Journal of Internal Medicine and Health Affairs

Abstract

Background: Hypertension and diabetes mellitus are significant non-communicable diseases (NCDs) that increasingly impact people living with HIV (PLHIV), especially in resource-limited settings. Antiretroviral therapy (ART) has extended life expectancy among PLHIV but poses metabolic and cardiovascular challenges, necessitating comprehensive NCD management. This study evaluates the prevalence and determinants of hypertension and diabetes mellitus among PLHIV receiving ART at Zonal Hospital Ahoada, Rivers State, Nigeria. Aim/Objective: To determine the prevalence of hypertension and diabetes mellitus among PLHIV, examine associations with ART duration, and provide data for integrated NCD and HIV care models. Methods: This cross-sectional study was conducted from January 2022 to February 2023. A total of 173 PLHIV receiving ART were consecutively recruited. Sociodemographic and clinical data were collected using the Electronic Medical Record system. Hypertension and diabetes prevalence were assessed through blood pressure and fasting blood glucose measurements, respectively. Statistical analysis, including chi-square and logistic regression, was conducted using SPSS v25 to explore associations between NCDs and ART duration. Results: The prevalence of hypertension and diabetes mellitus among PLHIV was 22% and 27.2%, respectively. Hypertension was most prevalent among participants on ART for over 10 years (28.6%), while diabetes peaked among those on ART for 1–5 years (29.5%). Statistical analysis revealed no significant associations between ART duration and hypertension (P = 0.76) or diabetes (P = 0.19). Demographic data showed that the majority of participants were female (74.6%) and aged 50 years or older (47.4%), with high unemployment rates (90.8%). Conclusion: PLHIV in this study demonstrated a significant burden of hypertension and diabetes, underlining the need for integrated HIV and NCD management. While ART duration showed no significant association with NCD prevalence, other factors such as age and socioeconomic status likely contribute to these outcomes. Comprehensive screening and targeted interventions are essential to improve health outcomes in this population.

Introduction

Hypertension and diabetes mellitus are chronic non-communicable diseases (NCDs) that present significant health challenges worldwide [1-2]. Characterized by persistently elevated blood pressure and heightened blood glucose levels, these conditions are leading contributors to severe complications such as cardiovascular diseases and kidney disorders [3]. In recent decades, their global prevalence has escalated, posing substantial burdens on public health and healthcare systems [4].

This burden is particularly pronounced among vulnerable groups, including people living with HIV (PLHIV), who face unique challenges in managing hypertension and diabetes due to the long-term effects of antiretroviral therapy (ART) and the interactions between HIV infection and the immune system [5]. Understanding the prevalence of these comorbidities among PLHIV is crucial for effective healthcare planning and resource allocation.

Subsequent research is essential to further explore the interaction between HIV infection, ART, and the emergence of hypertension and diabetes. Factors such as lifestyle behaviors, genetics, and socio-economic conditions must also be considered, as they significantly influence the development of NCDs among PLHIV.

Given the high prevalence of hypertension and diabetes globally and their potential impact on PLHIV, this study seeks to evaluate the frequency of these conditions among PLHIV receiving treatment at Zonal Hospital Ahoada. Additionally, it examines the relationship between ART duration and the occurrence of these comorbidities to provide actionable insights for improving healthcare delivery to this population.

The increased availability and effectiveness of ART have markedly improved the life expectancy and quality of life for PLHIV [6]. Consequently, the focus of HIV care has expanded to include the prevention and management of NCDs. However, evidence suggests that PLHIV experience a higher prevalence of hypertension and diabetes compared to the general population [7-9]. This trend raises concerns about the potential metabolic and cardiovascular implications of prolonged ART use. Persistent inflammation associated with HIV infection, combined with ART-induced metabolic alterations such as insulin resistance and dyslipidemia, may increase susceptibility to these conditionsthe coexistence of HIV and NCDs presents unique challenges for healthcare providers. Chronic inflammation from HIV, ART-induced metabolic disturbances, and conventional risk factors like age, obesity, and lifestyle behaviors contribute to higher rates of hypertension and diabetes among PLHIV [10].In Nigeria, with an estimated 3 million people living with HIV [11],

The Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) 2018 report revealed significant regional variations in HIV prevalence across Nigeria. While the national prevalence among adults aged 15-49 is 1.4%, it exceeds 3.8% in Rivers State, where Ahoada East Local Government Area has over 6,670 individuals receiving HIV treatment. These figures highlights the urgency of addressing HIV alongside its associated comorbidities, particularly hypertension and diabetes [12]. Despite advancements in HIV treatment, non-communicable diseases remain leading causes of mortality among PLHIV, especially in underserved areas. Inadequate screening and treatment support exacerbate these challenges, highlighting the need for research to inform targeted interventions.

This study at Zonal Hospital Ahoada aims to address these gaps by assessing the prevalence of hypertension and diabetes among PLHIV, evaluating ART regimens and their duration of use, and exploring the relationship between ART duration and the development of these conditions.

The findings will offer baseline data essential for designing effective interventions to address the dual burden of HIV and NCDs. Furthermore, the study emphasizes the importance of integrated HIV and NCD management services to improve health outcomes and the quality of life for PLHIV in Rivers State and similar settings.

Ultimately, addressing the coexistence of HIV, hypertension, and diabetes requires collaborative efforts among policymakers, healthcare professionals, and community stakeholders. This research aims to contribute valuable insights to guide healthcare policies and evidence-based interventions, ensuring holistic care for PLHIV and reducing the overall burden of these diseases.

Methodology

Study Design

This descriptive cross-sectional study was conducted at the HIV clinic of Zonal Hospital Ahoada, Rivers State, from January 2022 to February 2023. Participants were selected using the Electronic Medical Record (EMR) system and Nigeria Data Repository, which provided demographic and HIV-related data.

Study Area      

The research was conducted in Ahoada, a key trade hub in Rivers State, characterized by a tropical rainforest climate and essential infrastructure like health facilities and markets.

Study Population

The study involved 173 individuals living with HIV who had initiated ART at Zonal Hospital Bori within the past three years, a period marked by frequent communal conflicts. Participants were consecutively enrolled throughout the study until the required sample size was reached. All HIV-positive individuals receiving ART were eligible to participate, except those who did not meet the inclusion criteria.

Eligibility Criteria

The inclusion and exclusion criteria are stated as follows;

Inclusion Criteria

The study's inclusion criteria encompass individuals who are 18 years and older, living with HIV (PLHIV), and currently undergoing Antiretroviral Therapy (ART). Participants must have been on ART for a minimum duration of 6 months and should provide informed consent for their involvement.

Exclusion criteria

Individuals living with HIV but not currently undergoing Antiretroviral Therapy. Participants who have been on ART for less than 6 months. Individuals unable to provide informed consent. Participants with severe cognitive impairments or psychiatric disorders that could affect their ability to participate in the study and participants who were unable to comply with study procedures or requirements.

Sample and Sampling Method

The health facility was purposively chosen from a list provided by the Rivers State Ministry of Health as it represents one of the few comprehensive sites where people living with HIV from nearby villages receive treatment. The sample was randomly selected from the RADET (Retention and Audit Determination Tool). The study employed specific sampling procedures to align with the data collection strategy requirements. The sample size (173) consisted of all clients aged 18 years and above who visited the study site during the research period, encompassing recorded data such as their sex, age, BMI, fasting blood sugars, and blood pressure measurements on the data collection tools.

Stastistical Analysis

SPSS version 25 was employed for data capture and descriptive data analysis, focusing on determining frequencies and proportions. Categorical data was summarized using proportions, while continuous variables were represented as mean standard deviations where applicable. The non-communicable diseases (NCDs) were treated as dependent variables, while socio-demographic and lifestyle risk factors served as independent variables. Associations between the NCDs and these factors were assessed using chi-square tests. Adjusted odds ratios for each NCD, accounting for various socio-demographic and epidemiological cardiovascular risk factors, were computed through multivariable logistic regression models. The findings were presented in tables and graphs as suitable. Additionally, Pearson regression analysis was utilized to calculate the prevalence ratio (PR) of NCDs concerning sex, age, and duration on antiretroviral therapy   among people living with HIV.

Ethical Approval

Ethical clearance for this study was obtained from the Ethics Review Board of the Department of Public Health, University of Port Harcourt, as well as approval from the Rivers State Ministry of Health. Comprehensive information about the study was provided to all potential participants, and their confidentiality was ensured throughout the research process. Written informed consent was obtained from all participants prior to their enrollment in the study.

Result

Figure 2- Bar chart showing the prevalence of hypertension among PLHIV. Of the total 173 participants, 38 individuals (22.0%) were hypertensive, while 135 (78.0%) were non-hypertensive. The overall prevalence of hypertension in this population is approximately 21.97%. The overall prevalence of 21.97% was calculated by dividing the number of hypertensive PLHIV (38) by the total number of PLHIV (172) and multiplying by 100.

Figure 5 presents Bar chart depicting the relationship between ART duration and the prevalence of diabetes among PLHIV. The highest prevalence of diabetes was observed among those on ART for 1–5 years (29.5%), followed by 6–10 years (25.9%), and the lowest prevalence in participants on ART for more than 10 years (7.1%). Statistical analysis indicated no significant association between ART duration and diabetes (P = 0.19, P < 0.01).

Discussion

The findings of this study highlight an emerging epidemiological challenge: the significant burden of non-communicable diseases, particularly hypertension and diabetes mellitus, among people living with HIV (PLHIV). The prevalence of hypertension (22%) and diabetes (27.2%) observed in this cohort underscores the growing importance of integrating NCD management into routine HIV care, particularly in resource-limited settings like Rivers State, Nigeria. Compared to the general population, where NCD prevalence is often lower, these findings align with prior research demonstrating that PLHIV are at higher risk of metabolic and cardiovascular conditions. A study in South Africa, for example, reported hypertension prevalence rates of 19% to 26% among PLHIV, figures that are comparable to this study's findings and reinforce the notion that hypertension is a significant comorbidity in this population [13]. Similarly, diabetes prevalence rates of 20% to 30% have been documented in studies conducted in Zimbabwe and eThekwini, South Africa, further corroborating the elevated rates observed here [14].

The interplay between chronic inflammation induced by HIV infection, metabolic disturbances from antiretroviral therapy, and traditional risk factors like aging and lifestyle behaviors likely contributes to this heightened burden. However, this study adds nuance by examining ART duration as a potential determinant. In contrast to findings from the Data Collection on Adverse Events of Anti-HIV Drugs (D: A:D) study, which linked longer ART duration to increased NCD prevalence, this study found no statistically significant associations [15]. This discrepancy may be explained by the relatively short mean ART duration (1.32 years) in this cohort, limiting the ability to capture long-term effects.

The demographic composition of the cohort provides additional insights into NCD prevalence patterns. Women constituted the majority (74.6%), reflecting the feminization of the HIV epidemic in sub-Saharan Africa, where biological, social, and economic factors increase women’s vulnerability to infection. The high prevalence of hypertension and diabetes in this group may be partially attributable to sex-specific vulnerabilities, including hormonal influences on cardiovascular and metabolic health. These findings align with earlier research suggesting that women living with HIV are more susceptible to metabolic complications, particularly during ART. For instance, a study conducted in Kenya found that women were at higher risk of ART-induced dyslipidemia, a condition that often precedes diabetes and hypertension [16-17].

Age also emerged as a critical determinant, with nearly half of the participants aged 50 years or older. This is consistent with global trends showing an increased risk of NCDs among aging populations, particularly in PLHIV, where prolonged ART use compounds age-related risks [18-19]. A study in Ghana similarly reported that older PLHIV were more likely to develop hypertension and diabetes, reinforcing the importance of age as a predictor of NCDs. The older age profile of this cohort likely explains the higher prevalence of hypertension, as aging is strongly associated with vascular stiffness and endothelial dysfunction [20].

Socioeconomic factors further exacerbate health risks. The majority of participants were unemployed (90.8%) and lacked tertiary education (6.9%), highlighting significant socioeconomic disparities. Limited income and education restrict access to nutritious food, healthcare services, and opportunities for physical activity, creating a fertile ground for the development of NCDs [21]. These findings echo those of a study in South Africa, which found that unemployment and low educational attainment were significant predictors of hypertension and diabetes among PLHIV [22]. Addressing these social determinants of health is imperative for reducing NCD prevalence and improving overall health outcomes in this population.

The relationship between ART duration and the prevalence of hypertension and diabetes reveals intriguing patterns. Hypertension prevalence was highest among participants on ART for more than 10 years (28.6%), while diabetes prevalence peaked among those on ART for 1–5 years (29.5%). These trends contrast with findings from a study in Zimbabwe, which reported a consistent increase in both hypertension and diabetes prevalence with ART duration. The lack of statistically significant associations in this study (p = 0.76 for hypertension, p = 0.19 for diabetes) underscores the multifactorial nature of NCD development. Factors such as age, sex, lifestyle, and genetic predisposition likely interact with ART to influence health outcomes [23].

The uniform use of the TLD regimen (Tenofovir/Lamivudine/Dolutegravir) among participants provides a unique opportunity to assess its impact on metabolic health. While Dolutegravir is highly effective in viral suppression, it has been associated with weight gain and insulin resistance in previous studies, such as one conducted in Cameroon and South Africa [24-25]. These side effects could explain the elevated prevalence of diabetes observed in this cohort. However, the relatively short mean duration of ART limits the ability to capture long-term metabolic effects. Future studies should compare different ART regimens to better understand their specific contributions to NCD risk. Such research could guide clinical decision-making and support the development of personalized treatment plans that minimize NCD complications while maintaining effective viral suppression.

The 22% prevalence of hypertension among PLHIV in this study also aligns with global patterns, where hypertension is increasingly recognized as a significant comorbidity. Hypertension in PLHIV often results from a combination of ART-induced metabolic changes, chronic inflammation, and traditional cardiovascular risk factors [26]. However, the relatively low prevalence of obesity in this cohort suggests that ART and HIV-related inflammation may play a more prominent role than lifestyle factors. These findings are consistent with those of a Nigerian study by Jackzon et al, which reported that ART and chronic HIV inflammation were stronger predictors of hypertension than traditional risk factors like BMI [27].

The 27.2% prevalence of diabetes in this cohort exceeds reported rates in many general populations, highlighting the metabolic challenges faced by PLHIV [28-29]. ART-induced insulin resistance, driven by mitochondrial dysfunction, altered lipid metabolism, and adipose tissue redistribution, is a well-documented phenomenon [30]. The high prevalence of diabetes among participants on ART for 1–5 years suggests an initial period of metabolic adjustment, during which rapid changes in weight and insulin sensitivity may occur. The lower prevalence among those on ART for more than 10 years could reflect survivor bias or stabilization of metabolic parameters over time. However, this hypothesis requires further investigation.

The coexistence of HIV, hypertension, and diabetes presents significant challenges for healthcare providers, particularly in resource-limited settings. The high prevalence of NCDs observed in this study accentuates the urgent need for integrated care models that address both infectious and non-communicable conditions. Routine screening for hypertension and diabetes should become a standard component of HIV care, enabling early detection and management. Policy implications include the need for training healthcare providers in NCD management and ensuring the availability of essential diagnostic and therapeutic tools in HIV care facilities.

While this study provides valuable insights, it is not without limitations. The cross-sectional design precludes causal inferences about the relationships between ART duration and NCD prevalence. Additionally, reliance on medical record reviews and participant self-reports introduces potential biases. The relatively short mean ART duration limits the applicability of findings to long-term ART recipients. Future research should employ longitudinal designs to track the progression of NCDs over time and explore regimen-specific metabolic effects. Comparative studies across different ART regimens would provide deeper insights into their contributions to NCD risk. Qualitative research capturing the lived experiences of PLHIV with NCDs could also illuminate barriers to care and opportunities for intervention.

Conclusion

This study stresses the critical intersection of HIV and non-communicable diseases, particularly hypertension and diabetes mellitus, within the population of PLHIV at Zonal Hospital Ahoada, Rivers State, Nigeria. The findings reveal a notable prevalence of these conditions, with hypertension at 22% and diabetes at 27.2%, emphasizing the pressing need for integrated care models that address both HIV and NCDs effectively. The absence of a significant association between ART duration and the prevalence of these conditions points to the multifactorial nature of NCD development, involving demographic, socioeconomic, and lifestyle factors. The study highlights the disproportionate impact on older adults, women, and socioeconomically disadvantaged groups, accentuating the need for tailored interventions targeting these vulnerable populations.

Moreover, the uniform use of the TLD regimen offers insights into the metabolic challenges associated with current ART protocols. While the short mean ART duration limits long-term analysis, the data suggest that early metabolic alterations may contribute to the high diabetes prevalence observed.

This research calls for immediate action to incorporate routine NCD screening and management into HIV care services. By addressing both infectious and chronic conditions concurrently, healthcare providers can significantly enhance the quality of life and overall health outcomes for PLHIV. Future studies should adopt longitudinal designs and comparative analyses across ART regimens to deepen understanding and guide evidence-based interventions. Ultimately, combating the dual burden of HIV and NCDs requires collaboration among policymakers, healthcare professionals, and communities to foster holistic, accessible, and sustainable healthcare solutions.

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