routine home visits and telephone calls by designated clinical staff engage PLWHIV, ensuring they receive continued care and act on scheduled follow-up visits.¹⁰ Moreover, understanding the characteristics of PLWHIV missed HIV care appointments provides insights for re-engaging interventions that better optimize treatment care successes while monitoring programmatic performance that guesstimates defaulter rates.¹⁰

Influences of higher BMI in the development of NCD among PLWHIV are well described.^11,12 Development of NCDs among PLWHIV with a normal BMI reflects differential risks, including sedentary lifestyle behaviours and biological effects of adipose tissue after ART initiation.¹¹ This has necessitated calls for further studies that link well-managed HIV infection, excess adiposity and the growing NCD conditions among PLWHIV.¹³ Managing the ever-increasing HIV-NCD co-morbidities guarantees an improved quality of life among PLWHIV.¹² In this study, we estimated sub-national prevalence and investigated the NCD risks among PLWHIV in a referral facility in Central Kenya. PLWHIV in our study setting face limited access to diagnostic test kits for testing and screening blood pressure (BP) and random sugar levels (RBS), the key surrogate markers of prognosis in HIV-NCD conditions.

METHODS

Study area, design, and PLWHIV selection

This study was conducted between February to May 2021 in the comprehensive care centre (CCC) of Murang'a referral hospital. The health facility is the largest public referral hospital in Murang'a County in central Kenya, serving referred PLWHIV for Gatanga, Kandara, Kangema, Kigumo, Kiharu, Maragwa, and Mathioya wards in Murang'a County (Figure 1). The county has an estimated population of 1,056,600 people in a total land area of 2,523 km², representing a population density of 419 people per km².¹⁴

This study adopted a cross-sectional study design. We estimated a sample size of 281 participants using a 95% confidence interval, 0.05 margin of error, 21% NCD prevalence among PLWHIV, and a 10% non-response rate using Epi-info software.¹¹ A total of 281 eligible study participants aged 18 years or above were systematically sampled from the facility appointment registers, with the first participant randomly selected using a lottery method. We included >18-year-old PLWHIV and studied them for the occurrences of NCDs.

HIV and NCD case definition

PLWHIV included in the study had a laboratory-confirmed HIV test or were currently on ART medication and clinically examined for NCD. PLWHIV with systolic (SBP) and diastolic (DBP) blood pressure of ≥140/90 mmHg were considered hypertensive.¹⁵ Those on diabetes medication or with a random blood glucose of >11.1 mmol/L (≥200 mg/dL) and 7 to 11 mmol/L were considered diabetic and pre-diabetic respectively.¹⁶ Additionally, the PLWHIV were classified using their BMI, kg/m²) as underweight (<18.5 kg/m²), normal (18.5 to < 25 kg/m²), overweight (25 to <30 kg/m²), and obese (≥30 kg/m²).

Data collection and analysis

Using an interviewer-administered questionnaire, we first obtained PLWHIV characteristics, including the level of education categorized as those who attained primary, secondary, and post-secondary education and without formal schooling. PLWHIV were categorized into those with formal and informal occupations and/or those with unemployment. We also obtained the PLWHIV monthly income, marital status, religion, family support in accessing health facilities, and medical history. We also collected information on risk factors for NCDs and treatment history. PLWHIV on medication produced their hospital cards during their CCC visits that provided information on their health-seeking behaviours, including missed HIV care appointments and any history of hypertension and diabetes in their family. Other health-related characteristics obtained included mode of transport to the facility, availability of medical insurance coverage, NCD services satisfaction, and health providers' professionalism. Weekly behavioural risk factors for NCDs, including smoking tobacco, consuming alcohol, checking blood glucose, physical activity, balanced diet intake, and daily salt, fatty, fruit, or vegetable meal servings, were collected.

Measurements from the PLWHIV included weight and height (used to compute BMI), BP, and RBS measurement. We generated a study outcome variable dichotomized to yes versus no for those diagnosed with and without the NCD of interest (hypertension and/or diabetes), respectively. Using correlation analysis, BP, BMI, and blood glucose measurements were tested for correlation with increasing age. The chi-square test was used to compare categorical variables. To predict the factors associated with the NCD (hypertension and diabetes) among PLWHIV, we utilized logistic regression models, performed in R software version 4.2.0.

RESULTS

Characteristics of PLWHIV

Table 1 shows the characteristics of 281 PLWHIV enrolled in the study. Of these, 68% were female, while 91% were aged above 35 years. The average age of these study participants was 43±7 years. About 60% of the PLWHIV had attained primary or secondary education. Additionally, 180 (64%) were married, with a majority (90%) in monogamous relationships. Largely, 71% of the PLWHIV earned more than 10,000 Kenya shillings (KES) per month with a majority (61%) working in the informal sector. 89% of these PLWHIV were obese and overweight.

Prevalence of NCD among PLWHIV

Of the 281 PLWHIV, 77 (27%) and 154 (55%) were diagnosed with hypertension and at prediabetes. Of these PLWHIV, 56 (20%) were diagnosed to have both pre-diabetes and hypertension. None of the PLWHIV was diabetic. The prevalence of hypertension among PLWHIV was higher among females (19%) and those aged above 35 years (24%). Hypertension was prevalent among married PLWHIV, those who had attained secondary education (17%), and those working in the informal sector or self-employed (15%). Hypertension was prevalent among obese (18%) and overweight PLWHIV (9%) (Table 1).

In correlation analysis, the 204 PLWHIV without the NCD, their SBP, DBP, and BMI measurements were directly correlated with increasing age. Their random blood glucose measurements positively correlated with increasing age among males while negatively correlating in females (Figure 2). For the 77 PLWHIV with hypertension, their DBP measurement positively correlated with increasing age among females (R=0.28) and males (R=0.05) (Figure 3 A). The SBP and BMI measurements among these PLWHIV positively correlated with increasing age among females while negatively correlated among males (Figure 3 B and C). Additionally, their blood glucose levels remained constant with increasing age (Figure 3 D). The overall average distribution of SBP, DBP, BMI, and blood glucose measurements among the PLWHIV are described in Table 2.

Healthcare-seeking behaviour among PLWHIV

Table 3 describes healthcare-seeking behaviour among 281 PLWHIV and those with NCD. Of these PLWHIV, 88% used public means of transport to the health facility. Only 13% of PLWHIV had medical insurance coverage (Table 3). Generally, PLWHIV utilized an average of 234 KES in hospital costs to a max of 1,980 KES. Among the 77 PLWHIV with hypertension, 70% missed HIV care appointments and were in families with history of diabetes. Only five (6%) of these PLWHIV received familial support when going to a clinical appointment. Only 10 (13%) of these PLWHIV responded to satisfaction of their service providers and the services they provided while also responding to queries on NCDs (Table 3). Moreover, hypertension was prevalent among PLWHIV lacking medical coverage and using public and taxi (privately paid) means to the health facility (24%).

Behavioural risk characteristics among PLWHIV with NCDs

Table 4 describes NCD behavioural risk factors among PLWHIV. Of 77 PLWHIV with hypertension, 11 (14%) were smoking tobacco products, with most (90%) smoking more than once a day. About 13 (17%) of these PLWHIV consumed alcoholic drinks, with the half consuming alcohol at least weekly. Only 14 (18%) and 17 22%) of 77 PLWHIV engaged in moderate physical activities and exercises and took a balanced diet daily, respectively. Only 8 of these PLWHIV checked their blood glucose weekly. Largely (99%) these PLWHIV added table salt to their food servings and consumed fatty meals daily (Table 3). More than 90% of these PLWHIV included fruits and vegetables in their daily serving and taking processed foods such as bread weekly (Table 3). Further, though non-significant, weekly physical activity among the 77 PLWHIV is associated with reduced SBP, DBP and blood glucose levels (p>0.05).

Risk factors associated with NCDs among PLWHIV

Using univariable analysis, we determined factors discretely associated with NCDs among PLWHIV. These factors included education level, physical activity, processed food, adding salt to daily food servings, BMI, and missing HIV care appointments at p≤0.1 (Table 5). Multivariate analysis independently associated increasing BMI and missing HIV care appointments with NCDs among PLWHIV at p≤0.05. PLWHIV missing HIV care appointments had two folds increased risk of NCD compared to those not missing the appointments. Additionally, the risk of an NCD among PLWHIV increased by 15% for one unit increase of BMI (Table 6).

DISCUSSION

This study determined the risk factors associated with NCDs among PLWHIV attending a referral health facility in central Kenya. The frequently diagnosed NCD among the PLWHIV was hypertension in women compared to their male counterparts. Additionally, although none of the PLWHIV was diagnosed with diabetes, more than half (55%) were prediabetic. Missing HIV care appointments and higher BMI predicted the risk of NCDs among PLWHIV. Consistent with other studies, regular HIV care appointments among PLWHIV, including those for NCD care, delayed complications, and risk of hospitalization.¹⁷

Increasing BMI among PLWHIV predicted a 15% increased risk of hypertension, suggesting a possible risk associated with heavy weight. Indeed, most (89%) of the PLWHIV, irrespective of sex, were obese or overweight (BMI ≥25). Consistent with our findings, a study in South Africa reveals an increasing risks of chronic diseases including hypertension co-morbidities are associated with obesity among the PLWH.¹⁸ Additionally, hypertension increases the risk of diabetes occurrences due to hyperglycaemic conditions from the prolonged blood sugar build-up linked with obesity, weight gain, or high BMI among the PLWHIV.¹⁹ Further, ART initiation in the presence of obesogenic environment risks predisposes PLWHIV to overweight and the ultimate risk of NCD, including hypertension.²⁰ Behavioural interventions promoting lifestyle changes such as routine body weight screening, increasing physical exercise, consuming adequate fruits or vegetables, and caloric restrictions effectively maintain normal BMI for healthy body weight among PLWHIV.²¹

PLWHIV missing HIV care appointments were twice as at risk of hypertension compared to those attending these appointments suggesting the likelihood of poor adherence to proper care and management. Indeed, 70% of the PLWHIV missed HIV care appointments, with a majority (99%) linking their reasons to associated costs and the unavailability of ART drugs in the facility. Consistent with our findings, a study in Ethiopia associated HIV care appointments with additional care costs, quality of services received, and psychosocial support. This study did not assess healthcare workers' attitudes and related persistent HIV stigma and discrimination among the PLWHIV. However, these factors are among the major barriers to access and uptake of care services.²² Moreover, similar to our findings’, missed appointments are common among PLWHIV in low-income families unable to cover transport to health facilities and associated costs, resulting in delayed or missed care likely to worsen their health outcomes.²³ Adherence to HIV care appointments by PLWHIV promotes better HIV-NCD care, including treatment and management, thus warranting strategic approaches to promoting hospital attendance, such as eliminating transport costs, encouraging familial support, and good doctor-patient relationships.^24,25 Further, adopting technological reminder systems could support PLWHs in adhering to scheduled doctor appointments for care services and continuity.²⁶ To contribute to global health, identifying and understanding determinants of missed HIV care appointments will help to re-engage defaulters while promoting regular screening for NCD profiles.

Prediabetes was common among older PLWHIV aged >35 years (55%), suggesting a likelihood of progression to diabetes if left untreated or unchecked and an ultimate co-occurrence with hypertension. Additionally, our hypertension (17%) prevalence estimates among these PLWHIV were almost similar in proportions to that of the South Africa study, with increasing age among these PLWHIV being an indication of prolonged life, perhaps due to the ART treatment.^18,27 These hypertensive and risky pre-diabetes conditions we studied among PLWHIV warrants the need for the integration of HIV treatment and NCD screening services to reduce the progression and identification of undiagnosed hypertensive-related complication.^28,29 Further, these services can leverage the existing overlapping services to improve the development and delivery of quality chronic care services and reduce service duplication, fragmentation, associated costs, and inconveniences.^27,29,30

More than 22% of PLWHIV with hypertension took alcohol and smoked tobacco weekly while also missing their HIV care appointments, suggesting likely NCD behavioural risk exposure. In addition, these PLWHIV consumed an unbalanced diet and were physically inactive. Consistent with our findings, a study in Uganda and Kenya associated alcohol consumption with antiretroviral medication non-adherence and delayed initiation, and reduced retention of PLWHIV to care, contributing to HIV/AIDS complications.³¹ Further, alcohol consumption impacts decision-making, promoting riskier sexual behaviours, including engaging in unprotected sex among PLWHIV, ultimately increasing HIV incidence.³² Conversely, repeated alcohol and smoking are risk factors for hypertension and diabetic complications and risks among PLWHIV.³³ In our study area, alcohol consumption is a major public health concern that needs to be addressed using established means.³⁴ Smoking cessation improves health outcomes increasing life expectancy and risks of NCD and HIV infection itself.³⁵

Fewer (24%) PLWHIV participated in physical activities, including moderate exercises suggesting a reduced sedentary behaviour. Indeed, PLWHIV engaging in physical activities was associated with reduced systolic and/or diastolic blood pressure and blood glucose levels (p>0.05). Earlier findings in Sub-Saharan Africa link physical activities to improving blood glucose and blood pressure levels which are common non-communicable disease risks.³⁶ On the other hand, PLWH (76%) reporting not participating in any physical activities indicated sedentary lifestyle habits warranting more insights into health promotion covering physical inactivity given the longer ART treatment duration, especially among females.³⁷ Existing HIV and NCD care models can integrate PLWHIV physical activity interventions to include hospital-based training and a home-based exercise program to improve their fitness strengths, body composition, and quality of life.^36,38 Further, expanding national and community health education interventions promoting awareness on physical activity and healthy feeding practices would immensely benefit PLWHIV in tackling their greater risk of weight gain in BMI and obesity, among other associated risks.³⁹

Limitation and strengths

This study is limited to an institutional setting with a study population from a specific region. Our study did not explore the effects of ARVs on the potential build-up of blood sugar, and its contribution to hypertension among PLWHIV. In addition, the adopted cross-sectional study design is not designed to show temporal relationships, so the observed associations might not necessarily be causal. However, this study assessed factors associated with hypertension and diabetes among PLWHIV, thus providing insights for improving HIV-NCD integrated care model.

CONCLUSION

We established risks associated with higher BMI levels and missing HIV care appointments among PLWHIV by predicting the risk of hypertension at diagnosis. Regular medical appointments among PLWHIV, including those for NCD care increase patient engagement and are associated with preventing and delaying related complications. Understanding factors promoting missed or delayed appointments is essential in designing patient-centred support interventions and reducing their associated risks linked to NCDs.

ACKNOWLEDGEMENTS

Author would like to thank the study participants, data collectors for their support and participation. Also, to Muranga health facility staff for the institutional and administrative support for making the study a success.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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