Epidemiology of and health services for people living with HIV and comorbidities of non-communicable diseases

Gooden, Tiffany E. ORCID: 0000-0002-3905-5477 (2024). Epidemiology of and health services for people living with HIV and comorbidities of non-communicable diseases. University of Birmingham. Ph.D.

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Abstract

PLWH are increasingly experiencing comorbidities of non-communicable diseases (NCDs). This could be due to complex interactions of HIV and non-HIV mechanisms (i.e. antiretroviral therapy [ART], persistent viral presence, and behavioural and psychosocial risk factors). Most countries provide HIV care through specialised HIV/infectious disease clinics or sexual health clinics; thus, care for NCD comorbidities is often separate from HIV care with little to no integration, leading to fragmented care. Fragmented care can lead to drug-drug interactions, polypharmacy and negatively impact quality of life and clinical outcomes. The aim of this thesis is to understand the risk of NCD comorbidities among PLWH and determine how care for NCD comorbidities can and should be improved; the NCDs focused on in this thesis are cardiovascular disease (CVD), diabetes (DM), hypertension (HTN), chronic kidney disease (CKD) and mental health conditions.

Using a UK-based matched retrospective cohort study design, three research projects were conducted: 1) to determine the risk of DM, HTN, CKD, stroke, ischaemic heart disease (IHD), myocardial infarction (MI), peripheral vascular disease (PVD), heart failure (HF) and a composite measure of CVD in PLWH compared to people without HIV; 2) to determine the risk of depression, anxiety, severe mental illness (SMI) and a composite measure of mental health conditions in PLWH compared to people with HIV and; 3) to determine if age-related conditions occur prematurely and/or are attenuated and/or accelerated among PLWH. Using semi-structured interviews with healthcare professionals (HCPs) and PLWH in Tanzania, two qualitative analyses were conducted: 1) to identify the barriers and facilitators of PLWH receiving optimal care for HTN and DM in a fragmented healthcare system and; 2) to identify the preferred integration model for HIV, DM and HTN care and the associated barriers and facilitators for the preferred model.

PLWH were found to have a 28% increased risk for DM, 37% for HTN, 242% for CKD, 42% for stroke, 55% for IHD, 50% for composite CVD, 94% for depression, 38% for anxiety, 218% for SMI and 63% for composite mental health compared to people without HIV after matching and adjusting for confounders. Additionally, PLWH experience early onset of CVD and HTN and an exponential increase in CKD over time indicating possible premature and accelerated ageing. Many barriers were found for PLWH to receive optimal care for DM and HTN within the current model of care in Tanzania; most related to organisational and healthcare system factors (i.e. fragmented services, no protocol for NCD screening, lack of access to diagnostic equipment for NCDs, poor continuity of care for NCDs); however, syndemic factors of poverty, stigma and poor mental health were found to be cross-cutting barriers impacting each component of the care pathway. HCPs and PLWH preferred for DM and HTN care to be integrated within HIV clinics in Tanzania which would create little to no additional barriers to care; however, existing barriers to do with costs of NCD medication, lack of NCD medication and equipment would need to be improved for the preferred model to be effective.

The epidemiology findings from this thesis should highlight the need for prevention strategies and changes in policy and clinical care to improve care for PLWH with or at risk for developing CVD, DM, HTN, CKD and mental health conditions; however, future research is needed to better understand which mechanisms contribute to these higher risks. The qualitative findings from this research should inform both quick wins and long-term system changes to improve DM and HTN care for PLWH in Tanzania; though, procurement of NCD medication and equipment must be improved and reductions in stigma and poverty must be prioritised.

Type of Work:	Thesis (Doctorates > Ph.D.)
Award Type:	Doctorates > Ph.D.
Supervisor(s):	Supervisor(s) Email ORCID Thomas, G. Neil UNSPECIFIED orcid.org/0000-0002-2777-1847 Nirantharakumar, Krishnarajah UNSPECIFIED UNSPECIFIED Greenfield, Sheila UNSPECIFIED UNSPECIFIED Manaseki-Holland, Semira UNSPECIFIED orcid.org/0000-0001-5827-8855
Licence:	All rights reserved
College/Faculty:	Colleges (former) > College of Medical & Dental Sciences
School or Department:	Institute of Applied Health Research
Funders:	None/not applicable
Subjects:	R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
URI:	http://etheses.bham.ac.uk/id/eprint/14892

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