Balancing HIV treatment with a myriad lifestyle diseases such as diabetes and hypertension is tricky. Patients have to take lots of pills, some medicines interact badly and there are side-effects. But this is the future of our clinics as HIV positive patients age and poor diet and lack of exercise take their toll. HEALTH-E’s Kerry Cullinan reports.
It’s a cold winter’s morning at Delft Community Health Centre. Patients huddle under beanies and hoodies, some sitting on scraps of cardboard to ease the chill coming up through the icy plastic seats.
The busy 24-hour clinic sees around 35,000 patients a month from Cape Town’s northern areas, and every morning the corridors and waiting areas are clogged with people.
Infectious diseases – especially TB and HIV – are the main focus, but the incidence of non-communicable diseases (NCDs), particularly hypertension and diabetes, is steadily rising. Government clinics report that 10,000 new diabetic patients are being diagnosed every month, for example.
By 2025, around 12.3-million South Africans will be on long-term medication for HIV and various NCDs, according to the Department of Health. This is going to put massive strain on the health system, and treatment is particularly challenging for people living with both HIV and NCDs.
“Patients with HIV are living longer and lifestyle diseases are becoming more common in these patients,” says Dr Marcia Vermeulen, who dashes over for a quick chat before attending to a long line of patients.
“People are more likely to take their ARVs and be virally suppressed because they have seen the effects if they don’t. But hypertension and diabetes are more abstract,” says Vermeulen. “They can’t see the long-term effects so often don’t adhere to their medication. When we test them, their blood sugar levels are often very high.”
HIV positive patients with NCDs often have to take a lot of pills, which has health workers worried about whether they are going to be able to commit to a lifetime of pill swallowing.
Elizabeth Meyer was first diagnosed with HIV in 2002, but has managed to keep the virus in check for many years and only started ARV treatment a couple of months ago. She is far more plagued by her diabetes and hypertension.
“Two years ago, I was diagnosed with diabetes. My mouth was dry, I had painful burning under my feet,” says the soft-spoken 43-year-old mother.
Meyer now has to take seven pills every day. In the morning, she takes a “big thick” diabetes pill, a blood pressure pill and a cholesterol tablet. She repeats this at night, but adds her daily ARV, which is a three-in-one pill.
“In the beginning, it was hard and I wanted to vomit. I was drowsy and very nauseous but I am getting used to it,” says Meyer. She is also trying hard to cut sugar, salt and fizzy drinks from her diet and watch her weight, which is a constant battle.
Over 6,000 HIV positive patients have started on ARVs at the centre, and around 2,200 are stable with undetectable levels of the virus, says Sister Tresia Nontshinga, the operational manager for infectious diseases.
These stable patients are organised into “clubs” of up to 25 people with similar disease profiles. At the moment, 10% of stable HIV positive patients also have chronic diseases. Grouping the diabetic HIV positive patients together, for example, both creates a support system and makes it easier for nurses to address similar problems at the same time.
But treating patients with both NCDs and HIV is complicated and it takes much more time for health workers.
For a start, some ARVs – particularly protease inhibitors (PI) – can cause diabetes, in part because the medicine interferes with the body’s absorption of glucose. Luckily, these are “second line” ARVs, taken by people who have become resistant to first line treatment.
“The introduction of dolutegravir in late 2018, which doesn’t impact on glucose, will partly fix this,” says Professor Francois Venter from the Wits Reproductive Health and HIV Institute (WRHI). “We are also working on second line drugs that impact on glucose, to make them safer, which will hopefully become available in 2018 or 2019.”
But there are also the drug interactions between ARVs and NCD medicines to consider. For example, dolutegravir interferes with a diabetes medicine called metformin. The blood-thinning medicine, warfarin, for people in danger of clots, interferes with TB medication.
Delft’s head of clinical services, Dr Sheron Forgus, says that health workers working in infectious diseases have become much more aware of NCDs in the past few years, and are dedicated to screening their HIV positive patients. But it is complicated and time-consuming.
Stable HIV positive patients get to see a doctor once a year and these check-ups now take a long time as doctors need to test for NCDs too – which means that they test their “eyes, feet, do blood tests for their sugar levels, cholesterol tests, test their kidneys”, says Forgus.
Each Delft doctor currently sees 40 patients a day – that’s a patient every 12 minutes if you work for eight hours flat out without any breaks.
There is very little time to educate patients about healthy habits, particularly related to diet.
“Our patients drink litres and litres and litres of fizzy drinks,” says Forgus. “But the consultations are short and we have to address everything in one visit. To encourage behaviour change, you need at least 30 minutes with each patient. But we are lucky to have a dietician and I have to say that our staff are very dedicated and always go the extra mile for patients.”
Dr Samanta Lalla-Edward, the technical head of NCD research at WRHI, says that while some NCDs are genetic, “the lifestyle and environmentally induced NCDs” have to be addressed as a minimum. These include diseases linked to smoking, excessive alcohol and poor diet “because these are largely within the control of person”.
But, she says, policy-makers also need to understand what is driving NCDs, as well as advocate for tighter control over substances such as cigarettes and alcohol, and promote “healthier working and living conditions incorporating nutrition and exercise”.
But it isn’t easy. As Vermeulen says: “Most of our patients are suffering from poor diet and inactivity. They are unemployed and looking for a job, not going to the gym. There are no gyms here.” DM
Photo: Sister Tresia Nontshinga and Dr Marcia Vermeulen at Delft Community Centre Photo: Health-e