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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 AI110264 (Bassett) NIH K23 AI018393 (Drain)
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Disclosures Dr. Bassett has no financial relationships with commercial entities to disclose
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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
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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
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Objective To estimate the prevalence of and risk factors for hypertension and diabetes at the time of HIV testing in Durban, South Africa
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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
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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
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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) http://www.idf.org/webdata/docs/WHO_IDF_definition_diagnosis_of_diabetes.pdf
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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
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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
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Results Enrolled N = 3,852 HIV-infected N = 1,357 (35%)
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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%
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Clinical Characteristics HIV-infected participants CD4 count, median (IQR)299/µl (154-457) Hypertension10% Likely IGT or diabetes4% Obese (BMI≥30)20% HIV-uninfected participants Hypertension11%
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Univariate Models: Hypertension Risk factorValueOR (95% CI) Age<25- 25-341.2 (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
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Multivariable Logistic Regression: Hypertension The following were associated with hypertension: Age ≥35 (OR 2.7, 95% CI 1.4-5.1) (compared to <25) BMI ≥30 (OR 1.9, 95% CI 1.2-2.9) (compared to <30)
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Univariate Models: IGT/Diabetes Risk factorValueOR (95% CI) Age<25- 25-344 (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
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Only the following was associated with IGT/diabetes: Not walking to clinic (OR 2.6, 95% CI 1.2-5.5) (compared to walking to clinic) Multivariable Logistic Regression: IGT/diabetes
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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
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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
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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
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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
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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
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Acknowledgements Durban Sabina Govere Nosipho Dladla Esihle Mathonsi Yvonne Mbanjwa Simo Nkilana Siyabonga Nzimande Study participants and staff at iThembalabantu Clinic NIH R21 AI110264 (Bassett); NIH K23 AI018393 (Drain)
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