Obesity or hypertension at ART initiation and outcomes amongst HIV patients in South Africa

Abstract

Background: Aging, antiretroviral therapy (ART) and HIV infection itself have all been associated with increasing rates of chronic comorbidities in HIV patients but there are limited data on chronic disease risk factors and HIV treatment outcomes in resource-limited settings. We evaluated the association between high body mass index (BMI) or hypertension at ART initiation and mortality, loss to follow-up (LTF), and immunological and virologic response among HIV-positive patients on treatment in South Africa. Methods: Prospective cohort study over 4 years among ART naïve adults initiating ART in Johannesburg between April 2004 and July 2009. Cox regression was used to model the association with mortality and LTF of BMI (<18, 18-24.9, 25-29.9 and >30kg/m2) and blood pressure (BP) grouped as normal (systolic <140 and diastolic <90 mmHg), mild (systolic 140-159.9 and/or diastolic 90-99.9 mmHg) and moderate/severe (systolic >160 and/or diastolic >100 mmHg). Linear and log-binomial regression were used to evaluate associations with CD4 increase and viral load >400 copies/mL, respectively. For mortality and LTF, person-time started at ART initiation and ended at the earliest of death, LTF, transfer or dataset close (July 2013). Results: 63% of the 9693 patients included were female and the majority (92%) initiated stavudine-lamivudine-efavirenz. At ART initiation median (IQR) CD4 count was 86 cells/mm3 (33-154), BMI 21.4 kg/m2 (19.0-24.5), systolic BP 116 mm/Hg (105-128), and diastolic BP 76 mm/Hg (68-85). By 48 months, 1001 (10%) patients died and 2069 (21%) were LTF. We found patients with a BMI >30 kg/m2 had an increase in mortality over 48 months on ART compared to patients with a BMI of 18-24.9 kg/m2, but lower LTF and improved immune response during follow-up (Table). We found no association between obesity and having a detectable viral load. Patients with moderate/severe hypertension (vs. normal) had a slight increase in mortality (30-40%) over follow-up but no increase in LTF, CD4 response, or having a detectable viral load. Conclusion: Chronic disease risk factors at ART initiation may be associated with small increases in mortality but appear to be protective against LTF and poor immunological response. Successful management and treatment of comorbidities, specifically amongst obese patients that present with moderate to severe hypertension, may help decrease mortality in HIV-infected patients.

Conference: CROI conference 2014, Boston USA