Adrenal Insufficiency among People Living with HIV in Africa: Does Salivary Cortisol Make a Difference?

OBJECTIVE

Diagnosing adrenal insufficiency in people living with HIV (PLWH) is challenging, especially in resource limited settings. Salivary cortisol assessment, however, is simple, minimally invasive, efficient, and cost-effective, making it a viable alternative. We evaluated whether early morning salivary cortisol measurement among PLWH could replace Synacthen test in Africans.

METHODS

This cross-sectional study included 201 PLWH recruited from the HIV clinic of a tertiary health facility and a comparison group of 200 HIV-negative individuals. We used a locally established cut off and a low-dose Synacthen test to determine adrenal function. Serum and salivary cortisol samples were obtained simultaneously at baseline and during the test (at 30 and 60 minutes).

RESULTS

The prevalence of adrenal insufficiency among PLWH was 54.7% when using a salivary cortisol-based locally established cut off, compared to 10.5% using a serum derived diagnostic cut-off (p<0.001). Adrenal insufficiency was associated with HIV diagnosis and dolutegravir (DTG) use. Compared to HIV-negative participants, PLWH on DTG had 18 times the odds of developing adrenal insufficiency (adjusted odds ratio [aOR]=18.3, 95% confidence interval [CI]: 9.58-36.5), while PLWH not on DTG had 13 times the odds (aOR=13.7, 95% CI: 6.60-30.3).

CONCLUSION

HIV status is associated with development of adrenal insufficiency. Salivary cortisol measurement could serve as a useful non-invasive tool for diagnosing adrenal insufficiency among PLWH in similar settings.