Burden of Type 2 Diabetes Mellitus and associated factors among HIV negative and positive patients in two regional referral hospitals in the Manzini Region, Eswatini
Main Article Content
Abstract
Background: Type 2 diabetes mellitus is an emerging non-communicable disease in low and middle-income countries in sub-Saharan Africa Since the rollout of antiretroviral therapy in Eswatini, the burden of diabetes in human immunodeficiency virus infected people and comparison against HIV negative control population has not been evaluated in Eswatini.
Aim: This study aimed at assessing proximal and distal predictors of diabetes among HIV positive adults in comparison to HIV negative adults.
Material and Methods. We employed a cross-sectional study design with 498 subjects selected at random in each group. Face-to-face interviews were conducted to obtain socio-demographic and risk factors. Venous blood was collected, fasting blood glucose and 2-hour oral glucose tolerance test. Multivariable logistic regression was used to identify significant determinants of diabetes.
Results and Discussion. Prevalence of diabetes was 25.6% (95%CI: 22.6 – 28.2). A higher (36.1%; 95%CI: 31.9 – 40.4) prevalence of diabetes was observed in the HIV positive cohort compared to the HIV negative group (14.8%; 95%CI: 11.6 – 17.5). Being ≥40 years posed a higher risk (OR=1.04; 95%CI: 1.00 – 1.07, p=0.04) of developing T2DM compared to those <40 years. Overweight (OR=1.82; 95%CI: 1.06 – 3.10, p=0.029) and obesity (OR=3.73; 95%CI: 2.26 – 6.14, p<0.001) increased the risk of diabetes. Alcohol intake increased the risk of diabetes 15 folds (OR=15.05; 95%CI: 9.03 – 25.11, p<0.001) compared to not taking alcohol. Moderate (OR=0.4; 95%CI: 0.25 – 0.67, p<0.001) and vigorous physical activity (OR=0.1; 95%CI: 0.05 – 0.14, p<0.001) reduced the risk of diabetes. Being HIV positive increased the risk of T2DM (OR=3.43; 95%CI: 2.28 – 5.14; p<0.001) compared to being HIV negative.
Conclusions. HIV positive cohort had a higher prevalence of Type 2 diabetes mellitus and being HIV positive is a risk factor for diabetes; hence HIV care services need to include diabetes prevention and management.
Keywords:
Eswatini, Type 2 Diabetes Mellitus, associated factors, HIV negative patients, HIV positive patients
Article Details
How to Cite
MASUKU, Sakhile KS et al.
Burden of Type 2 Diabetes Mellitus and associated factors among HIV negative and positive patients in two regional referral hospitals in the Manzini Region, Eswatini.
Medical Research Archives, [S.l.], v. 13, n. 3, mar. 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6387>. Date accessed: 06 apr. 2025.
doi: https://doi.org/10.18103/mra.v3i3.6387.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. UNAIDS. Global report: UNAIDS report on the global AIDS epidemic. UN Joint Programme on HIV/AIDS; 2018. https://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf. Accessed February 11, 2025.
2. Haregu TN, Elliott J, Setswe G, Oldenburg B. Epidemiological patterns of HIV/AIDS and Diabetes in Developing Countries: a Cluster Analysis. IJTDH. 2013; 3(1):1-2.
3. Kharsany AB, Karim QA. HIV Infection and AIDS in Sub-Saharan Africa: Current Status, Challenges and Opportunities. Open AIDS J. 2016;10:34-48. Published 2016 Apr 8. doi:10.2174/1874613601610010034
4. UNAIDS. AIDSINFO. Joint United Nations Programme on HIV/AIDS; 2017. https://www.unaids.org/sites/default/files/media_asset/20170720_Data_book_2017_en.pdf. Accessed February 11, 2025
5. Estrada V, Portilla J. Dyslipidemia related to antiretroviral therapy. AIDS Rev. 2011;13(1):49-56.
6. Hu FB. Globalization of diabetes: the role of diet, lifestyle, and genes. Diabetes Care. 2011;34(6):1249-1257. doi:10.2337/dc11-0442
7. Moreno S, Martínez E. Lipodystrophy and long-term therapy with nucleoside reverse transcriptase inhibitors. AIDS. 2000;14(7):905-906. doi:10.1097/00002030-200005050-00024
8. Béténé A Dooko C, De Wit S, Neuhaus J, et al. Interleukin-6, high sensitivity C-reactive protein, and the development of type 2 diabetes among HIV-positive patients taking antiretroviral therapy. J Acquir Immune Defic Syndr. 2014;67(5):538-546. doi:10.1097/QAI.0000000000000354
9. Varma V, Yao-Borengasser A, Rasouli N, et al. Muscle inflammatory response and insulin resistance: synergistic interaction between macrophages and fatty acids leads to impaired insulin action. Am J Physiol Endocrinol Metab. 2009;296(6):E1300-E1310. doi:10.1152/ajpendo.90885.2008
10. Brown TT, Tassiopoulos K, Bosch RJ, Shikuma C, McComsey GA. Association between systemic inflammation and incident diabetes in HIV-infected patients after initiation of antiretroviral therapy. Diabetes Care. 2010;33(10):2244-2249. doi:10.2337/dc10-0633
11. Achari AE, Jain SK. Adiponectin, a Therapeutic Target for Obesity, Diabetes, and Endothelial Dysfunction. Int J Mol Sci. 2017;18(6):1321. doi:10.3390/ijms18061321
12. Maseko TS, Masuku SK. The effect of HIV and ART on the development of hypertension and type 2 diabetes mellitus. J Diabetes Metab. 2017;8(3). Doi: 10.4172/2155-6156.1000732
13. Stanley TL, Grinspoon SK. Body composition and metabolic changes in HIV-infected patients. J Infect Dis. 2012;205 Suppl 3(Suppl 3):S383-S390. doi:10.1093/infdis/jis205
14. Carr A. HIV lipodystrophy: risk factors, pathogenesis, diagnosis and management. AIDS. 2003;17 Suppl 1:S141-S148.
15. Haugaard SB, Andersen O, Pedersen SB, et al. Tumor necrosis factor alpha is associated with insulin-mediated suppression of free fatty acids and net lipid oxidation in HIV-infected patients with lipodystrophy. Metabolism. 2006;55(2):175-182. doi:10.1016/j.metabol.2005.08.018
16. Guilherme A, Virbasius JV, Puri V, Czech MP. Adipocyte dysfunctions linking obesity to insulin resistance and type 2 diabetes. Nat Rev Mol Cell Biol. 2008;9(5):367-377. doi:10.1038/nrm2391
17. Aslam M, Aggarwal S, Sharma KK, Galav V, Madhu SV. Postprandial Hypertriglyceridemia Predicts Development of Insulin Resistance Glucose Intolerance and Type 2 Diabetes. PLoS One. 2016;11(1):e0145730. Published 2016 Jan 25. doi:10.1371/journal.pone.0145730
18. Julius H, Basu D, Ricci E, et al. The burden of metabolic diseases amongst HIV positive patients on HAART attending The Johannesburg Hospital. Curr HIV Res. 2011;9(4):247-252. doi:10.2174/157016211796320360
19. Sinxadi PZ, McIlleron HM, Dave JA, et al. Plasma Efavirenz Concentrations Are Associated with Lipid and Glucose Concentrations. Medicine (Baltimore). 2016;95(2):e2385. doi:10.1097/MD.0000000000002385
20. Martín-Timón I, Sevillano-Collantes C, Segura-Galindo A, Del Cañizo-Gómez FJ. Type 2 diabetes and cardiovascular disease: Have all risk factors the same strength?. World J Diabetes. 2014;5(4):444-470. doi:10.4239/wjd.v5.i4.444
21. Blumenthal MJ, Ujma S, Katz AA, Schäfer G. The Role of Type 2 Diabetes for the Development of Pathogen-Associated Cancers in the Face of the HIV/AIDS Epidemic. Front Microbiol. 2017;8:2368. Published 2017 Nov 29. doi:10.3389/fmicb.2017.02368
22. Njuguna B, Kiplagat J, Bloomfield GS, Pastakia SD, Vedanthan R, Koethe JR. Prevalence, Risk Factors, and Pathophysiology of Dysglycemia among People Living with HIV in Sub-Saharan Africa. J Diabetes Res. 2018;2018:6916497. Published 2018 May 23. doi:10.1155/2018/6916497
23. Central Statistical Office. Eswatini Demographic and Health Survey 2006-07. 2008. Macro International Inc.
24. WHO. Scaling up antiretroviral therapy in resource-limited settings: guidelines for a public health approach. World Health Organization; 2002.
25. WHO. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: guidelines on care, treatment and support for women living with HIV/AIDS and their children in resource-constrained settings. World Health Organization; 2004.
26. WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach. June 2013. World Health Organization. Available at: http://www.who.int/about/licensing/copyright_form/en/index.html. Accessed [accessed 15 Jan 2025].
27. UNAIDS. UNAIDS World AIDS Day report. Joint United Nations Programme on HIV/AIDS; 2012.
28. WHO. Global update on HIV treatment 2013: results, impact and opportunities: WHO report in partnership with UNICEF and UNAIDS. Publication no. ISBN 978 92 4 150573 4. World Health Organization; 2013.
29. Ministry of Health. Eswatini integrated HIV management guidelines—2015. Eswatini Ministry of Health; 2015.
30. Worm SW, De Wit S, Weber R, et al. Diabetes mellitus, preexisting coronary heart disease, and the risk of subsequent coronary heart disease events in patients infected with human immunodeficiency virus: the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D Study). Circulation. 2009;119(6):805-811. doi:10.1161/CIRCULATIONAHA.108.790857
31. Sandoiu A. People with HIV more likely to develop diabetes, study finds. Med News Today. 2017.
32. Rimm EB, Chan J, Stampfer MJ, Colditz GA, Willett WC. Prospective study of cigarette smoking, alcohol use, and the risk of diabetes in men. BMJ. 1995;310(6979):555-559. doi:10.1136/bmj.310.6979.555.
33. Isa SE, Oche AO, Kang'ombe AR, et al. Human Immunodeficiency Virus and Risk of Type 2 Diabetes in a Large Adult Cohort in Jos, Nigeria. Clin Infect Dis. 2016;63(6):830-835. doi:10.1093/cid/ciw381
34. Manzini Health Performance Report. Regional health performance report. Strategic Information Department. Ministry of Health, Kingdom of Eswatini; 2015.
35. Hintze J. PASS 12. Kaysville, UT: NCSS LLC; 2013.
36. Rimm EB, Chan J, Stampfer MJ, Colditz GA, Willett WC. Prospective study of cigarette smoking, alcohol use, and the risk of diabetes in men. BMJ. 1995;310(6979):555-559. doi:10.1136/bmj.310.6979.555
37. van Poppel MN, Chinapaw MJ, Mokkink LB, van Mechelen W, Terwee CB. Physical activity questionnaires for adults: a systematic review of measurement properties. Sports Med. 2010;40(7):565-600. doi:10.2165/11531930-000000000-00000
38. WHO. BMI classification, Global Database on Body Mass Index. World Health Organization; 2007.
39. Jago R, Baranowski T, Watson K, et al. Development of new physical activity and sedentary behavior change self-efficacy questionnaires using item response modeling. Int J Behav Nutr Phys Act. 2009;6:20. Published 2009 Mar 31. doi:10.1186/1479-5868-6-20
40. Mudrak J, Stochl J, Slepicka P, Elavsky S. Physical activity, self-efficacy, and quality of life in older Czech adults. Eur J Ageing. 2015;13(1):5-14. Published 2015 Aug 23. doi:10.1007/s10433-015-0352-1
41. Voskuil VR, Pierce SJ, Robbins LB. Comparing the Psychometric Properties of Two Physical Activity Self-Efficacy Instruments in Urban, Adolescent Girls: Validity, Measurement Invariance, and Reliability. Front Psychol. 2017;8:1301. Published 2017 Aug 3. doi:10.3389/fpsyg.2017.01301
42. Lahner CR. Adult weight measurement: decoding the terminology used in literature. S Afr J Clin Nutr. 2018;1-4.
43. StataCorp. Stata statistical software: Release 14. College Station, TX: StataCorp LP; 2015.
44. Wearne N, Manning K, Price B, et al. The Evolving Spectrum of Kidney Histology in HIV-Positive Patients in South Africa. Kidney Int Rep. 2023;8(5):1087-1096. Published 2023 Feb 23. doi:10.1016/j.ekir.2023.02.1076
45. Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature. 2001;414(6865):782-787. doi:10.1038/414782a
46. Magodoro IM, Castle AC, Tshuma N, et al. Associations of HIV and prevalent type 2 diabetes mellitus in the context of obesity in South Africa. J Multimorb Comorb. 2024;14:26335565241293691. Published 2024 Oct 28. doi:10.1177/26335565241293691
47. Byereta LH, Olum R, Mutebi EI, et al. Prevalence and factors associated with hyperglycemia among persons living with HIV/AIDS on dolutegravir-based antiretroviral therapy in Uganda. Ther Adv Infect Dis. 2024;11:20499361241272630. Published 2024 Sep 10. doi:10.1177/20499361241272630
48. Hernandez-Romieu AC, Garg S, Rosenberg ES, Thompson-Paul AM, Skarbinski J. Is diabetes prevalence higher among HIV-infected individuals compared with the general population? Evidence from MMP and NHANES 2009-2010. BMJ Open Diabetes Res Care. 2017;5(1):e000304. Published 2017 Jan 5. doi:10.1136/bmjdrc-2016-000304
49. Martín-Timón I, Sevillano-Collantes C, Segura-Galindo A, Del Cañizo-Gómez FJ. Type 2 diabetes and cardiovascular disease: Have all risk factors the same strength?. World J Diabetes. 2014;5(4):444-470. doi:10.4239/wjd.v5.i4.444
50. Tien PC, Schneider MF, Cox C, et al. Association of HIV infection with incident diabetes mellitus: impact of using hemoglobin A1C as a criterion for diabetes. J Acquir Immune Defic Syndr. 2012;61(3):334-340. doi:10.1097/QAI.0b013e31826bfc32
51. Butt AA, McGinnis K, Rodriguez-Barradas MC, et al. HIV infection and the risk of diabetes mellitus. AIDS. 2009;23(10):1227-1234. doi:10.1097/QAD.0b013e32832bd7af
52. Diouf A, Cournil A, Ba-Fall K, et al. Diabetes and Hypertension among Patients Receiving Antiretroviral Treatment Since 1998 in Senegal: Prevalence and Associated Factors. ISRN AIDS. 2012;2012:621565. Published 2012 Dec 1. doi:10.5402/2012/621565
53. Domo G, Wunamir J. Prevalence of diabetes mellitus among HIV positive patients attending general hospital Mubi, Adamawa State. J. Novel Appl. Sci. 2015;4(1):13-17.
54. Ledergerber B, Furrer H, Rickenbach M, et al. Factors associated with the incidence of type 2 diabetes mellitus in HIV-infected participants in the Swiss HIV Cohort Study. Clin Infect Dis. 2007;45(1):111-119. doi:10.1086/518619
55. Polsky S, Floris-Moore M, Schoenbaum EE, Klein RS, Arnsten JH, Howard AA. Incident hyperglycaemia among older adults with or at-risk for HIV infection. Antivir Ther. 2011;16(2):181-188. doi:10.3851/IMP1711
56. Rasmussen LD, Mathiesen ER, Kronborg G, Pedersen C, Gerstoft J, Obel N. Risk of diabetes mellitus in persons with and without HIV: a Danish nationwide population-based cohort study. PLoS One. 2012;7(9):e44575. doi:10.1371/journal.pone.0044575
57. Shen Y, Wang Z, Liu L, Zhang R, Zheng Y, Lu H. Prevalence of hyperglycemia among adults with newly diagnosed HIV/AIDS in China. BMC Infect Dis. 2013;13:79. Published 2013 Feb 11. doi:10.1186/1471-2334-13-79
58. Wohl DA. Considering metabolic issues when initiating HIV therapy. Curr HIV/AIDS Rep. 2007;4(3):119-125. doi:10.1007/s11904-007-0018-5
59. Blumenthal MJ, Ujma S, Katz AA, Schäfer G. The Role of Type 2 Diabetes for the Development of Pathogen-Associated Cancers in the Face of the HIV/AIDS Epidemic. Front Microbiol. 2017;8:2368. Published 2017 Nov 29. doi:10.3389/fmicb.2017.02368
60. Nansseu JR, Bigna JJ, Kaze AD, Noubiap JJ. Incidence and Risk Factors for Prediabetes and Diabetes Mellitus Among HIV-infected Adults on Antiretroviral Therapy: A Systematic Review and Meta-analysis. Epidemiology. 2018;29(3):431-441. doi:10.1097/EDE.0000000000000815
2. Haregu TN, Elliott J, Setswe G, Oldenburg B. Epidemiological patterns of HIV/AIDS and Diabetes in Developing Countries: a Cluster Analysis. IJTDH. 2013; 3(1):1-2.
3. Kharsany AB, Karim QA. HIV Infection and AIDS in Sub-Saharan Africa: Current Status, Challenges and Opportunities. Open AIDS J. 2016;10:34-48. Published 2016 Apr 8. doi:10.2174/1874613601610010034
4. UNAIDS. AIDSINFO. Joint United Nations Programme on HIV/AIDS; 2017. https://www.unaids.org/sites/default/files/media_asset/20170720_Data_book_2017_en.pdf. Accessed February 11, 2025
5. Estrada V, Portilla J. Dyslipidemia related to antiretroviral therapy. AIDS Rev. 2011;13(1):49-56.
6. Hu FB. Globalization of diabetes: the role of diet, lifestyle, and genes. Diabetes Care. 2011;34(6):1249-1257. doi:10.2337/dc11-0442
7. Moreno S, Martínez E. Lipodystrophy and long-term therapy with nucleoside reverse transcriptase inhibitors. AIDS. 2000;14(7):905-906. doi:10.1097/00002030-200005050-00024
8. Béténé A Dooko C, De Wit S, Neuhaus J, et al. Interleukin-6, high sensitivity C-reactive protein, and the development of type 2 diabetes among HIV-positive patients taking antiretroviral therapy. J Acquir Immune Defic Syndr. 2014;67(5):538-546. doi:10.1097/QAI.0000000000000354
9. Varma V, Yao-Borengasser A, Rasouli N, et al. Muscle inflammatory response and insulin resistance: synergistic interaction between macrophages and fatty acids leads to impaired insulin action. Am J Physiol Endocrinol Metab. 2009;296(6):E1300-E1310. doi:10.1152/ajpendo.90885.2008
10. Brown TT, Tassiopoulos K, Bosch RJ, Shikuma C, McComsey GA. Association between systemic inflammation and incident diabetes in HIV-infected patients after initiation of antiretroviral therapy. Diabetes Care. 2010;33(10):2244-2249. doi:10.2337/dc10-0633
11. Achari AE, Jain SK. Adiponectin, a Therapeutic Target for Obesity, Diabetes, and Endothelial Dysfunction. Int J Mol Sci. 2017;18(6):1321. doi:10.3390/ijms18061321
12. Maseko TS, Masuku SK. The effect of HIV and ART on the development of hypertension and type 2 diabetes mellitus. J Diabetes Metab. 2017;8(3). Doi: 10.4172/2155-6156.1000732
13. Stanley TL, Grinspoon SK. Body composition and metabolic changes in HIV-infected patients. J Infect Dis. 2012;205 Suppl 3(Suppl 3):S383-S390. doi:10.1093/infdis/jis205
14. Carr A. HIV lipodystrophy: risk factors, pathogenesis, diagnosis and management. AIDS. 2003;17 Suppl 1:S141-S148.
15. Haugaard SB, Andersen O, Pedersen SB, et al. Tumor necrosis factor alpha is associated with insulin-mediated suppression of free fatty acids and net lipid oxidation in HIV-infected patients with lipodystrophy. Metabolism. 2006;55(2):175-182. doi:10.1016/j.metabol.2005.08.018
16. Guilherme A, Virbasius JV, Puri V, Czech MP. Adipocyte dysfunctions linking obesity to insulin resistance and type 2 diabetes. Nat Rev Mol Cell Biol. 2008;9(5):367-377. doi:10.1038/nrm2391
17. Aslam M, Aggarwal S, Sharma KK, Galav V, Madhu SV. Postprandial Hypertriglyceridemia Predicts Development of Insulin Resistance Glucose Intolerance and Type 2 Diabetes. PLoS One. 2016;11(1):e0145730. Published 2016 Jan 25. doi:10.1371/journal.pone.0145730
18. Julius H, Basu D, Ricci E, et al. The burden of metabolic diseases amongst HIV positive patients on HAART attending The Johannesburg Hospital. Curr HIV Res. 2011;9(4):247-252. doi:10.2174/157016211796320360
19. Sinxadi PZ, McIlleron HM, Dave JA, et al. Plasma Efavirenz Concentrations Are Associated with Lipid and Glucose Concentrations. Medicine (Baltimore). 2016;95(2):e2385. doi:10.1097/MD.0000000000002385
20. Martín-Timón I, Sevillano-Collantes C, Segura-Galindo A, Del Cañizo-Gómez FJ. Type 2 diabetes and cardiovascular disease: Have all risk factors the same strength?. World J Diabetes. 2014;5(4):444-470. doi:10.4239/wjd.v5.i4.444
21. Blumenthal MJ, Ujma S, Katz AA, Schäfer G. The Role of Type 2 Diabetes for the Development of Pathogen-Associated Cancers in the Face of the HIV/AIDS Epidemic. Front Microbiol. 2017;8:2368. Published 2017 Nov 29. doi:10.3389/fmicb.2017.02368
22. Njuguna B, Kiplagat J, Bloomfield GS, Pastakia SD, Vedanthan R, Koethe JR. Prevalence, Risk Factors, and Pathophysiology of Dysglycemia among People Living with HIV in Sub-Saharan Africa. J Diabetes Res. 2018;2018:6916497. Published 2018 May 23. doi:10.1155/2018/6916497
23. Central Statistical Office. Eswatini Demographic and Health Survey 2006-07. 2008. Macro International Inc.
24. WHO. Scaling up antiretroviral therapy in resource-limited settings: guidelines for a public health approach. World Health Organization; 2002.
25. WHO. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: guidelines on care, treatment and support for women living with HIV/AIDS and their children in resource-constrained settings. World Health Organization; 2004.
26. WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach. June 2013. World Health Organization. Available at: http://www.who.int/about/licensing/copyright_form/en/index.html. Accessed [accessed 15 Jan 2025].
27. UNAIDS. UNAIDS World AIDS Day report. Joint United Nations Programme on HIV/AIDS; 2012.
28. WHO. Global update on HIV treatment 2013: results, impact and opportunities: WHO report in partnership with UNICEF and UNAIDS. Publication no. ISBN 978 92 4 150573 4. World Health Organization; 2013.
29. Ministry of Health. Eswatini integrated HIV management guidelines—2015. Eswatini Ministry of Health; 2015.
30. Worm SW, De Wit S, Weber R, et al. Diabetes mellitus, preexisting coronary heart disease, and the risk of subsequent coronary heart disease events in patients infected with human immunodeficiency virus: the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D Study). Circulation. 2009;119(6):805-811. doi:10.1161/CIRCULATIONAHA.108.790857
31. Sandoiu A. People with HIV more likely to develop diabetes, study finds. Med News Today. 2017.
32. Rimm EB, Chan J, Stampfer MJ, Colditz GA, Willett WC. Prospective study of cigarette smoking, alcohol use, and the risk of diabetes in men. BMJ. 1995;310(6979):555-559. doi:10.1136/bmj.310.6979.555.
33. Isa SE, Oche AO, Kang'ombe AR, et al. Human Immunodeficiency Virus and Risk of Type 2 Diabetes in a Large Adult Cohort in Jos, Nigeria. Clin Infect Dis. 2016;63(6):830-835. doi:10.1093/cid/ciw381
34. Manzini Health Performance Report. Regional health performance report. Strategic Information Department. Ministry of Health, Kingdom of Eswatini; 2015.
35. Hintze J. PASS 12. Kaysville, UT: NCSS LLC; 2013.
36. Rimm EB, Chan J, Stampfer MJ, Colditz GA, Willett WC. Prospective study of cigarette smoking, alcohol use, and the risk of diabetes in men. BMJ. 1995;310(6979):555-559. doi:10.1136/bmj.310.6979.555
37. van Poppel MN, Chinapaw MJ, Mokkink LB, van Mechelen W, Terwee CB. Physical activity questionnaires for adults: a systematic review of measurement properties. Sports Med. 2010;40(7):565-600. doi:10.2165/11531930-000000000-00000
38. WHO. BMI classification, Global Database on Body Mass Index. World Health Organization; 2007.
39. Jago R, Baranowski T, Watson K, et al. Development of new physical activity and sedentary behavior change self-efficacy questionnaires using item response modeling. Int J Behav Nutr Phys Act. 2009;6:20. Published 2009 Mar 31. doi:10.1186/1479-5868-6-20
40. Mudrak J, Stochl J, Slepicka P, Elavsky S. Physical activity, self-efficacy, and quality of life in older Czech adults. Eur J Ageing. 2015;13(1):5-14. Published 2015 Aug 23. doi:10.1007/s10433-015-0352-1
41. Voskuil VR, Pierce SJ, Robbins LB. Comparing the Psychometric Properties of Two Physical Activity Self-Efficacy Instruments in Urban, Adolescent Girls: Validity, Measurement Invariance, and Reliability. Front Psychol. 2017;8:1301. Published 2017 Aug 3. doi:10.3389/fpsyg.2017.01301
42. Lahner CR. Adult weight measurement: decoding the terminology used in literature. S Afr J Clin Nutr. 2018;1-4.
43. StataCorp. Stata statistical software: Release 14. College Station, TX: StataCorp LP; 2015.
44. Wearne N, Manning K, Price B, et al. The Evolving Spectrum of Kidney Histology in HIV-Positive Patients in South Africa. Kidney Int Rep. 2023;8(5):1087-1096. Published 2023 Feb 23. doi:10.1016/j.ekir.2023.02.1076
45. Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature. 2001;414(6865):782-787. doi:10.1038/414782a
46. Magodoro IM, Castle AC, Tshuma N, et al. Associations of HIV and prevalent type 2 diabetes mellitus in the context of obesity in South Africa. J Multimorb Comorb. 2024;14:26335565241293691. Published 2024 Oct 28. doi:10.1177/26335565241293691
47. Byereta LH, Olum R, Mutebi EI, et al. Prevalence and factors associated with hyperglycemia among persons living with HIV/AIDS on dolutegravir-based antiretroviral therapy in Uganda. Ther Adv Infect Dis. 2024;11:20499361241272630. Published 2024 Sep 10. doi:10.1177/20499361241272630
48. Hernandez-Romieu AC, Garg S, Rosenberg ES, Thompson-Paul AM, Skarbinski J. Is diabetes prevalence higher among HIV-infected individuals compared with the general population? Evidence from MMP and NHANES 2009-2010. BMJ Open Diabetes Res Care. 2017;5(1):e000304. Published 2017 Jan 5. doi:10.1136/bmjdrc-2016-000304
49. Martín-Timón I, Sevillano-Collantes C, Segura-Galindo A, Del Cañizo-Gómez FJ. Type 2 diabetes and cardiovascular disease: Have all risk factors the same strength?. World J Diabetes. 2014;5(4):444-470. doi:10.4239/wjd.v5.i4.444
50. Tien PC, Schneider MF, Cox C, et al. Association of HIV infection with incident diabetes mellitus: impact of using hemoglobin A1C as a criterion for diabetes. J Acquir Immune Defic Syndr. 2012;61(3):334-340. doi:10.1097/QAI.0b013e31826bfc32
51. Butt AA, McGinnis K, Rodriguez-Barradas MC, et al. HIV infection and the risk of diabetes mellitus. AIDS. 2009;23(10):1227-1234. doi:10.1097/QAD.0b013e32832bd7af
52. Diouf A, Cournil A, Ba-Fall K, et al. Diabetes and Hypertension among Patients Receiving Antiretroviral Treatment Since 1998 in Senegal: Prevalence and Associated Factors. ISRN AIDS. 2012;2012:621565. Published 2012 Dec 1. doi:10.5402/2012/621565
53. Domo G, Wunamir J. Prevalence of diabetes mellitus among HIV positive patients attending general hospital Mubi, Adamawa State. J. Novel Appl. Sci. 2015;4(1):13-17.
54. Ledergerber B, Furrer H, Rickenbach M, et al. Factors associated with the incidence of type 2 diabetes mellitus in HIV-infected participants in the Swiss HIV Cohort Study. Clin Infect Dis. 2007;45(1):111-119. doi:10.1086/518619
55. Polsky S, Floris-Moore M, Schoenbaum EE, Klein RS, Arnsten JH, Howard AA. Incident hyperglycaemia among older adults with or at-risk for HIV infection. Antivir Ther. 2011;16(2):181-188. doi:10.3851/IMP1711
56. Rasmussen LD, Mathiesen ER, Kronborg G, Pedersen C, Gerstoft J, Obel N. Risk of diabetes mellitus in persons with and without HIV: a Danish nationwide population-based cohort study. PLoS One. 2012;7(9):e44575. doi:10.1371/journal.pone.0044575
57. Shen Y, Wang Z, Liu L, Zhang R, Zheng Y, Lu H. Prevalence of hyperglycemia among adults with newly diagnosed HIV/AIDS in China. BMC Infect Dis. 2013;13:79. Published 2013 Feb 11. doi:10.1186/1471-2334-13-79
58. Wohl DA. Considering metabolic issues when initiating HIV therapy. Curr HIV/AIDS Rep. 2007;4(3):119-125. doi:10.1007/s11904-007-0018-5
59. Blumenthal MJ, Ujma S, Katz AA, Schäfer G. The Role of Type 2 Diabetes for the Development of Pathogen-Associated Cancers in the Face of the HIV/AIDS Epidemic. Front Microbiol. 2017;8:2368. Published 2017 Nov 29. doi:10.3389/fmicb.2017.02368
60. Nansseu JR, Bigna JJ, Kaze AD, Noubiap JJ. Incidence and Risk Factors for Prediabetes and Diabetes Mellitus Among HIV-infected Adults on Antiretroviral Therapy: A Systematic Review and Meta-analysis. Epidemiology. 2018;29(3):431-441. doi:10.1097/EDE.0000000000000815