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.