Browsing by Author "Dave, Joel A"
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- ItemOpen AccessAnti-retroviral therapy increases the prevalence of dyslipidemia in South African HIV-infected patients(Public Library of Science, 2016) Dave, Joel A; Levitt, Naomi S; Ross, Ian L; Lacerda, Miguel; Maartens, Gary; Blom, DirkPurpose Data on the prevalence of dyslipidaemia and associated risk factors in HIV-infected patients from sub-Saharan Africa is sparse. We performed a cross-sectional analysis in a cohort of HIV-infected South African adults. METHODS: We studied HIV-infected patients who were either antiretroviral therapy (ART)-naive or receiving non-nucleoside reverse transcriptase inhibitor (NNRTI)-based or protease inhibitor (PI)-based ART. Evaluation included fasting lipograms, oral glucose tolerance tests and clinical anthropometry. Dyslipidemia was defined using the NCEP ATPIII guidelines. RESULTS: The median age of the participants was 34 years (range 19-68 years) and 78% were women. The prevalence of dyslipidemia in 406 ART-naive and 551 participants on ART was 90.0% and 85%, respectively. Low HDL-cholesterol (HDLC) was the most common abnormality [290/406 (71%) ART-naïve and 237/551 (43%) ART- participants]. Participants on ART had higher triglycerides (TG), total cholesterol (TC), LDL-cholesterol (LDLC) and HDLC than the ART-naïve group. Severe dyslipidaemia, (LDLC> 4.9 mmol/L or TG >5.0 mmol/L) was present in <5% of participants. In multivariate analyses there were complex associations between age, gender, type and duration of ART and body composition and LDLC, HDLC and TG, which differed between ART-naïve and ART-participants. CONCLUSION: Participants on ART had higher TG, TC, LDLC and HDLC than those who were ART-naïve but severe lipid abnormalities requiring evaluation and treatment were uncommon.
- ItemOpen AccessAntiretroviral therapy, especially Efavirenz, is associated with low bone mineral density in HIV-infected South Africans(Public Library of Science, 2015) Dave, Joel A; Cohen, Karen; Micklesfield, Lisa K; Maartens, Gary; Levitt, Naomi SPurpose We determined the prevalence and correlates of low bone mineral density (BMD) in HIV-infected South Africans as there is a paucity of such data from Africa. METHODS: BMD and serum 25-hydroxyvitamin D were measured in HIV-positive participants on antiretroviral therapy (ART) and in those not yet on ART (ART-naïve). RESULTS: We enrolled 444 participants [median age 35(IQR: 30, 40) years; 77% women]. BMD was low (z score <-2SD) in 17% and 5% of participants at the lumbar spine and total hip, respectively. Total hip [0.909 (SD 0.123) vs 0.956 (SD 0.124) g/cm 2 , p = 0.0001] and neck of femur BMD [0.796 (SD 0.130) vs 0.844 (SD 0.120) g/cm 2 , p = 0.0001] were lower in the ART, compared to the ART-naïve group. Vitamin D deficiency was present in 15% of participants and was associated with efavirenz use [adjusted OR 2.04 (95% CI 1.01 to 4.13)]. In a multivariate linear regression, exposure to efavirenz or lopinavir-based ART was associated with lower total hip BMD, whereas higher weight, being male and higher vitamin D concentration were associated with higher total hip BMD (adjusted R 2 = 0.28). Age, weight, sex, and the use of efavirenz-based ART were independently associated with lumbar spine BMD (adjusted R 2 = 0.13). CONCLUSIONS: Vitamin D status, use of efavirenz or lopinavir/ritonavir, weight, age and sex are significantly associated with lower BMD in this young cohort of HIV-infected South Africans.
- ItemOpen AccessAssociation of lopinavir concentrations with plasma lipid or glucose concentrations in HIV-infected South Africans: a cross sectional study(BioMed Central Ltd, 2012-10-26) Sinxadi, Phumla Z; McIlleron, Helen M; Dave, Joel A; Smith, Peter J; Levitt, Naomi S; Maartens, GaryAbstract Background Dyslipidaemia and dysglycaemia have been associated with exposure to ritonavir-boosted protease inhibitors. Lopinavir/ritonavir, the most commonly used protease inhibitor in resource-limited settings, often causes dyslipidaemia. There are contradictory data regarding the association between lopinavir concentrations and changes in lipids. Aim To investigate associations between plasma lopinavir concentrations and lipid and glucose concentrations in HIV-infected South African adults. Methods Participants stable on lopinavir-based antiretroviral therapy were enrolled into a cross-sectional study. After an overnight fast, total cholesterol, triglycerides, and lopinavir concentrations were measured and an oral glucose tolerance test was performed. Regression analyses were used to determine associations between plasma lopinavir concentrations and fasting and 2 hour plasma glucose, fasting cholesterol, and triglycerides concentrations. Results There were 84 participants (72 women) with a median age of 36 years. The median blood pressure, body mass index and waist: hip ratio were 108/72 mmHg, 26 kg/m2 and 0.89 respectively. The median CD4 count was 478 cells/mm3. Median duration on lopinavir was 18.5 months. The median (interquartile range) lopinavir concentration was 8.0 (5.2 to 12.8) μg/mL. Regression analyses showed no significant association between lopinavir pre-dose concentrations and fasting cholesterol (β-coefficient −0.04 (95% CI −0.07 to 0.00)), triglycerides (β-coefficient −0.01 (95% CI −0.04 to 0.02)), fasting glucose (β-coefficient −0.01 (95% CI −0.04 to 0.02)), or 2-hour glucose concentrations (β-coefficient −0.02 (95% CI −0.09 to 0.06)). Lopinavir concentrations above the median were not associated with presence of dyslipidaemia or dysglycaemia. Conclusions There was no association between lopinavir plasma concentrations and plasma lipid and glucose concentrations.
- ItemOpen AccessChanges in blood pressure, glucose levels, insulin secretion and anthropometry after long term exposure to antiretroviral therapy in South African women(2015-08-05) Abrahams, Zulfa; Dave, Joel A; Maartens, Gary; Levitt, Naomi SAbstract Background A number of metabolic abnormalities, such as dysglycaemia, insulin resistance, lipodystrophy and dyslipidaemia, are associated with the use of antiretroviral drugs. We aimed to assess the effects of long-term antiretroviral exposure on blood pressure, glycaemia, insulin secretion and anthropometric measures in black South African women. Methods A convenience sample of HIV-infected women on first-line ART for a median of 16 months at baseline, had the following evaluations twice, at baseline and after approximately 5 years: anthropometry, including skin fold thicknesses, blood pressure, oral glucose test, and insulin. Insulin sensitivity and secretion (HOMA-IR, IGI and DIo) were estimated. Results At baseline more than half the 103 women were using stavudine and efavirenz. The median interval between baseline and follow-up evaluation was 66 months. Weight, waist circumference, and waist-hip ratio increased over time, while limb skinfold thickness decreased over time. Systolic and diastolic blood pressure increased significantly and the proportion of participants with hypertension increased from 3.9 to 15.5% (p < 0.001). There were increases from baseline in plasma glucose concentrations at 30 and 120 min; insulin concentrations at 0 and 30 min; and IGI and DIo. The proportion of participants with diabetes increased from 1 to 7.5% (p = 0.070). Conclusion In black South African women with long-term exposure to ART, increases in hypertension and possibly diabetes were observed. Participants experienced an increase in central fat and a decrease in peripheral fat distribution. Early identification and management of these metabolic changes are important, especially in a region with the highest HIV-infected population in the world.
- ItemOpen AccessThe development of simple anthropometric measures to diagnose antiretroviral therapy-associated lipodystrophy in resource limited settings(BioMed Central, 2014-08-04) Abrahams, Zulfa; Dave, Joel A; Maartens, Gary; Lesosky, Maia; Levitt, Naomi SAbstract Background Lipohypertrophy does not appear to be an adverse ART reaction while lipoatrophy is clearly associated with the use of stavudine (d4T) and zidovudine (AZT). In low and middle income countries d4T has only recently been phased out and AZT is still widely being used. Several case definitions have been developed to diagnose lipodystrophy, but none of them are generalizable to sub-Saharan Africa where black women have less visceral adipose tissue and more subcutaneous adipose tissue than white women. We aimed to develop a simple, objective measure to define lipoatrophy and lipohypertrophy by comparing patient report to anthropometric and dual-energy X-ray absorptiometry (DXA) -derived variables. Methods DXA and anthropometric measures were obtained in a cross sectional sample of black HIV-infected South African men (n = 116) and women (n = 434) on ART. Self-reported information on fat gain or fat loss was collected using a standard questionnaire. Receiver operating characteristic (ROC) curves were used to describe the performance of anthropometric and DXA-derived variables using patient reported lipoatrophy and lipohypertrophy as the reference standard. Results Lipoatrophy and lipohypertrophy were more common in women (25% and 33% respectively) than in men (10% and 13% respectively). There were insufficient numbers of men with DXA scans for meaningful analysis. The best predictors of lipoatrophy in women were the anthropometric variables tricep (AUC = 0.725) and thigh skinfold (AUC =0.720) thicknesses; and the DXA-derived variables percentage lower limb fat (AUC = 0.705) and percentage lower limb fat/height (AUC = 0.713). The best predictors of lipohypertrophy in women were the anthropometric variable waist/hip ratio (AUC = 0.645) and the DXA-derived variable percentage trunk fat/percentage limb fat (AUC = 0.647). Conclusions We were able to develop simple, anthropometric measures for defining lipoatrophy and lipohypertrophy, using a sample of black HIV-infected South African women with DXA scans. This is of particular relevance in resource limited settings, where health professionals need simple and inexpensive methods of diagnosing patients with lipoatrophy and lipohypertrophy.
- ItemOpen AccessEarly identification and elective inpatient management of high-risk people living with diabetes diagnosed with COVID-19 decreases morbidity and mortality: a quasi-experimental study(2022) Aronson, Tatum; Ras, Tasleem; Dave, Joel AIntroduction: The Diabetes-COVID-19 relationship is complex, resulting in increased morbidity and mortality. In response to this enhanced vulnerability of people living with diabetes (PLWD) to COVID-19 morbidity and mortality, the Western Cape Department of Health established a telemedicine team (the VECTOR team) that fast tracked at-risk PLWD diagnosed with COVID-19 into the Hospital of Hope (HOH), a temporary intermediate health care facility (ICHF) established as a field hospital to cater for the anticipated overburdening of the acute hospitals in the Cape Metro. This study evaluated the effects of implementing a telemedicine mediated rapid admission process and applying a tertiary hospital practice guideline (the High Risk Diabetes-COVID-19 protocol - HRDCp) for treating high risk PLWD who were electively admitted to a field hospital. Aim: To assess the impact of early admission and application of a clinical practice guideline (HRDCp) developed for use at a specialised tertiary facility for the inpatient care of PLWD who were diagnosed with COVID-19, on clinical outcomes in a generalist run, intermediate healthcare facility. Methods: Using a retrospective quasi-experimental study design applied to the clinical dataset for the HOH, patients admitted prior to the implementation of the clinical protocol (control group) were compared to those admitted via the telemedicine team, who received care using the clinical protocol (experimental group). A total of 183 patients were included in this study. Using secondary data from the hospital clinical dataset, baseline characteristics, inpatient clinical course and clinical outcomes were compared between these two groups. Findings: The key findings showed that the experimental and control groups were similar at baseline for age, gender, renal function and co-morbidity. Glucose control on admission was better in the experimental than in the control group [HbA1C 8.1 vs 9.3% (p=0.013); HGT 10.2 vs 10.7 g/dL (p=0.039)].The experimental group needed less oxygen (p< 0.001), less antibiotics (p< 0.001), and less steroids (p=0.003), while the control group had a higher incidence of acute kidney injury during admission (p=0.046). The median inpatient glucose control was better in the experimental group (8.3 vs 10.0; p=0.006). The two groups had statistically similar clinical outcomes for discharge home (94% vs 89%), escalation in care (2% vs 3%) and inpatient death (4% vs 8%). Ethical considerations: Ethics approval was obtained from the Human Research Council University of Cape Town. (HREC 502/2020) Conclusions: This study demonstrated a novel approach that foregrounds risk of adverse outcomes as criteria for elective admission. Aggressive management had comparably good outcomes versus the usual practice of waiting for severe disease to arise and subsequent emergency admission. While showing noninferiority to usual care in terms of clinical outcomes, it is suggested that significant savings were made in terms of financial costs and emotional distress.
- ItemOpen AccessFactors that influence patient empowerment in inpatient chronic care: early thoughts on a diabetes care intervention in South Africa(2019-12-05) Abrahams, Nina; Gilson, Lucy; Levitt, Naomi S; Dave, Joel AAbstract Background The burden of non-communicable diseases is growing rapidly in low- and middle-income countries. Research suggests that health interventions that aim to improve patient self-management and empower patients to care actively for their disease will improve health outcomes over the long-term. There is, however, a gap in the literature about the potential role of the inpatient setting in supporting chronic care. This is particularly important in low-and-middle income countries where hospitals may be a rare prolonged point of contact between patient and health provider. The aim of this small scale, exploratory study was to understand what factors within the inpatient setting may affect patients’ feelings of empowerment in relation to their chronic disease care and provides recommendations for future inpatient-based interventions to support self-management of disease. Methods This study was based in a public, academic hospital in South Africa. Eighteen qualitative, semi-structured interviews were conducted with multiple participants with experience of diabetes care: inpatients and health professionals such as nurses, endocrinologists, and dieticians. Findings were analysed using a broad, exploratory, thematic approach, guided by self-management and chronic care literature. Results Interviews with both patients and providers suggest that patients living in low socio-economic contexts are likely to struggle to access appropriate healthcare information and services, and may often have financial and emotional priorities that take precedence over their chronic illness. Younger people may also be more dependent on their family and community, giving them less ability to take control of their disease care and lifestyle. In addition, hospital care remains bound by an acute care model; and the inpatient setting of focus is characterised by perceived staff shortages and ineffective communication that undermine the implementation of patient empowerment-focused interventions. Conclusions Patient and provider contexts are likely to make supporting patient engagement in long-term chronic care difficult in lower income settings. However, knowledge of these factors can be harnessed to improve chronic care interventions in South Africa and other similar countries.
- ItemOpen AccessHigh Molecular Weight (HMW): total adiponectin ratio is low in hiv-infected women receiving protease inhibitors(2014-12-16) Omar, Fierdoz; Dave, Joel A; King, Judy A; Levitt, Naomi S; Pillay, Tahir SAbstract Background At the time of the study, the HIV-treatment policy in South Africa included highly active antiretroviral therapy (HAART) regimens 1 (nucleotide reverse transcriptase inhibitors (NRTIs) only), and 2 (protease inhibitors (PI) and NRTIs). HAART is associated with the lipodystrophy syndrome, insulin resistance and reduced total adiponectin (TA) levels. The high molecular weight (HMW):TA ratio is a superior marker of insulin resistance. The aim of this study was to establish whether HMW:TA ratios are low in patients on PIs and whether they correlate with insulin resistance. Methods This was a cross-sectional study undertaken in an antiretroviral clinic at a tertiary hospital. The participants were 66 HIV-infected females: 22 were on regimen 2 (PI group), 22 on regimen 1 (non-PI) and 22 treatment naïve (TN), matched for BMI and age. Patients with a history of diabetes or impaired glucose tolerance were excluded. Serum adiponectin multimers were analysed using the AlpcoTM Adiponectin (Multimeric) enzyme immunoassay. Waist hip ratios (WHR), glucose and insulin levels were assessed, and HOMA-IR and QUICKI calculated. Data were analysed non-parametrically and multivariate analysis was performed. Results TA and HMW levels were lower in the treatment groups than in the TN group. HMW:TA was lower in the PI than in the non-PI and TN groups, and in the non-PI than in the TN groups. HMW:TA correlated negatively with waist, insulin and HOMA-IR, independently of BMI and duration of therapy. HOMA-IR and QUICKI did not differ among the groups. Conclusion HMW:TA is significantly decreased with HAART (particularly with PIs, but also with non-PIs) and may be a more sensitive marker of insulin resistance in these patients than conventional markers or HMW and total adiponectin individually.
- ItemOpen AccessLongitudinal study to assess the prevalence of hypogonadism in HIV-infected South African men and its association with bone density, body composition, metabolic abnormalities (dysglycaemia, dyslipidaemia) and quality of life.(2021) van Der Merwe, Le Roux; Dave, Joel ABackground: Hypogonadism has been described in association with HIV infection and anti-retroviral therapy (ART). Furthermore, hypogonadism is associated with comorbidity and a reduced quality of life. The prevalence of hypogonadism in HIVinfected South African men is unknown. We examined the prevalence of hypogonadism in HIV-infected men before and 12 months after the initiation of ART. Methods: This is a sub-study of the McHAART Study designed to investigate the metabolic complications of ART. HIV-infected men attending the Crossroad Community Healthcare Clinic were conveniently sampled prior to commencing ART and then followed for 6-months, 12-months and 24-months. Here we report on total testosterone, LH, FSH, SHBG and free testosterone measured on blood samples taken at 08h00 prior to initiating ART (baseline) and then again at 12 months on ART. Results: There were 44 patients at baseline and 30 patients at the 12-month visit. There were no participants with hypogonadism at baseline or after 12 months on ART. Testosterone levels or change in testosterone levels were not associated with alcohol intake, bone miner density, body mass index, waist circumference, fasting glucose, HOMA IR, HOMA β, fasting cholesterol or blood pressure at baseline or 12 months. Conclusions: There were no cases of hypogonadism in HIV-infected ART-naïve men and there were no cases of hypogonadism in HIV-infected men on ART for 12 months in this study population. Testosterone levels or change in testosterone levels were not associated with any measures of body composition, glucose metabolism, lipids or bone mineral density.
- ItemOpen AccessQuality of life in individuals living with HIV/AIDS attending a public sector antiretroviral service in Cape Town, South Africa(BioMed Central, 2014-07-03) Nglazi, Mweete D; West, Sacha J; Dave, Joel A; Levitt, Naomi S; Lambert, Estelle VBackground: Health related quality of life (HRQoL) is an important outcome helping to understand the impact of antiretroviral therapy (ART). We examined and compared the HRQoL in relation to ART status among HIV-infected patients in a public sector service in Cape Town, South Africa. In addition, we aimed to examine the relationship between ART status and HRQoL according to CD4 count strata. Methods: A cross sectional study sample of 903 HIV-infected patients who were categorized as not receiving ART (ART-naïve) or receiving first-line ART for > 6 months (ART). HRQoL outcomes were compared in the two groups. HRQoL was assessed using the EQ-5D (five domains) and Visual Analogue Scale (EQ-5D VAS). Results: Of the total sample, 435 were categorised as ART naïve (76% women) and 468 were on ART (78% women). There were no significant associations between groups for most of the EQ-5D domains, however ART-naïve experienced a significantly greater problem with mobility than the ART group. Being ART-naïve (adjusted odds ratio (aOR) 3.08 95% confidence interval (CI) 1.63- 7.89) and obese 2.78 (95% CI 1.24- 6.22) were identified as predictors for increased mobility problems in multivariate analysis. In addition, receiving ART (5.61 difference; 95% CI 2.50 - 8.72) and having some source of income (4.76; 95% CI 1.63 -7.89) were identified as predictors for a higher EQ-5D VAS score. When grouped according to CD4 count strata, there were no significant difference between groups for most of the EQ-5D domains, however the ART-naïve group indicated having significantly greater problems under the CD4 count of >500 cells/μL in the anxiety/depression domain (22.4% vs 8.8%, p = 0.018) and significantly lower EQ-5D VAS scores under the CD4 counts of ≤200 cells/μL (median 80 (IQR 60–90) vs 90 (IQR 80–100), p = 0.0003) and 201–350 cells/μL (median 80 (IQR 70–90) vs 90 (80–100), p = 0.0004) compared to ART group. Conclusions: HRQoL (self-rated health state) was improved with ART use, including those with immunocompromised status, which may be relevant to the public sector ART program in South Africa.
- ItemOpen AccessTumor-induced osteomalacia: a case report(2022-01-12) Aligail, Khalid; Dave, Joel A; Ross, Ian LBackground Tumor-induced osteomalacia is a rare, acquired paraneoplastic syndrome, including hypophosphatemia, high serum alkaline phosphatase, reduced active vitamin D, suboptimal bone mineral density, bone pain, fragility fractures, and muscle weakness. Case presentation We report a case of 74–year–old male of mixed ancestry with hypophosphatemia resistant to treatment despite optimal compliance, associated with profound reduction of bone mineral density and multiple nontraumatic fractures, including bilateral rib fractures, lower-thoracic (T11, T12) vertebrae, and two fractures involving the surgical and anatomical neck of the right humerus. We discuss an approach to identifying the underlying cause of hypophosphatemia associated with fragility fractures, and options for management of this rare condition. Conclusion Although rare, tumor-induced osteomalacia can be diagnosed if a logical stepwise approach is implemented. Surgery could be curative if the tumor is properly located and is resectable.