Evaluation of the management of HIV/AIDs with diabetes as a comorbid condition in public health facilities in eThekwini Metro of KwaZulu-Natal: defining contributory factors to patient outcomes.

Abstract

Introduction HIV/AIDS has remained a huge burden. It is still affecting large population of people globally with mortality of over 35 million people. South Africa is the most affected country. Substantial progress has been made in HIV antiretroviral therapy which is now capable of suppressing viral replication and prevent transmission. Great efforts and significant successes have been recorded in the fight against HIV/AIDS especially in South Africa. With effective medications, PLWH now have increased longevity, this makes them susceptible to chronic diseases like diabetes. The burden of diabetes is also high in KwaZulu-Natal, which also comes with its attendant complications. Despite the progress made, the scourge of HIV/AIDS and diabetes still persists. Hence this study aimed to evaluate the management of HIV/AIDS and diabetes as a comorbid condition, and to determine factors that contribute to patient outcomes. Methodology The study was conducted in 4 HIV clinics attached to Public Sector Hospitals in the eThekwini Metro of Kwazulu-Natal (KZN) South Africa after obtaining ethical approval. A total of 1,203 adult, non-pregnant patients living with HIV and were receiving antiretroviral therapy for at least 6 months between 2005 and 2019 were randomly selected and recruited in the study after obtaining written consent from them. Data was collected using questionnaire and from patient chart. The statistical package for social sciences (SPSS) software version 26 was used to analyze the data using descriptive statistics, Chi square and logistic regression. Results were presented, discussion and conclusion were made as appropriate.

Results There were 770 (64%) females and 405 (33.7%) males included in this study, with 29 to 48 years as the largest age group (60.2%). Clinicians prescribed the recommended add regimens in all cases. TDF + FTC + EFV was the most recommended regimen at 65%. On the average 43.85% of HIV patients were initiated on ART at CD4 count <200 cells/µL. Male gender and baseline CD4 count were the predictors of ART regimen changes. It was found that 40.8% of PLWH on ART were virally suppressed. The probability of achieving viral suppression was significantly less in younger patients, the less educated and those with baseline CD4 cells count less than 200cells/µL, while the likelihood of achieving viral suppression was about 4 times higher for those that received encouragement from family to adhere to ART. The prevalence of immunologic failure among PLWH on ART was 8.6 % (CD4 cell count <200 cells/µL). CD4 cells count outcome was statistically significantly associated with gender, poor adherence to ART and baseline CD4 cells count. The probability of immunologic decline for those who did not strictly adhere to ART was more than 3 folds higher than those who adhered to ART; and the probability of immunologic failure was more than 8 folds higher for those who had baseline CD4 cells <200 cells/µL than those who had baseline CD4 cells ≥200 cells/µL. The prevalence of diabetes among PLWH on ART was 9%. Over 47% of those who had diabetes, had uncontrolled blood sugar, with a mean fasting blood sugar (FBS) of 11.7 mmol/L. The predictors of diabetes among PLWH on ART were, gender and age. Male PLWH had 65% less chances of having diabetes and those who were between the ages of 18 and 48 years were 88% less probable to have diabetes compared to those who were older than 48 years. Conclusion and Recommendations Clinicians adhered to the national treatment guidelines, but significant percentage of the patients were initiated on ART late resulting in poor outcome. Those who test positive for HIV should be informed on the benefits of initiating ART early, the possible consequence of late initiation of ART and Clinicians must ensure everyone who needs ART is offered one without delay. The prevalence of immunologic failure was 8.6%. Predictors to immunologic failure were nonadherence and late initiation of ART (CD4 cells <200 cells/µL). Prevalence of viral suppression was low (40.8%). The chances of virological failure was higher among younger, less educated, patients who started ART late (<200cells/µL) and patients who received encouragement from family to adhere to ART. Young PLWH should be regularly counselled on the benefits of adherence to ART, those that are not educated should be taught in languages they best understand, and pictorial illustrations should be used for counselling and family members should be involved in the follow up and encouragement of patients. That should be done with the permission of patients. The prevalence of diabetes among PLWH was high (9%) and 47% of these did not have glyacemic control (mean FBS was 11.7 mmol/L). The predictors were male gender and older age. Those who test positive to HIV should also be screened for diabetes before commencement of ART and treatment for diabetes should be initiated as ART is initiated and blood sugar should be monitored regularly to ensure glycaemic control, which is essential for the prevention of diabetic complications.