Diagnosis and treatment of non-communicable diseases and geriatric syndromes in the HIV ageing population in sub-Saharan Africa (HASA Project)

Diagnosis and treatment of non-communicable diseases and geriatric syndromes in the HIV ageing population in sub-Saharan Africa (HASA Project)

Title : Diagnosis and treatment of non-communicable diseases and geriatric syndromes in the HIV aging population in sub-Saharan Africa (HASA).
Number : TMA2017GSF-1936
Type : GSK-EDCTP senior fellowship
PI/Fellow : Castelnuovo Barbara

This work proposed to establish a cohort of older people living with HIV in Uganda, screen the participants and follow them up for 3 years for non-communicable diseases (NCDs) and geriatric syndromes. This proposal also aimed to create capacity for research and training in geriatric medicine

The specific objectives were

Specific Aim 1. To establish a cohort of aging patients ≥60 years (Geriatric cohort) in order to capture NCD endpoints and their risk factors:

Specific Aim 2. To measure physical function using the Short Performance Physical Battery, muscle strength, (Gait speed and assessment of grip strength with handheld dynamometry), frailty phenotype, and history of falls.

Specific Aim 3. To form a group of established clinicians and researchers with interest in HIV and NCDs and HIV and geriatric medicine support 2 master and 1 PhD students.

WORKED PERFORMED

Research study

Enrolment

The study participants were recruited from the Adult HIV Clinic of the Infectious Diseases Institute (IDI), which is a centre of excellence for HIV care and treatment since 2004. ART is provided and monitored according to updated WHO guidelines. Generally, response to ART is monitored by annual viral load testing only; safety laboratory results (e.g. renal and liver function) are not routinely performed. Ultimately, 500 patients were enrolled in the HASA cohort.

Study Procedures at enrolment and follow up (years 1 to 3)

Hypertension was diagnosed if patient were on medications or average blood pressure of two readings was ≥140/90 mmHg. Diabetes was considered if on antidiabetic medication and if elevated blood glucose (non-fasting ≥ 11.1 mmol/L or fasting ≥ 7 mmol/L) in the presence of symptoms. If elevated values in someone asymptomatic; a repeat fasting blood sugar was done on a subsequent day to confirm the diagnosis. Cardiovascular risk was calculated using World Health Organization (WHO)/International Society of Hypertension (ISH) charts for region Africa taking in consideration risk by gender, age, systolic blood pressure, smoking and diabetes mellitus.

Frailty was assessed using the Fried frailty phenotype through five criteria. namely, unintentional weight loss, self-reported exhaustion, slowness in walking speed, weakness in grip strength, and reduced physical activity, and participants were classified as robust, prefrail, or frail. Co-medication was defined as the number of concomitant non ART drugs prescribed for at least three month. Sarcopenia was assessed using the European Working Group criteria on Sarcopenia in Older People (EWGSOP2). Cognitive functioning was assessed using the Montreal Cognitive Assessment (MoCA) with the addition of 1 point if ≤ 12 years of education. Cognitive impairment was defined as a score ≤ 24 (lowered from 26 to account for cultural differences). Depression screening was performed using the Patient Health Questionnaires PHQ-2 and PHQ-9 and categorised as minimal mild, moderate, moderately severe, and severe. Nutritional status was assessed using the Mini Nutritional Assessment (MNA) and categorised as normal, at risk of malnutrition, or malnourished. Urinary incontinence was assessed by asking the participants about the frequency, amount, and circumstances under which they leak urine. Bone mineral density was assessed using quantitative calcaneal ultrasound which was validated in our population.

Laboratory tests are performed annually at the IDI Core Laboratory which is certified by the College of America pathologists. These include CD4 count, HIV viral load, serum creatinine, urine dip stick and lipid profile if deemed at risk of cardiovascular diseases (CVD) using the WHO risk prediction charts, which have been validated in our population. Depending on the findings, patients may be prescribed drugs, or counselled on health and dietary habits. Blood samples are stored at every visit; packed cells (at enrolment only, one aliquot), plasma and serum (at enrolment and at follow up, two aliquots each).

Overview of the results (outputs, achievements) and their exploitation and dissemination

Results or the research study

The median age was 64 years, time on ART 15 years, and 81.9% were still on first-line ART. Generally, the majority of the participants were at advanced stage diseases at ART start (76% in WHO stage III and IV) and with low CD4 count (159, cells/µL, interquartile range (IQR) 74-235), but experienced a good immune recovery with a median CD4 count of 645 cells/µL (462-850) at cohort enrolment. Viral suppression was exceptionally high at 99.6% using the WHO recommended cut-off 1,000 copies/ml, and at 92.2% using a more stringent cut-off of 50 copies/ml. We found high prevalence (50.1%) of hypertension, impaired renal function (46.2%), and diabetes (14%) and with no substantial differences across gender.

More women were living below the poverty line of 1$/day (43.2% versus 19.8%). A higher proportion of women reported symptoms of arthritis (27.1%) as compared to men (5.1%,), and had more than one non-communicable diseases (38.1 versus 22.7%). While 13.1% of the women were classified as frail as compared to 5.1% of the men and had lower physical (57% of women had high physical function compare to 73.4% men) function, more women (93%) had no sarcopenia compared to men (86%). We also found a higher proportion of women with osteoporosis (32.9%), any degree of cognitive impairment (83.2%), and history of falls (48.8%) as compared to men. While we did not observe differences in the overall functional status more men preserved the ability of going shopping (94.5% versus 88.1%) and more women were able to prepare meals as compared to men (96.7% versus 89.4%).

Women, older participants, those with no education or primary education, underweight participants, those with 2 or more NCDs and WHO stage III–IV had a higher mean number of geriatric syndromes. [1].

Overall, we observed a good quality of life (using the WHOQOL-OLD tool). People with better quality of life were male, and had higher income. More people with lower quality of life had depression, of geriatric syndromes, malnutrition and low physical function [2].

We also found higher kidney function impairment among older PLWH compared to those without; 33.1% had kidney function impairment versus 12.9% among people without HIV. The prevalence of proteinuria among PLWH versus people without HIV was 43.9% versus 19.4% [3].

Research capacity building outputs

We supported 2 master and 1 PhD students in the areas of HIV, NCDs and 7 additional research fellowships, of which 3 Glocal fellowships and 2 CFAR awards.

Dissemination

Blogs and other not peer reviewed publications

Blog Promoting health aging in Africa . The AIDS society of Africa https://www.saafrica.org/pages/2023/06/09/promoting-healthy-aging-and-independence-for-older-individuals-living-with-hiv-the-fourth-95/
Article (the daily moniotr) Addressing the needs of older epople with HIV and frailty https://www.monitor.co.ug/uganda/oped/commentary/address-needs-of-older-people-with-frailty-hiv-4214668
INTEREST conference 2022 Invited talk on HIV and aging in sub-Saharan Africa (Castelnuovo). Available at: https://www.youtube.com/watch?v=7GoVD5IYXEM
INTEREST conference 2023 Invited talk on HIV and aging in sub-Saharan Africa (Castelnuovo). Available at
https://www.youtube.com/watch?v=TxumzfymL5Y
Blog on HIV and aging Cambridge https://www.cph.cam.ac.uk/news/blogs/urgency-address-needs-older-people-frailty-and-hiv
Blog on HIV and aging IDI https://idi.mak.ac.ug/promoting-healthy-aging-and-independence-for-older-individuals-living-with-hiv/

Publications

Mbabazi P, Banturaki G, Naikoba S, Nasuuna EM, Manabe YC, Greene M, Castelnuovo B. Sex Differences in the Prevalence of Geriatric Syndromes Among Older People Living with HIV Attending an Urban Outpatient Clinic in Kampala, Uganda. HIV AIDS (Auckl). 2024 Nov 26;16:455-465. doi: 10.2147/HIV.S489598. PMID: 39619619; PMCID: PMC11608049.
Senkoro E, Mbabazi P, Banturaki G, Naikoba S, Castelnuovo B. The impact of geriatric syndromes on quality of life among older people living with HIV in Kampala, Uganda. Front Public Health. 2024 Jan 23;12:1306151. doi: 10.3389/fpubh.2024.1306151. PMID: 38322125; PMCID: PMC10845335.
Ssemasaazi AJ, Kalyesubula R, Manabe YC, Mbabazi P, Naikooba S, Ssekindi F, Nasuuna E, Byakika-Kibwika P, Castelnuovo B. Higher prevalence of kidney function impairment among older people living with HIV in Uganda. BMC Nephrol. 2024 Sep 27;25(1):321. doi: 10.1186/s12882-024-03761-1. PMID: 39334034; PMCID: PMC11428404.