Cardiovascular risk factors among Ghanaian patients with HIV: A cross‐sectional study

Abstract Background Cardiovascular disease (CVD) poses a significant cause of morbidity and mortality among people living with human immunodeficiency virus (HIV). However, data are limited on CVD risk burden among HIV patients in Ghana. We describe the age‐ and sex‐adjusted prevalence of CVD risk factors among HIV patients in Ghana. Methods From January 2013 to May 2014, we identified eligible HIV patients 18 years and older, as well as uninfected adult blood donors presenting to the Komfo Anokye Teaching Hospital as controls. Using a standardized protocol, we collected demographic, clinical, laboratory, and electrocardiographic data. We created multivariable logistic regression models to compare the prevalence of abnormal risk factors between the two groups. Results We recruited 345 patients with HIV (n = 173 on HAART, n = 172 not on HAART) and 161 uninfected adult blood donors. Patients with HIV were older (mean [SD] age: 41 [11] vs 32 [11] years) and were more likely to be female (72% vs 28%) than blood donors. Among patients on HAART, median (interquartile range) treatment duration was 17 (4‐52) months. The prevalence of hypertension, hypercholesterolemia, and diabetes mellitus among HIV patients was 9%, 29%, and 5%, respectively, compared with 5%, 15%, and 0.6% among uninfected blood donors. Smoking was the least prevalent CVD risk factor (1%‐2%). After adjustment for age, sex, and body mass index, HIV patients had a 10‐fold higher odds of prevalent diabetes compared with controls, (adjusted OR = 10.3 [95% CI: 1.2, 86.7]). Conclusion CVD risk factors are common among HIV patients in Ghana, demonstrating the urgent need for creation and implementation of strategic CVD interventions.


| INTRODUCTION
Human immunodeficiency virus/ acquired immune deficiency syndrome (HIV/AIDS) is the leading cause of death in Africa accounting for 20% of mortality. HIV prevalence is also high: although sub-Saharan Africa (SSA) has only 11% of the world's population, 70% of all adults with HIV live in SSA. 1 Antiretroviral therapy has substantially improved the prognosis for HIV-infected patients 2 with steadily declining HIV/AIDs-related deaths within SSA following the dramatic scaling up of antiretroviral therapy and other priority HIV/AIDS interventions since 2004. 3 Amidst falling HIV incidence rates, people living with HIV are living longer and are thus exposed to risks for comorbid conditions, especially cardiovascular diseases (CVD). HIV/AIDS, highly active antiretroviral therapy (HAART), and associated behaviors lead to 50% to 100% higher risk for CVD among individuals living with HIV compared with the general population. 4,5 The combination of HIV and CVD has created an epidemic that is projected to surpass infectious disease alone as the leading cause of mortality in SSA by 2030 6 and presents a significant risk toward achieving the United Nations' Sustainable Development Goals 3.3 and 3.4 which aim to end the AIDS epidemic and to reduce the risk of premature deaths from noncommunicable diseases by one-third by 2030, respectively. 7 Routine assessment and monitoring of CVD risk among HIV patients globally is generally suboptimal 8 with only one published report from Ghana, in particular. 9 This current study sought to fill this gap in knowledge and to estimate the CVD burden of HIV patients presenting for routine visits at the largest HIV clinic in central Ghana.
The ultimate aim is to drive policy and practice reforms in universal access to comprehensive, accessible, and quality health services to reduce HIV-related morbidity and mortality. We recruited consecutive adult HIV patients 18 years or older presenting to the HIV clinic for routinely scheduled visits and HIV-negative adult blood donors presenting to the blood bank of the hospital to serve as controls. All participants provided written informed consent.

| Study procedures
All participants completed a standardized questionnaire to capture data on demographics, socioeconomic position, medical history, and medication use by trained study personnel. At the time of interview, anthropometry, blood pressure, and 12-lead electrocardiographic measurements were obtained. Weight and height were measured without shoes while wearing light clothes, and body mass index (BMI) was calculated as the weight in kilograms divided by the square of the height in meters. The abdominal circumference was measured as the narrowest circumference between the lower rib margin and anterior superior iliac crest above the umbilicus at exhalation. Participants had their systolic blood pressure (SBP) and diastolic blood pressure (DBP) measured after 5 minutes of rest in a seated position with their arms, back, and feet supported. The first and fifth Korotkoff sounds were registered to indicate SBP and DBP, respectively. Two blood pressure measures were obtained, and the mean was calculated. Hypertension was defined as SBP ≥ 140 mmHg, DBP ≥ 90 mmHg, or taking blood pressure lowering medications.

| Statistical analysis
We first compared the demographics and clinical covariates of individuals with HIV infection and adult blood donors without HIV. Subsequently, we compared the prevalence of CVD risk factors for two groups before and after adjustment for demographics using multivariable logistic regression models that adjusted for age, sex, and BMI.
We also explored differences among individuals with HIV who were and were not on baseline HAART. In all analyses, two-sided P-values of < .05 were considered statistically significant. We used Stata SE (version 13) for statistical analyses.

| Characteristics of study population
The flowchart of participants is shown in Figure 1, and baseline characteristics of the participants are outlined in Table 1 Tables S1 and S2.

| Comparison with previous research
DM was prevalent in 5% of patients with HIV in this study, which is similar to rates ranging from 4% to 8% reported in seven Latin American countries and South Africa, respectively. 10,11 The prevalence of diabetes in the present study was similar to reported rates in the general Ghanaian population, 12,13 but lower than rates among individuals with HIV in Nigeria (11% prevalence) and Senegal (15% prevalence), respectively. 14,15 In these studies, patients had been on HAART for a longer duration and on predominantly protease inhibitor-based regimes, which was very low in the current study (1%). Protease inhibitors increase the risk for dysmetabolic states, which contributes to the increased incidence of diabetes in the HIV population. 16 Abdominal obesity was commonly seen among patients with HIV on baseline HAART compared with patients with HIV not on baseline HAART, even after adjusting for confounders; a similar trend was also observed for BMI. Plausible reasons include the improved immune system function with initiating HAART, deliberate attempts by patients to gain weight to obscure their HIV diagnosis, and the syndrome of fat redistribution that is associated with the use of HAART including zidovudine. 28 These results may also mirror the rising trend in weight gain in the general Ghanaian population. 29 Hypertriglyceridemia and high LDL-C levels were similar across the various study groups, with similar results reported within other studies in SSA. 30 37 A higher prevalence has been reported, however, in both a Senegalese cohort (28%) and a recent Ghanaian cohort (40%), which may be due to differences in baseline age and sex. 9,15,38 These findings underscore the fact that the burden of hypertension is likely to rise with an aging HIV population and should attract proportionate public health and clinical response to curb the projected increase in prevalence and its associated disease burden.
A smoking prevalence of 2% among patients with HIV and 1% prevalence in blood donors without HIV likely reflect the low smoking habits of Ghanaians, in general when compared to its West African counterparts. 39

| Strengths and limitations
This study is one of the first few studies describing the prevalence of abnormal undiagnosed CVD risk factors within the Ghanaian HIV population and will help contribute to accruing data and ongoing debate on the burden of CVD and the need to integrate CVD care in the routine care of HIV patients. On the other hand, this study also has inherent limitations, including a nonrepresentative sampling frame, its cross-sectional study design, and baseline dif-

| CONCLUSION
This study demonstrates that abnormal undiagnosed CVD risk factors including obesity, hypertension, hypercholesterolemia, and DM were common and that HIV patients with CD4 count above 350 had higher odds of having more than one CVD risk factors compared to adult blood donors without HIV. HIV physicians and systems must scale up efforts to consolidate gains made so far with HAART by routinely assessing CVD risk factors for better prevention, treatment, and control.