Noncommunicable Diseases in HIV Infection in Low- and Middle-Income Countries

Abstract

The purpose of this review is to outline the interaction between HIV and non-communicable diseases (NCDs) affecting the gastrointestinal (GI) tract, liver, and nutritional disorders in low- and middle-income countries (LMICs), and to identify research priorities. Non-communicable GI tract disorders are only moderately influenced by HIV, and peptic ulceration is actually less common. However, the impact of HIV on GI cancers needs further investigation. HIV interacts strongly with environmental enteropathy, exacerbating malabsorption of nutrients and drugs. HIV has two major effects on non-communicable liver disease: drug-induced liver injury and non-alcoholic fatty liver disease (NAFLD) (particularly in persons of African genetic descent). The effect of HIV on nutrition was one of the first markers of the epidemic in the 1980s, and HIV continues to have major nutritional consequences. Childhood malnutrition and HIV frequently co-exist in some regions, e.g., southern Africa, resulting in powerful negative interactions with poorer responses to standard nutritional rehabilitation. HIV and nutritional care need to be better integrated, but many questions on how best to do this remain unanswered. Across the spectrum of gastrointestinal, hepatic, and nutritional disorders in HIV infection, there is increasing evidence that the microbiome may play an important role in disease pathogenesis, but work in this area, especially in LMICs, is in its infancy.

Challenges of malnutrition care among HIV-infected children on antiretroviral treatment in Africa

“…Nutrition is an issue for HIV-infected patients in resourcelimited countries [69], especially in children who have special needs for growth and development. However, anthropometric and nutritional data remains insufficient, whether on interactions between nutrition and antiretroviral treatment, or on the impact of HIV infection and treatment on metabolism, or on nutritional supplementation and its effects.…”

HIV and Noncommunicable Disease Comorbidities in the Era of Antiretroviral Therapy

“…After the consultation, US and LMIC scientists collaborated on articles that articulate the current scientific landscape as well as the urgent research and capacity-building priorities associated with specific HIV and NCD comorbidities featured in this supplement: (1) cancers, 18 (2) renal and genitourinary comorbidities, 19 (3) metabolic, body, and bone disorders, 20 (4) cardiovascular and pulmonary diseases, 21 (5) mental, neurological, and substance use disorders, 22 and (6) gastrointestinal, hepatic and nutritional aspects, 23 as well as key related (7) methodological, 24 and (8) cost-effectiveness issues 25 on the subject. In addition, given that the focus of these articles is on sub-Saharan Africa, two commentaries were solicited to provide broad perspectives from both Latin American 26 and Asian 27 contexts.…”

Observational Research on NCDs in HIV-Positive Populations

“…13,14 Figure 1 illustrates how these complex interactions contribute to cardiovascular disease. Similar causal relationships occur for many other NCDs, including diabetes, liver disease, chronic kidney disease, depression, and a wide range of cancers 6,10,11,15–18 …”

“…Unless appropriately accounted for, these factors can result in overestimates of the association between HIV infection and a wide range of cancers, liver disease, and neurocognitive disorders. 10,15,18 In LMICs, both magnitudes of such confounding and the key confounding variables may differ because of differences in HIV risk factors. Ideally, HIV-negative comparators would be drawn from the same population as their HIV-positive counterparts.…”

“…Examples include developing and evaluating thresholds for intervening on metabolic abnormalities, strategies for modifying ART regimens to prevent alcohol-associated liver disease, adjuvant therapies for the treatment of HIV-associated nephropathy, and strategies for integrated service delivery on a wide range of NCDs. 15,17,18,48 However, realizing this potential requires that diagnostic tests, laboratory monitoring, and medications for treating both HIV and NCDs be available in clinics, and that their indications and use be reliably captured by data systems.…”