HIV infection impacts heavily on the infected individual’s overall health status.
To determine significant health, lifestyle (smoking and alcohol use) and independent clinical manifestations associated with HIV status in rural and urban communities.
Adults aged between 25 and 64 years completed a questionnaire in a structured interview with each participant. Blood specimens were analysed in an accredited laboratory using standard techniques and controls. Anthropometric measurements were determined using standardised methods.
Of the 567 rural participants, 97 (17.1%) were HIV-infected, and 172 (40.6%) of the 424 urban participants. More than half of HIV-infected rural participants used alcohol and more than 40% smoked. Median body mass index (BMI) of HIV-infected participants was lower than that of uninfected participants. Significantly more HIV-infected participants reported experiencing cough (rural), skin rash (urban), diarrhoea (rural and urban), vomiting (rural), loss of appetite (urban) and involuntary weight loss (rural). Significantly more HIV-uninfected participants reported diabetes mellitus (urban) and high blood pressure (rural and urban). In rural areas, HIV infection was positively associated with losing weight involuntarily (odds ratio 1.86), ever being diagnosed with tuberculosis (TB) (odds ratio 2.50) and being on TB treatment (odds ratio 3.29). In the urban sample, HIV infection was positively associated with having diarrhoea (odds ratio 2.04) and ever being diagnosed with TB (odds ratio 2.49).
Involuntary weight loss and diarrhoea were most likely to predict the presence of HIV. In addition, present or past diagnosis of TB increased the odds of being HIV-infected. Information related to diarrhoea, weight loss and TB is easy to obtain from patients and should prompt healthcare workers to screen for HIV.
Lifestyle factors such as tobacco smoking, use of snuff and alcohol intake impact on quality of life. Cigarette smoking accounts for a large burden of preventable disease in South Africa.
In resource-limited countries both infectious and lifestyle diseases contribute to disease burden. Infection with HIV initiates a series of events that ultimately leads to profound immunosuppression caused by functional abnormalities in the immune system, mainly because of severe depletion of CD4+ T cells.
Nutritional alterations are common in HIV infection.
Concurrent HIV and tuberculosis (TB) infection remains a serious challenge. In 2010, 8.8 million people acquired active TB worldwide, of which 1.1 million were living with HIV.
Lifestyle diseases are the leading cause of death globally, killing more people each year than all other causes combined.
This study formed part of the Assuring Health for All in the Free State (AHA-FS) study, which aimed to determine how living in rural and urban communities can influence lifestyle and health. Despite the large body of evidence related to clinical and anthropometric manifestations of HIV, epidemiological data on these manifestations in the Free State Province are limited. The clinical relevance of identifying variables that are likely to predict HIV lies in improved screening, diagnosis and care of the large numbers of patients that visit primary healthcare facilities. The aim of this sub-study was thus to investigate health (history of disease, medication, anthropometric symptoms experienced) and lifestyle (smoking and alcohol use) of HIV-infected and HIV-uninfected, rural and urban respondents and to determine significant independent clinical manifestations associated with HIV status.
The rural study was performed in three Free State towns, namely, Trompsburg, Philippolis and Springfontein, and the urban study in Mangaung.
A cross-sectional study was undertaken. In rural areas, all households were eligible to participate. Before data were collected, induction meetings for community members and other role-players were arranged in each community. The role-players included clinic staff, church leaders, community leaders and any members of the community who were interested in learning more about the project or had questions that they wanted to ask. These role-players informed community members that were not present at induction meetings that all adults that met the inclusion criteria were welcome to participate. On days of data collection, adults that arrived at the research venue were included in the rural sample.
In urban Mangaung, the number of plots in the Mangaung University Community Partnerships Programme (MUCPP) service area was counted on a municipal map and included Buffer, Freedom Square, Kagisanong, Chris Hani, Namibia and Turflaagte. An estimate was made of additional squatter households in open areas. A stratified proportional cluster sample was selected, stratified by area and formal plot or squatter households in open areas. Using randomly selected X and Y coordinates, 100 starting points were selected in this way. From each point, five adjacent starting households were approached to participate in the study. Every adult member of households in these black and mixed-ethnic communities, who gave informed consent and was between 25 and 64 years of age, was eligible to participate.
Prior to the main survey, a pilot study was undertaken with five individuals in each area, similar to the target group, in order to determine whether questions included in the questionnaire could be easily understood and to estimate the amount of time needed to complete the questionnaires. The questionnaire and all anthropometric measurements were piloted. Minor changes (mostly technical editing) were made to questionnaire after the pilot study.
For the purpose of this study, health referred to medical history, medication used, hospitalisation, anthropometry and symptoms experienced. Lifestyle referred to tobacco and alcohol consumption patterns. Among others, laboratory investigations included HIV status.
Anthropometric variables included height, weight and waist circumference (WC). Adults were categorised as underweight (body mass index [BMI] less than 18.5 kg/m2); normal weight (BMI 18.5 kg/m2 or over, but less than 25 kg/m2); overweight (BMI 25 kg/m2 or over, but less than 30 kg/m2); or obese (BMI 30 kg/m2 or over).
A health questionnaire, adapted from the one developed for the Prospective Urban Rural Epidemiology (PURE) study,
Data collection took place at different research venues, including the community hall in the rural area or at the MUCPP nutrition centre in the urban area. On days of data collection, identity documents were screened in order to make sure that participants met the inclusion criteria with regard to age. The research venues included stations for the collection of blood samples; a food station; medical examination; anthropometric measurements (participants arrived in a fasting state for the collection of blood samples). Thereafter, questionnaires related to the following were completed: sociodemography; household food security; dietary intake; physical activity; and self-reported health.
All analyses were performed by the Department of Biostatistics, UFS. Descriptive statistics, including frequencies and percentages for categorical data, and means and standard deviations (SDs) for symmetrical numerical variables, or medians and percentiles for skew numerical variables, were calculated. Differences between HIV-infected and HIV-uninfected groups were assessed by
In addition to descriptive comparisons between HIV-infected and HIV-uninfected participants, logistic regression was applied to identify significant clinical manifestations associated with HIV. For each of the variables, a univariate analysis was applied to identify variables that could be included in the rural and urban model (
In the urban sample, the health variables that were included in the model were: loose stools or diarrhoea for at least three days in last six months, loss of appetite in last six months, involuntary weight loss > 3 kg in last six months, ever diagnosed with TB and TB treatment.
Following this, logistic regression with forward selection (
The study was approved by the Ethics Committee of the Faculty of Health Sciences at the UFS (ETOVS 21/07), the Free State Department of Health (DoH) and local municipalities. The researchers obtained written consent from all participants in their language of choice.
Of the 570 rural participants, 567 had HIV results. Of these, 97 (17.1%) were HIV-infected. Of the 426 urban participants, 424 had HIV results, of which 172 (40.6%) were HIV-infected. Twenty-five per cent (
Results related to smoking and use of snuff are shown in
History of smoking and use of snuff.
Variable | Sample | Rural |
Urban |
||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
HIV-positive |
HIV-negative |
HIV-positive |
HIV-negative |
||||||||
% | % | % | % | ||||||||
RHP 88, RHN 452; UHP 164, UHN 244 | - | - | - | - | - | - | - | - | - | - | |
Never smoked | - | 35 | 39.8 | 190 | 42.0 | - | 113 | 68.9 | 162 | 66.4 | - |
Currently smoke | - | 36 | 40.9 | 179 | 39.6 | 0.81 | 39 | 23.8 | 52 | 21.3 | 0.55 |
Formerly smoked | - | 17 | 19.3 | 83 | 18.4 | - | 12 | 7.3 | 30 | 12.3 | - |
RHP 87, RHN 449; UHP 164, UHN 244 | - | - | - | - | - | - | - | - | - | - | |
Never used snuff | - | 68 | 78.2 | 346 | 77.1 | - | 111 | 67.7 | 170 | 69.7 | - |
Currently use snuff | - | 15 | 17.2 | 79 | 17.6 | 0.93 | 41 | 25.0 | 62 | 25.4 | 0.92 |
Formerly used snuff | - | 4 | 4.6 | 24 | 5.4 | - | 12 | 7.3 | 12 | 4.9 | - |
,
,
RHP, rural, HIV-positive; RHN, rural, HIV-negative; UHP, urban, HIV-positive; UHN, urban, HIV-negative.
Alcohol consumption.
Variable | Sample | Rural |
Urban |
||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
HIV-positive |
HIV-negative |
HIV-positive |
HIV-negative |
||||||||
% | % | % | % | ||||||||
RHP 88, RHN 450; UHP |
|||||||||||
Never used alcohol | - | 13 | 14.8 | 100 | 22.2 | - | 68 | 41.7 | 118 | 48.4 | - |
Currently use alcohol | - | 48 | 54.6 | 214 | 47.6 | 0.23 | 69 | 42.3 | 89 | 36.5 | 0.22 |
Formerly used alcohol | - | 27 | 30.7 | 136 | 30.2 | - | 26 | 16.0 | 37 | 15.2 | - |
Spirits | RHP 47, RHN 204; UHP 66, UHN 84 | 10 | 21.3 | 34 | 16.7 | - | 7 | 10.6 | 5 | 6.0 | - |
Wine | RHP 47, RHN 206; UHP 65, UHN 83 | 8 | 17.0 | 41 | 19.9 | - | 8 | 12.3 | 10 | 12.1 | - |
Beer, cider | RHP 46, RHN 205; UHP 66, UHN 83 | 31 | 67.4 | 114 | 55.6 | - | 47 | 71.2 | 54 | 65.1 | - |
Homemade beer | RHP 45, RHN 202; UHP 65 UHN 83 | 22 | 47.8 | 117 | 57.9 | - | 13 | 20.0 | 24 | 28.9 | - |
RHP 48, RHN 206; UHP 66, UHN 88 | 21 | 43.8 | 88 | 42.7 | 0.89 | 26 | 39.4 | 34 | 41.0 | 0.84 | |
RHP 19, RHN 68; UHP 22, UHN 27 | 16 | 84.2 | 42 | 61.8 | 0.07 | 15 | 68.2 | 22 | 81.5 | 0.28 |
,
,
RHP, rural, HIV-positive; RHN, rural, HIV-negative; UHP, urban, HIV-positive; UHN, urban, HIV-negative.
Reported symptoms and medication use of HIV-infected and HIV-uninfected rural and urban participants are described in
Reported symptoms, diagnoses and medication use.
Variable | Sample | Rural |
Urban |
||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
HIV-positive |
HIV-negative |
HIV-positive |
HIV-negative |
||||||||
% | % | % | % | ||||||||
Loose stools, diarrhoea for at least 3 days | RHP 89, RHN 451, UHP 164, UHN 243 | 34 | 38.2 | 125 | 27.7 | 0.04 |
54 | 32.9 | 48 | 19.8 | 0.002 |
Vomiting | RHP 89, RHN 450, UHP 164, UHN 244 | 29 | 32.6 | 98 | 21.8 | 0.02 |
41 | 25.0 | 47 | 19.3 | 0.16 |
Loss of appetite | RHP 89, RHN 451, UHP 164, UHN 244 | 41 | 46.1 | 184 | 40.8 | 0.35 | 95 | 57.9 | 111 | 45.5 | 0.01 |
Involuntary weight loss > 3 kg | RHP 89, RHN 451, UHN 164, UHN 244 | 57 | 64.0 | 227 | 50.3 | 0.01 |
78 | 47.6 | 92 | 37.7 | 0.05 |
Chest pain or tightness with usual activity | RHP 89, RHN 451; UHP 164, UHN 243 | 54 | 60.7 | 211 | 46.8 | 0.02 |
97 | 59.2 | 137 | 56.4 | 0.57 |
Cough for at least 2 weeks | RHP 89, RHN 451, UHP 164, UHN 244 | 48 | 53.9 | 184 | 40.8 | 0.02 |
74 | 45.1 | 96 | 39.3 | 0.24 |
Wheezing or whistling in chest | RHP 89, RHN 451, UHP 164, UHN 244 | 41 | 46.1 | 195 | 43.2 | 0.62 | 62 | 37.8 | 86 | 35.3 | 0.59 |
Sexually transmitted diseases | RHP 89, RHN 452, UHP 164, UHN 244 | 12 | 13.5 | 32 | 7.1 | 0.04 |
56 | 34.2 | 13 | 5.3 | 0.0001 |
Blood in urine | RHP 89, RHN 452, UHP 164, UHN 244 | 11 | 12.4 | 32 | 7.1 | 0.09 | 11 | 6.7 | 18 | 7.4 | 0.79 |
Skin rash | RHP 89, RHN 451, UHP 164, UHN 244 | 26 | 29.2 | 115 | 25.5 | 0.46 | 62 | 37.8 | 60 | 24.6 | 0.004 |
Breathlessness with usual activity | RHP 89, RHN 452, UHP 164, UHN 244 | 53 | 59.6 | 223 | 49.3 | 0.07 | 81 | 49.4 | 129 | 52.9 | 0.49 |
Swelling of feet | RHP 89, RHN 452, UHP 164, UHN 244 | 32 | 36.0 | 177 | 39.2 | 0.57 | 67 | 40.9 | 124 | 50.8 | 0.04 |
Joint pain | RHP 88, RHN 451, UHP 164, UHN 244 | 49 | 55.7 | 316 | 70.1 | 0.008 |
96 | 58.5 | 163 | 66.8 | 0.09 |
Liver disease, hepatitis, jaundice | RHP 89, RHN 452, UHP 164, UHN 244 | 4 | 4.5 | 12 | 2.7 | 0.31 | 12 | 7.3 | 7 | 2.9 | 0.03 |
Lung disease, e.g. emphysema or asthma | RHP 89, RHN 451, UHP 164, UHN 244 | 13 | 14.6 | 58 | 12.9 | 0.65 | 14 | 8.5 | 18 | 7.4 | 0.66 |
TB | RHP 88, RHN 452, UHP 164, UHN 244 | 24 | 27.3 | 46 | 10.2 | 0.0001 |
40 | 24.4 | 26 | 10.7 | 0.0002 |
Diabetes mellitus | RHP 89, RHN 450, UHP 164, UHN 244 | 5 | 5.6 | 55 | 12.2 | 0.07 | 7 | 4.3 | 25 | 10.3 | 0.02 |
High blood pressure | RHP 89, RHN 451, UHP 164, UHN 244 | 40 | 44.9 | 298 | 66.1 | 0.002 |
58 | 35.4 | 139 | 57.0 | 0.0001 |
Stroke | RHP 89, RHN 452, UHP 164, UHN 244 | 8 | 9.0 | 27 | 6.0 | 0.29 | 9 | 5.5 | 11 | 4.5 | 0.65 |
Heart disease, angina, heart attack | RHP 89, RHN 448, UHP 164, UHN 244 | 14 | 15.7 | 69 | 15.4 | 0.93 | 27 | 16.5 | 43 | 17.6 | 0.76 |
Heart failure | RHP 89, RHN 452, UHP 164, UHN 244 | 1 | 1.1 | 5 | 1.1 | 1.0 | 8 | 4.9 | 11 | 4.5 | 0.86 |
Cancer | RHP 89, RHN 452, UHP 164, UHN 244 | 0 | 0.0 | 6 | 1.3 | 0.59 | 3 | 1.8 | 6 | 2.5 | 0.74 |
Epilepsy | RHP 89, RHN 451, UHP 164, UHN 244 | 4 | 4.5 | 22 | 4.9 | 1.0 | 11 | 6.7 | 14 | 5.7 | 0.68 |
Allergy | RHP 89, RHN 451, UHP 164, UHN 244 | 12 | 13.5 | 68 | 15.1 | 0.69 | 28 | 17.1 | 45 | 18.4 | 0.72 |
Taking medication regularly | RHP 88, RHN 448, UHP 164, UHN 244 | 62 | 70.5 | 347 | 77.5 | 0.16 | 90 | 54.9 | 132 | 54.1 | 0.87 |
Type of medication | RHP 62, RHN 347, UHP 90, UHN 132 | - | - | - | - | - | - | - | - | - | - |
ART | - | 4 | 6.5 | 0 | 0.0 | 0.0001 |
43 | 47.8 | 0 | 0.0 | - |
TB treatment | - | 10 | 16.1 | 8 | 2.3 | 0.0001 |
10 | 11.1 | 4 | 3.0 | 0.01 |
Diabetes (oral) | - | 2 | 3.2 | 42 | 12.1 | 0.02 |
0 | 0.0 | 13 | 9.9 | 0.0027 |
Hypertension | - | 28 | 45.2 | 252 | 72.6 | 0.0001 |
22 | 24.4 | 90 | 68.2 | 0.0001 |
Other | - | 54 | 87.1 | 314 | 90.5 | - | 46 | 51.1 | 49 | 37.1 | - |
RHP 88; RHN 451, UHP 164, UHN 244 | 26 | 29.6 | 104 | 23.1 | - | 46 | 28.1 | 65 | 26.6 | - |
,
,
TB, tuberculosis; RHP, rural, HIV-positive; RHN, rural, HIV-negative; UHP, urban, HIV-positive; UHN, urban, HIV-negative.
, Statistically significant difference.
In urban areas, significantly more HIV-infected urban participants reported loose stools or diarrhoea for at least three days (32.9% vs. 19.8%,
HIV-infected participants in both groups were significantly more likely to have been diagnosed with TB (27.3% vs. 10.2% in rural areas [
In rural areas, the median BMI of HIV-uninfected men fell into the normal weight category at 21.0 kg/m2 compared to 18.7 kg/m2 of the HIV-infected men, indicating a median difference of 2.3 kg/m2, which was statistically significant (
Body mass index of HIV-infected and HIV-uninfected participants in rural and urban communities.
Community | Gender | HIV-positive |
HIV-negative |
|||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Median | Mean | SD | Min | Max | Median | Mean | SD | Min | Max | |||||
Rural | Male | 25 | 18.7 | 19.6 | 4.5 | 15.5 | 33.6 | 85 | 21.0 | 21.84 | 5.27 | 11.8 | 41.4 | 0.02 |
Urban | 36 | 19.4 | 19.8 | 2.58 | 14.5 | 25.3 | 61 | 20.9 | 22.64 | 6.6 | 14.7 | 49.9 | 0.07 | |
Rural | Female | 63 | 23.1 | 24.9 | 6.8 | 13.7 | 42.5 | 359 | 27.7 | 28.8 | 8.9 | 11.9 | 53.6 | 0.009 |
Urban | 131 | 25.0 | 26.0 | 7.6 | 13.3 | 55.7 | 185 | 31.8 | 32.4 | 8.8 | 14.5 | 55.1 | 0.001 |
, for median difference.
, statistically significant at
SD, standard deviation.
The median BMI of HIV-infected and uninfected urban men fell within the normal weight category at 19.4 kg/m2 and 20.9 kg/m², respectively, a difference which was not statistically significant (
A larger percentage of HIV-infected women had a WC below 80 cm compared to HIV-uninfected women, a difference that was statistically significant (
Logistic regression was applied to identify significant clinical manifestations associated with HIV in the rural (
Reported clinical manifestations associated with HIV status (rural).
Variable | Yes vs. no | Odds ratio | 95% CI | |
---|---|---|---|---|
Age | – | 0.02 | 0.89; 0.95 | < 0.0001 |
Involuntary weight loss > 3 kg in last 6 months | Yes vs. no | 1.86 | 1.08; 3.20 | 0.0255 |
Ever diagnosed with TB | Yes vs. no | 2.50 | 1.18; 5.23 | 0.0163 |
TB treatment | Yes vs. no | 3.29 | 1.00; 10.80 | 0.0498 |
TB, Tuberculosis; CI, confidence interval; vs, versus.
Reported clinical manifestations associated with HIV status (urban).
Variable | Yes vs. no | Odds ratio | 95% CI | |
---|---|---|---|---|
Age | – | 0.93 | 0.91; 0.95 | < 0.0001 |
Loose stools or diarrhoea for at least 3 days in last 6 months | Yes vs. no | 2.04 | 1.23; 3.41 | 0.0061 |
Ever diagnosed with TB | Yes vs. no | 2.49 | 1.37; 4.53 | 0. 0028 |
TB, Tuberculosis; CI, confidence interval; vs, versus.
In the rural sample, for every year that age increased, the odds of having HIV decreased by 8%. HIV infection was positively associated with losing weight involuntarily (> 3 kg in the past six months; odds ratio 1.86), ever being diagnosed with TB (odds ratio 2.50) and being on TB treatment (odds ratio 3.29).
In the urban sample, for every year that age increased, the odds of having HIV decreased by 7%. HIV infection was positively associated with having diarrhoea for at least three days in the past six months (odds ratio 2.04) and ever being diagnosed with TB (odds ratio 2.49).
The high prevalence of HIV in urban Mangaung has been reported previously.
A fairly large percentage of participants in the current study smoked and used snuff. Lifestyle factors such as tobacco smoking, use of snuff and alcohol intake impact on quality of life of both the general population, as well as those with HIV. More HIV-infected participants tended to use alcohol than their uninfected counterparts, with beer being the most frequently consumed alcoholic beverage in all groups. Alcohol may be a mediating factor in risky sexual behaviour and therefore impacts on the transmission of HIV.
In the early period, infectious diseases such as HIV and lifestyle diseases were perceived to be largely different.
Significantly more HIV-infected participants reported experiencing loose stools and diarrhoea, as well as involuntary weight loss, compared to HIV-uninfected participants, and were therefore at higher risk of developing malnutrition. Diarrhoea affects 40–80% of HIV-infected adults who do not receive ART.
In the current study, logistic regression indicated that HIV infection was positively associated with losing weight involuntarily (more than 3 kg in the past six months) (rural) and having diarrhoea for at least three days in the past six months (urban). Previous research has shown significant weight loss and a high prevalence of underweight among HIV-infected adults.
South Africa has a high TB–HIV co-infection rate of 73%, yet only 46% of TB patients are tested for HIV.
In the current study a larger percentage of HIV-uninfected participants reported having diabetes mellitus and hypertension. This could probably be ascribed to the lower median BMI and WC of HIV-infected participants. A similar trend has also been reported among HIV-infected black women in Mangaung.
Overnutrition is prevalent among the general population of adult South Africans, particularly women.
The results of the current study confirm that the clinical and anthropometric manifestations of HIV infection reported in the literature are also evident in HIV-infected persons from the Free State. The high prevalence of overweight (among women) associated with symptoms such as weight loss and diarrhoea that were identified in the participants in the current study, can complicate the management of HIV-infected patients in the primary healthcare setting. Information about unintentional weight loss, diarrhoea and a history of TB can prompt healthcare professionals to screen for HIV, even in women who are not underweight.
We acknowledge that there could have been a certain degree of bias because older and unemployed individuals were more likely to participate. It is also possible that because of limited health services, ill persons might have been more likely to participate in the study where medical examinations were conducted, especially in rural areas. Furthermore, the younger age and lower BMI of HIV-infected participants complicate a comparison of clinical manifestations of HIV-infected participants to those of HIV-uninfected participants. Because of these reasons, the authors are aware that the study group is probably not representative of the general population.
Involuntary weight loss (rural) and diarrhoea (urban) were most likely to predict HIV infection. In both samples, a history of TB (rural and urban) or TB treatment (rural) was positively associated with HIV infection. In addition, median BMI and WC of HIV-infected respondents were significantly lower than in HIV-uninfected respondents (although many HIV-infected women were still in the overweight category). The HIV-uninfected group consequently had a higher occurrence of lifestyle diseases, such as diabetes mellitus and hypertension.
The results of the current study confirm the higher prevalence of opportunistic infections and the associated symptoms (such as diarrhoea and weight loss) in HIV-infected persons in this sample. Information related to diarrhoea, weight loss and past or present TB is easy to obtain from patients and should prompt healthcare workers to screen patients for HIV and to implement relevant interventions.
We acknowledge the National Research Foundation (NRF) for funding this study; the participants; the local community members and the research team; and Dr Daleen Struwig, medical writer/editor, Faculty of Health Sciences. University of the Free State, for technical and editorial preparation of the manuscript.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
M.P. was a PhD student and primary author of the manuscript. C.M.W. was the principal investigator and promotor. F.C.v.R. was responsible for statistical analysis of the data.