This study describes documentation of NCD and NCD risk screening and health promotion in HIV-infected adolescents and youth receiving ART in an urban setting in South Africa. We found that only 55% of the folders reviewed had any information on other comorbidities and 62% had risk factor information. Of these, 11% were NCD comorbidities ranging from mental health conditions to chronic respiratory diseases. A key finding of this study is the paucity of data on NCD and NCD risk captured as part of clinical care of adolescents with HIV. Poor documentation and screening of NCD risk-factors for the majority of participants in our study demonstrates a missed opportunity for detecting comorbidity and NCD risk in primary health care and for early intervention in AYLHIV who represent an important population and are less inclined to seek regular or preventive care. Early identification and intervention to modify behaviour would prevent a costly future epidemic of NCDs and avert morbidity and mortality due to NCDs [10].
Data paucity notwithstanding, our results highlight evidence of co-existing NCD multimorbidity and NCD risk factors (overweight and obesity, elevated BP and smoking, alcohol and substance use) in AYLHIV. A similar study in the US conducted a retrospective chart review in HIV-positive children and adolescents aged 2–25 years and found an 18% prevalence of high blood pressure [47]. In that study, there were significant associations with other medical comorbidities and risk factors such as tobacco exposure and male gender. The authors highlighted that the life-long cardiovascular risks associated with HIV infection and its management call for closer monitoring and possibly treatment of elevated BP in this population [47]. Another study conducted in Cape Town adults in similar peri-urban informal settings as our study demonstrated that 19% of HIV-infected patients on ART were on treatment for another chronic disease (diabetes, tuberculosis or hypertension), with 77% and 17% of them receiving anti-hypertensive and diabetic treatment respectively [14].
Previous studies in healthy young people have shown prevalence rates of overweight and obesity of 23–7% respectively [48] and hypertension/elevated blood pressure rates of 6.7% in respondents in the 15–24 year age group [44]. Whilst the prevalence of these NCD risks cannot be estimated from our study due to the limited documentation, these previous surveys in South Africa demonstrate high NCD rates in adolescents in the general population. Given the data from adults with HIV in South Africa, there is an indication that the prevalence of NCD risk in adolescents with HIV is potentially higher than their healthy counterparts [14, 49], strengthening the argument for targeted NCD prevention efforts in this population group to prevent multimorbidity. Given that some NCDs (such as mental disorders) and many NCD risk behaviours such as substance abuse also influence HIV control, our finding that 69% of participants were virally suppressed further emphasises the need for strengthened integrated health systems.
In this study, we noted that only 19% had a documented health promoting intervention, ranging from alcohol or substance abuse (13%) to healthy weight or diet (13%) and mental health counselling (10%). Family history of an NCD has been shown to be a significant risk factor for NCD in South Africa [51] and so should form an important component of NCD risk assessment. In this study, only 6% had a documented family history recorded. Other upstream determinants of NCD risk such as the social environment were not noted.
As has been demonstrated in adult patients, chronic disease care requires a comprehensive, holistic approach that integrates treatment and prevention of multiple conditions [52, 53]. Such an approach, integrating NCD primary prevention with HIV care, will be an important component of strategies to reduce multimorbidity and the future burden of NCDs in high HIV-burden settings.
In response to the complex dual burden of chronic communicable and non-communicable diseases, the South African Department of Health developed an Integrated Chronic Disease Management model as part of the re-engineering of Primary Health Care in 2011 [54]. Pilot projects are underway in selected primary health care facilities to investigate the most effective models of integrated care. Early findings demonstrate provider and patient satisfaction with several dimensions of the model [55]. But leveraging elements of HIV programmes for NCDs, like hypertension management was noted to be inadequate, in part due to malfunctioning equipment and drug stock-outs [56]. To date, these models have focused on the general adult population, with no integrated clinics for adolescents planned; largely due to a paucity of data on NCD comorbidities and NCD risk in adolescents with HIV. Our results demonstrate a missed opportunity to improve health, and prevent multimorbidity, in this important population group with unique health needs.
A key limitation of our study was the retrospective nature of data collection. As information that was not documented could not be verified or measured, we were unable to estimate the prevalence of NCD or NCD risk in this population. However, the NCD data paucity noted represents an important finding for the health system as it demonstrates a lack of integration of NCD prevention into HIV care. Another limitation is that we were unable to explore determinants of NCD comorbidity due to the low number of NCD diagnoses recorded. Such information could be used to inform targeted and cost-effective approaches to NCD screening.