This study describes the prevalence of NCDs and NCD risk factors among South African AYLHIV in an urban setting. Previous studies in SSA have described NCD comorbidities in adults living with HIV [23]. Few studies have assessed the prevalence of NCDs and particularly NCD risk factors in AYLHIV in SSA. Risk behaviour research on AYLHIV in SSA has predominantly focused on sexual risk behaviour [70]. We therefore set out to investigate NCD multimorbidity and risk factors in this population group given the emerging NCD epidemic in SSA occurring against a background of a high HIV burden and increased comorbidity risk in PLHIV.
We highlight several key findings. Almost half of our participants experienced significant symptoms of depression and psychological distress. More than a third were overweight or obese, a third had insufficient levels of weekly physical activity and the majority did not meet dietary guidelines for fruit and vegetable intake. There was low nutritional knowledge, particularly on healthy food choices and diet-disease relationships. A detailed interpretation of these findings, comparisons to the general population and previous findings in PLHIV as well as implications for integrated prevention are discussed below.
More than two-thirds of our respondents were female which reflects the gendered nature of the HIV epidemic in South Africa [71], and much higher rates of health care-seeking among young women compared to young men [72]. A greater proportion of AYLHIV in this study were multidimensionally poor compared to national estimates which indicate that 33.4% of young people aged 15 - 24 years are MPI poor [73]. Although the proportion of NEETs in this study was lower than the national average of 34% [74], they experienced other dimensions of deprivation which may interact to exacerbate vulnerability to NCDs.
Previous studies in South Africa corroborate the findings that HIV/AIDS-affected and infected youth face multiple deprivations of poverty [75,76], and food insecurity [77], which are commonly cited challenges for adolescents receiving HIV treatment and care in SSA. This is concerning because socioeconomic factors impact adherence to ART and retention in HIV care, which has implications for viral suppression and chronic disease pathways [78,79]. Addressing this challenge requires a multi-sectoral approach for NCD prevention with appropriate social protection systems to meet the needs of AYLHIV.
With respect to NCD risk factors associated with behaviour and knowledge, we found that almost three-quarters of AYLHIV did not meet recommended dietary guidelines of eating at least five portions of fruit and vegetables daily necessary to reduce the risk of NCDs [80]. Compared to provincial estimates for youth in the Western Cape, more respondents, particularly females, consumed deep-fried foods and fast-foods daily, while the proportion who consumed SSB daily was lower than the provincial average (42%) [10] and estimates from 44 other LMICs (44%) [81]. A meta-analysis on SSB intake found that individuals who consumed 1–2 servings per day had a 26% greater risk of developing type 2 diabetes mellitus (T2DM), and a 20% greater risk of metabolic syndrome compared to those who did not consume SSB or had less than one serving/month [82]. Although the South African government has made strides in promoting healthier food environments by implementing mandatory legislation for salt reduction in processed foods [83] and a tax on SSB [84], our findings suggest that greater efforts are needed to translate these measures into action at a community and household level, especially amongst young girls who have higher prevalence of obesity which is likely to persist until adulthood without intervention.
Our results support findings of gender differences in physical activity levels among South African adolescents similar to global reports [85,86]. More than two-thirds of our respondents used active transport; either walking to and from school or work. This is notable and important that future interventions to increase physical activity consider strategies to retain this healthy behaviour. However, fewer than one-third had sufficient levels of physical activity necessary to promote health and prevent chronic diseases. This is similar to physical inactivity levels reported in urban-based South African students [85]. The proportion who spent more than three hours per day sedentary was higher than general population estimates of 30% [14] and higher than estimates from other LMICs of 27% [81].
Our results are consistent with those from a study conducted in Botswana which found that youth living with HIV had significantly lower levels of daily physical activity compared to HIV negative controls [87]. Similarly, a study in Brazil in 10–15-year-old perinatally-infected adolescents found that participants living with HIV had lower physical activity scores compared to healthy peers [88]. Additional research is needed in this setting to explore the relationship between physical activity and HIV in adolescents. A study with an age-and sex-matched HIV-negative control group from the same community would help to elucidate whether this relationship exists in South Africa.
Participants scored low on general nutrition knowledge questions and particularly had poor knowledge of healthy food choices and associations between diet and diseases. To our knowledge, this is the first study to assess nutrition knowledge in AYLHIV in Africa. A South African study in school-going adolescents aged 15–18 years found that 77.5% scored below average on diet and nutrition knowledge questions [89]. The poor knowledge on nutrition-related NCDs amongst AYLHIV in our study is concerning in a country undergoing nutritional transition [90]. Nutrition knowledge is strongly correlated with dietary intake and is needed for better dietary habits [57]. Although adolescents may lack autonomy in navigating their food environment, this life stage is characterised by increasing independence highlighting the importance of good dietary knowledge including how diet affects their current and future health [89] to support making healthier food choices.
Our blood pressure findings are consistent with findings from studies in adolescents in the general population of urban South Africa which have reported hypertension prevalence rates ranging from 8–16% [91] and elevated BP prevalence of 35% [92]. A study in the United States reported a significantly higher prevalence of elevated blood pressure in a cohort of HIV-infected, predominantly African-American adolescents and young adults compared to healthy children [93]. Globally, studies involving HIV-infected adults have demonstrated higher hypertension prevalence than the general population [94] and hypertension has been found to be associated with ART [95,96]. One in five young adults (18–35 years) attending an HIV clinic in the same setting in Khayelitsha were found to have comorbid hypertension [97]. There are conflicting data on the link between HIV infection and elevated BP in paediatric populations. Nevertheless, our findings support the need for routine monitoring of BP in HIV care, even in younger populations, in settings like South African with a high background prevalence of hypertension, in order to avert future disease.
None of those with self-reported diabetes symptoms had an abnormal random blood glucose. In a cohort study of South African youth living with perinatally-acquired HIV, the authors found a high prevalence of insulin resistance but this did not differ from that in HIV-negative age-matched adolescents [98]. A systematic review and meta-analysis of African studies recently reported that there was no statistically significant association between HIV infection or ART exposure and T2DM in adults [99]. This is in contrast to findings from European and North American studies that have shown a higher prevalence of T2DM in HIV-positive adults particularly those on ART [100-102]. The International Diabetes Federation (IDF) estimates that 60% of people with diabetes in Africa are undiagnosed [103] suggesting that T2DM might be a major, underdiagnosed public health problem in African populations in general, warranting further attention.
We found high levels of depression and psychological distress in our study compared to less than a quarter of young people nationally [12]. Concerningly, only 11% of those with mild to severe psychological distress reported previously being diagnosed with a mental health condition highlighting a significant gap in care. Mental health conditions are prevalent in AYLHIV in both high-income and resource-limited settings [104]. Our results are generally consistent with prevalence rates of depression among children and adolescents living with HIV from other African countries ranging from 18.9% in Malawi [105] to 51.2% prevalence of psychological distress in Uganda [106].
Notably, significantly more female participants reported depressive symptoms compared to males which is in line with global statistics on depression [107]. Our findings show that only 17% of those identified as having significant depression reported being previously diagnosed with anxiety or depression. In a previous retrospective review in the same population, mental health conditions were documented in less than 5% of clinic records reviewed [35]. In a recent study conducted in South Africa, the authors found similar rates of mental illness in perinatally-infected and uninfected adolescents, suggesting that other prevalent social factors in the community may override the effect of HIV, especially in the ART era [108]. Nevertheless, these findings highlight that there is a significant missed opportunity for identifying youth with mental health problems in our setting.
More than a third of our respondents were overweight or had obesity, with significantly more overweight and centrally obese females compared to males. Although our rates of overweight and obesity are slightly lower than prevalence rates for youth in the Western Cape (31.5% overweight and 11.3% obese) [14], our rates appear similar to obesity trends in the general population. A previous study in adult patients attending primary health care HIV-clinics in South Africa found that more than half of female patients were overweight or had obesity compared to 16% of male patients [109]. Obesity in PLHIV is well documented in high-income countries and is emerging as a major challenge in Africa [24] with several studies showing increased rates of obesity in PLHIV [109,110]. But few studies in Africa have reported on overweight and obesity levels in AYLHIV other than in the context of ART-associated dyslipidaemia [87,111,112]. One study conducted among South African university students living with HIV (the majority aged 20–25 years) found that 21% were overweight and 30% had obesity [113]. Our results are consistent with these findings and confirm results from a folder review conducted in this same population that reported similar levels of overweight and obesity [35].
In addition to BMI, we assessed central obesity using waist and hip circumference indicators and found that 26% of our respondents with normal BMI had high WHR or WHtR, meeting criteria for central obesity. Another South African study in adults attending three HIV-clinics reported a high prevalence of central obesity, primarily in women – 45% (4% in men) [113].
Implications for integrated care
Our findings underscore the importance of anthropometry beyond BMI, especially in females. In a comparison of anthropometric measures in HIV patients in Cameroon, Dimala et al found that markers of adiposity like WC, WHR and WHtR are better than BMI at identifying HIV/AIDS patients with increased cardiometabolic risk [114]. In our study, obesity co-occurred with hypertension – 35% of those with elevated BP or hypertension were also overweight or obese (data not shown). By screening for obesity, other related conditions which tend to cluster with obesity can also be detected. Given that anthropometric measurements and calculations are non-invasive, low-cost and easy-to-use interventions, our findings support the need to integrate this screening into routine care to identify AYLHIV who are at increased cardiometabolic risk and intervene early as they transition into adulthood, especially with prolonged exposure to ART regimens which are linked to obesity, altered glucose metabolism and dyslipidaemia [115]. This is supported by the WHO and the IDF who recommend monitoring changes in WC in addition to measuring BMI, particularly in HIV-positive populations on ART and in female patients who have a higher prevalence of obesity [68,116].
Recommendations calling for integration of mental health services into HIV care have been made for adults [117] given the multiple psychological vulnerabilities associated with living with HIV and high rates of suicide in PLHIV [118,119]. Our findings further support the need for integration of mental health screening in HIV care for AYLHIV. A study conducted in Johannesburg found that a simple way of identifying youth struggling with mental health problems at primary care level is by asking them about their future aspirations. Those who do not feel like they have control of their future or do not have a dream for the future were found to be more likely to have symptoms of depression, anxiety or PTSD requiring further support [120].
The recently introduced integrated chronic disease management (ICDM) model in South Africa recognises the importance of monitoring both chronic communicable and NCDs in order to achieve optimal clinical outcomes [121]. Our findings underscore the importance of applying an evidence-based integrated approach to the healthcare services for AYLHIV. In the context of resource limitations, further research exploring the multilevel determinants of these NCDs and their risk factors would be useful to inform tailored strategies to identify those at highest risk.
Strengths and Limitations
Our study adds to the limited evidence base on NCD prevalence and risk factors in AYLHIV in SSA. To our knowledge, only four other studies in SSA have investigated modifiable NCD risk factors besides alcohol and substance use in AYLHIV [87,113,122,123]. While our study provides novel findings for the sub-Saharan African context, we note some limitations.
The low response rate and lack of random sampling may limit the generalizability of our findings, however sampling from six different facilities across all substructures in the City of Cape Town mitigated unmeasured facility-specific effects. Although we recruited younger adolescents, requiring parental consent may have led to participant bias as the majority enrolled were older adolescents and young adults who could provide independent consent to participate.
We utilised subjective recall methods to asses physical activity which may be prone to over-reporting, recall bias and cultural misinterpretation. However, self-report methods like the IPAQ have acceptable validity and have been widely used to measure physical activity in PLHIV in similar contexts allowing for some comparability [25]. The use of POC random blood glucose testing may have underestimated diabetes risk, however, POC methods are better suited for community screening of diabetes, have high specificity and provide reliable and immediate results [124]. Similarly, the mental health tools used are screening and not diagnostic tools. But they are appropriate for case-finding in primary care and have been validated in HIV-positive populations in South Africa [64,65]. Despite these limitations, this study represents an important contribution to the limited literature on HIV / NCD multimorbidity in adolescents and youth in SSA.