Non-communicable disease (NCD) risk among people living with HIV in KwaZulu-Natal, South Africa: evidence from a randomised trial of community-based differentiated service delivery

Abstract

Introduction: As differentiated HIV services provided outside of clinics are scaled up, clients may have fewer interactions with ancillary services for non-communicable disease (NCD) prevention and management traditionally offered within facilities. This study was embedded in the DO ART randomised trial (2016-2019), which demonstrated that community-based differentiated service delivery (DSD) improved HIV viral suppression compared with facility-based care. We assessed NCD risk among men and women living with HIV accessing community-based DSD versus facility-based care in KwaZulu-Natal, South Africa.

Methods: First, we described lifestyle and clinical NCD risk among DO ART participants in rural and semi-rural KwaZulu-Natal. Next, we compared clinical NCD risk at 12 months by randomisation arm (community-based DSD vs. facility-based care). Finally, we explored the relationship between 12-month viral suppression and clinical NCD risk, overall and stratified by randomisation arm (i.e. service delivery type).

Results: Among 1010 participants, the median age was 32 years, 245 (24%) smoked, 229 (23%) had hypertension and 502 (50%) were overweight or obese (body mass index [BMI] ≥ 25). Smoking was more common among men than women (43% vs. 6%, p ≤ 0.001), while overweight/obesity was more common among women than men (65% vs. 34%, p ≤ 0.001). We found no statistically significant association between service delivery type and clinical NCD risk factors at 1 year. We also found no significant associations between viral suppression at 12 months and blood pressure, haemoglobin A1c or smoking. However, virally suppressed clients had higher mean BMI (+0.93 kg/m², p = 0.004) and higher mean cholesterol (+5.79 mg/dl, p = 0.001). These associations were greater in effect size and statistically significant among clients receiving community-based DSD (BMI: p = 0.003; cholesterol: p = 0.001), but smaller and not significant for facility-based care (BMI: p = 0.299; cholesterol: p = 0.448).

Conclusions: Relatively younger adults accessing HIV treatment in South Africa had substantial NCD risk, which differed by gender and may increase with age. Among clients receiving community-based DSD, viral suppression was associated with modestly higher BMI and cholesterol levels. Community-based DSD programmes should consider integrating NCD risk screening and management that addresses gender-specific needs to prevent premature mortality among people living with HIV.

Clinical trial number: NCT0292999.

Keywords: antiretroviral therapy; cardiovascular risk; community health services; differentiated service delivery; integrated care; non‐communicable diseases.