Cardiovascular Journal of Africa: Vol 30 No 1 (January/February 2019)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 1, January/February 2019

AFRICA

and D4T-containing regimens [adjusted OR 3.13 (1.72–5.71),

0.002]. However, the median duration on ART was not

significantly different for those with or without a raised total

cholesterol level (Mann–Whitney test,

0.1261). There was no

significant association between CD4 count and total cholesterol

level (Table 4).

Thirty-one (2.1%) subjects had a random blood glucose level

7.8 mmol/l. These patients were referred to the physician for

fasting glucose determination and/or oral glucose tolerance tests.

Eight (0.55%) of those above 40 years of age had more than

10% risk of developing a major adverse cardiovascular event in

10 years, according the WHO (Afri-E) risk score performed on

these clients.

Discussion

In this study, cardiovascular screening of people living with HIV

revealed a significant prevalence of undiagnosed hypertension

(13.3%) and raised total cholesterol levels (14%), two of the

major cardiovascular risk factors. Possible aetiological factors for

hypertension include traditional risk factors (such as age, gender,

smoking and obesity), ART, or possibly HIV infection itself. Our

analysis of risk factors indicated significant associations between

the occurrence of hypertension and male gender, older age (

years) and increased waist circumference. There was however no

association between ART regimen and hypertension, suggesting

that other factors may have been contributory.

In a population survey targeting a peri-urban community

in Nairobi, prevalence of hypertension was 22%,

which is

higher than seen in this study. One of the possible reasons for

this disparity is that despite living with HIV, the age of this

cohort was relatively young and with fewer smokers compared

to those reported in the general population (2015 Kenya STEPS

survey). Also, the prevalence of other known risk factors for

hypertension such as overweight and obesity was at 14%, well

lower than reported in the national STEPS survey (27%).

In another retrospective review of data from an HIV-positive

population in western Kenya, the prevalence of hypertension was

11.2% in men and 7.4% in women.

The figures observed in this

review compare well with those found in our study.

Possible aetiological factors for high cholesterol levels include

genetic factors, diet, ART or HIV infection itself. After adjusting

for confounders, elevated cholesterol level was associated

with three ART regimens (TDF, AZT and D4T) suggesting a

potential causal relationship. However, since a full lipid profile

was not performed, it remains unclear if this was due to a raised

low-density lipoprotein cholesterol level.

Astudy inTanzania showed a high prevalence of dyslipidaemia

(low high-density lipoprotein cholesterol and elevated triglyceride

levels) in an ART-naïve cohort of HIV patients.

There is

therefore a need for further research to illustrate the role of ART

therapy on the patterns of dyslipidaemia.

The prevalence of smoking, obesity, glucose intolerance

and diabetes were low in this population at 1.9, 12.1 and 2.6%,

respectively, and only 0.6% had a WHO cardiovascular risk

score

10%. This is much lower compared to the peri-urban

population study of Nairobi where 10% were smokers, 5% had

diabetes, and more than 40% had central obesity.

Our rural

hospital setting may present a different HIV population where

disease and lifestyle advice provided to the patients may have

altered risk factors, particularly smoking incidence.

With increasing longevity of people living with HIV, the

prevalence of hypertension, hyperlipidaemia and glucose

intolerance is likely to increase. Therefore routine and systematic

screening for cardiovascular risk factors among this population

is crucial. The majority of cardiovascular risk factors, also seen

in people with HIV, such as smoking, hypertension and obesity,

are modifiable, therefore early identification and treatment of

these conditions provides an opportunity to improve the quality

of care and possibly survival rate in this population. Existing

studies conducted in sub-Saharan Africa suggest there is little

knowledge of the risk posed by CVD in this population.

There

is therefore a need to establish CVD care in HIV programmes

to potentially mitigate adverse cardiovascular events in these

patients.

This study has several limitations, including collecting data

from patient charts at one time point. Further studies are

needed to establish how screening, referral and evidence-based

interventions could reduce cardiovascular risk of people living

with HIV in rural Kenya and beyond. Cardiovascular risk was

determined after a median duration of 32 months of ART.

A longer period of observation may be required to detect

transition in cardiovascular risk. However the high prevalence of

hypertension indicates that there was a considerable amount of

undiagnosed incipient and actual hypertension in this population.

Lastly, fasting lipid profiles were not performed where elevated

non-fasting values were found, and inferences from an elevated

total cholesterol level may not accurately reflect the prevalence

of hypercholesterolaemia. However, recent guidelines advocate

the use of non-fasting cholesterol tests.

Our data are from

2013 to 2016, and the situation in terms of ART regimens and

cardiovascular risk may have changed since then.

Conclusion

CVD screening in a primary HIV-care clinic revealed a high

prevalence of undiagnosed hypertension and raised total

cholesterol levels, and suggests an association between raised

total cholesterol level and nucleoside reverse-transcriptase

inhibitor (NRTI)-based ART regimens in an HIV-infected

African population. Our findings provide further rationale for

integrating routine cardiovascular risk-factor screening into

HIV-care services in resource-limited settings. Larger studies

with more detailed investigations and longer follow up are

recommended.

This work was supported by Grand Challenges Canada and implemented in

collaboration with ICAP Kenya, which implements HIV PEPFAR care in the

Nyanza region in Kenya.

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