Introduction
At the end of 2019, there were 38.0 million [36.2 million adults] people living with HIV (PLWH) worldwide, with 62% of them having access to life-saving Antiretroviral Therapy (ART) [
1,
2]. With more than 17.7 million PLWH in Eastern Africa, it is the second most affected region in Africa, after South Africa [
3,
4]. In 2016, the estimated prevalence of HIV in Ethiopia was 1.1% [
5]. PLWHs who receive ART can live long and healthy lives, and this advancement has transformed HIV infection from an acute to a chronic disease [
6,
7]. However, the toxic side effects of ART, long-term HIV infection, increased obesity, and visceral adiposity have made PLWHs more vulnerable to chronic non-communicable diseases (NCDs), such as cardiovascular disease and diabetes mellitus [
8‐
10]. The presence of NCD comorbidities among PLWHs may impair HIV prognosis [
11].
PLWH share many NCD risk factors, such as unhealthy diets (high intake of fat, salt, and refined sugars), physical inactivity, tobacco use, and harmful alcohol use [
12,
13]. A systematic review of PLWHs from high-income countries found that physical activity improves health and functional capacity [
14]. According to other systematic reviews and meta-analyses, physical activity is beneficial for adults with HIV in terms of cardiorespiratory fitness, strength, body composition, and quality of life [
15]. A study conducted in the United States indicates the benefit of PA in decreasing comorbidities in PLWHs [
16]. The World Health Organization (WHO) guidelines on PA for health recommend 150 min of moderate intensity or 75 min of vigorous intensity per week for adults aged 18–64 for substantial health benefits [
17]. Given the substantial benefits of regular PA, cross-sectional studies conducted in low-income countries indicate that most PLWHs are insufficiently physically active [
18,
19].
An unhealthy diet is one of the most important modifiable risk factors for the most common NCD, as it can contribute to the development of conditions such as hypertension and type 2 diabetes mellitus (T2DM), as well as being overweight or obese, which are both risk factors for many NCDs [
20]. There is growing concern in the public health sector that a poor diet increases the risk of chronic diseases and nutrition problems [
21]. Unhealthy diets, particularly a lack of fruits and vegetables, are also major behavioral risk factors for NCDs [
22]. Despite this, consumption of these foods remains significantly lower than the recommended level [
22]. Several studies have found that the proportion of PLWHs who are overweight or obese is increasing in Sub-Saharan Africa [
23]. The World Health Organization has issued warnings predicting the emergence of NCDs in resource-limited countries in the coming decades due to an increase in risk factors such as being overweight or obese [
23]. In Africa, the impact of HIV/AIDS on food insecurity is well documented [
24]. According to research, food insecurity and less diversified food are linked to a number of key metabolic risk factors, including obesity, overweight, and dyslipidemia [
25,
26].
Despite a few cross-sectional studies conducted in Ethiopia, there is insufficient evidence on PA level and survival in chronic comorbidity among HIV patients. Such research could be critical in identifying and differentiating modifiable factors that are certain to reduce chronic comorbidity in these subjects. Therefore, the purpose of this study was to assess PA and survival in chronic comorbidity among adult PLWHs in Ethiopia. The results of this study could be used to develop strategies to reduce the risks associated with chronic comorbidities in adult HIV patients.
Discussion
The findings of this study show that most PLWHs had a low level of PA. Walking was the most frequently practiced PA. People living in rural areas were more physically active than those living in urban areas, yet sitting was also more common among the rural residents. Self-management skills of the participants was associated with a high level of PA. During the two-year follow-up period, 20 (5.5%) new cases of diabetes, 19 (5.2%) new cases of hypertension, and 3 new cases of both DM and hypertension were registered. The overall incidence rate of chronic comorbidity was 10.83 per 1000 people per month. A lack of regular physical exercise and a low level of PA, low fruit and vegetable consumption, and having a BMI greater than or equal to 25 kg/m2 were associated with the development of chronic comorbidity.
We found that the majority of participants (39%) had low levels of PA and slightly more than half (53%) of our study participants were not engaged in regular PA. This implies that they fell short of the 2020 Global Recommendations on PA for Health [
38] recommended PA levels. Compared to previous studies on ART patients using the IPAQ system, the percentage of low PA level in our study is high [
39,
40]. Similar to previous studies, walking was the most frequently practiced PA [
41,
42]. Neither men nor women, however, walked for more than 150 min per week. Contrary to what we found, a research done among Saudi adults showed that 37.8% of men and 28.5% of women reported walking for 150 min or more every week [
43]. Additionally, the Women’s Health Initiatives follow-up study showed that walking needs to be done for at least 30 min, five days a week, in order to protect against chronic illnesses like cardiac disease [
44]. Therefore, promoting PA as an intervention strategy is crucial to preventing the added burden of chronic comorbidity among adult HIV patients.
In our study, 50% of participants from rural areas had high levels of PA, which is higher than that of urban dwellers. It is consistent with studies conducted in sub-Saharan African countries, Ethiopia, Northern Tanzania and Vietnam [
19,
39,
45]. Most rural areas in Ethiopia lack access to transportation, thus people must travel large distances by foot for a variety of social reasons, such as moving from one farm site to another or moving from one location to another. Furthermore, rural residents frequently engage in manual labor and physical travel, which promotes robust and moderate PA, in contrast to their urban counterparts who appear to embrace sedentary habits [
19]. On the other hand, sitting was also more common among the rural residents, and the average day per week of walking activity was also lower among the rural residents. A plausible reason for this could be that in the rural setup of the current study area, walking frequency could be influenced by the lack of pedestrian infrastructure such as sidewalks that may discourage people from regular walking. But the MET score obtained by walking activity among the rural residents was higher compared to their urban counterparts, and this reflects that rural dwellers walk long distances but not on a regular basis. As a result, healthcare professionals working in the ART clinic should promote awareness of the importance of regular PA among HIV patients.
The study participants’ self-management skills, such as those who saw maintaining PA as an important part of their HIV management strategy, attended social support groups, and those who had success in maintaining PA consistently, had a significant association with a high level of PA. There is supporting evidence from the study conducted in Thailand indicating self-management is an effective strategy for enhancing exercise behavior [
46]. Therefore, health care providers working in ART clinics should pay attention to HIV patients’ self-management skills in order to increase PA levels and thereby decrease the risk of chronic comorbidity.
The lack of longitudinal studies on the incidence of chronic comorbidity in PLWHs in low-income settings is concerning. There is evidence from cross-sectional studies that the prevalence of chronic comorbidities (hypertension and diabetes mellitus) is high in the African population, including Ethiopia [
47‐
49]. Our current study’s results revealed that among adult HIV patients, the hazard of developing chronic comorbidity increased over time, with an overall incidence rate of chronic comorbidities of 10.83 per 1000 person-months. The incidence rate of diabetes mellitus was 11 per 1000 people-year follow-up as an independent case, according to the retrospective cohort study done on PLWHs in Thailand [
50]. There are more cases of hypertension, according to studies on the incidence in other parts of Ethiopia, Uganda, Tanzania, and South Africa [
51‐
54]. The higher cut-off value used in this study to diagnose incident hypertension compared to some of the other studies may be contributing to the lower incidence. Incidence rate variations may also be caused by variations in sample size, study design (prospective vs. retrospective cohort), study area, and socio-demographic characteristics of study participants.
Our study found that patients who did not exercise regularly and those with low levels of PA had a considerably higher estimated cumulative probability of developing chronic comorbidity over time. PA has been shown in numerous studies to play a significant role in lowering the morbidity and mortality of various diseases. People of all ages can benefit from PA in terms of their physical health, psychological health, social health, and emotional health [
55,
56]. In spite of the benefits that have been found, a sizable portion of PLWHs in sub-Saharan Africa, including Ethiopia, still do not exercise as part of their rehabilitation [
57]. For these groups to have better health and experience a lower likelihood of developing chronic comorbidity, interventions that encourage PA will be crucial.
According to the results of the current study, people with a BMI of 25 kg/m
2 or more had a significantly increased estimated cumulative likelihood of having a chronic comorbidity over time. In this study, being overweight is also another modifiable predictor of chronic comorbidity. There are similar studies showing that high BMI is a modifiable predictor of chronic comorbidity in PLWHs [
28,
58,
59]. According to the study, which was conducted in two hospitals in the United Kingdom, the diagnosis of metabolic syndrome increased significantly as BMI increased [
60]. Previous studies indicate the association between high BMI (obesity and overweight) and a lack of PA [
61,
62]. For instance, a study conducted among adult PLWHs in South-west Ethiopia [
63] shows that patients who had no regular PA were 1.3 times more likely to develop obesity/overweight compared to those who had. Therefore, it is crucial to support intervention programs that emphasize encouraging PA among HIV/AIDS patients.
Participants in the study who consumed less fruits and vegetables than their counterparts were also more likely to develop chronic comorbidity. This result is in line with a systemic review study that demonstrates the significant preventative potential of increasing vegetable and fruit consumption in relation to a range of diseases, including hypertension and diabetes mellitus [
64]. WHO also emphasizes the inclusion of fruits and vegetables in our diets to promote health and lower the risk of certain non-communicable diseases (NCDs) [
65]. Therefore, nutritional counselling intended to increase HIV patients’ consumption of fruits and vegetables should be taken into consideration to lower the chance of acquiring chronic comorbidity.
Our study has some limitations, such as the fact that it only focused on the incidence of hypertension and diabetes mellitus, two common chronic comorbidities in HIV patients. To better understand the incidence of chronic comorbidities in this particular population, long-term follow-up of chronic comorbidities such as liver disease, cancer, and respiratory disease should be considered. The majority of our study participants were younger; to be aware of the effect of age, a proportionate number of participants from an older group should also be taken into account. Self-reported information was used to obtain the data, which is subject to recall bias, social desirability bias, and interviewer bias. To minimize these biases, patients were given clear instructions about the benefits of the study. Although self-report measures are considered appropriate for large-scale surveys, further research may indicate the use of objective measures of physical activity, such as accelerometry, to support these findings.
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