Screening for hypertension and diabetes at the time of HIV testing in Umlazi Township, Durban, South Africa Ingrid V. Bassett, Ting Hong, Paul Drain, Sabina Govere, Hilary Thulare, Meighan Krows, Mahomed-Yunus Moosa, Bright Mhlongo, Deborah J. Wexler, Mingshu Huang, Simone Frank, Emily P. Hyle, Robert A. Parker Abstract number: THAE0204 Funded by NIH R21 AI (Bassett) NIH K23 AI (Drain)

Disclosures  Dr. Bassett has no financial relationships with commercial entities to disclose

Background: HIV and Diabetes  As HIV-infected people age, they are at increased risk for diabetes and associated cardiovascular disease risk factors, such as hypertension, compared to age- matched, HIV-uninfected peers  The proportion of adults living with diabetes in sub-Saharan Africa is expected to double in the next 20 years Brown 2005 Peer 2014

Background: HIV and NCDs  2015 South African HIV treatment guidelines recommend screening for hypertension and diabetes before ART  How to best implement this guideline and the yield of integrated screening strategies remains unknown  Predictors of hypertension and diabetes in this setting may be useful for targeted screening–e.g., food insecurity is a risk factor for diabetes in US Department of Health South Africa, National Consolidated Guidelines, January 2015 Berkowitz, 2013

Objective  To estimate the prevalence of and risk factors for hypertension and diabetes at the time of HIV testing in Durban, South Africa

Methods: Study Population  Adult (≥18y) patients  English or Zulu speaking  Presenting for voluntary HIV testing at a high-volume HIV clinic in Umlazi Township, September 2013 – May 2016

Methods: Enrollment Procedures Enrollment and baseline assessment Rapid HIV test Height, weight, random glucose by point-of-care glucometer If HIV-infected Mode of transport to clinic (walk, public bus/taxi, car) Food insecurity access scale Seated blood pressure

Methods: Outcomes  Hypertension: systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg  Diabetes: random blood glucose ≥11.1 mmol/L  Likely impaired glucose tolerance (IGT) or prediabetes: random blood glucose ≥7.8 to <11.1 mmol/L (based on International Diabetes Federation definition 2 hours post a 75g oral glucose load)

Methods: Definitions  Obese: body mass index (BMI) ≥30 kg/m 2  Food insecurity: USAID household food insecurity access scale score (secure, mildly, moderately, and severely food insecure) USAID Household Food Insecurity Access Scale: Indicator Guide, 2007

Methods: Statistical Analysis  We used separate univariate and multivariable logistic regression models to determine risk factors for hypertension and IGT/diabetes among HIV-infected participants

Results Enrolled N = 3,852 HIV-infected N = 1,357 (35%)

Baseline Characteristics HIV+ (N=1,357)HIV- (N=2,495) Age, mean (SD)33 (9)30 (10) Female60%45% Mode of transport to clinic Walk Public bus/taxi Car 79% 21% <1% 79% 20% 1% Food insecurity Food secure Mildly food insecure Moderately food insecure Severely food insecure 86% 4% 6% 4% 88% 4% 5% 2%

Clinical Characteristics HIV-infected participants CD4 count, median (IQR)299/µl ( ) Hypertension10% Likely IGT or diabetes4% Obese (BMI≥30)20% HIV-uninfected participants Hypertension11%

Univariate Models: Hypertension Risk factorValueOR (95% CI) Age< (0.6, 2.3) ≥352.9 (1.5, 5.4) GenderFemale0.7 (0.5, 1.1) Male- BMI<30- ≥302.0 (1.4, 3.0)* Walking to clinicYes- No1.1 (0.7, 1.7) Baseline CD4 count (per 100)1.1 (1.0, 1.1) Household food insecuritySeverely food insecure2.5 (1.0, 6.1) *p value < 0.05

Multivariable Logistic Regression: Hypertension  The following were associated with hypertension:  Age ≥35 (OR 2.7, 95% CI ) (compared to <25)  BMI ≥30 (OR 1.9, 95% CI ) (compared to <30)

Univariate Models: IGT/Diabetes Risk factorValueOR (95% CI) Age< (0.5, 30.9) ≥357.6 (1,58.4) GenderFemale0.6 (0.3, 1.3) Male- BMI<30- ≥302.3 (1.0, 5.0)* Walking to clinicYes- No2.7 (1.3, 5.7)* Baseline CD4 count (per 100)1.0 (0.9, 1.2) HypertensionStage 1 and above2.4 (1.0, 6.2) Normal or pre - Household food insecuritySeverely food insecure1.8 (0.2,14) *p value < 0.05

 Only the following was associated with IGT/diabetes:  Not walking to clinic (OR 2.6, 95% CI ) (compared to walking to clinic) Multivariable Logistic Regression: IGT/diabetes

Limitations  We only measured blood glucose for HIV- infected participants  Blood glucose levels were random; we applied IDF 2-hour glucose levels for IGT definition  Because of a relatively small number of diabetes cases, we could only assess a small number of risk factors  We did not know about prior diagnosis of hypertension or diabetes

Summary of Results  HIV-infected participants had similar rates of hypertension compared to HIV- uninfected participants (10% - 11%)  Among HIV-infected participants, 4% met criteria for likely IGT or diabetes and 20% were obese  10% of people with HIV had moderate/severe household food insecurity scores  Food insecurity and CD4 count were not associated with diabetes or hypertension

 Age ≥35 (OR 2.7) and BMI ≥30 (OR 1.9) were associated with hypertension  Not walking to clinic (OR 2.6) was associated with IGT/diabetes Summary of Results

Conclusions (1)  Screening for hypertension was high-yield at the time of HIV testing  A substantial number of hypertension cases identified among those without HIV, further supporting integrated screening

Conclusions (2)  Screening for diabetes was also high-yield among those with HIV infection  Traveling to clinic by public transport/car vs. walking may indicate low physical activity and is a novel predictor of IGT/diabetes  The timing and yield of screening for incident hypertension and diabetes while on ART remains unknown

Acknowledgements Durban Sabina Govere Nosipho Dladla Esihle Mathonsi Yvonne Mbanjwa Simo Nkilana Siyabonga Nzimande Study participants and staff at iThembalabantu Clinic NIH R21 AI (Bassett); NIH K23 AI (Drain)