Body mass index trends and its impact of under and overweight on outcome among PLHIV on antiretroviral treatment in rural Tanzania: A prospective cohort study

PLOS ONE RESEARCH ARTICLE Body mass index trends and its impact of under and overweight on outcome among PLHIV on antiretroviral treatment in rural Tanzania: A prospective cohort study Aneth Vedastus Kalinjuma ID1,2☯*, Hannah Hussey1,3☯, Getrud Joseph Mollel1,4, Emilio Letang5,6, Manuel Battegay7, Tracy R. Glass5,8, Daniel Paris ID5,8, Fiona Vanobberghen5,8‡, Maja Weisser1,5,7,8‡, on behalf of the KIULARCO study group¶ a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Kalinjuma AV, Hussey H, Mollel GJ, Letang E, Battegay M, Glass TR, et al. (2023) Body mass index trends and its impact of under and overweight on outcome among PLHIV on antiretroviral treatment in rural Tanzania: A prospective cohort study. PLoS ONE 18(8): e0290445. https://doi.org/10.1371/journal. pone.0290445 Editor: I. Marion Sumari-de Boer, Kilimanjaro Clinical Research Institute, UNITED REPUBLIC OF TANZANIA Received: March 28, 2023 Accepted: August 9, 2023 Published: August 22, 2023 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0290445 Copyright: © 2023 Kalinjuma et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1 Department of Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, Tanzania, 2 Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, 3 Division of Public Health, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa, 4 St. Francis Referral Hospital, Ifakara, Tanzania, 5 Swiss Tropical and Public Health Institute, Allschwil, Switzerland, 6 Barcelona Institute for Global Health, Hospital Clı́nic-University of Barcelona, Barcelona, Spain, 7 Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland, 8 University of Basel, Basel, Switzerland ☯ These authors contributed equally to this work. ‡ FV and MW also contributed equally to this work. ¶ Membership of the KIULARCO study group is provided in the Acknowledgments. * Abstract Introduction Increased body weight is an important risk factor for cardiovascular disease and is increasingly reported as a health problem in people living with HIV (PLHIV). There is limited data from rural sub-Saharan Africa, where malnutrition usually presents with both over- and undernutrition. We aimed to determine the prevalence and risk factors of underweight and overweight/obesity in PLHIV enrolled in a cohort in rural Tanzania before the introduction of integrase inhibitors. Methods This nested study of the prospective Kilombero and Ulanga Antiretroviral Cohort included adults aged �19 years initiated on antiretroviral therapy between 01/2013 and 12/2018 with follow-up through 06/2019. Body Mass Index (BMI) was classified as underweight (<18.5 kg/m2), normal (18.5–24.9 kg/m2), or overweight/obese (�25.0 kg/m2). Stratified piecewise linear mixed models were used to assess the association between baseline characteristics and follow-up BMI. Cox proportional hazard models were used to assess the association between time-updated BMI and death/loss to follow-up (LTFU). PLOS ONE | https://doi.org/10.1371/journal.pone.0290445 August 22, 2023 1 / 17 PLOS ONE Data Availability Statement: All datasets used for this manuscript is uploaded in Zenodo. The DOI is 10.5281/zenodo.7699707 The URL is: https://doi. org/10.5281/zenodo.7699707. Funding: This work was supported through the CDCI by the Ministry of Health, Community Development, Gender, Elderly and Children Tanzania; the Government of the Canton of Basel, Switzerland; the Swiss Tropical and Public Health Institute, Switzerland; the University Hospital Basel, Switzerland; the Ifakara Health Institute, Tanzania; and USAID Boresha Afya (through the United States Agency for International Development (USAID) from the President’s Emergency Plan for AIDS Relief (PEPFAR) programme). Aneth Vedastus Kalinjuma was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No. G19-57145), Sida (Grant No:54100113), Uppsala Monitoring Center, Norwegian Agency for Development Cooperation (Norad), and by the Wellcome Trust [reference no. 107768/Z/15/Z] and the UK Foreign, Commonwealth & Development Office, with support from the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) programme. The statements made and views expressed are solely the responsibility of the Fellow. The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript. Competing interests: I have read the journal’s policy and the author of this manuscript has the following competing interests: Emilio Letang is a full-time employee ViiV Healthcare since May 2021. This does not alter our adherence to PLOS ONE policies on sharing data and materials. Other authors have declared that no competing interests exist. Body mass index trend among people living with HIV Results Among 2,129 patients, 22,027 BMI measurements (median 9 measurements: interquartile range 5–15) were analysed. At baseline, 398 (19%) patients were underweight and 356 (17%) were overweight/obese. The majority of patients were female (n = 1249; 59%), and aged 35–44 years (779; 37%). During the first 9 months, for every three additional months on antiretroviral therapy, BMI increased by 2% (95% confidence interval 1–2%, p<0.0001) among patients underweight at baseline and by 0.7% (0.5–0.6%, p<0.0001) among participants with normal BMI. Over a median of 20 months of follow-up, 107 (5%) patients died and 592 (28%) were LTFU. Being underweight was associated with >2 times the hazard of death/LTFU compared to participants with normal BMI. Conclusion We found a double burden of malnutrition, with underweight being an independent predictor of mortality. Monitoring and measures to address both states of malnutrition among PLHIV should be integrated into routine HIV care. Introduction Increased body weight is an important risk factor for cardiovascular disease [1–3]. Worldwide, the prevalence of overweight (body mass index (BMI) of 25–29 kg/m2) and obesity (BMI �30 kg/m2) has steadily increased in both high and low to middle-income countries [1, 4]. Obesity has been regarded as a problem in urban areas, b (...truncated)