High cholesterol and diabetes common among people on HIV treatment in Malawi

High LDL cholesterol levels and diabetes are much more common in people living with HIV on long-term antiretroviral treatment in Malawi compared to people of a similar age without HIV, especially in people over 60, a study conducted in Chiradzulu, Malawi, has found. The findings, published in the journal AIDS, indicate a large unmet need for cardiovascular disease risk management among people taking antiretroviral therapy in a low-income setting.

Non-communicable diseases such as diabetes and cardiovascular disease are becoming more common among people living with HIV as antiretroviral treatment prolongs life. The prevalence of cardiovascular disease is higher among people living with HIV than those without HIV, partly because of the higher prevalence of smoking in people with HIV but also because of HIV-related factors. Low-level inflammation caused by HIV infection and some antiretroviral drugs may increase the risk of cardiovascular disease too.

In 2016, 13.8 million people were taking antiretroviral drugs in sub-Saharan Africa, yet little is known about the prevalence of cardiovascular disease and associated risk factors in Africans living with HIV, nor how these patterns might vary by region and between rural and urban settings. Diagnosis, monitoring and treatment of non-communicable diseases are all very limited in sub-Saharan Africa, but as the number of people on long-term antiretroviral treatment grows, non-communicable diseases are likely to become as significant as the management of AIDS-defining illnesses in HIV care.

To investigate these issues, Médecins Sans Frontières carried out a cross-sectional study in the Chiradzulu district of Malawi, in people with HIV who had been taking antiretroviral treatment for at least ten years and HIV-negative people aged 30 or over receiving care at local health centres. Médecins Sans Frontières has been providing antiretroviral treatment in the district since 2001.

The study recruited 379 people with HIV and 356 HIV-negative controls matched by sex. The study population was 73% female. People living with HIV were somewhat younger than the control group (median 47 vs 52 years). Study participants were stratified into three age cohorts: 30-44 years (139 people with HIV and 116 controls), 45-59 (202 people with HIV and 121 controls) and 60 and over (38 people with HIV and 119 controls).

In people living with HIV, the predominant form of current treatment consisted of tenofovir, lamivudine and efavirenz (88%) but the vast majority of people had started treatment with stavudine, lamivudine and nevirapine, and the median time on treatment was 11.6 years.

The study found that people with HIV over 60 were much more likely to have type 2 diabetes (13.2 vs 1.7%). People with HIV were also more likely to have elevated LDL cholesterol levels (13.6 vs 8.8%) above 130mg/dL (3.36 mmol/L) and people with HIV aged 60 and over were five times more likely to have elevated LDL cholesterol (adjusted odds ratio 5.1, 95% CI 2.3-11.1). There was no gender difference in either cholesterol elevation or HbA1c (glycated haemoglobin, a measure of average blood sugar levels), but cholesterol elevation was more frequent among those people with HIV who had secondary education or higher, and among people with HIV who were obese or overweight.

When the researchers looked at Framingham 10-year risk score for heart disease they found that the prevalence of a risk score above 20% – indicating a 20% or higher risk of a cardiovascular event within ten years – did not differ between people with HIV and controls aged 60 and over, but was significantly higher overall in men with HIV when compared to women (23.7 vs 3.9%, p < 0.001). Indeed, regardless of HIV status, men were more likely to have an elevated risk of heart disease.

Undiagnosed high blood pressure was more common in people with HIV despite clinic visits and check-ups every 3-6 months.

The researchers conclude: “Our findings highlight the need to implement screening and treatment of diabetes, hypertension and hypercholesterolaemia for at-risk, HIV-infected individuals on ART [antiretroviral therapy]. However, they also serve as a reminder that CVD [cardiovascular disease] risk is not limited to those with HIV, and that at-risk uninfected individuals, especially older community members, have NCD [non-communicable disease] screening and treatment needs as well.”

Mathabire Rücker S et al. High rates of hypertension, diabetes, elevated cholesterol, and cardiovascular disease risk factors in HIV-infected patients in Malawi. AIDS 32: 253-60, 2018.