Missed opportunities for NCD multimorbidity prevention in adolescents and youth living with HIV in urban South Africa

Non-communicable diseases (NCDs) are responsible for more than half of the global burden of disease [1] with 71% of global deaths in 2016 due to NCDs [2]. The burden of NCDs is increasing most rapidly in low- and middle-income countries (LMIC) with NCDs projected to account for nearly half of the burden of disease in low-income countries by 2030 and a four-fold higher probability of NCD-related premature deaths compared to high-income countries [2]. This trend is driven by rapid unplanned urbanization, globalization of unhealthy lifestyles such as tobacco use, physical inactivity, unhealthy diet and harmful use of alcohol [3] and population ageing [4, 5], resulting in a protracted epidemiological transition [6] with an emerging epidemic of obesity, diabetes and other NCDs alongside persisting infectious disease epidemics [7].

Of note, NCDs are affecting younger populations, and are associated with worse health and economic outcomes in low- and middle-income countries compared to high-income countries [8]. The estimated overall cost of diabetes in sub-Saharan Africa was US$19·45 billion or 1·2% of cumulative gross domestic product in 2015 [9] with health systems unable to provide adequate management for diabetes and its associated risk factors and sequelae [9]. This growing cost of NCDs is of particular concern as LMICs are grappling with higher levels of NCD at earlier stages of economic development, with fewer resources, and with less time to respond effectively [10]. This highlights the importance of a focus on prevention of NCDs through early identification of modifiable risk factors at the primary care level across the life-course as the most feasible and cost- effective approach to maintaining population health [11].

Adolescence, a period of transition from childhood to adulthood, is defined as the period between the ages of 10–19 years [12], with some definitions extending this life stage to 24 years [13]. It is a period that comes with unique challenges as adolescents strive to develop autonomy and self-identity through exploration and risk-taking [14‐16], with a significant part of adolescence lying in its power to translate childhood experiences into competencies and statuses that facilitate the transition to adulthood [16].

Adolescents and youth aged 10–24 years make up over 25% of the global population, and their numbers are set to rise to two billion by 2032 [17]. Africa has the youngest population in the world, with more than one-third of the total population of sub-Saharan African aged 10 to 24 years [18]. Although adolescents are generally healthy, up to 70% of premature adult deaths reflect behaviours started or reinforced during adolescence [19]. Worldwide, over 10% of young people smoke [20], 81% of adolescents have insufficient physical activity; and 11.7% of adolescents partake in heavy episodic drinking [3, 21]. This is further shaped by the social and commercial determinants of health which influence health-related behaviours. Reinforcing healthier behaviours and protective factors during this critical period of adolescence, can significantly change the health trajectory into adulthood [22].

With the introduction of antiretroviral therapy (ART), HIV can be considered a chronic disease [27]. In countries with a high burden of HIV undergoing rapid urbanization and epidemiological transition, HIV/NCD multimorbidity is becoming increasingly prevalent [25] as people are living longer with HIV [23, 24]. HIV-infected individuals are at increased risk of NCDs compared to HIV-uninfected persons, due partly to HIV-infection [26, 27] and the complications of long-term anti-retroviral therapy [28‐30]. A study in the United States reported that HIV-infected adults had a 1.5 fold increased risk of having a heart attack [31] and were nearly 50% more likely to have received a diagnosis of chronic obstructive pulmonary disease (COPD) compared to demographically and behaviourally similar uninfected controls [32]. Other NCDs more commonly reported in HIV-infected compared to un-infected persons include cardiovascular events [33], hypertension [34, 35], osteoporosis [36], renal impairment [37], diabetes mellitus [38], and depression and neurocognitive disorders [39].

In high HIV-burden settings, multimorbidity is occurring at younger ages with younger persons at a higher level of risk for heart-related conditions attributed to HIV infection [27]. HIV-infected adolescents, particularly those with increased HIV viral load, have been reported to have increased levels of cholesterol and triglycerides [40] and increased biomarkers of vascular dysfunction than HIV-exposed, uninfected adolescents [41]. This is concerning for LMICs where there is a younger age distribution of HIV-infected populations [27]. In a review by Lowenthal et al., the authors found that in sub-Saharan Africa, one of the striking features of HIV infection in adolescence is the high prevalence of chronic complications like chronic lung disease, cardiac disease, growth failure, neurocognitive disease, skin, renal and bone diseases [42].

This trend, and the fact that many unhealthy behavioural patterns develop in adolescence, make integrated prevention efforts necessary, and highlight the importance of a focus on HIV-infected adolescents and youth for multimorbidity prevention.

South Africa has the largest HIV epidemic worldwide and the largest ART programme in the world. In 2016, an estimated seven million people were living with HIV in South Africa, with four million of those receiving ART [43]. This epidemic persists in the context of epidemiological transition characterised by a quadruple burden of communicable, non-communicable, perinatal and maternal, and injury-related disorders [44]. Of the 1.6 million adolescents (aged 10–19 years) living with HIV globally in 2018, 310,000 (19%) are in South Africa [45]. These adolescents are growing up in an era of epidemiological transition, characterised by increasing burden of NCDs driven by the unhealthy environments within which they live, necessitating interventions to enhance protective environmental factors and minimize risk behaviours [46].

Whilst young people generally do not access health care services regularly, living with a chronic condition like HIV which requires regular interaction with the health care system [47] represents an opportunity for early identification of NCD risk and intervention to reduce the risk of NCD.

In South Arica, HIV patients in the public sector are primarily seen and treated in HIV clinics. They are routinely monitored via physical examination, point of care and laboratory assessments as part of routine clinical management for HIV. This includes general health screening, patient history and biomedical assessments which can also be used for other chronic disease screening. There has been a gradual move away from vertical services within HIV care, towards more integrated care that includes NCD screening and management in low- and middle-income countries which face a dual burden of HIV and NCDs. An integrated approach which harnesses the successful programmatic approach of the HIV treatment program is recommended to scale up services for NCDs [48]. In South Africa, the National Health Department introduced the Integrated Chronic Disease Management (ICDM) model into primary health care facilities in 2011 in order to bridge fragmented chronic disease care within the public health care system and improve chronic disease health outcomes [49, 50]. However, to date, these efforts have focused on adults. This is despite a recognition of an increasing burden of NCDs among people living with HIV occurring at increasingly earlier ages [25, 27, 51], and the importance of the adolescent and early youth period for development of NCD risk factors that increase the risk of NCDs [13, 14].

Although systematic NCD screening is not formally integrated within adolescent primary care HIV services, general health screening and laboratory tests are done to identify biomedical risk factors. However, it is unclear the extent to which these preventive activities are conducted. We therefore set out to investigate the extent to which NCD comorbidity (prevention, screening and management) is incorporated within existing adolescent HIV primary healthcare services in Cape Town, South Africa.

We conducted a descriptive retrospective study from November 2018 to March 2019, reviewing clinic folders of adolescents and youth enrolled in HIV care across Cape Town.

Health care visits in the preceding 12 months were reviewed in each folder. In patients that had another chronic disease diagnosis recorded, all episodes recorded in the folder, irrespective of date, were extracted.

Data relating to HIV including treatment and opportunistic infections, NCD diagnosis and treatment (diabetes, hypertension, asthma, mood disorders, epilepsy), NCD risk (overweight/obesity, raised blood pressure, substance abuse, and smoking), and general medical history including family history, were extracted from participant folders (See Table 1). Any recorded health promotion interventions related to HIV, sexual health or NCD risk were also extracted. A more detailed description of data collected and definitions used is included in an additional file [see Additional file 1].

The majority of patients were virally suppressed (69%) (median CD4 count 489 cells/mm³ (IQR (355—690 cells/mm³)) and on first line ART regimens (78%), (fixed-dose tenofovir-based (61%); abacavir- lamivudine based regimens (17%)) as shown in Table 1.

Seven percent (36/491) had a documented HIV opportunistic infection or an ART-related condition. Of those, the most prevalent conditions were herpes zoster/ shingles (39%), followed by pruritic papular eruption (PPE) (29%), and oral thrush (7%) or oral candida (7%). The reported cases of opportunistic infections were documented to have received appropriate treatment (antibiotics, antivirals or antifungals). In addition, 14% of non-ARV medications prescribed in the previous 12 months consisted of cotrimoxazole prophylaxis to prevent opportunistic infections.

Fifty-five percent (n = 268) of folders reviewed had documented information on comorbidities, of which 11% were NCD comorbidities. Of these, the most prevalent NCDs documented were chronic respiratory diseases (asthma, bronchitis, COPD (60%)) and mental health disorders (depression, anxiety or other mental health conditions (37%)) (Table 1). Despite this, only one participant was documented as receiving treatment for asthma. Other documented NCD treatment received in the previous 12 months were for high blood pressure, psychosis and high cholesterol/ triglycerides.

In terms of NCD risk factors documented, 4% were current smokers or had a history of smoking, and 3% used alcohol, drugs or other substances. Only 62% of folders reviewed had documented anthropometric data (height and weight). Of these, 48% were overweight or obese (26 and 22% respectively) and 10% were underweight. Fifty-nine percent of folders reviewed had a documented blood pressure. Of these, the majority (73%) were normal (< 130/85 mmHg), 14% had elevated blood pressure, and 12% showed signs of mild hypertension (SBP 140-159 mmHg or DBP 90- 99 mmHg). There were three cases (1%) with moderate hypertension documented (SBP 160–179 mmHg or DBP 100–109 mmHg).

Family history was documented in 6% of the folders reviewed. Of these, the most common condition documented was tuberculosis (69%), followed by diabetes (14%), high blood pressure (7%) and alcoholism (7%). Other non-infectious conditions were documented in 11% of the folders reviewed. These conditions ranged from current/ previous pregnancy (60%), experiences of trauma due to injury or violence (11%) and epilepsy, learning difficulties (10%) and failure to thrive (10%). There were isolated cases reported of conditions such as peripheral neuropathy, hearing loss, impetigo, severe dermatitis and lymphadenopathy.

Other non-ARV medications prescribed in the last 12 months (27%) were TB prophylaxis (22%), antibiotics (33%), STI treatment (17%), steroids (12%), antiviral medication (2%) and contraceptives (4%).

Twenty-six percent of participants had a documented health promoting intervention, ranging from HIV- and NCD- to sexual and reproductive health-related interventions. Seven percent received disclosure counselling to facilitate full disclosure of their HIV status and 9% underwent adherence counselling (Table 2). For NCD-related health promotion, 13% received alcohol or substance abuse counselling; 10% received mental health counselling, 9% were advised on healthy weight or diet and 9% were counselled about smoking tobacco. One singular case was documented of a diabetes screening intervention. Eleven percent underwent family planning or basic antenatal care counselling each, while 5% were referred for a pap smear or breast examination, Medical male circumcision and safe sex counselling were documented in 2% of the folders. Other health promotion interventions documented were hygiene counselling (3%) and physiotherapy/occupational therapy (2%).