HIV and noncommunicable cardiovascular and pulmonary diseases in low- and middle-income countries in the ART era: what we know and best directions for future research

Burden of metabolic syndrome in the global adult HIV-infected population: a systematic review and meta-analysis

BACKGROUND

Metabolic syndrome (MetS) elevates the risk of heart disease and stroke. In recent decades, the escalating prevalence of MetS among people living with HIV/AIDS (PLWHA) has garnered global attention. Despite MetS development being associated with both traditional and HIV-related factors, evidence from prior studies has shown variability across geographical regions. This study aimed to conduct a systematic review and meta-analysis of MetS burdens in adult PLWHA at the regional and global levels, focusing on the common effect size of HIV infection and antiretroviral therapy (ART) on MetS.

METHODS

This review followed the PRISMA 2020 guidelines. A comprehensive search and review of original articles related to MetS and HIV published in peer-reviewed journals between January 2000 and December 2023 were conducted. A random effects model was used to calculate the pooled prevalence/incidence of MetS and the common effect size of HIV infection and ART exposure on MetS.

RESULTS

A total of 102 studies from five continents comprising 78,700 HIV-infected participants were included. The overall pooled prevalence of MetS was 25.3%, 25.6% for PLWHA on ART, and 18.5% for those not receiving treatment. The pooled incidence of MetS, calculated from five studies, was 9.19 per 100 person-years. The highest pooled prevalence of MetS was observed in the Americas (30.4%), followed by the Southeast Asia/Western Pacific regions (26.7%). HIV-infected individuals had 1.6 times greater odds of having MetS than non-HIV-infected individuals did (pooled OR = 1.604; 95% CI 1.154-2.230), and ART exposure had 1.5 times greater odds of having MetS than nontreatment had (pooled OR = 1.504; 95% CI 1.217-1.859).

CONCLUSIONS

HIV infection and ART exposure contribute significantly to the increased burden of MetS. Regions with a high burden of HIV and MetS should prioritize awareness and integrated care plans for major noncommunicable diseases (NCDs), such as heart disease and stroke. The implementation of integrated care for HIV/AIDS patients and NCDs is essential for addressing the high burden of multimorbidity in PLWHA.

REGISTRATION NUMBER

INPLASY202290018.

Preferences for Hypertension Care in Malawi: A Discrete Choice Experiment Among People Living with Hypertension, With and Without HIV

Hypertension is the most common non-communicable disease diagnosed among people in sub-Saharan Africa. However, little is known about client preferences for hypertension care. We performed a discrete choice experiment in Malawi among people with hypertension, with and without HIV. Participants were asked to select between two care scenarios, each with six attributes: distance, waiting time, provider friendliness, individual or group care, antihypertensive medication supply, and antihypertensive medication dispensing frequency (three versus one month). Eight choice sets (each with two scenarios) were presented to each individual. Mixed effects logit models quantified preferences for each attribute. Estimated model coefficients were used to predict uptake of hypothetical models of care. Between July 2021 and April 2022 we enrolled 1003 adults from 14 facilities in Malawi; half were living with HIV and on ART for a median of 11 years. Median age of respondents was 57 years (IQR 49-63), 58.2% were female, and median duration on antihypertensive medications was 4 years (IQR 2-7). Participants strongly preferred seeing a provider alone versus in a group (OR 11.3, 95% CI 10.4-12.3), with stronger preference for individual care among those with HIV (OR 15.4 versus 8.6, p < 0.001). Three-month versus monthly dispensing was also strongly preferred (OR 4.2; 95% CI 3.9-4.5). 72% of respondents would choose group care if all other facility attributes were favorable, although PLHIV were less likely to make this trade-off (66% versus 77%). These findings have implications for the scale-up of hypertension care in Malawi and similar settings.

Cardiometabolic complications in children and adolescents with HIV on antiretroviral therapy

INTRODUCTION

The course of HIV infection has changed radically with the introduction of antiretroviral therapy (ART), which has significantly reduced mortality and improved quality of life. However, antiretroviral drugs can cause adverse effects, including cardiometabolic complications and diseases, which are among the most common. Compared to the adult population, there are fewer studies in the pediatric population on treatment-related complications. The purpose of this review is to provide an update on the literature regarding cardiometabolic complications and diseases in children and adolescents with HIV.

AREAS COVERED

A comprehensive literature review was conducted using PubMed and related bibliographies to provide an overview of the current knowledge of metabolic complications (dyslipidemia, insulin resistance, lipodystrophy, weight gain and liver complications) and diseases (prediabetes/diabetes and cardiovascular diseases) associated with ART in children and adolescents with HIV.

EXPERT OPINION

Metabolic complications are conditions that need to be closely monitored in children and adolescents with HIV, as they increase the risk of early development of non-communicable diseases, such as cardiovascular disease. Key areas for improvement include ensuring access to treatment, reducing side effects and improving diagnostic capabilities. Overcoming existing challenges will require collaborative efforts across disciplines, advances in technology, and targeted interventions to address socioeconomic disparities.

High rate of uncontrolled hypertension among adults receiving integrated HIV and hypertension care with aligned multi-month dispensing in Malawi: results from a cross-sectional survey and retrospective chart review

INTRODUCTION

People living with HIV have high rates of hypertension. Integrated HIV and hypertension care with aligned multi-month dispensing of medications (MMD) could decrease the burden of care for individuals and health systems. We sought to describe hypertension control and evaluate its association with different durations of MMD among Malawian adults receiving integrated care with aligned dispensing of antiretroviral therapy (ART) and antihypertensive medication.

METHODS

We conducted a cross-sectional survey and retrospective chart review of adults (≥18 years) receiving integrated HIV and hypertension care on medications for both conditions for at least 1 year, with aligned MMD at seven clinics in Malawi. Data were collected from July 2021 to April 2022 and included socio-demographics, clinical characteristics, antihypertensive medications and up to the three most recent blood pressure measurements. Bivariate analyses were used to characterize associations with hypertension control. Uncontrolled hypertension was defined as ≥2 measurements ≥140 and/or ≥90 mmHg. Chart reviews were conducted for a random subset of participants with uncontrolled hypertension to describe antihypertensive medication adjustments in the prior year.

RESULTS

We surveyed 459 adults receiving integrated care with aligned dispensing (58% female; median age 54 years). Individuals most commonly received a 3-month aligned dispensing of ART and antihypertensive medications (63%), followed by every 6 months (16%) and every 4 months (15%). Hypertension control was assessed in 359 respondents, of whom only 23% had controlled hypertension; 90% of individuals in this group reported high adherence to blood pressure medications (0-1 missed days/week). Control was more common among those with longer aligned medication dispensing intervals (20% among those with 1- to 3-month dispensing vs. 28% with 4-month dispensing vs. 40% with 6-month dispensing, p = 0.011). Chart reviews were conducted for 147 individuals with uncontrolled hypertension. Most had high self-reported adherence to blood pressure medications (89% missing 0-1 days/week); however, only 10% had their antihypertensive medication regimen changed in the prior year.

CONCLUSIONS

Uncontrolled hypertension was common among Malawian adults receiving integrated care with aligned MMD and was associated with shorter refill intervals and few antihypertensive medication escalations. Integrated care with aligned MMD is promising, but further work is needed to understand how to optimize hypertension outcomes.

"I only seek treatment when I am ill": experiences of hypertension and diabetes care among adults living with HIV in urban Tanzania

BACKGROUND

For adults living with HIV (ALHIV) and comorbidities, access to comprehensive healthcare services is crucial to achieving optimal health outcomes. This study aims to describe lived experiences, challenges, and coping strategies for accessing care for hypertension and/or diabetes (HTN/DM) in HIV care and treatment clinics (CTCs) and other healthcare settings.

METHODOLOGY

We conducted a qualitative study that employed a phenomenological approach between January and April 2022 using a semi-structured interview guide in six HIV CTCs in Dar es Salaam, Tanzania. We purposively recruited 33 ALHIV with HTN (n = 16), DM (n = 10), and both (n = 7). Thematic content analysis was guided by the 5As framework of access to care.

FINDINGS

The majority of the participants were females, between the ages of 54-73, and were recruited from regional referral hospitals. HIV CTCs at regional referral hospitals had more consistent provision of HTN screening services compared to those from district hospitals and health centers. Participants sought HTN/DM care at non-CTC health facilities due to the limited availability of such services at HIV CTCs. However, healthcare delivery for these conditions was perceived as unaccommodating and poorly coordinated. The need to attend multiple clinic appointments for the management of HTN/DM in addition to HIV care was perceived as frustrating, time-consuming, and financially burdensome. High costs of care and transportation, limited understanding of comorbidities, and the perceived complexity of HTN/DM care contributed to HTN/DM treatment discontinuity. As a means of coping, participants frequently monitored their own HTN/DM symptoms at home and utilized community pharmacies and dispensaries near their residences to check blood pressure and sugar levels and obtain medications. Participants expressed a preference for non-pharmaceutical approaches to comorbidity management such as lifestyle modification (preferred by young participants) and herbal therapies (preferred by older participants) because of concerns about side effects and perceived ineffectiveness of HTN/DM medications. Participants also preferred integrated care and focused patient education on multimorbidity management at HIV CTCs.

CONCLUSION

Our findings highlight significant barriers to accessing HTN/DM care among ALHIV, mostly related to affordability, availability, and accessibility. Integration of NCD care into HIV CTCs, could greatly improve ALHIV health access and outcomes and align with patient preference.

The immune response to SARS-CoV-2 in people with HIV

This review examines the intersection of the HIV and SARS-CoV-2 pandemics. People with HIV (PWH) are a heterogeneous group that differ in their degree of immune suppression, immune reconstitution, and viral control. While COVID-19 in those with well-controlled HIV infection poses no greater risk than that for HIV-uninfected individuals, people with advanced HIV disease are more vulnerable to poor COVID-19 outcomes. COVID-19 vaccines are effective and well tolerated in the majority of PWH, though reduced vaccine efficacy, breakthrough infections and faster waning of vaccine effectiveness have been demonstrated in PWH. This is likely a result of suboptimal humoral and cellular immune responses after vaccination. People with advanced HIV may also experience prolonged infection that may give rise to new epidemiologically significant variants, but initiation or resumption of antiretroviral therapy (ART) can effectively clear persistent infection. COVID-19 vaccine guidelines reflect these increased risks and recommend prioritization for vaccination and additional booster doses for PWH who are moderately to severely immunocompromised. We recommend continued research and monitoring of PWH with SARS-CoV-2 infection, especially in areas with a high HIV burden.

Gaussian process emulation to improve efficiency of computationally intensive multidisease models: a practical tutorial with adaptable R code

BACKGROUND

The rapidly growing burden of non-communicable diseases (NCDs) among people living with HIV in sub-Saharan Africa (SSA) has expanded the number of multidisease models predicting future care needs and health system priorities. Usefulness of these models depends on their ability to replicate real-life data and be readily understood and applied by public health decision-makers; yet existing simulation models of HIV comorbidities are computationally expensive and require large numbers of parameters and long run times, which hinders their utility in resource-constrained settings.

METHODS

We present a novel, user-friendly emulator that can efficiently approximate complex simulators of long-term HIV and NCD outcomes in Africa. We describe how to implement the emulator via a tutorial based on publicly available data from Kenya. Emulator parameters relating to incidence and prevalence of HIV, hypertension and depression were derived from our own agent-based simulation model and other published literature. Gaussian processes were used to fit the emulator to simulator estimates, assuming presence of noise for design points. Bayesian posterior predictive checks and leave-one-out cross validation confirmed the emulator's descriptive accuracy.

RESULTS

In this example, our emulator resulted in a 13-fold (95% Confidence Interval (CI): 8-22) improvement in computing time compared to that of more complex chronic disease simulation models. One emulator run took 3.00 seconds (95% CI: 1.65-5.28) on a 64-bit operating system laptop with 8.00 gigabytes (GB) of Random Access Memory (RAM), compared to > 11 hours for 1000 simulator runs on a high-performance computing cluster with 1500 GBs of RAM. Pareto k estimates were < 0.70 for all emulations, which demonstrates sufficient predictive accuracy of the emulator.

CONCLUSIONS

The emulator presented in this tutorial offers a practical and flexible modelling tool that can help inform health policy-making in countries with a generalized HIV epidemic and growing NCD burden. Future emulator applications could be used to forecast the changing burden of HIV, hypertension and depression over an extended (> 10 year) period, estimate longer-term prevalence of other co-occurring conditions (e.g., postpartum depression among women living with HIV), and project the impact of nationally-prioritized interventions such as national health insurance schemes and differentiated care models.

Evaluation of some immune and inflammatory responses in diabetes and HIV co-morbidity

BACKGROUND

Co-existence of diabetes in the HIV infected reportedly further complicates the attendant impairment of immunity and increases susceptibility to opportunistic infections.

OBJECTIVE

This study aimed to evaluate some immune and inflammatory parameters in HIV and type 2 diabetes (T2D) co-morbidity: Immunoglobulin M and G (IgM and IgG), Interleukin-6, CD4+ T-cells and C-reactive protein.

METHOD

The study involved 200 subjects grouped according to their HIV and diabetes status: Group 1 'Diabetic HIV seropositive' (n=40), Group 2 'Non diabetic HIV seropositive'(n=60), Group 3 'Diabetic HIV seronegative'(n=50), and Group 4 'Control non diabetic HIV seronegative'(n=50). Blood samples were collected for testing.

RESULTS

CRP levels were significantly elevated in diabetes and HIV co-morbidity compared to other groups. IL-6 levels were significantly higher in diabetics with or without HIV infection. In addition, IL-6 was significantly elevated in individuals with poor glycemic control (HbA1c > 9.0%) compared to those with good glycemic control. IgG and IgM levels in diabetic HIV seropositive subjects were highest compared with other groups.

CONCLUSION

The increased IL-6, CRP, IgG, IgM and decreased CD4+ T cell counts observed in co-morbidity suggest that HIV and T2D co-morbidity exacerbate the immune and inflammatory impairment observed in either disease entity.

Integrating community-based HIV and non-communicable disease care with microfinance groups: a feasibility study in Western Kenya

BACKGROUND

The Harambee study is a cluster randomized trial in Western Kenya that tests the effect, mechanisms, and cost-effectiveness of integrating community-based HIV and non-communicable disease care within microfinance groups on chronic disease treatment outcomes. This paper documents the stages of our feasibility study conducted in preparation for the Harambee trial, which include (1) characterizing the target population and gauging recruitment capacity, (2) determining community acceptability of the integrated intervention and study procedures, and (3) identifying key implementation considerations prior to study start.

METHODS

Feasibility research took place between November 2019 and February 2020 in Western Kenya. Mixed methods data collection included surveys administered to 115 leaders of 105 community-based microfinance groups, 7 in-person meetings and two workshops with stakeholders from multiple sectors of the health system, and ascertainment of field notes and geographic coordinates for group meeting locations and HIV healthcare facilities. Quantitative survey data were analyzed using STATA IC/13. Longitude and latitude coordinates were mapped to county boundaries using Esri ArcMap. Qualitative data obtained from stakeholder meetings and field notes were analyzed thematically.

RESULTS

Of the 105 surveyed microfinance groups, 77 met eligibility criteria. Eligible groups had been in existence from 6 months to 18 years and had an average of 22 members. The majority (64%) of groups had at least one member who owned a smartphone. The definition of "active" membership and model of saving and lending differed across groups. Stakeholders perceived the community-based intervention and trial procedures to be acceptable given the minimal risks to participants and the potential to improve HIV treatment outcomes while facilitating care integration. Potential challenges identified by stakeholders included possible conflicts between the trial and existing community-based interventions, fear of group disintegration prior to trial end, clinicians' inability to draw blood for viral load testing in the community, and deviations from standard care protocols.

CONCLUSIONS

This study revealed that it was feasible to recruit the number of microfinance groups necessary to ensure that our clinical trial was sufficient powered. Elicitation of stakeholder feedback confirmed that the planned intervention was largely acceptable and was critical to identifying challenges prior to implementation.

TRIAL REGISTRATION

The original trial was prospectively registered with ClinicalTrials.gov (NCT04417127) on 4 June 2020.

ECG Abnormalities and Arterial Stiffness by HIV Status among High-Risk Populations in Rakai, Uganda: A Pilot Study

Background

People living with HIV are at increased risk for cardiovascular disease (CVD). In sub-Saharan Africa, population-based data on major CVD events such as stroke and myocardial infarction are difficult to collect. The use of proxy measures could be a feasible way to better study CVD in such settings. This study aimed to determine the acceptance of incorporating ECG and arterial function measurements into a population-based cohort study and to assess the prevalence of ECG abnormalities and arterial stiffness.

Methods

A pilot study was conducted within the Rakai Community Cohort Study in Uganda on two high-risk CVD populations; one determined by age (35-49) and Framingham CVD risk scores and the other by age alone (50+). Data on ECG, arterial function, blood pressure, and HIV status were collected. The acceptability of incorporating ECG and arterial function measurements was established as an acceptance rate difference of no more than 5% to blood pressure measurements.

Results

A total of 118 participants were enrolled, 57 participants living with HIV and 61 HIV-negative participants. Both ECG measurements and arterial function were well accepted (2% difference). Left ventricular hypertrophy (LVH) and arterial stiffness (>10 m/s) were common in both participants living with HIV and HIV-negative participants across the two high-risk populations. Prevalence rates ranged from 30% to 53% for LVH and 25% to 58% for arterial stiffness. Arterial stiffness at the 11 m/s cutoff (p = 0.03) was found to be more common among participants living with HIV in the 35-49 population.

Conclusions

The incorporation of ECG and arterial function measurements into routine activities of a population-based cohort was acceptable and incorporating these proxy measures into cohort studies should be explored further. LVH and arterial stiffness were both common irrespective of HIV status with arterial stiffness potentially more common among people living with HIV.

Integration of a task strengthening strategy for hypertension management into HIV care in Nigeria: a cluster randomized controlled trial study protocol

BACKGROUND

In regions with weak healthcare systems, critical shortages of the healthcare workforce, and increasing prevalence of dual disease burdens, there is an urgent need for the implementation of proven effective interventions and strategies to address these challenges. Our mixed-methods hybrid type II effectiveness-implementation study is designed to fill this evidence-to-practice gap. This study protocol describes a cluster randomized controlled trial which evaluates the effectiveness of an implementation strategy, practice facilitation (PF), on the integration, adoption, and sustainability of a task-strengthening strategy for hypertension control (TASSH) intervention within primary healthcare centers (PHCs) in Lagos State, Nigeria.

DESIGN

Guided by the Consolidated Framework for Implementation Research (CFIR) and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM), this study tests the impact of a proven effective implementation strategy to integrate hypertension management into the HIV care cascade, across 30 PHCs. The study will be conducted in three phases: (1) a pre-implementation phase that will use CFIR to develop a tailored PF intervention for integrating TASSH into HIV clinics; (2) an implementation phase that will use RE-AIM to compare the clinical effectiveness of PF vs. a self-directed condition (receipt of information on TASSH without PF) on BP reduction; and (3) a post-implementation phase that will use RE-AIM to evaluate the effect of PF vs. self-directed condition on adoption and sustainability of TASSH. The PF intervention components comprise (a) an advisory board to provide leadership support for implementing TASSH in PHCs; (b) training of the HIV nurses on TASSH protocol; and (c) training of practice facilitators, who will serve as coaches, provide support, and performance feedback to the HIV nurses.

DISCUSSION

This study is one of few, if any trials, to evaluate the impact of an implementation strategy for integrating hypertension management into HIV care, on clinical and implementation outcomes. Findings from this study will advance implementation science research on the effectiveness of tailoring an implementation strategy for the integration of an evidence-based, system-level hypertension control intervention into HIV care and treatment.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT04704336 ). Registered on 11 January 2021.

Risk factors and outcomes of HIV-associated stroke in Zambia

OBJECTIVE

To compare risk factors and clinical outcomes between people with HIV (PWH) and HIV-uninfected (HIV-) adults with stroke hospitalized in Zambia.

METHODS

We retrospectively reviewed charts of all adults admitted to the University Teaching Hospital in Lusaka, Zambia with a clinical diagnosis of stroke between October 2018 and March 2019. Standardized data collection instruments were used to collect demographic, clinical, laboratory and imaging results. Comparison between individuals with and without HIV infection was made using t tests for continuous parametric variables, Wilcoxon rank-sum tests for continuous nonparametric variables, and chi-square analyses for categorical variables.

RESULTS

Two hundred and seventy-two adults with stroke were admitted of whom 58 (21%) were PWH. Compared with HIV- participants, PWH were younger [(48 ± 14) years versus 62 ± 18) years, P < 0.001]. PWH were less likely to have hypertension (65 versus 83%, P = 0.003) and more likely to have no traditional cerebrovascular risk factors (34 versus 15%, P = 0.01). Deep vein thrombosis (DVT) (4 versus 1%, P = 0.04) was more common during hospitalization amongst PWH but there was no difference in in-hospital mortality (21 versus 23%, P = 0.65). Among PWH with stroke, factors associated with in-hospital mortality were Glasgow Coma Scale (GCS) on admission (7 versus 10, P = 0.046), hypertension (92 versus 59%, P = 0.04) and fever (58 versus 13%, P = 0.003).

CONCLUSION

This Zambian cohort of PWH and stroke is notable for being significantly younger with fewer traditional stroke risk factors but higher rates of DVT than their HIV-uninfected counterparts. GCS on admission, hypertension and fever were associated with in-hospital mortality.

Integration of non-communicable disease and HIV/AIDS management: a review of healthcare policies and plans in East Africa

Background

Low-income and middle-income countries are struggling to manage growing numbers of patients with chronic non-communicable diseases (NCDs), while services for patients with HIV infection are well established. There have been calls for integration of HIV and NCD services to increase efficiency and improve coverage of NCD care, although evidence of effectiveness remains unclear. In this review, we assess the extent to which National HIV and NCD policies in East Africa reflect the calls for HIV-NCD service integration.

Methods

Between April 2018 and December 2020, we searched for policies, strategies and guidelines associated with HIV and NCDs programmes in Burundi, Kenya, Rwanda, South Sudan, Tanzania and Uganda. Documents were searched manually for plans for integration of HIV and NCD services. Data were analysed qualitatively using document analysis.

Results

Thirty-one documents were screened, and 13 contained action plans for HIV and NCDs service integration. Integrated delivery of HIV and NCD care is recommended in high level health policies and treatment guidelines in four countries in the East African region; Kenya, Rwanda, Tanzania and Uganda, mostly relating to integrating NCD care into HIV programmes. The increasing burden of NCDs, as well as a move towards person-centred differentiated delivery of services for people living with HIV, is a factor in the recent adoption of integrated HIV and NCD service delivery plans. Both South Sudan and Burundi report a focus on building their healthcare infrastructure and improving coverage and quality of healthcare provision, with no reported plans for HIV and NCD care integration.

Conclusion

Despite the limited evidence of effectiveness, some East African countries have already taken steps towards HIV and NCD service integration. Close monitoring and evaluation of the integrated HIV and NCD programmes is necessary to provide insight into the associated benefits and risks, and to inform future service developments.

Global burden of hypertension among people living with HIV in the era of increased life expectancy: a systematic review and meta-analysis

BACKGROUND

Although HIV infection and antiretroviral therapy (ART) increase the risk for hypertension in people living with HIV (PLHIV), the global and regional burden of hypertension in PLHIV is not well characterized.

METHODS

In this systematic review and meta-analysis, we searched multiple databases for studies reporting on hypertension in PLHIV and conducted between 2007 and 2018. Meta-analysis through random-effect models served to obtain the pooled prevalence estimates. Heterogeneity was assessed via the χ test on Cochran's Q statistic.

RESULTS

We included 194 studies (396 776 PLHIV from 61 countries). The global prevalence of hypertension was 23.6% [95% confidence interval (95% CI: 21.6-25.5)] with substantial heterogeneity. The regional distribution was Western and Central Europe and North America [28.1% (95% CI: 24.5-31.9)], West and Central Africa [23.5% (16.6-31.0)], Latin America and the Caribbean [22.0% (17.8-26.5)], Eastern and Southern Africa [19.9% (17.2-22.8)], and Asia and Pacific [16.5% (12.5-21.0)]; P = 0.0007. No study originated from the Middle East and North Africa, and Eastern Europe and Central Asia regions. The prevalence was higher in high-income countries than others (P = 0.0003) and higher in PLHIV taking ART than those ART-naive (P = 0.0003). The prevalence increased over time (mainly driven by Eastern and Southern Africa) and with age. There was no difference between men and women. We estimated that in 2018, there were 8.9 (95% CI: 8.3-9.6) million cases of hypertension in PLHIV globally, among whom 59.2% were living in Sub-Saharan Africa.

CONCLUSION

Cost-effective strategies to curb the dreadful burden of hypertension among PLHIV are needed.

Factors associated with prognostic or treatment outcomes in HIV/AIDS patients with and without hypertension in Eswatini

Non-communicable diseases are increasing faster in HIV/AIDS patients than in the general population. We studied the association between hypertension and other possible confounding factors on viral load and CD4-cell counts in hypertensive and non-hypertensive HIV/AIDS patients receiving antiretroviral therapy (ART) at a large hospital in Eswatini over a 4-year period. We performed a retrospective longitudinal review of the medical records of 560 ART patients divided into non-hypertension and hypertension groups (n = 325 and n = 235) from July 27 to September 8, 2018. Generalized Estimated Equation was used to analyze the longitudinal data. Hypertensive patients were more likely to have improved CD4-cell counts than non-hypertensive patients (OR = 1.83, [1.37–2.44]). ART patients with hypertension were more likely to have detectable viral loads, though not significant (OR = 1.37 [0.77–2.43]). In non-hypertensive patients, second line ART was significantly associated with viral load (OR = 8.61 [2.93–25.34]) and adverse side effects (OR = 3.50 [1.06–11.54]), while isoniazid preventive therapy was significantly associated with CD4-cell counts (OR = 1.68 [1.16–2.45]). In hypertensive patients, factors associated with viral load were WHO HIV stage (OR = 2.84 [1.03–7.85]) and adherence (OR = 8.08 [1.33–49.04]). In both groups, CD4-cell counts significantly and steadily increased over time (p-value < 0.001). Results show a significant association between hypertension and CD4 cell counts but not viral load. In ART patients with and without hypertension, the factors associated with prognostic markers were different. More attention may need to be paid to ART patients with well controlled HIV status to monitoring and controlling of hypertension status.

Integrated community-based HIV and non-communicable disease care within microfinance groups in Kenya: study protocol for the Harambee cluster randomised trial

INTRODUCTION

In Kenya, distance to health facilities, inefficient vertical care delivery and limited financial means are barriers to retention in HIV care. Furthermore, the increasing burden of non-communicable diseases (NCDs) among people living with HIV complicates chronic disease treatment and strains traditional care delivery models. Potential strategies for improving HIV/NCD treatment outcomes are differentiated care, community-based care and microfinance (MF).

METHODS AND ANALYSIS

We will use a cluster randomised trial to evaluate integrated community-based (ICB) care incorporated into MF groups in medium and high HIV prevalence areas in western Kenya. We will conduct baseline assessments with n=900 HIV positive members of 40 existing MF groups. Group clusters will be randomised to receive either (1) ICB or (2) standard of care (SOC). The ICB intervention will include: (1) clinical care visits during MF group meetings inclusive of medical consultations, NCD management, distribution of antiretroviral therapy (ART) and NCD medications, and point-of-care laboratory testing; (2) peer support for ART adherence and (3) facility referrals as needed. MF groups randomised to SOC will receive regularly scheduled care at a health facility. Findings from the two trial arms will be compared with follow-up data from n=300 matched controls. The primary outcome will be VS at 18 months. Secondary outcomes will be retention in care, absolute mean change in systolic blood pressure and absolute mean change in HbA1c level at 18 months. We will use mediation analysis to evaluate mechanisms through which MF and ICB care impact outcomes and analyse incremental cost-effectiveness of the intervention in terms of cost per HIV suppressed person-time, cost per patient retained in care and cost per disability-adjusted life-year saved.

ETHICS AND DISSEMINATION

The Moi University Institutional Research and Ethics Committee approved this study (IREC#0003054). We will share data via the Brown University Digital Repository and disseminate findings via publication.

TRIAL REGISTRATION NUMBER

NCT04417127.

Toxic Metals and Non-Communicable Diseases in HIV Population: A Systematic Review

Background and Objectives: HIV has been a serious global health concern since its discovery, with about 37.9 million people living with HIV worldwide as of 2018. Sub-Saharan Africa (SSA) accounts for 68% of the infection and contributed 74% of the 1.5 million deaths in 2013 despite having only 12% of the total world population residing in the region. This systematic review has attempted to determine the association between heavy metal toxicity and the occurrence of non-communicable diseases in the HIV/AIDS population. Materials and Methods: Three databases were systematically searched: PubMed, Scopus, and Google Scholar for studies written in English and published between 1 April 2000 and 12 April 2020. Studies were excluded if the main outcomes were not measured or did not meet the inclusion criteria. Results: All the six included studies are cross-sectional in design, and therefore were evaluated using the STROBE checklist. The data extraction was done using an extraction table; the ratio of female to male participants included in the study was 1.09:1. Qualitative analysis was used due to the heterogeneity in the heavy metal biomarkers and the outcome measured by the included studies. Two studies compared the concentration of heavy metals in HIV-positive and HIV-negative participants while one compared the levels between HAART-naïve and HAART-treated participants, and three determined the association between heavy metal toxicity and non-communicable diseases (liver fibrosis, anaemia, and reproductive parameters, respectively) in HIV-positive patients. Conclusions: Blood lead, cadmium, and mercury levels were higher in HIV-seropositive than -seronegative subjects, whereas serum zinc level was lower in HIV-seropositive than -seronegative subjects, but the causal association between heavy metals and non-communicable diseases in HIV subjects is largely unknown. Interdisciplinary research between nutrition, toxicology, and human health is envisaged for primary and secondary prevention and treatment.

[Diabetes mellitus and high blood pressure over risk in HIV-infected people followed at Souro Sanou University Hospital Day Hospital, Bobo-Dioulasso 2018]

BACKGROUND

Non-communicable diseases (NCDs) represent the leading causes of death worldwide. HIV also increases the risk of developing NCDs including diabetes mellitus and hypertension.

METHODS

A cross-sectional study, based on an analysis of the cohort database of the day hospital of the Souro Sanou teaching hospital in Bobo-Dioulasso (Burkina Faso). Diabetes mellitus was defined by the undergoing of anti-diabetic treatment or two successive measurements of fasting blood sugar above 7mmol/l and high blood pressure by the undergoing of antihypertensive treatment or two successive measurements of blood pressure above 140/90mmHg. Comparison of the frequency of diabetes and hypertension in the people living with HIV/AIDS (PLWHA) population on antiretroviral therapy (ART) with that of the general population of Burkina Faso was made by indirect standardization according to age and gender.

RESULTS

A total of 4259 patients including 3148 women (73.9%) were included in this study. The median age of the patients was 45 years (IQR: 38-52); the median body mass index (BMI) was 19.6kg/m² (IQR: 15.4 - 22.7) and 48.3% of patients had a BMI≥25kg/m². The median CD4 count was 590 cells/mm³ (IQR: 417-785). The median ART duration was 8.2 years (IQR: 4.7-11.2). The majority of patients (82.9%) were on treatment combinations consisting in 2 INTI+1 NNRTI. Prevalence of hypertension was 39.8%; it was statistically higher in men than in women (45.8% versus 37.8%). Prevalence of hypertension was 87.0% higher in the PLWHA population than among same-sex and same-age subjects in the general population. Prevalence of diabetes mellitus was 7.3%. Diabetes mellitus was more common in men than in women (10.1% versus 6.3%; P<10^-3). Prevalence of diabetes mellitus was 36.0% higher in the PLWHA population than among same-sex and same-age subjects in the general population.

CONCLUSION

Prevalence of diabetes mellitus and hypertension was higher among PLHWA undergoing ART than in the general population. Care for the PLHWA population should more widely include NCD treatment.

Predictors of glucose metabolism and blood pressure among Ethiopian individuals with HIV/AIDS after one-year of antiretroviral therapy

OBJECTIVE

Better understanding of glucose metabolism in patients with HIV after initiating antiretroviral therapy (ART) is important to target treatment and follow-up for diabetes risk and other non-communicable diseases in resource-limited settings. The aim of this study was to assess the changes and predictors of glucose metabolism and blood pressure among patients with HIV on ART for 12 months.

METHODS

One-year follow-up of Ethiopian patients with HIV after initiation of ART was done. Outcomes were changes in fasting plasma glucose (FPG), and 30-minute (30mPG) and 2-hour plasma glucose (2hPG) after oral glucose tolerance test, glycated haemoglobin (HbA1c), fasting plasma insulin (p-insulin), homeostatic model assessment index for insulin resistance (HOMA-IR) and blood pressure.   RESULTS: The mean age was 33 years, and the majority were women. During the first 12 months, levels of all plasma glucose parameters decreased, while p-insulin (10^B 3.1; 95% CI2.4, 4.0), HOMA-IR (10^B 3.1; 95% CI2.3, 4.0) and systolic blood pressure (B 4.0; 95% CI2.5, 5.5) increased. Fat-free mass at baseline predicted higher increments in p-insulin, HOMA-IR and blood pressure; whereas, fat mass predicted higher increment in HbA1c.

CONCLUSIONS

Among Ethiopian patients with HIV, blood pressure and insulin increased, and all glucose parameters declined during 12-month of ART. Only longer-term follow-up will tell us whether insulin increase is due to insulin resistance or from recovering β-cells.

Effectiveness of a psychological intervention delivered by general nurses for alcohol use disorders in people living with HIV in Zimbabwe: a cluster randomized controlled trial

INTRODUCTION

There have been very few randomized clinical trials of interventions for alcohol use disorders (AUD) in people living with HIV (PLWH) in African countries. This is despite the fact that alcohol use is one of the modifiable risk factors for poor virological control in PLWH on antiretroviral therapy.

METHODS

Sixteen clinic clusters in Zimbabwe were selected through stratified randomization and randomized 1: 1 to Intervention and Control arms. Inclusion criteria for individual participants were being adult, living with HIV and a probable alcohol use disorder as defined by a score of 6 (women) or 7 (men) on the Alcohol Use Disorders Identification Test (AUDIT). In the Intervention clusters, participants received 8 to 10 sessions of Motivational Interviewing blended with brief Cognitive Behavioural Therapy (MI-CBT). In the control clusters, participants received four Enhanced Usual Care (EUC) sessions based on the alcohol treatment module from the World Health Organisation mhGAP intervention guide. General Nurses from the clinics were trained to deliver both treatments. The primary outcome was a change in AUDIT score at six-month post-randomization. Viral load, functioning and quality of life were secondary outcomes. A random-effects analysis-of-covariance model was used to account for the cluster design.

RESULTS

Two hundred and thirty-four participants (n = 108 intervention and n = 126 control) were enrolled across 16 clinics. Participants were recruited from November 2016 to November 2017 and followed through to May 2018. Their mean age was 43.3 years (SD = 9.1) and 78.6% (n = 184) were male. At six months, the mean AUDIT score fell by -6.15 (95% CI -6.32; -6.00) in the MI-CBT arm, compared to a fall of - 3.09 95 % CI - 3.21; -2.93) in the EUC arm (mean difference -3.09 (95% CI -4.53 to -1.23) (p = 0.05). Viral load reduced and quality of life and functioning improved in both arms but the difference between arms was non-significant.

CONCLUSIONS

Interventions for hazardous drinking and AUD comprising brief, multiple alcohol treatment sessions delivered by nurses in public HIV facilities in low-income African countries can reduce problematic drinking among PLWH. Such interventions should be integrated into the primary care management of AUD and HIV and delivered by non-specialist providers. Research is needed on cost-effectiveness and implementation of such interventions, and on validation of cut-points for alcohol use scales in low resource settings, in partnership with those with lived experience of HIV and AUD.

Universal HIV Testing and Treatment (UTT) Integrated with Chronic Disease Screening and Treatment: the SEARCH study

PURPOSE OF REVIEW

The growing burden of untreated chronic disease among persons with HIV (PWH) threatens to reverse heath gains from ART expansion. Universal test and treat (UTT)'s population-based approach provides opportunity to jointly identify and treat HIV and other chronic diseases. This review's purpose is to describe SEARCH UTT study's integrated disease strategy and related approaches in Sub-Saharan Africa.

RECENT FINDINGS

In SEARCH, 97% of adults were HIV tested, 85% were screened for hypertension, and 79% for diabetes at health fairs after 2 years, for an additional $1.16/person. After 3 years, population-level hypertension control was 26% higher in intervention versus control communities. Other mobile/home-based multi-disease screening approaches have proven successful, but data on multi-disease care delivery are extremely limited and show little effect on clinical outcomes. Integration of chronic disease into HIV in the UTT era is feasible and can achieve population level effects; however, optimization and implementation remain a huge unmet need.

A comparison of HIV outpatient care in primary and secondary healthcare-level settings in Zimbabwe

Setting

Decentralisation of HIV care to nurse-led primary care services is being implemented across low- and middle-income countries in sub-Saharan Africa.

Objective

To compare services offered to clients attending for HIV care at a physician-led and a nurse-led service in Harare, Zimbabwe.

Design

A cross-sectional study was performed at Harare Central Hospital (HCH) and Budiriro Primary Care Clinic (PCC) from June to August 2018. An interviewer-administered questionnaire was used to collect sociodemographics, HIV treatment and clinical history from clients attending for routine HIV care. The Mann-Whitney U-test was used to evaluate for differences between groups for continuous variables. For categorical variables, the χ² test was used.

Results

The median age of the 404 participants recruited was 38 years (IQR 28-47); 69% were female. Viral suppression was comparable between sites (HCH, 70% vs. PCC, 80%; P = 0.07); however, screening for comorbidities such as cervical cancer screening (HCH, 61% vs. PCC, 41%; P = 0.001) and provision of referral services (HCH, 23% vs. PCC, 13%; P = 0.01) differed between sites.

Conclusion

Efforts to improve service provision in primary care settings are needed to ensure equity for users of health services.

HIV and cardiovascular disease

HIV-related cardiovascular disease research is predominantly from Europe and North America. Of the estimated 37·9 million people living with HIV worldwide, 25·6 million live in sub-Saharan Africa. Although mechanisms for HIV-related cardiovascular disease might be the same in all people with HIV, the distribution of cardiovascular disease risk factors varies by geographical location. Sub-Saharan Africa has a younger population, higher prevalence of elevated blood pressure, lower smoking rates, and lower prevalence of elevated cholesterol than western Europe and North America. These variations mean that the profile of cardiovascular disease differs between low-income and high-income countries. Research in, implementation of, and advocacy for risk reduction of cardiovascular disease in the global context of HIV should account for differences in the distribution of traditional cardiovascular disease risk factors (eg, hypertension, smoking), consider non-traditional cardiovascular disease risk factors (eg, access to antiretroviral therapy with more benign cardiovascular disease side effect profiles, indoor air pollution), and encourage the inclusion of relevant risk reduction approaches for cardiovascular disease in HIV-care guidelines. Future research priorities include implementation science to scale up and expand integrated HIV and cardiovascular disease care models, which have shown promise in sub-Saharan Africa; HIV and cardiovascular disease epidemiology and mechanisms in women; and tobacco cessation for people living with HIV.

Comorbidity of HIV, hypertension, and diabetes and associated factors among people receiving antiretroviral therapy in Bahir Dar city, Ethiopia

Background:

People living with human immunodeficiency virus (HIV) are facing an increased burden of noncommunicable diseases (NCDs) comorbidity. There is, however, paucity of information on the magnitude of HIV-NCDs comorbidity, its associated factors, and how the health system is responding to the double burden in Ethiopia.

Objective:

To determine the magnitude of comorbidity between HIV and hypertension or diabetes and associated factors among HIV-positive adults receiving antiretroviral therapy (ART) in Bahir Dar city, Ethiopia.

Methods:

A facility-based cross-sectional study was conducted among 560 randomly selected HIV-positive adults taking ART. Data were collected using a structured questionnaire and analyzed using SPSS version 23. Descriptive statistics were used to describe the data. A logistic regression model was fit to identify associated factors with comorbidity of HIV and NCDs.

Results:

The magnitude of comorbidity was 19.6% (95% confidence interval (CI): 16.0–23.0). Being older (55 and above years) adjusted odds ratio (AOR: 8.5; 95% CI: 3.2–15.1), taking second-line ART regimen containing tenofovir (AOR: 2.7; 95% CI: 1.3–5.6), and increased body mass index (BMI) ≥25 (AOR: 2.7; 95% CI: 1.2–6.5) were the factors associated with comorbidity. Participants reported that they were not managed in an integrated and coordinated manner.

Conclusions:

The magnitude of comorbidity among adults was high in the study area. Being older, second-line ART regimen and high BMI ≥25 increased the odds of having NCDs among HIV-positive adults. Targeted screening for the incidences of NCDs, addressing modifiable risk factors, and providing integrated care would help to improve the quality of life comorbid patients.

The prevalence of selected non-communicable disease risk factors among HIV patients on anti-retroviral therapy in Bushbuckridge sub-district, Mpumalanga province

Background

The rates of non-communicable diseases (NCD’s) appear to be increasing in human immunodeficiency virus (HIV) infected people as compared to non-HIV infected people and this will have major implications for clinical care. The aim of the current study was to profile selected cardiovascular disease risk factors among HIV patients on anti-retroviral therapy (ART) in Bushbuckridge sub-district.

Methods

The current study followed a quantitative cross-sectional study design using a questionnaire which was adapted from World Health Organization STEPwise approach to Surveillance (WHO STEPS). Participants were HIV infected people on ART and data was entered into a computer software Microsoft excel, then imported to Stata 12 for analysis.

Discussion

The overall prevalence of overweight at the initiation of ART amongst the participants was 18.1% and obesity was 11.5% as compared to the time of the study which was 21.4% overweight and 19.6% obese. The average time of ART initiation to study period was 3.6 years. The study findings revealed a significant difference (p-value 0.006) between the baseline and current body mass index at time of study for females. Hypertension was found to be having a significant difference (p-value 0.026 and 0.038) between the baseline and current body mass index at time of study for males and females respectively. The overall prevalence of hypertension was found to be 34.6%, overweight was 21.4% obesity was 19.6%.

The overall prevalence of abnormal waist circumference was 31.9% and females had a higher prevalence of 42.5% as compared to 4.4% of males. The overall prevalence of smoking 10.8% and alcohol consumption was 21.7%. Males were 22.5 times more likely to be smokers than females (p < 0.001) and older people were found to be 0.3 times less likely to consume alcohol as compared to young people.

Conclusions

The high levels of selected risk factors for NCDs among adults on ART in the current study area suggest an urgent need for health interventions to control risk factors in an era of HIV with an aim of reducing multiple morbidity of chronic diseases. Occurrence of NCDs and their risk factors with an aim to achieve positive effects of the long-term ART.

Integrated care experiences and out-of-pocket expenditures: a cross-sectional survey of adults receiving treatment for HIV and hypertension in Malawi

OBJECTIVES

As HIV-positive individuals' life expectancy extends, there is an urgent need to manage other chronic conditions during HIV care. We assessed the care-seeking experiences and costs of adults receiving treatment for both HIV and hypertension in Malawi.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey was conducted with HIV-positive adults with hypertension at a health facility in Lilongwe that offers free HIV care and free hypertension screening, with antihypertensives available for purchase (n=199). Questions included locations and costs of all medication refills and preferences for these refill locations. Respondents were classified as using 'integrated care' if they refilled HIV and antihypertensive medications simultaneously. Data were collected between June and December 2017.

RESULTS

Only half of respondents reported using the integrated care offered at the study site. Among individuals using different locations for antihypertensive medication refills, the most frequent locations were drug stores and public sector health facilities which were commonly selected due to greater convenience and lower medication costs. Although the number of antihypertensive medications was equivalent between the integrated and non-integrated care groups, the annual total cost of care differed substantially (approximately US$21 in integrated care vs US$90 for non-integrated care)-mainly attributable to differences in other visit costs for non-integrated care (transportation, lost wages, childcare). One-third of those in the non-integrated care group reported no expenditure for antihypertensive medication, and six people in each group reported no annual hypertension care-seeking costs at all.

CONCLUSIONS

Individuals using integrated care saw efficiencies because, although they were more likely to pay for antihypertensive medications, they did not incur additional costs. These results suggest that preferences and experiences must be better understood to design effective policies and programmes for integrated care among adults on antiretroviral therapy.

Knowledge about modifiable risk factors for non-communicable diseases adults living with HIV in Rwanda

BACKGROUND

Non-communicable diseases (NCD) are of international public health concern. Of more concern are people living with HIV (PLHIV), who have the increased risk of developing NCDs, such as hypertension, stroke and diabetes. Research has revealed that there is a relationship between knowledge of NCD risk factors and risk perceptions in the general population. Therefore, an assessment of PLHIV's NCD risk factors knowledge is quite critical, to design effective NCD prevention programmes.

OBJECTIVE

To assess the level of knowledge of modifiable risk factors for NCDs and its associated factors among adults living with HIV in Rwanda.

METHODS

A cross-sectional quantitative design was used to collect the data. The study targeted PLHIV who visited the out-patients' public health centres in three purposively selected provinces of Rwanda. The knowledge assessment questionnaire relating to risk factors for chronic diseases of lifestyle was used to collect the data. Data were analysed using SPSS version 23.

RESULTS

Of the 794 respondents, 64.6% were women, and the mean age was 37.9 (±10.8) years. The results revealed that the majority of the respondents (65.0%) had low levels of knowledge about NCD risk factors, while some (35.6%) were of the opinion that they had a low risk of contracting NCDs. Good knowledge was significantly associated with high educational status, a low CD4+ cell count (< 350 cells/mm3) and normotension.

CONCLUSION

The current study findings highlight the need for comprehensive health education, to raise awareness of non-communicable diseases' risk factors for adults living with HIV in Rwanda.

'When you take pills you must eat': Food (in)security and ART adherence among older people living with HIV

South Africa has increasing numbers of persons living with HIV on antiretroviral treatment (ART). There is evidence for a relationship between food, food security and HIV. Despite increasing rates of people older than 50 living with HIV coinciding with greater levels of co-morbidity, the existing research is largely limited to those aged 15-49 years. In this paper, we therefore explore how older people living with HIV (OPLWH) in two urban communities within South Africa negotiate and ensure they have sufficient access to food and how food insecurity may affect their retention in care and ART adherence. This study used exploratory qualitative semi-structured in-depth interviews with 23 OPLWH to collect data in isiXhosa. Data were analysed using thematic content analysis. Factors at the community, household and individual levels influence (a) access to sufficient and quality food, and (b) beliefs about ART and food based on (mis)understandings of messaging from health care providers. The results demonstrate the need to explore further and clarify the nutritional guidelines that OPLWH receive from providers to ensure this does not result in reduced adherence or retention in care. They also demonstrate the role that social welfare and family or kin obligations plays in ensuring the food security of OPLWH.

Epidemiological And Health Systems Implications Of Evolving HIV And Hypertension In South Africa And Kenya

Health systems in sub-Saharan Africa are facing an ongoing HIV epidemic and increasing burden of noncommunicable disease. With the focus shifting to the development of comprehensive primary health care and chronic disease treatment, multidisease modeling is integral to estimating future health care needs. We extended an established agent-based model of HIV transmission to include hypertension in two rural settings: KwaZulu-Natal, South Africa, and western Kenya. We estimated that from 2018 to 2028 hypertension prevalence would increase from 40 percent to 46 percent in KwaZulu-Natal and from 29 percent to 35 percent in western Kenya, while HIV prevalence is stabilizing and predicted to decrease. As the health system burden in sub-Saharan Africa is changing, innovative chronic disease treatment and the broadening of successful programs, such as integrated HIV and noncommunicable disease care, are necessary to reach universal health care coverage.

Association between highly active antiretroviral therapy (HAART) and hypertension in persons living with HIV/AIDS at the Bamenda regional hospital, Cameroon

Introduction

The introduction of highly active antiretroviral therapy (HAART) in the treatment of HIV infection has provided different good results: like long-term viral suppression, the decrease of opportunistic infections, and repair of the immune system.

Methods

We carried out a hospital-based cross-sectional analytic study involving 315 participants 228 were on HAART (group 1) and 87 were HAART-naïve (group 2) at the HIV treatment centre of the Bamenda regional hospital with our study population being all people living with HIV (PLWHIV) in the North West region of Cameroon. The sampling was performed from the 15^th of March to the 30^th of June 2017. The questionnaire was administered face to face with participants and their vital signs taken. Blood pressure was measured using an automated electronic blood pressure monitor and hypertension (HTN) was considered as systolic blood pressure (BP) ≥ 140 mmHg and/or diastolic BP ≥ 90mmHg.

Results

The prevalence of hypertension in the HAART group was 36.44% (n=82, CI: 30.15%-43.10%) compared to that of the HAART-naïve group which was 13.33% (n=12, CI: 7.08%-22.13%, P=0.01). HAART was associated with HTN after controlling for gender, family history of hypertension, body mass index (BMI), smoking and alcohol consumption. The odds ratio of the HAART-treated versus the HAART-naïve was 3.86 (95% CI: 1.98-7.50). We also found an association between TDF/3TC/EFV (OR=2.83), AZT/3TC/NVP (OR=2.82), AZT/3TC+EFV (OR=3.48) and TDF/3TC+NVP (OR=2.36) and HTN whereas those on AZT+3TC+ATV/r (OR=0.84) and TDF+3TC+ATV/r (OR=0.45) were not associated to hypertension.

Conclusion

Our result suggests that blood pressure should be periodically measured and treated when necessary in PLWHIV on HAART.

Role of Noncommunicable Diseases (NCDs) in Resource-Limited Settings (RLS)

PURPOSE OF REVIEW

As access to effective antiretroviral therapy (ART) expands globally, a decline in AIDS-related morbidity and mortality has been complicated by rising rates of noncommunicable diseases (NCDs). This review provides a brief description of NCDs and existing gaps on knowledge about NCDs among HIV-infected adults mostly in Africa.

RECENT FINDINGS

Recent reports show that one in every five persons living with HIV has a chronic illness, predominantly diabetes and/or hypertension, depression, and most of these conditions are either not diagnosed or not being managed. Human papilloma virus-associated anal dysplasia occurs among 70% of HIV-infected women in RLS. Recognizing risk factors for NCDs and providing effective screening and optimal care remains challenging. Research is urgently needed to carefully characterize HIV-associated NCDs in RLS. Such studies should provide a framework for high-priority NCDs that the limited resources can be focused on in these settings.

Co-morbid Non-communicable Diseases and Associated Health Service Use in African and Caribbean Immigrants with HIV

We sought to characterize non-communicable disease (NCD)-related and overall health service use among African and Caribbean immigrants living with HIV between April 1, 2010 and March 31, 2013. We conducted two population-based analyses using Ontario's linked administrative health databases. We studied 1525 persons with HIV originally from Africa and the Caribbean. Compared with non-immigrants with HIV (n = 11,931), African and Caribbean immigrants had lower rates of hospital admissions, emergency department visits and non-HIV specific ambulatory care visits, and higher rates of health service use for hypertension and diabetes. Compared with HIV-negative individuals from these regions (n = 228,925), African and Caribbean immigrants with HIV had higher rates of health service use for chronic obstructive pulmonary disease [rate ratio (RR) 1.78; 95% confidence interval (CI) 1.36-2.34] and malignancy (RR 1.20; 95% CI 1.19-1.43), and greater frequency of hospitalizations for mental health illness (RR 3.33; 95% CI 2.44-4.56), diabetes (RR 1.37; 95% CI 1.09-1.71) and hypertension (RR 1.85; 95% CI 1.46-2.34). African and Caribbean immigrants with HIV have higher rates of health service use for certain NCDs than non-immigrants with HIV. The evaluation of health services for African and Caribbean immigrants with HIV should include indicators of NCD care that disproportionately affect this population.

Noncommunicable disease burden among HIV patients in care: a national retrospective longitudinal analysis of HIV-treatment outcomes in Kenya, 2003-2013

BACKGROUND

Over the last decade, the Kenyan HIV treatment program has grown exponentially, with improved survival among people living with HIV (PLHIV). In the same period, noncommunicable diseases (NCDs) have become a leading contributor to disease burden. We sought to characterize the burden of four major NCDs (cardiovascular diseases, cancer, chronic respiratory diseases and diabetes mellitus) among adult PLHIV in Kenya.

METHODS

We conducted a nationally representative retrospective medical chart review of HIV-infected adults aged ≥15 years enrolled in HIV care in Kenya from October 1, 2003 through September 30, 2013. We estimated proportions of four NCD categories among PLHIV at enrollment into HIV care, and during subsequent HIV care visits. We compared proportions and assessed distributions of co-morbidities using the Chi-Square test. We calculated NCD incidence rates and their confidence intervals in assessing cofactors for developing NCDs.

RESULTS

We analyzed 3170 records of HIV-infected patients; 2115 (66.3%) were from women. Slightly over half (51.1%) of patient records were from PLHIVs aged above 35 years. Close to two-thirds (63.9%) of PLHIVs were on ART. Proportion of any documented NCD among PLHIV was 11.5% (95% confidence interval [CI] 9.3, 14.1), with elevated blood pressure as the most common NCD 343 (87.5%) among PLHIV with a diagnosed NCD. Despite this observation, only 17 (4.9%) patients had a corresponding documented diagnosis of hypertension in their medical record. Overall NCD incidence rates for men and women were (42.3 per 1000 person years [95% CI 35.8, 50.1] and 31.6 [95% CI 27.7, 36.1], respectively. Compared to women, the incidence rate ratio for men developing an NCD was 1.3 [95% CI 1.1, 1.7], p = 0.0082). No differences in NCD incidence rates were seen by marital or employment status. At one year of follow up 43.8% of PLHIV not on ART had been diagnosed with an NCD compared to 3.7% of patients on ART; at five years the proportions with a diagnosed NCD were 88.8 and 39.2% (p < 0.001), respectively.  CONCLUSIONS: PLHIV in Kenya have a high prevalence of NCD diagnoses. In the absence of systematic, effective screening, NCD burden is likely underestimated in this population. Systematic screening and treatment for NCDs using standard guidelines should be integrated into HIV care and treatment programs in sub-Saharan Africa.

Hypertension and diabetes control along the HIV care cascade in rural South Africa

INTRODUCTION

Participation in antiretroviral therapy (ART) programmes has been associated with greater utilization of care for hypertension and diabetes in rural South Africa. The objective of this study was to assess whether people living with HIV on ART with comorbid hypertension or diabetes also have improved chronic disease management indicators.

METHODS

The Health and Aging in Africa: a longitudinal study of an INDEPTH Community in South Africa (HAALSI) is a cohort of 5059 adults >40 years old. Enrollment took place between November 2014 and November 2015. The study collected population-based data on demographics, healthcare utilization, height, weight, blood pressure (BP) and blood glucose as well as HIV infection, HIV-1 RNA viral load (VL) and ART exposure. We used regression models to determine whether HIV care cascade stage (HIV-negative, HIV+ /No ART, ART/Detected HIV VL, and ART/Undetectable VL) was associated with diagnosis or treatment of hypertension or diabetes, and systolic blood pressure and glucose among those with diagnosed hypertension or diabetes. ART use was measured from drug level testing on dried blood spots.

RESULTS AND DISCUSSION

Compared to people without HIV, ART/Undetectable VL was associated with greater awareness of hypertension diagnosis (adjusted risk ratio (aRR) 1.18, 95% CI: 1.09 to 1.28) and treatment of hypertension (aRR 1.24, 95% CI: 1.10 to 1.41) among those who met hypertension diagnostic criteria. HIV care cascade stage was not significantly associated with awareness of diagnosis or treatment of diabetes. Among those with diagnosed hypertension or diabetes, ART/Undetectable VL was associated with lower mean systolic blood pressure (5.98 mm Hg, 95% CI: 9.65 to 2.32) and lower mean glucose (3.77 mmol/L, 95% CI: 6.85 to 0.69), compared to being HIV-negative.

CONCLUSIONS

Participants on ART with an undetectable VL had lower systolic blood pressure and blood glucose than the HIV-negative participants. HIV treatment programmes may provide a platform for health systems strengthening for cardiometabolic disease.

Depressive Symptoms Before and After Antiretroviral Therapy Initiation Among Older-Aged Individuals in Rural Uganda

This study aims to characterize associations between depression symptom severity and HIV infection, both prior to and in years after ART initiation, among older adults. The Ugandan Non-Communicable Diseases & Aging Cohort Study (UGANDAC) is a study of 154 PLWH on ART and 142 community-based, HIV-negative controls. The Hopkins Checklist (HSCL), a 15-item depression scale, was used to screen for depression. We estimate differences in depressive symptoms by HIV and ART status and use multivariable log binomial regression to quantify differences in probable depression between PLWH on ART. HIV-infected and HIV-uninfected participants had a similar age (mean 52.0 vs. 51.9, p = 0.854) and sex distribution (47.4 vs. 47.9% female, p = 0.934). PLWH on ART had lower depression symptom severity than HIV-uninfected controls (mean score: 1.50 vs. 1.60, p = 0.006) and a lower prevalence of probable depression (21.4 vs. 33.8%, p = 0.017). Among 102 PLWH with pre-ART depression screening scores available, their mean depression symptom severity was similar to HIV-uninfected participants (mean 1.56 vs. 1.60, p = 0.512). In adjusted models, PLWH on ART had a lower prevalence of probable depression than HIV-negative controls [adjusted prevalence ratio: 0.68 (95% CI 0.47-0.99)]. In an observational cohort of PLWH over 40 on long-term ART and matched, community-based HIV-uninfected controls in rural Uganda, we found a lower prevalence of self-reported depression among aging PLWH on ART.

Doye I, Toure M, Sy MP, Kiviat NB, Sow PS, Gottlieb GS, Hawes SE. Increasing prevalence of hypertension among HIV-positive and negative adults in Senegal, West Africa, 1994-2015

BACKGROUND

Non-communicable diseases, including hypertension (HTN), are increasingly recognized as important causes of morbidity and mortality among people living with HIV (PLHIV) in resource-limited settings. The goals of this study were to determine the prevalence of HTN among PLHIV in Senegal over time and to identify predictors of HTN among HIV-positive versus HIV-negative adults.

METHODS

We conducted a retrospective study using data from individuals enrolled in previous studies in Senegal from 1994-2015. Blood pressure (BP) measurements taken during study visits were used for analysis. HTN was defined as systolic BP≥140 or diastolic BP≥90. We used logistic regression to identify predictors of HTN.

RESULTS

We analyzed data from 2848 adults (1687 HIV-positive, 1161 HIV-negative). Among PLHIV, the prevalence of HTN increased from 11% during 1994-1999 to 22% during 2010-2015. Among HIV-negative individuals, the prevalence of HTN increased from 16% to 32%. Among both groups, the odds of HTN more than doubled from 1994-1999 to 2010-2015 (HIV-positive OR 2·4, 95% CI 1·1-5·0; HIV-negative OR 2·6, 95% CI 1·5-4·6). One quarter of all individuals with HTN had stage 2 HTN. The strongest risk factor for HTN was obesity (HIV-positive OR 3·2, 95% CI 1·7-5·8; p<0·01; HIV-negative OR 7·8, 95% CI 4·5-13·6; p<0·01). Male sex and age ≥50 were also predictive of HTN among both groups. Among HIV-positive subjects, WHO stage 1 or 2 disease was predictive of HTN and among HIV-negative subjects, having no formal education was predictive.

CONCLUSION

Over the past 20 years, the prevalence of HTN has doubled among both HIV-positive and HIV-negative adults in Senegal. Our study indicates that there is an increasing need for the integration of chronic disease management into HIV programs in Senegal. Furthermore, our findings highlight the need for enhanced prevention, recognition, and management of non-communicable diseases, including hypertension and obesity, among both HIV-positive and HIV-negative individuals in Senegal.

Incidence and Persistence of Depression Among Women Living with and Without HIV in South Africa: A Longitudinal Study

Depression and trauma are common among women living with HIV. This is the first study to track the longitudinal course of depression and examine the relationship between depression and trauma over time among women in South Africa. HIV-infected and uninfected women (N = 148) were assessed at baseline and one year later. Results of a path analysis show the multi-directional and entwined influence of early life stress, other life-threatening traumas across the lifespan, depression and PTSD over the course of HIV. We also observed higher rates of depressive symptomatology and more persistent cases among infected women compared to uninfected women, as well as a more consistent and enduring relationship between childhood trauma and depression among women living with HIV. The present study is unique in documenting the course of untreated depression and PTSD in women with and without HIV infection with a high prevalence of early childhood trauma.

The association between antiretroviral therapy and selected cardiovascular disease risk factors in sub-Saharan Africa: A systematic review and meta-analysis

BACKGROUND

With increasing adverse cardiovascular disease (CVD) outcomes in HIV/AIDS patients, the possible contribution of antiretroviral therapy (ART) to the prevailing CVD epidemic in sub-Saharan Africa (SSA) through its effect on CVD risk factors has rather been under investigated. This study aimed to assess the extent to which ART is associated with hypertension, diabetes mellitus (DM) and dyslipidemia in SSA.

METHODS

This is a systematic review and meta-analysis of studies from SSA, published between January 1946 and December 2017, from Medline, Embase, Africa-wide Information, the Cochrane library, African Index and Medicus databases. Both observational and interventional studies with comparable ART-treated and ART-naïve populations were selected and data was extracted from eligible studies. Pooled estimates of the effect of ART on the outcomes of interest (hypertension, diabetes and abnormal lipid profiles) were obtained using random effects meta-analysis, and meta-regression analysis was used to explore between-study heterogeneity.

RESULTS

Twenty cross-sectional studies were included involving 5386 participants. There was no association between ART use and hypertension (OR: 1.9, 95%CI: 0.96-3.76, n = 8, I2 = 73.8%) and DM (OR: 2.53, 95%CI: 0.87-7.35, n = 8, I2 = 73.8%). ART use was associated with high total cholesterol (OR: 3.85, 95%CI: 2.45-6.07, n = 8, I2 = 67.0%), high triglycerides (OR: 1.46, 95%CI: 1.21-1.75, n = 14, I2 = 10.0%) and high LDL-cholesterol (OR: 2.38, 95%CI: 1.43-3.95, n = 11, I2 = 87.6%). ART was associated with rather lower odds of having low HDL-cholesterol (OR: 0.53, 95%CI: 0.32-0.87, n = 8, I2 = 78.2%). There was evidence of between-study heterogeneity for all outcomes except high triglycerides.

CONCLUSIONS

ART appears to be associated with CVD risk in HIV/AIDS patients in SSA only through dyslipidemia but not through hypertension and DM, however, high quality and robust research in SSA is mandated to accurately ascertain the actual contribution of ART to the CVD burden in this part of the world. Nevertheless, HIV/AIDS patients should still benefit from systematic CVD screening alongside their regular care services.

TRIAL REGISTRATION

Prospero Registration - CRD42016042306.

Expert consensus statement on the science of HIV in the context of criminal law

INTRODUCTION

Globally, prosecutions for non-disclosure, exposure or transmission of HIV frequently relate to sexual activity, biting, or spitting. This includes instances in which no harm was intended, HIV transmission did not occur, and HIV transmission was extremely unlikely or not possible. This suggests prosecutions are not always guided by the best available scientific and medical evidence.

DISCUSSION

Twenty scientists from regions across the world developed this Expert Consensus Statement to address the use of HIV science by the criminal justice system. A detailed analysis of the best available scientific and medical research data on HIV transmission, treatment effectiveness and forensic phylogenetic evidence was performed and described so it may be better understood in criminal law contexts. Description of the possibility of HIV transmission was limited to acts most often at issue in criminal cases. The possibility of HIV transmission during a single, specific act was positioned along a continuum of risk, noting that the possibility of HIV transmission varies according to a range of intersecting factors including viral load, condom use, and other risk reduction practices. Current evidence suggests the possibility of HIV transmission during a single episode of sex, biting or spitting ranges from no possibility to low possibility. Further research considered the positive health impact of modern antiretroviral therapies that have improved the life expectancy of most people living with HIV to a point similar to their HIV-negative counterparts, transforming HIV infection into a chronic, manageable health condition. Lastly, consideration of the use of scientific evidence in court found that phylogenetic analysis alone cannot prove beyond reasonable doubt that one person infected another although it can be used to exonerate a defendant.

CONCLUSIONS

The application of up-to-date scientific evidence in criminal cases has the potential to limit unjust prosecutions and convictions. The authors recommend that caution be exercised when considering prosecution, and encourage governments and those working in legal and judicial systems to pay close attention to the significant advances in HIV science that have occurred over the last three decades to ensure current scientific knowledge informs application of the law in cases related to HIV.

A scoping review of the role of HIV-related stigma and discrimination in noncommunicable disease care

Background

People living with HIV are increasingly burdened by noncommunicable diseases (NCDs) as a result of the NCD susceptibility that accompanies increased life expectancy and the rising global prevalence of NCDs. Health systems are being strengthened and programs are being developed to address this burden, often building on HIV care strategies and infrastructure or through integrated care models. HIV remains a stigmatized condition and the role of HIV stigma in the provision of NCD care is not well understood.

Methods

We conducted a scoping literature review of both peer reviewed and grey literature to identify evidence of the role of HIV stigma in the NCD-care continuum (prevention, diagnosis, care seeking, retention in care, and adherence to treatment of NCDs). We searched PsychInfo and Pubmed and conducted additional searches of programmatic reports and conference abstracts. Included studies were published in English within the past decade and examined HIV-related stigma as it relates to NCD-care or to integrated NCD-and HIV-care programs.

Results

Sixteen articles met the inclusion criteria. Findings suggest: fear of disclosure, internalized shame and embarrassment, and negative past experiences with or negative perceptions of health care providers negatively influence engagement with NCD care; HIV stigma can adversely affect not only people living with HIV in need of NCD care, but all NCD patients; some NCDs are stigmatized in their own right or because of their association with HIV; integrating NCD and HIV care can both reduce stigma for people living with HIV and a present a barrier to access for NCD care.

Conclusion

Due to the dearth of available research and the variability in initial findings, further research on the role of HIV stigma in the NCD-care continuum for people living with HIV is necessary. Lessons from the field of HIV-stigma research can serve as a guide for these efforts.

Adolescent age is an independent risk factor for abnormal spirometry among people living with HIV in Kenya

OBJECTIVES

As life expectancy of people living with HIV (PLWH) improves in low-income and middle-income countries (LMICs), the spectrum of HIV-related pulmonary complications may reflect a greater burden of chronic lung diseases as in high-income countries. We determined whether the risk of abnormal spirometry was greater among adolescent compared with adult PLWH at the Coptic Hope Center for Infectious Diseases in Nairobi, Kenya, and evaluated the role of other cofactors for abnormal spirometry.

DESIGN

We prospectively enrolled adolescent and adult PLWH for this cross-sectional study.

METHODS

Data collection included standardized questionnaires, clinical assessment, and prebronchodilator and postbronchodilator spirometry. Adolescents additionally underwent noncontrast chest computed tomography. Multivariable logistic regression determined associations of adolescent age with abnormal spirometry, adjusting for cofactors.

RESULTS

Of 427 PLWH, 21 (40%) adolescents and 64 (17%) adults had abnormal spirometry. Among adolescents, 80% had abnormal chest CTs, and 79% had at least one respiratory symptom. Adolescent age (adjusted odds ratio 3.22; 95% confidence interval 1.48-6.98) was independently associated with abnormal spirometry, adjusting for recent CD4, HIV clinical stage, low BMI, indoor kerosene use, smoking pack-years, and prior pulmonary tuberculosis. Additional important cofactors for abnormal spirometry included prior pulmonary tuberculosis (3.15; 1.70-5.58), kerosene use (1.77; 1.04-3.04) and smoking pack-years (1.05; 1.00-1.10). Adolescent age, prior pulmonary tuberculosis, and smoking pack-years were significantly associated with airflow limitation.

CONCLUSION

Adolescent age was independently associated with increased risk of abnormal spirometry, particularly airflow limitation. Studies to improve prevention, detection, and management of chronic lung disease across the lifespan among PLWH are needed in LMICs.

Features of cardiovascular disease in low-income and middle-income countries in adults and children living with HIV

PURPOSE OF REVIEW

The current article addresses crucial issues in identifying risk of cardiovascular disease (CVD) in people living with HIV in low-income and middle-income countries (LMICs). These issues are in need of urgent attention to advance our knowledge and inform actions to mitigate CVD in this population. We address CVDs in adults living with HIV as well as the unique aspects pertaining to children living with HIV (CLHIV), a group sorely under-represented in this field.

RECENT FINDINGS

CVDs affecting adults such as hypertension, dyslipidemia, coronary artery disease, and heart failure, in addition to myocardial dysfunction, vascular diseases, and autoimmune phenomena are also being reported in CLHIV. In addition to the background disparity in prevalence of traditional CVD risk factors, it is also likely that differential access to antiretroviral treatment, the younger age of the HIV-infected population, and types of antiretroviral treatment commonly used in LMICs contribute to the observed differences.

SUMMARY

Overall, the state of evidence for CVD in LMICs is limited and at times contradictory. We summarize the evidence with suggestions for high priorities for further scientific investigation. Now is the crucial time to intervene in modifying CVD risk in LMICs.

Chronicity, crisis, and the 'end of AIDS'

In biomedical, public health, and popular discourses, the 'end of AIDS' has emerged as a predominant way to understand the future of HIV research and prevention. This approach is predicated on structuring and responding to HIV in ways that underscore its presumed lifelong nature. In this article, I examine the phenomenon of HIV chronicity that undergirds the 'end of AIDS' discourse. In particular, I explore how the logic of HIV chronicity, induced by technological advances in treatment and global financial and political investments, intensifies long-term uncertainty and prolonged crisis. Focusing on over 10 years of anthropological and public health research in the United States, I argue that HIV chronicity, and subsequently, the 'end of AIDS' discourse, obscure the on-going HIV crisis in particular global communities, especially among marginalised and ageing populations who live in under-resourced areas. By tracing the 'end of AIDS' discourse in my field sites and in other global locations, I describe how HIV chronicity signals a continuing global crisis and persistent social precarity rather than a 'break' with a hopeless past or a promising future free from AIDS.

Non-infectious Pulmonary Diseases and HIV

Pulmonary complications remain among the most frequent causes of morbidity and mortality for individuals with HIV despite the advent of antiretroviral therapy (ART) and improvement in its efficacy and availability. The prevalence of non-infectious pulmonary diseases is rising in this population, reflecting both an increase in smoking and the independent risk associated with HIV. The unique mechanisms of pulmonary disease in these patients remain poorly understood, and direct effects of HIV, genetic predisposition, inflammatory pathways, and co-infections have all been implicated. Lung cancer, chronic obstructive pulmonary disease (COPD), and pulmonary hypertension are the most prevalent non-infectious pulmonary diseases in persons with HIV, and the risk of each of these diseases is higher among HIV-infected (HIV+) persons than in the general population. This review discusses the latest advances in the literature on these important complications of HIV infection.

The association between HIV and atherosclerotic cardiovascular disease in sub-Saharan Africa: a systematic review

Background

Sub-Saharan Africa (SSA) has confronted decades of the HIV epidemic with substantial improvements in access to life-saving antiretroviral therapy (ART). Now, with improved survival, people living with HIV (PLWH) are at increased risk for non-communicable diseases (NCDs), including atherosclerotic cardiovascular disease (CVD). We assessed the existing literature regarding the association of CVD outcomes and HIV in SSA.

Methods

We used the PRISMA guidelines to perform a systematic review of the published literature regarding the association of CVD and HIV in SSA with a focus on CVD surrogate and clinical outcomes in PLWH.

Results

From January 2000 until March 2017, 31 articles were published regarding CVD outcomes among PLWH in SSA. Data from surrogate CVD outcomes (n = 13) suggest an increased risk of CVD events among PLWH in SSA. Although acute coronary syndrome is reported infrequently in SSA among PLWH, limited data from five studies suggest extensive thrombus and hypercoagulability as contributing factors. Additional studies suggest an increased risk of stroke among PLWH (n = 13); however, most data are from immunosuppressed ART-naïve PLWH and thus are potentially confounded by the possibility of central nervous system infections.

Conclusions

Given ongoing gaps in our current understanding of CVD and other NCDs in PLWH in SSA, it is imperative to ascertain the burden of CVD outcomes, and to examine strategies for intervention and best practices to enhance the health of this vulnerable population.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4940-1) contains supplementary material, which is available to authorized users.

The ART Advantage: Health Care Utilization for Diabetes and Hypertension in Rural South Africa

BACKGROUND

The prevalence of diabetes and hypertension has increased in HIV-positive populations, but there is limited understanding of the role that antiretroviral therapy (ART) programs play in the delivery of services for these conditions. The aim of this study is to assess the relationship between ART use and utilization of health care services for diabetes and hypertension.

METHODS

Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa is a cohort of 5059 adults. The baseline study collects biomarker-based data on HIV, ART, diabetes, and hypertension and self-reported data on health care utilization. We calculated differences in care utilization for diabetes and hypertension by HIV and ART status and used multivariable logistic regressions to estimate the relationship between ART use and utilization of services for these conditions, controlling for age, sex, body mass index, education, and household wealth quintile.

RESULTS

Mean age, body mass index, hypertension, and diabetes prevalence were lower in the HIV-positive population (all P < 0.001). Multivariable logistic regression showed that ART use was significantly associated with greater odds of blood pressure measurement [adjusted odds ratio (aOR) 1.27, 95% confidence interval (CI): 1.04 to 1.55] and blood sugar measurement (aOR 1.26, 95% CI: 1.05 to 1.51), counseling regarding exercise (aOR 1.57, 95% CI: 1.11 to 2.22), awareness of hypertension diagnosis (aOR 1.52, 95% CI: 1.12 to 2.05), and treatment for hypertension (aOR 1.63, 95% CI: 1.21 to 2.19).

CONCLUSIONS

HIV-positive patients who use ART are more likely to have received health care services for diabetes and hypertension. This apparent ART advantage suggests that ART programs may be a vehicle for strengthening health systems for chronic care.

Mbarara University Research Training Initiative: a spin-off of the Medical Education Partnership Initiative in Uganda

Scientific productivity in Africa is insignificant compared to that in the rest of the world. This has been attributed to the fact that, in spite of academic qualifications, junior faculty, who form the majority of academics in low- and middle-income countries lack experience in research. This calls for a need to put in place programs that provide hands-on training in research so that junior faculty can conduct relevant research. The Mbarara University Research Training Initiative, a Fogarty International Center-funded program, is one such program that was developed to provide research capacity training for junior faculty at the Mbarara University of Science and Technology. The program utilizes health priority areas to provide research training to junior faculty. During the training, they are given short-term-focused research training on particular knowledge and skills, which they apply while conducting the mentored research.