The burden of non-communicable diseases (NCD) and their modifiable risk factors is on the rise in Sub-Saharan Africa (SSA). Among people living with HIV (PLHIV), epidemiological studies have revealed a trend of increasing prevalence of four major risk factors of NCDs; hypertension, hyperglycemia, dyslipidemia and obesity [1-3]. With the increasing availability of antiretroviral therapy (ART), the ageing HIV population is susceptible to traditional risk factors for NCDs. Furthermore, both the HIV virus and prolonged ART use have been associated with dyslipidemia, insulin resistance, and atherosclerosis, interacting with traditional risk factors to increase the risk of NCDs among PLHIV [3, 4]. The increased NCDs risk among PLWH has the potential to threaten the success of ART use, causing morbidity, poor quality of life and premature mortality.

In Cameroon, the universal test and treat approach was instituted in 2016. This novel approach requires placing all persons testing positive for HIV on ART irrespective of their immunological and clinical statuses. Since the institution of this novel strategy in Cameroon, very few studies have investigated the epidemiology of NCDs among PLHIV in the context of the universal test and treat strategy. Approximately more than 35 million deaths are caused by non-communicable diseases (NCDs) on an annual basis. Morbidity and mortality due to NCDs contribute significant threat globally on health and economy of individuals, societies and health systems [5, 6]. The four main NCDs which are being targeted for control globally are cardiovascular diseases (CVDs), chronic respiratory diseases, cancers and diabetes and the selected NCD risk factors also targeted for control are tobacco use, harmful alcohol use, salt intake, obesity, raised blood pressure, raised blood glucose and diabetes, and physical inactivity [6].

Coupled to the rapid urbanization observed in Fako Division, the double crises (socio-political and COVID-19 pandemics) could increase the prevalence of NCDs through either inaccessibility to health facilities and/or stressors. The lock-downs imposed by these two crises have led to increase in sedentary life, psychological stress and inadequate exercise with a long term consequence of spikes in NCDs such as hypertension and diabetes  [7]. These double crises have considerably disrupted the health system through reduction in access to health facilities and reduction in staff and essential medication for patients suffering from NCDs. There is consistent evidence across the globe that the COVID-19 pandemic has considerably disrupted NCDs services. This disruption has been particularly problematic for people living with chronic conditions and requiring long term care. Triage and telemedicine have been used to address this disruption in NCD services across the world.

The prevalence of HIV in Cameroon was 3.9% in 2015 [8]. The World Health Organization (WHO) estimates for deaths attributed to Non-Communicable Diseases (NCD) in Cameroon was 35.0% in 2018 [9]. The prevalence of HIV is 3.6% and that of hypertension is 31.1% in the South West Region (SWR) of Cameroon [2, 8]. The prevalence of hypertension (38.0%) and dyslipidemia (51.0%) in HIV patients on ART have reached epidemic levels in Fako Division, SWR of Cameroon [2, 3].  Fako Division as well as the other fast urbanizing divisions in Cameroon is experiencing a double burden of HIV and NCDs. Although evidence from high-income countries is definitive as to the emerging importance of NCDs in PLHIV, there are far fewer data and research advances regarding such conditions in low and middle income countries (LMICs). In Cameroon, the burden of NCDs and their risk factors among PLHIV remains largely unquantified. This study aimed to describe the prevalence of hypertension, osteoporosis, diabetes mellitus, renal impairment, asthma, cardiomyopathy and multi-morbidity, among HIV positive patients receiving ART in Fako Division.

MATERIALS AND METHODS

Ethical and administrative consideration

For administrative approval, the study protocol was read and approved by South West Regional Delegation of Public Health and heads of the health facilities hosting the HTCs. Ethical clearance was obtained from the Faculty of Health Science Institutional Review Board, University of Buea, Cameroon

Study design

This was a cross-sectional survey that took place in the months of June to August 2021.

Study area and setting

The study was carried out in in 5 purposively (HTCs receiving the highest number of patients) in Fako Division (Figure 1). These hospitals are specialized HIV treatment centers that provide free antiretroviral therapy in addition to HIV counseling and testing services. According to the RTG of the Regional Delegation of Public Health for the South West Region report for 2020, a total of 18,000 HIV patients were receiving treatment in Fako Division [10]. Patients report every 1, 3 and 6 months for antiretroviral therapy refill depending on the availability of drugs. The number of HIV patients on ART has seen a hick because most patients have been transferred-in from the highly hit conflict areas to Fako Division which is relatively safer. The patients who attend the facility are of different socioeconomic statuses. Information on NCDs is not collected in routine care at the facility during patient visits. Hypertension is sometimes screened for at every clinic visit, diabetes mellitus II, asthma, cardiomyopathy and osteoporosis are usually screened for when a patient complains of certain symptoms during the routine follow up visits. Renal impairment is screened for among patients upon being started on tenofovir based regimen. However, some NCDs are screened for as a result of participation in research projects that require screening for certain ailments / medical conditions.

Figure 1: Map showing the HTCs in Fako Division

Study population

The study population consisted of HIV patients aged 18 years and above receiving ART in the selected treatment centers in Fako Division.

Inclusion criteria

• Only HIV patients on ART were included.
• Only patients aged 18 years and above.

Exclusion criteria

• Participants with mental and physical disabilities,
• Patients who were debilitated and bed ridden as well as
• Pregnant women were excluded.

Sample size

The single population proportion formula by Fischer for cross-sectional studies was used for the WHO STEP approach [11]. To adjust for the design effect of the sample design, we multiplied the sample size by the design effect. To adjust for anticipated non-response, we divided by the anticipated response rate. Hence, Z-score=1.96; Proportion=38% [2]; marginal error=0.05; Design effect=1.5 and non-response rate=10%.

                                      n = Z2 *p*(1-p)e2*1.5

                                      n = (1.96)2*0.38*0.62(0.05)2*1.5

                                       n = 545

To adjust for anticipated non-response, we added 10% of the sample. Thus a minimum total of 600 participants were anticipated and a total of 1440 clients were sampled using probability proportionate to size (PPS) as shown in table 1 below.

Table 1: Proportionate samples for each HTC

A two stage sampling method was used. In the first stage, a purposeful sampling technique was used to select 5 HIV treatment centers in Fako Division. These treatment centers receive the largest number of clients and relatively secured in the current socio-political context. In the second stage, 1440 HIV patients on ART were recruited from the 5 selected treatment centers based on probability proportionate to size (Figure 2). A serial or consecutive sampling technique was used to recruit participants from the treatment centers until the sample size is reached.

Figure 2: Sampling method for the first cross-sectional study

Study variables

Outcomes of interest: Hypertension, osteoporosis, diabetes mellitus, renal impairment, asthma, cardiomyopathy and multi-morbidity were the outcomes of interest. They were all treated as binary variables. An individual was categorized as having a condition or not.

Other variables: Demographic factors: age, sex, marital status, level of education, occupation

Other health related factors: WHO HIV stage, duration on ART.

Life style factors: smoking, alcohol use.

Data collection

Research experienced personnel with bachelors in nursing and midwifery, already working within the HIV treatment centers were recruited and trained as research assistants. They were responsible for the data extraction and interviews. Patients presenting to the study facility for clinical review and/or drug re-supply, were consented into the study. Relevant information was then extracted from their patient files and entered into a data extraction form by the nurses. The patient files included information on a particular individual from when they were enrolled as patients in the selected HIV treatment centers. At the facility the following criterion is used to determine whether an individual has one of the above diseases:

Hypertension: Individual having a systolic blood pressure (SBP) of 140mmHg or more, or a diastolic blood pressure (DBP) of 90 mm Hg or more, or taking anti-hypertensive medication.

Diabetes mellitus: Having a fasting blood sugar equal to or more than 140mg/dl (7.8mmol/l) on 2 or more occasions, or a Random blood sugar of more than 200mg/dl (11.8mmol/l) or having a history of diagnosis of diabetes mellitus.

Renal impairment: Having urea levels, creatinine levels or potassium levels above the normal range or a calculated glomerular filtration rate (eGFR) of less than 60ml/ min.

Asthma: This is assessed using medical history and proof of asthma relief medicines for example salbutamol inhaler and medical documents showing asthma treatment, clinical examination to confirm presence of bronchi, spirometry to assess reversible airway obstruction with an FEV1 /FVC ratio less than 0.7 in an attack but with marked improvement on administration of bronchodilators that it: an increase in FEV1 (or FVC) of ≥12% and an absolute increase in FEV1 (or FVC) of ≥200mL.

Cardiomyopathy: A chest X-ray indicative of an enlarged heart; or a cardiac echo with a cardiologist report confirming a cardiomyopathy.

Osteoporosis: This is based on a clinical history of low velocity, atraumatic fractures or fragility fractures (hip, vertebrae, spine, forearm and wrist) and associated bone pain, taking medications for bone health, clinical examination and X-ray reports.

Data management

All study data was checked for accuracy, completeness and consistency at the end of each day by the PI, and any identified errors were corrected in real time. Hard copies of the questionnaires were stored in a water proof box file and electronic data bases were kept in password protected computers. An external hard drive was used to back up the data. Double data entry was done using Epi-info version 7.

Data analysis

All data analysis was done using STATA version 13.0 (STATA, College Station, Texas, USA). All continuous variables were summarized using means and standard deviations or medians and inter-quartile ranges, while categorical variables were summarized using proportions or percentages. Prevalence was reported with 95% confidence intervals. Multivariate logistic regression was used to identify the independent risk factors of NCDs among HIV patients on ART in Fako Division, SWR of Cameroon.

RESULTS

Socio-demographic Characteristics of Participants

Table 20 describes the socio-demographic characteristics of 1440 consecutively sampled adult HIV patients on ART in HTCs in Fako Division. The mean age of the participants was 45.6 (SD = 7.3) years. Of 1440 participants sampled, 1023 (71.0%) were females, 753 (52.4%) were either married or cohabiting and 156 (10.9%) had no formal education. One-fifth of the participants were unemployed.  Majority (89.2%) of the participants were Christians. There was a bi-polarization of WHO HIV staging at initiation with 36.6% (stage I) and 26.9% (stage IV). Of the 1440 participants sampled, only 51 (4.7%) were on ART with a protease inhibitor. The mean duration of these HIV patients on ART was 7.3 (SD=2.3). Forty percent of the participants were initiated on ART during the universal test and treat era. One third of the participants had a family history of hypertension.

Table 2: Socio-demographic Characteristics of Participants

ART=Antiretroviral therapy, UTT=Universal test and treat, PI=Protease inhibitor, SD=Standard deviation

Prevalence of NCDs among adults HIV patients on ARTs in Fako Division

The overall prevalence of having at least one NCD was 26.9% (95% CI: 24.6 – 29.2). The most commonly observed NCD was hypertension at 18.1% (95% CI: 16.2 – 20.2), followed by osteoporosis at 8.7% (95% CI: 7.3 – 10.5), diabetes mellitus at 4.8% (95% CI: 3.6 – 6.0), renal impairment at 1.9% (95% CI: 1.3 – 2.7), cardiomyopathy at 1.1% (95% CI: 0.6 – 1.7) and asthma at 0.4% (95% CI: 0.1 – 0.9) as shown on figure 2. Prevalence of multi-morbidity was 7.7% (95% CI: 6.4 – 9.2) (Table 3).

Table 3: Prevalence of NCDs among adults HIV patients on ARTs

Figure 2: Prevalence of NCDs among adults HIV patients on ARTs

Of the 387 participants with NCDs, 276 (19.2%) had a single NCD, 105 (7.3%) had 2 NCDs and 06 (0.4%) had 3 NCDs (Figure 3).

Figure 3: Clustering of NCDs among adult HIV patients on ART

The most common NCD co-morbidities among PLHIV were hypertension-DM (48; 3.3%), hypertension-osteoporosis (39; 2.7%) and hypertension-kidney impairment (15; 1.0%). Interestingly all 69 cases of DM were co-morbid. Three (0.2%) participants had a combination of hypertension-DM-CKD (Figure 4). Asthma seemed isolated as only one case had a co-morbidity with osteoporosis.

Determinants of NCDs among adults HIV patients on ARTs in Fako Division

After adjusting for confounders in the multivariate analysis, the characteristics that demonstrated a significant and strong relationship with the risk of NCD comorbidity among HIV patients on ART were age (51 years and above) (AOR 3.90; 95% CI 1.50-10.11), tertiary education (AOR 0.25; 95% CI 0.09-0.45), family history of hypertension/diabetes (AOR 5.40; 95% CI 3.69-7.54), psychological stress (AOR 2.33; 95% CI 31.56-3.44), harmful alcohol consumption (AOR 2.61; 95% CI 1.03-4.03), smoking (AOR 3.51; 95% CI 1.96-6.11), baseline WHO clinical stage IV (AOR 4.10; 95 % CI 2.99-5.96) and duration of HIV patient on ART for more than 5  years (AOR 2.03; 95% CI 1.39-2.99) as shown in table 4.

Table 4: Determinants of NCDs among adults HIV patients on ARTs

UOR: Unadjusted Odd Ratio, AOR: Adjusted Odd Ratio; CI: Confidence Interval; * = significant variables at p< 0.05, PIs: Protease inhibitors