This is the first study in Nepal to document CVRF among the HIV population on ART. The key findings of this study are a high prevalence of central obesity, CKD and tachycardia. Risky lifestyle habits such as a high prevalence of smoking and alcohol consumption, especially in males and poor dietary habits (low fruit and vegetable and high salt intake) were also found. Overall, a third (34.6%) of the participants had central obesity and females had a disproportionately higher prevalence (60.0%) than the males (9.8%). This corroborates findings in larger studies, where the prevalence of central adiposity among HIV patients on HAART was 30% to 62% 31. Falutz suggested that factors such as female gender and treatment with antiretroviral drugs zidovudine (AZT) and efavirenz (EFV) may contribute to raise the risk of central adiposity 32. In our study, the vast majority of the participants (84.2%) were on AZT, EFV was also used by 24.2% and 17.9% were concurrently treated with both AZT and EFV along with other drug combinations. However, we could not demonstrate significant associations between HIV drug combinations and any of the CVRF. Due to the small sample size, we had to categorize nine drug combinations of the participants into two groups (duovir + nevirapine and remaining combinations) for analysis.
Very little research has been conducted in Nepal on central obesity based on W-H ratio and findings are hugely conflicting. In a study on healthy Nepalese males, central obesity was observed in 51.2% of the 1000 participants 17. By contrast, a recent study among 241 Nepalese men and women, found a prevalence of 2.5% in males and 10% in females 33. The difference in cut-off values used to classify central obesity might have partly contributed to the difference in findings as Vaidya and colleagues 17 used a cut-off value of ≥0.95 for males and Adhikari and colleagues 35 did not mention the cut-off point. Geographical and cultural differences of the study sites may also have played role in the variation. Nonetheless, the finding of a higher prevalence of central obesity in females may underpin the notion that abdominal lipohypertrophy is predominant in HIV treated females 34, taking into consideration findings that South Asian populations, especially females, are more vulnerable to abdominal obesity 35. This finding suggests the possible added risk of central obesity among HIV infected Nepalese females on ART.
The CKD prevalence in this study (20.7%) was the highest compared to other Asian studies conducted on HIV infected patients on ART - A Japanese study found 15.4% 36 and a Chinese study found 16.8% prevalence of CKD 37. Notably, the prevalence found was also higher than in the general Nepalese population, where Sharma and colleagues reported CKD in 14.4% of 8398 Nepalese adults 19. The methodological differences in defining CKD though should be noted (this study estimated eGFR using a Cockcroft-Gault formula, whereas Sharma and colleagues and the Chinese study followed the Modification of Diet in Renal Disease Equation (MDRD), and the Japanese study followed the equation suggested by Japanese Society of Nephrology).
Among the antiretroviral agents, Tenofovir disoproxil fumerate (TDF) has been found to be associated with increased renal dysfunction 37, and the WHO has recognized it’s renal toxicity. However, in this study only two participants were being treated with TDF. This is an important factor for future studies as the use of TDF among the Nepalese HIV population is likely to increase rapidly in the future due to the recent guidelines of the WHO 38 which recommends the reduction of stavudine (d4T) and use of TDF in a first line regimen. Stavudine is currently the dominant HIV drug in the Nepalese HIV population. Thus, clinicians and researchers should be more aware of renal health of HIV treated patients in Nepal.
Hypertension (systolic or diastolic) was found in 11.8% of the participants, which is significantly lower than the findings from other studies conducted in developed countries 39, 40, but is similar to a study conducted in Africa (11.2%) 41. It is interesting to note that the prevalence found is also lower than that of the general Nepalese population of 19.7% to 33.9% 18, 42. Several studies have demonstrated an association between hypertension and the duration of HAART. A large multi-centered study suggested a significant association after two years on HAART 43, and an American study showed no association till six months 44. In this study, the median duration of HAART use was eight months and could partly explain the lower rates. Larger studies are required to confirm the prevalence and aetiology of hypertension in the HIV treated Nepalese population.
Findings suggest that health education should target certain lifestyle habits i.e. smoking, alcohol consumption, diet and physical activity within the HIV treated Nepalese population to decrease their CVRF. The prevalence of smoking in this study was higher than in the general Nepalese population (current smokers: 46.6% vs. 23.8%) 20, but is consistent with findings among other HIV+ populations 3, 45. A propensity for smoking among people living with HIV could be due to its perceived role in emotional support and stress reduction 46. Men especially should be targeted to educate them regarding the increased cardiovascular risk of smoking and other stress reduction therapies introduced.
In contrast, a considerably lower prevalence of current alcohol consumption was reported in the HIV infected participants than in the general Nepalese community (6.9% vs. 28.5%) 20. This is also in contradiction to common trends found in studies conducted in developed countries 10, 47. It is noteworthy that the prevalence of ever having consumed alcohol is higher though which could indicate that participants may have under-reported their alcohol consumption owing to social desirability bias or alternatively, due to the fact that two-thirds of the participants were poor, were not able to afford the high cost of alcohol. Alternatively, health education may have targeted this and resulted in a change in alcohol consumption habits.
As this was a cross-sectional study, a cause-effect relationship between CVRF and ART cannot be inferred. As participants were non-randomly selected and all based at one ART centre, the results shouldn’t be extrapolated to Nepal as a whole. Further limitations of self-reported responses could have introduced bias and restricted recorded biochemical measurements resulted in not being able to investigate the prevalence of other CVRF such as dyslipidaemia, clinical lipodystrophy and diabetes mellitus.
Although this was a cross-sectional study on a small sample, it provides important insights on the apparent risk of CVRF among HIV infected Nepalese patients on ART and warrants the need for further prospective and longitudinal studies.