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Kivuyo S, Birungi J, Okebe J, Wang D, Ramaiya K, Ainan S, Tumuhairwe F, Ouma S, Namakoola I, Garrib A, van Widenfelt E, Mutungi G, Jaoude GA, Batura N, Musinguzi J, Ssali MN, Etukoit BM, Mugisha K, Shimwela M, Ubuguyu OS, Makubi A, Jeffery C, Watiti S, Skordis J, Cuevas L, Sewankambo NK, Gill G, Katahoire A, Smith PG, Bachmann M, Lazarus JV, Mfinanga S, Nyirenda MJ, Jaffar S. Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic cluster-randomised, controlled trial. Lancet 2023; 402:1241-1250. [PMID: 37805215 DOI: 10.1016/s0140-6736(23)01573-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND In sub-Saharan Africa, health-care provision for chronic conditions is fragmented. The aim of this study was to determine whether integrated management of HIV, diabetes, and hypertension led to improved rates of retention in care for people with diabetes or hypertension without adversely affecting rates of HIV viral suppression among people with HIV when compared to standard vertical care in medium and large health facilities in Uganda and Tanzania. METHODS In INTE-AFRICA, a pragmatic cluster-randomised, controlled trial, we randomly allocated primary health-care facilities in Uganda and Tanzania to provide either integrated care or standard care for HIV, diabetes, and hypertension. Random allocation (1:1) was stratified by location, infrastructure level, and by country, with a permuted block randomisation method. In the integrated care group, participants with HIV, diabetes, or hypertension were managed by the same health-care workers, used the same pharmacy, had similarly designed medical records, shared the same registration and waiting areas, and had an integrated laboratory service. In the standard care group, these services were delivered vertically for each condition. Patients were eligible to join the trial if they were living with confirmed HIV, diabetes, or hypertension, were aged 18 years or older, were living within the catchment population area of the health facility, and were likely to remain in the catchment population for 6 months. The coprimary outcomes, retention in care (attending a clinic within the last 6 months of study follow-up) for participants with either diabetes or hypertension (tested for superiority) and plasma viral load suppression for those with HIV (>1000 copies per mL; tested for non-inferiority, 10% margin), were analysed using generalised estimating equations in the intention-to-treat population. This trial is registered with ISCRTN 43896688. FINDINGS Between June 30, 2020, and April 1, 2021 we randomly allocated 32 health facilities (17 in Uganda and 15 in Tanzania) with 7028 eligible participants to the integrated care or the standard care groups. Among participants with diabetes, hypertension, or both, 2298 (75·8%) of 3032 were female and 734 (24·2%) of 3032 were male. Of participants with HIV alone, 2365 (70·3%) of 3365 were female and 1000 (29·7%) of 3365 were male. Follow-up lasted for 12 months. Among participants with diabetes, hypertension, or both, the proportion alive and retained in care at study end was 1254 (89·0%) of 1409 in integrated care and 1457 (89·8%) of 1623 in standard care. The risk differences were -0·65% (95% CI -5·76 to 4·46; p=0·80) unadjusted and -0·60% (-5·46 to 4·26; p=0·81) adjusted. Among participants with HIV, the proportion who had a plasma viral load of less than 1000 copies per mL was 1412 (97·0%) of 1456 in integrated care and 1451 (97·3%) of 1491 in standard care. The differences were -0·37% (one-sided 95% CI -1·99 to 1·26; pnon-inferiority<0·0001 unadjusted) and -0·36% (-1·99 to 1·28; pnon-inferiority<0·0001 adjusted). INTERPRETATION In sub-Saharan Africa, integrated chronic care services could achieve a high standard of care for people with diabetes or hypertension without adversely affecting outcomes for people with HIV. FUNDING European Union Horizon 2020 and Global Alliance for Chronic Diseases.
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Affiliation(s)
- Sokoine Kivuyo
- National Institutes for Medical Research, Dar es Salaam, Tanzania; Barcelona Institute for Global Health Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Josephine Birungi
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda; Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda; School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Joseph Okebe
- Institute for Global Health, University College London, London, UK
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kaushik Ramaiya
- Tanzania NCDs Alliance, Dar es Salaam, Tanzania; Shree Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | - Samafilan Ainan
- National Institutes for Medical Research, Dar es Salaam, Tanzania
| | - Faith Tumuhairwe
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | - Simple Ouma
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | - Ivan Namakoola
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Anupam Garrib
- Institute for Global Health, University College London, London, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Ministry of Health, Kampala, Uganda
| | | | - Neha Batura
- Institute for Global Health, University College London, London, UK
| | | | | | | | - Kenneth Mugisha
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | | | | | | | - Caroline Jeffery
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Stephen Watiti
- The National Forum of People Living with HIV Networks in Uganda, Kampala, Uganda
| | - Jolene Skordis
- Institute for Global Health, University College London, London, UK
| | - Luis Cuevas
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Geoff Gill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anne Katahoire
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Peter G Smith
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Max Bachmann
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health Hospital Clinic, University of Barcelona, Barcelona, Spain; CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | - Sayoki Mfinanga
- National Institutes for Medical Research, Dar es Salaam, Tanzania; Institute for Global Health, University College London, London, UK
| | - Moffat J Nyirenda
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Shabbar Jaffar
- Institute for Global Health, University College London, London, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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Garrib A, Kivuyo S, Bates K, Ramaiya K, Wang D, Majaliwa E, Simbauranga R, Charles G, van Widenfelt E, Luo H, Alam U, Nyirenda MJ, Jaffar S, Mfinanga S. Metformin for the prevention of diabetes among people with HIV and either impaired fasting glucose or impaired glucose tolerance (prediabetes) in Tanzania: a Phase II randomised placebo-controlled trial. Diabetologia 2023; 66:1882-1896. [PMID: 37460828 PMCID: PMC10474205 DOI: 10.1007/s00125-023-05968-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/12/2023] [Indexed: 09/02/2023]
Abstract
AIMS/HYPOTHESIS In sub-Saharan Africa (SSA), 5% of adults are living with type 2 diabetes and this is rising sharply, with a greater increase among people with HIV. Evidence on the efficacy of prevention strategies in this cohort is scarce. We conducted a Phase II double-blind placebo-controlled trial that aimed to determine the impact of metformin on blood glucose levels among people with prediabetes (defined as impaired fasting glucose [IFG] and/or impaired glucose tolerance [IGT]) and HIV in SSA. METHODS Adults (≥18 years old) who were stable in HIV care and found to have prediabetes (IFG and/or IGT) and who were attending hospitals in Dar es Salaam, Tanzania, were randomised to receive sustained-release metformin, 2000 mg daily, or matching placebo between 4 November 2019 and 21 July 2020. Randomisation used permuted blocks. Allocation was concealed in the trial database and made visible only to the Chief Pharmacist after consent was taken. All participants, research and clinical staff remained blinded to the allocation. Participants were provided with information on diet and lifestyle and had access to various health information following the start of the coronavirus disease 2019 (COVID-19) pandemic. Participants were followed up for 12 months. The primary outcome measure was capillary blood glucose measured 2 h following a 75 g glucose load. Analyses were by intention-to-treat. RESULTS In total, 364 participants (182 in each arm) were randomised to the metformin or placebo group. At enrolment, in the metformin and placebo arms, mean fasting glucose was 6.37 mmol/l (95% CI 6.23, 6.50) and 6.26 mmol/l (95% CI 6.15, 6.36), respectively, and mean 2 h glucose levels following a 75 g oral glucose load were 8.39 mmol/l (95% CI 8.22, 8.56) and 8.24 mmol/l (95% CI 8.07, 8.41), respectively. At the final assessment at 12 months, 145/182 (79.7%) individuals randomised to metformin compared with 158/182 (86.8%) randomised to placebo indicated that they had taken >95% of their medicines in the previous 28 days (p=0.068). At this visit, in the metformin and placebo arms, mean fasting glucose levels were 6.17 mmol/l (95% CI 6.03, 6.30) and 6.30 mmol/l (95% CI 6.18, 6.42), respectively, and mean 2 h glucose levels following a 75 g oral glucose load were 7.88 mmol/l (95% CI 7.65, 8.12) and 7.71 mmol/l (95% CI 7.49, 7.94), respectively. Using a linear mixed model controlling for respective baseline values, the mean difference between the metformin and placebo group (metformin-placebo) was -0.08 mmol/l (95% CI -0.37, 0.20) for fasting glucose and 0.20 mmol/l (95% CI -0.17, 0.58) for glucose levels 2 h post a 75 g glucose load. Weight was significantly lower in the metformin arm than in the placebo arm: using the linear mixed model adjusting for baseline values, the mean difference in weight was -1.47 kg (95% CI -2.58, -0.35). In total, 16/182 (8.8%) individuals had a serious adverse event (Grade 3 or Grade 4 in the Division of Acquired Immunodeficiency Syndrome [DAIDS] adverse event grading table) or died in the metformin arm compared with 18/182 (9.9%) in the placebo arm; these events were either unrelated to or unlikely to be related to the study drugs. CONCLUSIONS/INTERPRETATION Blood glucose decreased over time in both the metformin and placebo arms during the trial but did not differ significantly between the arms at 12 months of follow up. Metformin therapy was found to be safe for use in individuals with HIV and prediabetes. A larger trial with longer follow up is needed to establish if metformin can be safely used for the prevention of diabetes in people who have HIV. TRIAL REGISTRATION The trial is registered on the International Standard Randomised Controlled Trial Number (ISRCTN) registry ( www.isrctn.com/ ), registration number: ISCRTN76157257. FUNDING This research was funded by the National Institute for Health Research using UK aid from the UK Government to support global health research.
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Affiliation(s)
- Anupam Garrib
- UCL Institute for Global Health, University College London, London, UK.
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Sokoine Kivuyo
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Katie Bates
- UCL Institute for Global Health, University College London, London, UK
- Institute of Medical Statistics and Informatics, Medical University Innsbruck, Innsbruck, Austria
| | | | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Edna Majaliwa
- Shree Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | - Rehema Simbauranga
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Godbless Charles
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
| | | | - Huanyan Luo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Liverpool University NHS Hospital Foundation Trust, Liverpool, UK
- Department of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Moffat J Nyirenda
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
- NCD Theme, MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Shabbar Jaffar
- UCL Institute for Global Health, University College London, London, UK
| | - Sayoki Mfinanga
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar es Salaam, Tanzania
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Moyo F, Birungi J, Garrib A, Namakoola I, Okebe J, Kivuyo S, Mutungi G, Mfinanga S, Nyirenda M, Jaffar S. Scaling up integrated care for HIV and other chronic conditions in routine health care settings in sub-Saharan Africa: Field notes from Uganda. Int J Integr Care 2023; 23:8. [PMID: 37577142 PMCID: PMC10418142 DOI: 10.5334/ijic.6962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/01/2023] [Indexed: 08/15/2023] Open
Abstract
Introduction Integration of HIV and non-communicable disease (NCD) services is proposed to increase efficiency and coverage of NCD care in sub-Saharan Africa. Description Between October 2018 to January 2020 in Tanzania and Uganda, working in partnership with health services, we introduced an integrated chronic care model for people with HIV, diabetes and hypertension. In this model, patients were able to access care from a single point of care, as opposed to the standard of siloed care from vertical clinics. When the study ended, routine clinical services adopted the integrated model. In this article, we discuss how the model transitioned post hand-over in Uganda and draw lessons to inform future scale-up. Discussion The findings suggest potential for successful uptake of integrated chronic care by routine clinical services in sub-Saharan Africa. This approach may appeal to health care service providers and policy makers when they can quantify benefits that accrue from it, such as optimal utilization of health resources. For patients, integrated care may not appeal to all patients due to HIV-related stigma. Key considerations include good communication with patients, strong leadership, maintaining patient confidentiality and incorporating patient needs to facilitate successful uptake. Conclusion Evidence on the benefits of integrated care remains limited. More robust evidence will be essential to guide scale-up beyond research sites.
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Affiliation(s)
- Faith Moyo
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Josephine Birungi
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- The AIDS Support Organization, Kampala, Uganda
| | - Anupam Garrib
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Ivan Namakoola
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Sokoine Kivuyo
- Muhimbili Medical Research Centre, National Institute for Medical Research Muhimbili Research Centre, Dar Es Salaam, Tanzania
| | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Ministry of Health, Kampala, Uganda
| | - Sayoki Mfinanga
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Muhimbili Medical Research Centre, National Institute for Medical Research Muhimbili Research Centre, Dar Es Salaam, Tanzania
| | - Moffat Nyirenda
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Garrib A, Njim T, Adeyemi O, Moyo F, Halloran N, Luo H, Wang D, Okebe J, Bates K, Santos VS, Ramaiya K, Jaffar S. Retention in care for type 2 diabetes management in Sub-Saharan Africa: A systematic review. Trop Med Int Health 2023; 28:248-261. [PMID: 36749181 PMCID: PMC10947597 DOI: 10.1111/tmi.13859] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Diabetes prevalence has risen rapidly in Sub-Saharan Africa, but rates of retention in diabetes care are poorly understood. We conducted a systematic review and meta-analysis to determine rates of retention in care of persons with type 2 diabetes. METHODS We searched MEDLINE, Global Health and CINAHL online databases for cohort studies and randomised control trials (RCTs) published up to 12 October 2021, that reported retention in or attrition from care for patients with type 2 diabetes in Sub-Saharan Africa. Retention was defined as persons diagnosed with diabetes who were alive and in care or with a known outcome, while attrition was defined as loss from care. RESULTS From 6559 articles identified, after title and abstract screening, 209 articles underwent full text review. Forty six papers met the inclusion criteria, comprising 22,610 participants. Twenty one articles were of RCTs of which 8 trials had 1 year or more of follow-up and 25 articles were of non-randomised studies of which 19 had 12 months or more of follow-up. A total of 11 studies (5 RCTs and 6 non-randomised) were assessed to be of good quality. Sixteen RCTs were done in secondary or tertiary care settings. Their pooled retention rate (95% CI) was 80% (77%, 84%) in the control arm. Four RCTs had been done in primary care settings and their pooled retention rate (95% CI) was 53% (45%, 62%) in the control arm. The setting of one trial was unclear. For non-randomised studies, retention rates (95% CI) were 68% (62%, 75%) among 19 studies done in secondary and tertiary care settings, and 40% (33%, 49%) among the 6 studies done in primary care settings. CONCLUSION Rates of retention in care of people living with diabetes are poor in primary care research settings.
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Affiliation(s)
- Anupam Garrib
- Department of Clinical SciencesLiverpool School of Tropical MedicineLiverpoolUK
| | - Tsi Njim
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
| | - Olukemi Adeyemi
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
| | - Faith Moyo
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
| | - Natalie Halloran
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
| | - Huanyuan Luo
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
| | - Duolao Wang
- Department of Clinical SciencesLiverpool School of Tropical MedicineLiverpoolUK
| | - Joseph Okebe
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
| | - Katie Bates
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
- Department of Medical Statistics, Informatics and Health EconomicsMedical University of InnsbruckInnsbruckAustria
| | - Victor Santana Santos
- Department of MedicineFederal University of SergipeLagartoBrazil
- Health Science Graduate ProgramFederal University of SergipeAracajuBrazil
| | | | - Shabbar Jaffar
- UCL Institute for Global HealthUniversity College LondonLondonUK
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Manisha H, Amani W, Garrib A, Senkoro M, Mfinanga S. IPT coverage and determinants of care coverage in Tanzania. Public Health Action 2022; 12:141-146. [PMID: 36160724 PMCID: PMC9484591 DOI: 10.5588/pha.22.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: TB is a major cause of mortality worldwide, with the highest risk in people living with HIV/AIDS (PLWHA). Isoniazid preventive therapy (IPT), in combination with antiretroviral therapy (ART), reduces the overall incidence and mortality from TB by up to 90% among PLWHA.
Tanzania has limited published data on IPT coverage among PLWHA.OBJECTIVE: To investigate coverage and determinants of IPT among PLWHA receiving care in selected care and treatment clinics in Dar es Salaam, Tanzania.METHODS: An analytical cross-sectional design to study
31,480 HIV-positive adults. Proportions and comparisons were obtained using χ2 tests, while determinants for IPT were assessed using adjusted multivariable analysis.RESULTS: The IPT coverage among eligible PLWHA was generally low (28.9%), with increased coverage over
time. The determinants for IPT coverage included age >36 years, having WHO Clinical Stages 1 and 2 compared to 3 and 4, and having normal weight, or being overweight and obesity compared to underweight.CONCLUSION: IPT coverage in Dar es Salaam is very low; individuals with minor
HIV disease severity were more likely to initiate IPT. This shows a possible gap in the prescribing practices among healthcare providers. More efforts to ensure IPT coverage implementation in Dar es Salaam are required.
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Affiliation(s)
- H. Manisha
- National Institute for Medical Research Muhimbili Centre, Dar es Salaam, Tanzania, Tanzania Field Epidemiology and Laboratory Training Programme, Dar es Salaam, Tanzania, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - W. Amani
- National Institute for Medical Research Muhimbili Centre, Dar es Salaam, Tanzania
| | - A. Garrib
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - M. Senkoro
- National Institute for Medical Research Muhimbili Centre, Dar es Salaam, Tanzania
| | - S. Mfinanga
- National Institute for Medical Research Muhimbili Centre, Dar es Salaam, Tanzania, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, Liverpool School of Tropical Medicine, Liverpool, UK, Alliance for Africa Health and
Research, Dar es Salaam, Tanzania
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Aikaeli F, Njim T, Gissing S, Moyo F, Alam U, Mfinanga SG, Okebe J, Ramaiya K, Webb EL, Jaffar S, Garrib A. Prevalence of microvascular and macrovascular complications of diabetes in newly diagnosed type 2 diabetes in low-and-middle-income countries: A systematic review and meta-analysis. PLOS Glob Public Health 2022; 2:e0000599. [PMID: 36962416 PMCID: PMC10021817 DOI: 10.1371/journal.pgph.0000599] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/19/2022] [Indexed: 11/19/2022]
Abstract
There is an excessive burden of diabetes complications in low-resource settings. We conducted a systematic review to determine the nature and frequency of diabetes complications in newly diagnosed with type 2 diabetes. A systematic search was performed using Medline, CINAHL and Global Health online databases from inception to July 2020. Articles reporting prevalence of microvascular or macrovascular complications within six months of type 2 diabetes diagnosis and published in English or French from low- and middle-income countries (LMICs) were eligible for analysis. Data were extracted using a standardized data extraction tool. Descriptive statistics were used to describe the prevalence of micro and macrovascular complications in newly diagnosed type 2 diabetes. Assessment of heterogeneity was conducted using the inconsistency index (I2) and Cochran-Q chi2 statistical tests. Publication bias was assessed by the Funnel plot and Egger test. A total of 3 292 records underwent title or abstract screening and 95 articles underwent full text review. Thirty-three studies describing 13 283 participants (aged 20 years and older) met the inclusion criteria. The eligible studies were from Asia (n = 24), Africa (n = 4), Oceania (n = 2), South America (n = 2) and the Caribbean (n = 1). For microvascular complications, the median prevalence (interquartile range) of retinopathy, nephropathy and neuropathy were 12% (6%-15%), 15% (7%-35%) and 16% (10%25%) respectively. For macrovascular complications, the median prevalence (interquartile range) was 10% (7%-17%) for ischaemic heart disease, 6% (1%-20%) for peripheral arterial disease and 2% (1%-4%) for stroke. There was evidence of substantial heterogeneity between studies for all outcomes (I2 > 90%. We found a high prevalence of complications in newly diagnosed type 2 diabetes in LMICs. Findings suggest that many people live with diabetes and are only diagnosed when they present with complications in LMICs. Research is needed to guide timely and effective identification of people living with diabetes in these settings.
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Affiliation(s)
- Faith Aikaeli
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar Es Salaam, Tanzania
| | - Tsi Njim
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Stefanie Gissing
- School of Public Health Yorkshire & Humber, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Faith Moyo
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Uazman Alam
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool, United Kingdom
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, United Kingdom
| | - Sayoki G Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research, Dar Es Salaam, Tanzania
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Emily L Webb
- Medical Research Council International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Anupam Garrib
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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McCombe G, Murtagh S, Lazarus JV, Van Hout MC, Bachmann M, Jaffar S, Garrib A, Ramaiya K, Sewankambo NK, Mfinanga S, Cullen W. Integrating diabetes, hypertension and HIV care in sub-Saharan Africa: a Delphi consensus study on international best practice. BMC Health Serv Res 2021; 21:1235. [PMID: 34781929 PMCID: PMC8591882 DOI: 10.1186/s12913-021-07073-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 09/16/2021] [Indexed: 11/25/2022] Open
Abstract
Background Although HIV continues to have a high prevalence among adults in sub-Saharan Africa (SSA), the burden of noncommunicable diseases (NCD) such as diabetes and hypertension is increasing rapidly. There is an urgent need to expand the capacity of healthcare systems in SSA to provide NCD services and scale up existing chronic care management pathways. The aim of this study was to identify key components, outcomes, and best practice in integrated service provision for the prevention, identification and treatment of HIV, hypertension and diabetes. Methods An international, multi stakeholder e-Delphi consensus study was conducted over two successive rounds. In Round 1, 24 participants were asked to score 27 statements, under the headings ‘Service Provision’ and ‘Benefits of Integration’, by importance. In Round 2, the 16 participants who completed Round 1 were shown the distribution of scores from other participants along with the score that they attributed to an outcome and were asked to reflect on the score they gave, based on the scores of the other participants and then to rescore if they wished to. Nine participants completed Round 2. Results Based on the Round 1 ranking, 19 of the 27 outcomes met the 70% threshold for consensus. Four additional outcomes suggested by participants in Round 1 were added to Round 2, and upon review by participants, 22 of the 31 outcomes met the consensus threshold. The five items participants scored from 7 to 9 in both rounds as essential for effective integrated healthcare delivery of health services for chronic conditions were improved data collection and surveillance of NCDs among people living with HIV to inform integrated NCD/HIV programme management, strengthened drug procurement systems, availability of equipment and access to relevant blood tests, health education for all chronic conditions, and enhanced continuity of care for patients with multimorbidity. Conclusions This study highlights the outcomes which may form key components of future complex interventions to define a model of integrated healthcare delivery for diabetes, hypertension and HIV in sub-Saharan Africa.
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Affiliation(s)
| | | | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | | | | | - Anupam Garrib
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Sayoki Mfinanga
- National Institute for Medical Research, Dar es Salaam, Tanzania
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Birungi J, Kivuyo S, Garrib A, Mugenyi L, Mutungi G, Namakoola I, Mghamba J, Ramaiya K, Wang D, Maongezi S, Musinguzi J, Mugisha K, Etukoit BM, Kakande A, Niessen LW, Okebe J, Shiri T, Meshack S, Lutale J, Gill G, Sewankambo N, Smith PG, Nyirenda MJ, Mfinanga SG, Jaffar S. Integrating health services for HIV infection, diabetes and hypertension in sub-Saharan Africa: a cohort study. BMJ Open 2021; 11:e053412. [PMID: 34728457 PMCID: PMC8565555 DOI: 10.1136/bmjopen-2021-053412] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND HIV, diabetes and hypertension have a high disease burden in sub-Saharan Africa. Healthcare is organised in separate clinics, which may be inefficient. In a cohort study, we evaluated integrated management of these conditions from a single chronic care clinic. OBJECTIVES To determined the feasibility and acceptability of integrated management of chronic conditions in terms of retention in care and clinical indicators. DESIGN AND SETTING Prospective cohort study comprising patients attending 10 health facilities offering primary care in Dar es Salaam and Kampala. INTERVENTION Clinics within health facilities were set up to provide integrated care. Patients with either HIV, diabetes or hypertension had the same waiting areas, the same pharmacy, were seen by the same clinical staff, had similar provision of adherence counselling and tracking if they failed to attend appointments. PRIMARY OUTCOME MEASURES Retention in care, plasma viral load. FINDINGS Between 5 August 2018 and 21 May 2019, 2640 patients were screened of whom 2273 (86%) were enrolled into integrated care (832 with HIV infection, 313 with diabetes, 546 with hypertension and 582 with multiple conditions). They were followed up to 30 January 2020. Overall, 1615 (71.1%)/2273 were female and 1689 (74.5%)/2266 had been in care for 6 months or more. The proportions of people retained in care were 686/832 (82.5%, 95% CI: 79.9% to 85.1%) among those with HIV infection, 266/313 (85.0%, 95% CI: 81.1% to 89.0%) among those with diabetes, 430/546 (78.8%, 95% CI: 75.4% to 82.3%) among those with hypertension and 529/582 (90.9%, 95% CI: 88.6 to 93.3) among those with multimorbidity. Among those with HIV infection, the proportion with plasma viral load <100 copies/mL was 423(88.5%)/478. CONCLUSION Integrated management of chronic diseases is a feasible strategy for the control of HIV, diabetes and hypertension in Africa and needs evaluation in a comparative study.
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Affiliation(s)
- Josephine Birungi
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- The AIDS Support Organization, Kampala, Uganda
| | - Sokoine Kivuyo
- Muhimbili Medical Research Centre, National Institute for Medical Research Muhimbili Research Centre, Dar Es Salaam, Tanzania
| | - Anupam Garrib
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Ministry of Health, Kampala, Uganda
| | - Ivan Namakoola
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Janneth Mghamba
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | | | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sarah Maongezi
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | | | | | | | - Ayoub Kakande
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Louis Wihelmus Niessen
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Tinevimbo Shiri
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Janet Lutale
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geoff Gill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Peter G Smith
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Moffat J Nyirenda
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sayoki Godfrey Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research Muhimbili Research Centre, Dar Es Salaam, Tanzania
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Mfinanga SG, Nyirenda MJ, Mutungi G, Mghamba J, Maongezi S, Musinguzi J, Okebe J, Kivuyo S, Birungi J, van Widenfelt E, Van Hout MC, Bachmann M, Garrib A, Bukenya D, Cullen W, Lazarus JV, Niessen LW, Katahoire A, Shayo EH, Namakoola I, Ramaiya K, Wang D, Cuevas LE, Etukoit BM, Lutale J, Meshack S, Mugisha K, Gill G, Sewankambo N, Smith PG, Jaffar S. Integrating HIV, diabetes and hypertension services in Africa: study protocol for a cluster randomised trial in Tanzania and Uganda. BMJ Open 2021; 11:e047979. [PMID: 34645657 PMCID: PMC8515479 DOI: 10.1136/bmjopen-2020-047979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION HIV programmes in sub-Saharan Africa are well funded but programmes for diabetes and hypertension are weak with only a small proportion of patients in regular care. Healthcare provision is organised from stand-alone clinics. In this cluster randomised trial, we are evaluating a concept of integrated care for people with HIV infection, diabetes or hypertension from a single point of care. METHODS AND ANALYSIS 32 primary care health facilities in Dar es Salaam and Kampala regions were randomised to either integrated or standard vertical care. In the integrated care arm, services are organised from a single clinic where patients with either HIV infection, diabetes or hypertension are managed by the same clinical and counselling teams. They use the same pharmacy and laboratory and have the same style of patient records. Standard care involves separate pathways, that is, separate clinics, waiting and counselling areas, a separate pharmacy and separate medical records. The trial has two primary endpoints: retention in care of people with hypertension or diabetes and plasma viral load suppression. Recruitment is expected to take 6 months and follow-up is for 12 months. With 100 participants enrolled in each facility with diabetes or hypertension, the trial will provide 90% power to detect an absolute difference in retention of 15% between the study arms (at the 5% two-sided significance level). If 100 participants with HIV infection are also enrolled in each facility, we will have 90% power to show non-inferiority in virological suppression to a delta=10% margin (ie, that the upper limit of the one-sided 95% CI of the difference between the two arms will not exceed 10%). To allow for lost to follow-up, the trial will enrol over 220 persons per facility. This is the only trial of its kind evaluating the concept of a single integrated clinic for chronic conditions in Africa. ETHICS AND DISSEMINATION The protocol has been approved by ethics committee of The AIDS Support Organisation, National Institute of Medical Research and the Liverpool School of Tropical Medicine. Dissemination of findings will be done through journal publications and meetings involving study participants, healthcare providers and other stakeholders. TRIAL REGISTRATION NUMBER ISRCTN43896688.
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Affiliation(s)
- Sayoki Godfrey Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research Muhimbili Research Centre, Dar Es Salaam, Tanzania
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Republic of Uganda Ministry of Health, Kampala, Uganda
| | - Janneth Mghamba
- Directors office, Ministry of Health Community Development Gender Elderly and Children, Dar es Salaam, Tanzania
| | - Sarah Maongezi
- Non-Communicable Diseases Control Programme, Ministry of Health Community Development Gender Elderly and Children, Dar es Salaam, Tanzania
| | - Joshua Musinguzi
- AIDS Control Programme, Republic of Uganda Ministry of Health, Kampala, Uganda
| | - Joseph Okebe
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sokoine Kivuyo
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | | | | | | | - Max Bachmann
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Anupam Garrib
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Walter Cullen
- School of Medicine, University College Dublin School of Medicine, Dublin, Ireland
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal) Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | - Anne Katahoire
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Elizabeth Henry Shayo
- Policy Analysis and Advocacy, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Ivan Namakoola
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - L E Cuevas
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Janet Lutale
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | | | - Geoff Gill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Peter G Smith
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
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Adeyemi O, Lyons M, Njim T, Okebe J, Birungi J, Nana K, Claude Mbanya J, Mfinanga S, Ramaiya K, Jaffar S, Garrib A. Integration of non-communicable disease and HIV/AIDS management: a review of healthcare policies and plans in East Africa. BMJ Glob Health 2021; 6:bmjgh-2020-004669. [PMID: 33947706 PMCID: PMC8098934 DOI: 10.1136/bmjgh-2020-004669] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/27/2021] [Accepted: 04/02/2021] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Olukemi Adeyemi
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mary Lyons
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Tsi Njim
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Kevin Nana
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaounde, Cameroon
| | - Jean Claude Mbanya
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaounde, Cameroon
| | - Sayoki Mfinanga
- Muhimbili Medical Research Centre, National Institute of Medical Research, Dar es Salaam, United Republic of Tanzania
| | - Kaushik Ramaiya
- Shree Hindu Mandal Hospital, Dar es Salaam, United Republic of Tanzania
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anupam Garrib
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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11
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Garrib A, Birungi J, Lesikari S, Namakoola I, Njim T, Cuevas L, Niessen L, Mugisha K, Mutungi G, Mghamba J, Ramaiya K, Jaffar S, Mfinanga S, Nyirenda M. Integrated care for human immunodeficiency virus, diabetes and hypertension in Africa. Trans R Soc Trop Med Hyg 2020; 113:809-812. [PMID: 30265362 DOI: 10.1093/trstmh/try098] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/07/2018] [Accepted: 09/14/2018] [Indexed: 11/13/2022] Open
Abstract
The rising burden from non-communicable diseases (NCDs) poses a huge challenge for health care delivery in Africa, where health systems are already struggling with the long-term care requirements for the millions of people now on antiretroviral therapy requiring regular visits to health facilities for monitoring, adherence support and drugs. The HIV chronic disease management programme is comparatively well-funded, well-organised and well-informed and offers many insights and opportunities for the expansion of NCD prevention and treatment services. Some degree of human immunodeficiency virus (HIV) and NCD service integration is essential, but how to do this without risking the HIV treatment gains is unclear. Both HIV and NCD services must expand within a resource-constrained environment and policymakers are in urgent need of evidence to guide cost-effective and acceptable changes in these health services.
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Affiliation(s)
- Anupam Garrib
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Josephine Birungi
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda.,Aids Support Organisation, Old Mulago Complex, Kampala, Uganda
| | - Sokoine Lesikari
- National Institute of Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Ivan Namakoola
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Tsi Njim
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Luis Cuevas
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Louis Niessen
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Kenneth Mugisha
- Aids Support Organisation, Old Mulago Complex, Kampala, Uganda
| | | | - Janneth Mghamba
- Ministry of Health and Social Welfare, 6 Samora Machel Road, Dar es Salaam, Tanzania
| | | | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Sayoki Mfinanga
- National Institute of Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Moffat Nyirenda
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
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12
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Shayo E, Van Hout MC, Birungi J, Garrib A, Kivuyo S, Mfinanga S, Nyrienda MJ, Namakoola I, Okebe J, Ramaiya K, Bachmann MO, Cullen W, Lazarus JV, Gill G, Shiri T, Bukenya D, Snell H, Nanfuka M, Cuevas LE, Shimwela M, Mutungi G, Musinguzi J, Mghamba J, Mugisha K, Jaffar S, Smith PG, Sewankambo NK. Ethical issues in intervention studies on the prevention and management of diabetes and hypertension in sub-Saharan Africa. BMJ Glob Health 2020; 5:bmjgh-2019-002193. [PMID: 32636311 PMCID: PMC7342469 DOI: 10.1136/bmjgh-2019-002193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Elizabeth Shayo
- National Institutes for Medical Research, Dar es Salaam, United Republic of Tanzania
| | - Marie Claire Van Hout
- Faculty of Education, Health & Community, Liverpool John Moores University, Liverpool, Merseyside, UK
| | | | - Anupam Garrib
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Sokoine Kivuyo
- National Institutes for Medical Research, Dar es Salaam, United Republic of Tanzania
| | - Sayoki Mfinanga
- National Institutes for Medical Research, Dar es Salaam, United Republic of Tanzania
| | - Moffat J Nyrienda
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda.,Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Max Oscar Bachmann
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Walter Cullen
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Jeffrey V Lazarus
- Hospital Clinic, University of Barcelona, Instituto de Salud Global de Barcelona, Barcelona, Spain.,CHIP, Rigshospitalet, Kobenhavn, Denmark
| | - Geoff Gill
- Emeritus Professor of International Medicine, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Tinevimbo Shiri
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Hazel Snell
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Luis E Cuevas
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Gerald Mutungi
- Non-communicable Disease Control Programme, Ministry of Health, Kampala, Uganda
| | | | - Janneth Mghamba
- Department of Preventive Services, Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
| | | | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Peter G Smith
- MRC Tropical Epidemiology Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Abstract
OBJECTIVE To estimate injury mortality rates in a rural population in KwaZulu-Natal, South Africa and to identify socio-demographic risk factors associated with adult injury-related deaths. METHODS The study used population-based mortality data collected by a demographic surveillance system on all resident and non-resident members of 11,000 households. Deaths and person-years of observation (pyo) were aggregated for individuals between 01 January 2000 and 31 December 2007. Cause of death was determined by verbal autopsy, coded using ICD-10 and further categorised using global burden of disease categories. Socio-demographic risk factors associated with injuries were examined using regression analyses. RESULTS We analysed data on 133,483 individuals with 717,584.6 person-years of observation (pyo) and 11,467 deaths. Of deaths, 8.9% were because of injury-related causes; 11% occurred in children <15 years old. Homicide, road traffic injuries and suicide were the major causes. The estimated crude injury mortality rate was 142.4 (134.0, 151.4)/100,000 pyo; 116.9 (108.1, 126.5)/100,000 pyo among residents and 216.8 (196.5, 239.2)/100,000 pyo among non-residents. In multivariable analyses, the differences between residents and non-residents remained but were no longer significant for women. In men and women, full-time employment was significantly associated with lower mortality [adjusted rate ratios 0.6 (0.4, 0.9); 0.4 (0.2, 0.9)]; in men, higher asset ownership was independently associated with increased mortality [adjusted rate ratio 1.5 (1.1, 1.9)]. CONCLUSIONS Reducing the high levels of injury-related mortality in South Africa requires intersectoral primary prevention efforts that redress the root causes of violent and accidental deaths: social inequality, poverty and alcohol abuse.
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Affiliation(s)
- Anupam Garrib
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
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Jaffar S, Lazarus JV, Onyebujoh P, Chakaya J, Garrib A, Mwaba P, Mboup S, Bellis K, Egwaga S, Corrah T, Coutinho A. Health services strengthening in Africa - research is a key component. Trop Med Int Health 2010; 15:1270-3. [DOI: 10.1111/j.1365-3156.2010.02626.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Garrib A, Stoops N, McKenzie A, Dlamini L, Govender T, Rohde J, Herbst K. An evaluation of the District Health Information System in rural South Africa. S Afr Med J 2008; 98:549-552. [PMID: 18785397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Since reliable health information is essential for the planning and management of health services, we investigated the functioning of the District Health Information System (DHIS) in 10 rural clinics. DESIGN AND SUBJECTS Semi-structured key informant interviews were conducted with clinic managers, supervisors and district information staff. Data collected over a 12-month period for each clinic were assessed for missing data, data out of minimum and maximum ranges, and validation rule violations. SETTING Our investigation was part of a larger study on improving information systems for primary care in rural KwaZulu-Natal. OUTCOMES We assessed data quality, the utilisation for facility management, perceptions of work burden, and usefulness of the system to clinic staff. RESULTS A high perceived work burden associated with data collection and collation was found. Some data collation tools were not used as intended. There was good understanding of the data collection and collation process but little analysis, interpretation or utilisation of data. Feedback to clinics occurred rarely. In the 10 clinics, 2.5% of data values were missing, and 25% of data were outside expected ranges without an explanation provided. CONCLUSIONS The culture of information use essential to an information system having an impact at the local level is weak in these clinics or at the sub-district level. Further training and support is required for the DHIS to function as intended.
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Affiliation(s)
- A Garrib
- Africa Centre for Health and Population Studies, Somkhele, University of KwaZulu-Natal.
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Abstract
OBJECTIVE To determine child mortality rates in a rural area of South Africa with high HIV prevalence. METHODS A community-based survey was conducted between 1 January 2000 and 31 December 2002 on deaths in children under the age of 15 years. Children were followed up through four monthly home visits. Cause of death was ascertained by verbal autopsy. Rates were calculated using Poisson regression. RESULTS Mortality ratios were 59.6 deaths per 1000 live births for infants and 97.1 for children under 5 years of age. Infant and under-5 mortality rates were, respectively, 67.5 and 21.1 deaths per 1000 person-years. HIV/AIDS was attributed to 41% of deaths in the under-5 age group, with a mortality rate of 8.6 per 1000 person-years. Lower respiratory infections caused an estimated 24.9 deaths per 1000 person-years in children under 1 year of age. CONCLUSIONS In rural South Africa, infant and child mortality levels are high, with HIV/AIDS estimated as the single largest cause of death. Interventions to reduce child mortality are required urgently.
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Affiliation(s)
- Anupam Garrib
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa.
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Jaffar S, Govender T, Garrib A, Welz T, Grosskurth H, Smith PG, Whittle H, Bennish ML. Antiretroviral treatment in resource-poor settings: public health research priorities. Trop Med Int Health 2005; 10:295-9. [PMID: 15807791 DOI: 10.1111/j.1365-3156.2005.01390.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Many countries in Africa are planning to provide highly active antiretroviral therapy (HAART) to millions of people with acquired immune deficiency syndrome. This will be a highly complex therapy programme. Physician-based models of care adapted from industrialized countries will not succeed in providing treatment to the majority of those who need it in resource-constrained settings. A high priority is to identify care models for Africa that will increase coverage of HAART safely and effectively: key issues are (i) whether nursing staff or non-clinically qualified staff can take the major role in the treatment programme and reduce the workload of physicians, (ii) whether treatment and monitoring can be delivered through peripheral health centres or through home visits and achieve better adherence and be more cost-effective than delivery at hospitals and (iii) which clinical algorithms used by nursing or non-clinically qualified staff will be effective for screening, diagnosing and managing treatment-related side-effects and medical problems being incurred. Many current ART support programmes are making little or no investment in research, but answering important questions on delivery of HAART will be essential if HAART programmes are to be successful in African nations with a high burden of human immunodeficiency virus infection.
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Affiliation(s)
- Shabbar Jaffar
- Medical Research Council Tropical Epidemiology Group, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
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Garrib A, Griffiths W, Eldridge P, Hatton R, Worsley A, Crook M. Artifactually low glycated haemoglobin in a patient with severe hypertriglyceridaemia. J Clin Pathol 2003; 56:394-5. [PMID: 12719463 PMCID: PMC1769953 DOI: 10.1136/jcp.56.5.394] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This report describes a case of artifactually low glycated haemoglobin (Hb) in a patient with type II diabetes and severe hypertriglyceridaemia. The effect of hypertriglyceridaemia on glycated Hb determination using the Abbott Vision method was investigated in a series of patients with diabetes. The interference of triglycerides in glycated Hb assays was also investigated by two other methods, the Beckman Synchron CX4 delta immunoturbidimetric method, and the Primus affinity chromatography high performance liquid chromatography assay.
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Affiliation(s)
- A Garrib
- Department of Clinical Biochemistry and Diabetes, University Hospital Lewisham, Lewisham, London SE13 6LH, UK.
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19
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Affiliation(s)
- A Garrib
- Dept of Clinical Biochemistry, King's College School of Medicine and Dentistry, London, UK
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20
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Affiliation(s)
- A Garrib
- Dept of Clinical Biochemistry, King's College of Medicine and Dentistry, London, UK
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Garrib A, McMurray WC. Cell-free synthesis of a putative precursor to the rat liver mitochondrial glycerol-3-phosphate dehydrogenase. J Biol Chem 1988; 263:19821-6. [PMID: 2461944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Antibodies to purified glycerol-3-phosphate dehydrogenase were raised in rabbits and purified from serum by affinity chromatography on enzyme-bound Sepharose columns. RNA from membrane-free polyribosomes, or poly(A)+ RNA (total cellular RNA) of rat liver, was translated in a rabbit reticulocyte protein-synthesizing system in the presence of [35S]methionine, and the glycerol-3-phosphate dehydrogenase synthesized was isolated by immunoprecipitation using the antibody. The in vitro product moved on sodium dodecyl sulfate-polyacrylamide gels as a polypeptide that was about 5,000 daltons larger than the subunit of the mature enzyme (74,000 daltons). Digestion of both the mature and the in vitro newly synthesized forms of the enzyme yielded respective sets of peptide fragments which had similar patterns upon sodium dodecyl sulfate-gel electrophoresis. When the presumptive precursor that had been synthesized in vitro was incubated with isolated intact rat liver mitochondria, it was converted to "mature" subunits that were no longer susceptible to externally added proteases. Import of the presumptive precursor is dependent upon an electrochemical potential across the inner mitochondrial membranes. The mature form of the protein is assembled in its native location (the outer surface of the inner mitochondrial membrane).
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Affiliation(s)
- A Garrib
- Department of Biochemistry, University of Western Ontario, London, Canada
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Garrib A, McMurray WC. Cell-free synthesis of a putative precursor to the rat liver mitochondrial glycerol-3-phosphate dehydrogenase. J Biol Chem 1988. [DOI: 10.1016/s0021-9258(19)77709-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Garrib A, McMurray WC. Purification and characterization of glycerol-3-phosphate dehydrogenase (flavin-linked) from rat liver mitochondria. J Biol Chem 1986; 261:8042-8. [PMID: 3711123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
We have purified the membrane-intrinsic glycerol-3-phosphate dehydrogenase from both normal and hyperthyroid rat liver mitochondria by extraction with Triton X-100, hydrophobic affinity chromatography, ion exchange chromatography, gel filtration, and FAD-linked Sepharose 4B affinity chromatography. The yields in both cases were over 20%, and purification ranged from 800- to 650-fold in mitochondria from hyperthyroid and normal rats, respectively. The final preparations appeared to be greater than 95% pure by polyacrylamide gel electrophoresis in the presence or absence of sodium dodecyl sulfate. The pure enzyme focused at pH 5.5 and produced a biphasic thermal inactivation plot at 50 degrees C. The holoenzyme was found to have a molecular mass of 250,000 daltons on gel filtration. The subunit molecular mass was found to be 74,000 daltons +/- 3,000 by sodium dodecyl sulfate-gel electrophoresis and high-performance liquid chromatography gel filtration in 0.1% sodium dodecyl sulfate. 1 mol of the holoenzyme preparation contains 1.1 mol of non-heme iron and 0.7-0.9 mol of noncovalently bound FAD. The absorption spectrum has a maximum at 375 nm and a shoulder at 450 nm which is bleached on treatment with sodium dithionite. The enzymatic reaction is competitively inhibited by glyceraldehyde 3-phosphate, dihydroxyacetone phosphate, phosphoenolpyruvate, and phosphoglycolic acid. The apparent Km for DL-alpha-glycerol 3-phosphate and noncovalently bound FAD were found to be 6 mM and 7 microM, respectively.
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Garrib A, McMurray WC. Purification and characterization of glycerol-3-phosphate dehydrogenase (flavin-linked) from rat liver mitochondria. J Biol Chem 1986. [DOI: 10.1016/s0021-9258(19)57509-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Garrib A, McMurray WC. A sensitive, continuous spectrophotometric method for assaying alpha-glycerophosphate dehydrogenase: activation by menadione. Anal Biochem 1984; 139:319-21. [PMID: 6476369 DOI: 10.1016/0003-2697(84)90011-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
By use of a more sensitive method than standard assays, it is demonstrated that alpha-glycerophosphate dehydrogenase activity can be monitored continuously in rat liver mitochondria; maximum activity was obtained by sonication in the presence of Triton X-100. Vitamin K3 (menadione) seems to enhance the activity of the enzyme. The assay in the presence of menadione is linear over a much greater mitochondrial concentration (up to 250 micrograms of protein in the reaction mixture).
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