High rates of undiagnosed and uncontrolled hypertension upon a screening campaign in rural Rwanda: a cross-sectional study

Background

Hypertension remains the major risk factor for cardiovascular diseases (CVDs) worldwide with a prevalence and mortality in low- and middle-income countries (LMICs) among the highest. The early detection of hypertension risk factors is a crucial pillar for CVD prevention.

Design and method

This cross-sectional study included 4284 subjects, mean age 46 ± 16SD, 56.4% females and mean BMI 26.6 ± 3.7 SD. Data were collected through a screening campaign in rural area of Kirehe District, Eastern of Rwanda, with the objective to characterize and examine the prevalence of elevated blood pressure (BP) and other CVD risk factors. An adapted tool from the World Health Organization STEPwise Approach was used for data collection. Elevated BP was defined as ≥ 140/90 mm/Hg and elevated blood glucose as blood glucose ≥ 100 mg/dL after a 6-h fast.

Results

Of the sampled population, 21.2% (n = 910) had an elevated BP at screening; BP was elevated among individuals not previously known to have HTN in 18.7% (n = 752). Among individuals with a prior diagnosis of HTN, 62.2% (n = 158 of 254) BP was uncontrolled. Age, weight, smoking, alcohol history and waist circumference were associated with BP in both univariate analyses and multivariate analysis.

Conclusion

High rates of elevated BP identified through a health screening campaign in this Rwandan district were surprising given the rural characteristics of the district and relatively low population age. These data highlight the need to implement an adequate strategy for the prevention, diagnosis, and control of HTN that includes rural areas of Rwanda as part of a multicomponent strategy for CVD prevention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02606-9.

Exploring contextual factors influencing the implementation of evidence-based care for hypertension in Rwanda: a cross-sectional study using the COACH questionnaire

IMPORTANCE

Hypertension is the largest contributor to the Global Burden of Disease. In Rwanda, as in most low-income and middle-income countries, an increasing prevalence of hypertension and its associated morbidity and mortality is causing major healthcare and economic impact. Understanding healthcare systems context in hypertension care is necessary.

OBJECTIVE

To study the hypertension healthcare context as perceived by healthcare providers using the Context Assessment for Community Health (COACH) tool.

DESIGN

A cross-sectional cohort responded to the COACH questionnaire and a survey about hypertension training.

SETTING

Three tertiary care hospitals in Rwanda.

PARTICIPANTS

Healthcare professionals (n=223).

PRIMARY OUTCOMES AND MEASURES

The COACH tool consists of 49 items with eight subscales: resources, community engagement, commitment to work, informal payment, leadership, work culture, monitoring services for action (5-point Likert Scale) and sources of knowledge (on a 0-1 scale). Four questions surveyed training on hypertension.

RESULTS

Responders (n=223, 75% women; 56% aged 20-35 years) included nurses (n=142, 64%, midwives (n=42, 19%), primary care physicians (n=28, 13%) and physician specialists (n=11, 5%)). The subscales commitment to work, leadership, work culture and informal payment scored between 4.7 and 4.1 and the community engagement, monitoring services for action and organizational resources scored between 3.1 and 3.5. Sources of knowledge had a mean score of 0.6±0.3. While 73% reported having attended a didactic hypertension seminar in the past year, only 28% had received long-term training and 51% had <3-year experience working with hypertension care delivery. The majority (99%) indicated a need for additional training in hypertension care.

CONCLUSIONS

There is a need for increased and continuous training in Rwanda. Healthcare responders stated a commitment to work and reported supportive leadership, while acknowledging limited resources and no monitoring systems. The COACH tool provides contextual guidance to develop training strategies prior to the implementation of a sustainable hypertension care programme.

The TDR MOOC training in implementation research: evaluation of feasibility and lessons learned in Rwanda

Background

Hypertension (HTN) affects nearly 1 billion people globally and is a major cause of morbidity and mortality. In low- and middle-income countries (LMICs), HTN represents an unmet health care gap that can be addressed by strengthening national health care systems. The National Heart, Lung, and Blood Institute recently funded the T4 Translation Research Capacity Building Initiative in Low Income Countries (TREIN) program to build capacity in dissemination and implementation (D&I) research in HTN in LMICs. The Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) recently developed a massive open online course (MOOC) to train in D&I. Herein, we report on the use of the TDR WHO MOOC in D&I for the TREIN program in Rwanda, assessing feasibility of the MOOC and D&I competencies after MOOC training.

Methods

Participants in one-group MOOC training completed pre- and post-training questionnaires to assess dissemination and implementation (D&I) competency outcomes and feasibility. D&I competencies were measured by use of a scale developed for a US-based training program, with the change in competency scores assessed by paired t test. Feasibility was measured by completion of homework and final project assignment and analyzed using descriptive statistics.

Results

Of the 92 trainees enrolled, 35 (38%) completed all MOOC components. D&I competency scores showed strong evidence of improvements from pre- to post-test. The full-scale average score improved by an average of 1.09 points, representing an effect size of 1.25 (CI 0.48-2.00); all four subscales also showed strong evidence of improvements. Trainees reported challenges to MOOC course completion that included technological issues (i.e., limited internet access) and competing demands (i.e., work, family).

Conclusions

In the context of LMIC training, the MOOC course was feasible and course completion showed improvement in D&I competency scores. While the program was designed with a focus on training for tropical diseases, there is potential for scalability to a wider audience of health care researchers, workers, administrators, and policymakers in LMIC interested in D&I research in non-communicable diseases.

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.

Dissemination and Implementation Program in Hypertension in Rwanda: Report on Initial Training and Evaluation

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide and in low- and middle-income countries, and hypertension (HTN) is a major risk factor for CVD. Although effective evidence-based interventions for control of HTN in high-income countries exist, implementation of these in low- and middle-income countries has been challenging due to limited capacity and infrastructure for late-phase translational research. In Rwanda, the 2015 STEPS NCD (STEPwise Approach to Surveillance of Noncommunicable Diseases) risk survey reported an overall prevalence of HTN of 15% (95% confidence interval [CI]: 13.8 to 16.3) for those ages 15 to 64 years; prevalence increased with increasing age to 39% (95% CI: 35.7 to 43.1) for those ages 55 to 64 years; CVD was the third most common cause of mortality (7%). Suboptimal infrastructure and capacity in Rwanda hinders research and community knowledge for HTN control.

OBJECTIVES

To address the issue of suboptimal capacity to implement evidence-based interventions in HTN, this project was designed with the following objectives: 1) to develop a regional needs assessment of infrastructure for dissemination and implementation (D & I) strategies for HTN-CVD control; 2) to develop HTN-CVD research capacity through creation of countrywide resources such as core research facilities and training in the fields of HTN-CVD, D & I, and biostatistics; and 3) to engage and train multiple stakeholders in D & I and HTN-CVD evidence-based interventions.

METHODS

A weeklong training program in HTN-CVD, biostatistics, and D & I was conducted in Rwanda in August 2018, and pre- and post-D & I training competency questionnaires were administered.

RESULTS

Questionnaire results show a statistically significant increase in D & I knowledge and skills as a result of training (full scale pre- to post-test scores: 2.12 ± 0.78 vs. 3.94 ± 0.42; p < 0.0001).

CONCLUSIONS

Using principles of community engagement and train-the-trainer methods, we will continue to adapt guidelines and treatments for HTN-CVD developed in high-income countries to the context of Rwanda with the goal of establishing a sustainable platform to address the burden of disease from HTN-CVD.

Health-related quality of life and associated factors in adults living with HIV in Rwanda

In Rwanda, as in other sub-Saharan African (SSA) countries, life expectancy of people living with HIV (PLWH) has increased dramatically as a result of combined antiretroviral therapy (cART). People living with HIV can now live longer but with increasing rates of non-communicable diseases (NCDs). Thus, prevention of NCD comorbidities in PWLHI is crucial to maintain and gain health-related benefits and to maximise the health-related quality of life (HRQOL) in the long-term management of PLWH. This study determines the association between physical and mental health-related dimensions of quality of life (QOL) with behavioural and biological risk factors, after controlling socio-demographic and HIV-related factors in adults living with HIV in Rwanda. A cross-sectional study using the WHO STEPwise approach and Kinyarwanda version of the MOS-HIV Health Survey, risk factors for NCDs and HRQOL were analysed for 794 PLWH, both HIV+ on ART and ART-naïve. Multiple regression analysis was used to examine the relationship between CMD risk factors and physical health and mental health summary scores. A total of 794 participants were interviewed. The mean age of the sample was 37.9 (±10.8) years and the majority of the participants were women (n = 513; 64.6%). About 16.2% reported daily smoking, 31.4% reported harmful alcohol use and 95% reported insufficient consumption of vegetables and fruits while 26.1% reported being physically inactive. 18.4% were overweight 43.4% had abdominal obesity, i.e. waist-hip-ratio (WHR) ≥0.95 in males and 0.85 in females. High blood pressure (HBP), i.e. systolic blood pressure (SBP) of ≥140 mmHg, or diastolic blood pressure (DBP) ≥90 mmHg was 24.4%. The results reveal that mean physical health summary and mental health summary score values were 63.96 ± 11.68 and 53.43 ± 10.89, respectively. While participants indicated that tobacco users and those who had abdominal obesity reported poor mental HRQOL, physical inactivity and hypertension have a negative impact on physical HRQOL. In addition, certain socio-demographic and HIV-related variables - specifically being unmarried, lack of HIV disclosure and low CD4 count (less 350 cell counts /mm³) - were associated with significantly lower mental and physical dimensions of quality of life. The results of this study reveal that behavioural and biological risk factors for NCDs were significantly associated with a lower HRQOL. These research findings also suggest that the assessment of the association between behavioural and biological risk factors for NCDs and a HRQOL provides opportunities for targeted counselling and secondary prevention efforts, so that health care providers can implement strategies that have a significant impact on the HRQOL.

HIV treatment is associated with a two-fold higher probability of raised triglycerides: Pooled Analyses in 21 023 individuals in sub-Saharan Africa

BACKGROUND

Anti-retroviral therapy (ART) regimes for HIV are associated with raised levels of circulating triglycerides (TG) in western populations. However, there are limited data on the impact of ART on cardiometabolic risk in sub-Saharan African (SSA) populations.

METHODS

Pooled analyses of 14 studies comprising 21 023 individuals, on whom relevant cardiometabolic risk factors (including TG), HIV and ART status were assessed between 2003 and 2014, in SSA. The association between ART and raised TG (>2.3 mmol/L) was analysed using regression models.

FINDINGS

Among 10 615 individuals, ART was associated with a two-fold higher probability of raised TG (RR 2.05, 95% CI 1.51-2.77, I2=45.2%). The associations between ART and raised blood pressure, glucose, HbA1c, and other lipids were inconsistent across studies.

INTERPRETATION

Evidence from this study confirms the association of ART with raised TG in SSA populations. Given the possible causal effect of raised TG on cardiovascular disease (CVD), the evidence highlights the need for prospective studies to clarify the impact of long term ART on CVD outcomes in SSA.

Bone quality assessed using quantitative ultrasound at the distal radius does not differ in antiretroviral therapy-naïve HIV-positive and HIV-negative Rwandan women

OBJECTIVES

The incidence of fractures appears to be increased in HIV-infected individuals.

METHODS

We assessed bone quality using quantitative ultrasound (QUS) in HIV-infected and uninfected Rwandan women. A Sunlight Omnisense 7000 QUS was used to measure the speed of ultrasound (SOS) at the distal radius in 646 antiretroviral therapy (ART)-naïve HIV-infected women and 211 HIV-uninfected women. The Z-scores for SOS were based on data for women of the same age from the manufacturer's reference material.

RESULTS

The mean CD4 cell count was 285 (± 166) cells/μL in the HIV-positive women. SOS Z-scores adjusted and unadjusted for body mass index did not differ between the groups. SOS did not differ by CD4 count (< 200 vs. ≥ 200 cells/μL: 4016 (± 117) vs. 4028 (± 107) m/s, respectively; p=0.19.

CONCLUSIONS

In HIV-positive ART-naïve Rwandan women with advanced HIV disease, bone quality at the distal radius was similar to that in HIV-negative controls.

Decentralizing Maternity Services to Increase Skilled Attendance at Birth and Antenatal Care Utilization in Rural Rwanda: A Prospective Cohort Study

To evaluate the effectiveness of decentralizing ambulatory reproductive and intrapartum services to increase rates of antenatal care (ANC) utilization and skilled attendance at birth (SAB) in Rwanda. A prospective cohort study was implemented with one control and two intervention sites: decentralized ambulatory reproductive healthcare and decentralized intrapartum care. Multivariate logistic regression analysis was performed with primary outcome of lack of SAB and secondary outcome of ≥3 ANC visits. 536 women were entered in the study. Distance lived from delivery site significantly predicted SAB (p = 0.007), however distance lived to ANC site did not predict ≥3 ANC visits (p = 0.81). Neither decentralization of ambulatory reproductive healthcare (p = 0.10) nor intrapartum care (p = 0.40) was significantly associated with SAB. The control site had the greatest percentage of women receive ≥3 ANC visits (p < 0.001). Receiving <3 ANC visits was associated with a 3.98 times greater odds of not having SAB (p = 0.001). No increase in adverse outcomes was found with decentralization of ambulatory reproductive health care or intrapartum care. The factors that predict utilization of physically accessible services in rural Africa are complex. Decentralization of services may be one strategy to increase rates of SAB and ANC utilization, but selection biases may have precluded accurate analysis. Efforts to increase ANC utilization may be a worthwhile investment to increase SAB.

Sexual Behavior and Risk Practices of HIV Positive and HIV Negative Rwandan Women

It is not well understood how infection with HIV and prior experience of sexual violence affects sexual behavior in African women. We describe factors influencing current sexual practices of Rwandan women living with or without HIV/AIDS. By design, 75 % of participants were HIV positive and ~50 % reported having experienced genocidal rape. Univariate and multivariate logistic regression models were fit to describe demographic and clinical characteristics that influenced sexual behavior in the previous 6 months, condom use, history of transactional sex, and prior infection with a non-HIV sexually transmitted disease. Respondents' age, where they lived, whether or not they lived with a husband or partner, experience of sexual trauma, CD4 count, CES-D and PTSD scores were strongly associated with risky sexual behavior and infection with non-HIV STI. HIV positive women with a history of sexual violence in the contexts of war and conflict may be susceptible to some high-risk sexual behaviors.

Association of Abnormal Liver Function Parameters with HIV Serostatus and CD4 Count in Antiretroviral-Naive Rwandan Women

We determined the associations of HIV infection/CD4 count with markers of hepatocellular damage [elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT)] and liver synthetic function (decreased albumin) in HIV-infected (HIV(+)) antiretroviral therapy (ART)-naive and uninfected (HIV(-)) Rwandan women. In 2005, 710 HIV(+) ART-naive and 226 HIV(-) women enrolled in the Rwanda Women's Interassociation Study and Assessment. Liver enzymes were measured with abnormality defined as either AST or ALT ≥1.25 times the upper limit of normal. Low serum albumin level was defined as <3.5 g/dl. Multivariable logistic regression analysis identified independent predictors of elevated AST/ALT and low serum albumin. HIV(-) women had the lowest prevalence (6.6%) of abnormal AST/ALT, with the highest prevalence (16.4%) in HIV(+) women with CD4 <200 cells/μl (p=0.01). The odds of having serum albumin <3.5 g/dl was 5.7-fold higher in HIV(+) than HIV(-) women (OR=5.68, 95% CI: 3.32-9.71). The risk of low albumin decreased from low to high CD4 count, with OR=2.62, 95% CI: 1.66, 4.14 and OR=1.57, 95% CI: 1.01, 2.43 in HIV(+) women with a CD4 count <200 and 200-350 cells/μl, respectively vs. HIV(+) with CD4 >350 (p<0.001 and p<0.05 for all comparisons). Our findings suggest that HIV-associated liver damage may occur in ART-naive patients. Although liver abnormality prevalences in this cohort of HIV-infected Rwandan women are less than reported in developed countries, caution is needed for risk assessment measures to monitor and screen HIV-infected patients pre- and post-ART initiation in African clinical settings to curtail potential risks associated with HIV infection.

HIV Malaria Co-Infection Is Associated with Atypical Memory B Cell Expansion and a Reduced Antibody Response to a Broad Array of Plasmodium falciparum Antigens in Rwandan Adults

HIV infected individuals in malaria endemic areas experience more frequent and severe malaria episodes compared to non HIV infected. This clinical observation has been linked to a deficiency in antibody responses to Plasmodium falciparum antigens; however, prior studies have only focused on the antibody response to <0.5% of P. falciparum proteins. To obtain a broader and less-biased view of the effect of HIV on antibody responses to malaria we compared antibody profiles of HIV positive (HIV+) and negative (HIV-) Rwandan adults with symptomatic malaria using a microarray containing 824 P. falciparum proteins. We also investigated the cellular basis of the antibody response in the two groups by analyzing B and T cell subsets by flow cytometry. Although HIV malaria co-infected individuals generated antibodies to a large number of P. falciparum antigens, including potential vaccine candidates, the breadth and magnitude of their response was reduced compared to HIV- individuals. HIV malaria co-infection was also associated with a higher percentage of atypical memory B cells (MBC) (CD19+CD10-CD21-CD27-) compared to malaria infection alone. Among HIV+ individuals the CD4+ T cell count and HIV viral load only partially explained variability in the breadth of P. falciparum-specific antibody responses. Taken together, these data indicate that HIV malaria co-infection is associated with an expansion of atypical MBCs and a diminished antibody response to a diverse array of P. falciparum antigens, thus offering mechanistic insight into the higher risk of malaria in HIV+ individuals.

Insulin resistance change and antiretroviral therapy exposure in HIV-infected and uninfected Rwandan women: a longitudinal analysis

Background

We longitudinally assessed predictors of insulin resistance (IR) change among HIV-uninfected and HIV-infected (ART-initiators and ART-non-initiators) Rwandan women.

Methodology

HIV-infected (HIV+) and uninfected (HIV-) women provided demographic and clinical measures: age, body mass index (BMI) in Kg/(height in meters)², Fat-Mass (FMI) and Fat-Free-Mass (FFMI) index, fasting serum glucose and insulin. Homeostasis Model Assessment (HOMA) was calculated to estimate IR change over time in log₁₀ transformed HOMA measured at study enrollment or prior to ART initiation in 3 groups: HIV- (n = 194), HIV+ ART-non-initiators (n=95) and HIV+ ART-initiators (n=371). ANCOVA linear regression models of change in log₁₀-HOMA were fit with all models included the first log₁₀ HOMA as a predictor.

Results

Mean±SD log₁₀-HOMA was -0.18±0.39 at the 1^st and -0.21±0.41 at the 2^nd measure, with mean change of 0.03±0.44. In the final model (all women) BMI at 1^st HOMA measure (0.014; 95% CI=0.006-0.021 per kg/m²; p<0.001) and change in BMI from 1^st to 2^nd measure (0.024; 95% CI=0.013-0.035 per kg/m²; p<0.001) predicted HOMA change. When restricted to subjects with FMI measures, FMI at 1^st HOMA measure (0.020; 95% CI=0.010-0.030 per kg/m²; p<0.001) and change in FMI from 1^st to 2^nd measure (0.032; 95% CI=0.020-0.043 per kg/m²; p<0.0001) predicted change in HOMA. While ART use did not predict change in log₁₀-HOMA, untreated HIV+ women had a significant decline in IR over time. Use or duration of AZT, d4T and EFV was not associated with HOMA change in HIV+ women.

Conclusions

Baseline BMI and change in BMI, and in particular fat mass and change in fat mass predicted insulin resistance change over ~3 years in HIV-infected and uninfected Rwandan women. Exposure to specific ART (d4T, AZT, EFV) did not predict insulin resistance change in ART-treated HIV-infected Rwandan women.

The T-Cell Inhibitory Molecule Butyrophilin-Like 2 Is Up-regulated in Mild Plasmodium falciparum Infection and Is Protective During Experimental Cerebral Malaria

Plasmodium falciparum infection can result in severe disease that is associated with elevated inflammation and vital organ dysfunction; however, malaria-endemic residents gain protection from lethal outcomes and manifest only mild symptoms during infection. To characterize host responses associated with this more effective antimalarial response, we characterized whole-blood transcriptional profiles in Rwandan adults during a mild malaria episode and compared them with findings from a convalescence sample. We observed transcriptional up-regulation in many pathways, including type I interferon, interferon γ, complement activation, and nitric oxide during malaria infection, which provide benchmarks of mild disease physiology. Transcripts encoding negative regulators of T-cell activation, such as programmed death ligand 1 (PD-L1), programmed death 1 ligand 2 (PD-L2), and the butyrophilin family member butyrophilin-like 2 (BTNL2) were also increased. To support an important functional role for BTNL2 during malaria infection, we studied chimeric mice reconstituted with BTNL2(-/-) or wild-type hematopoietic cells that were inoculated with Plasmodium berghei ANKA, a murine model of cerebral malaria. We found that BTNL2(-/-) chimeric mice had a significant decrease in survival compared with wild-type counterparts. Collectively these data characterize the immune responses associated with mild malaria and uncover a novel role for BTNL2 in the host response to malaria.

Prevalence of shingles and its association with PTSD among HIV-infected women in Rwanda

OBJECTIVE

To examine the prevalence of reported shingles in the last 6 months and its association with post-traumatic stress disorder (PTSD), depression and severity of HIV disease in Rwandan women with HIV.

SETTINGS

This cross-sectional study was conducted as part of the Rwanda Women's Interassociation Study and Assessment (RWISA), an observational cohort study designed to assess the impact of HIV and residual factors from experiencing rape in the 1994 genocide in Rwandan women. Participants were recruited through grassroots women's associations of people living with HIV infection and clinical care sites for HIV infection. Most participants (58.5%, n=405/692) had PTSD.

PARTICIPANTS

This cross-sectional analysis was conducted in 710 HIV-infected women enrolled in RWISA. Inclusion criteria were: age >15 years, informed consent, HIV test, ability to complete the interview in the local language, travel to and from the research site and participate in a baseline outpatient visit, and being naive to antiretroviral therapy at enrolment.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome of interest was self-reported shingles in the past 6 months. The exposure was PTSD defined using the cross-culturally validated Harvard Trauma Questionnaire.

RESULTS

Overall prevalence of reported shingles in the past 6 months was 12.5% (n=89/710). There was an inverse relationship between shingles prevalence and immunological status: 7.6%, 12.3% and 16.7% of women with CD4 >350, 200-350 and <200 cells/µL, respectively, reported singles (p=0.01). In multivariate analysis, PTSD (aOR 1.7; 95% CI 1.02 to 2.89) and low CD4 (aOR 2.4; 95% CI 1.23 to 4.81) were independently associated with reported shingles in the past 6 months.

CONCLUSIONS

Our study found a significant independent relationship between PTSD and reported shingles, suggesting that PTSD may be associated with immune compromise that can result in herpes zoster reactivation. Further study is needed. It also confirmed previous findings of a strong relationship between shingles and greater immunosuppression in women with HIV infection.

Use of Traditional Botanical Medicines During Pregnancy in Rural Rwanda

OBJECTIVE

To evaluate the perceptions of healthcare and traditional medicine providers regarding the type, indications, side effects, and prevalence of traditional medicine use amongst pregnant women in a rural Rwandan population.

METHODS

Six focus groups with physicians, nurses, and community health workers and four individual in-depth interviews with traditional medicine providers were held. Qualitative data was gathered using a structured questionnaire querying perceptions of the type, indications, side effects, and prevalence of use of traditional medicines in pregnancy.

RESULTS

The healthcare provider groups perceived a high prevalence of traditional botanical medicine use by pregnant women (50-80%). All three groups reported similar indications for use of the medicines and the socioeconomic status of the pregnant women who use them. The traditional medicine providers and the healthcare providers both perceived that the most commonly used medicine is a mixture of many plants, called Inkuri. The most serious side effect reported was abnormally bright green meconium with a poor neonatal respiratory drive. Thirty-five traditional medicines were identified that are used during pregnancy.

CONCLUSION

Perceptions of high prevalence of use of traditional medicines during pregnancy with possible negative perinatal outcomes exist in areas of rural Rwanda.

Prevalence and risk factors for High-Risk Human Papillomavirus (hrHPV) infection among HIV-infected and Uninfected Rwandan women: implications for hrHPV-based screening in Rwanda

BACKGROUND

New World Health Organization guidelines recommend high-risk human papillomavirus (hrHPV) screen-and-treat strategies for cervical cancer prevention. We describe risk of, and risk factors for, testing hrHPV positive in a pilot study of hrHPV screen-and-treat conducted in Rwanda.

METHODS

A total of 2,964 women, 1,289 HIV-infected (HIV [+]) and 1,675 HIV-uninfected (HIV [-]), aged 30-60 years and living in Rwanda were enrolled in 2010. Cervical specimens were collected and tested by careHPV, a DNA test for a pool of 14 hrHPV types. Prevalence with binomial 95% confidence intervals (95% CI) and determinants of testing hrHPV positive were calculated.

RESULTS

hrHPV prevalence was higher in HIV [+] (31.8%, 95% CI = 29.2-34.4%) than HIV [-] women (8.2%, 95% CI = 6.7-9.8%; P < 0.0001). Among HIV [+] women, there was a significant trend (ptrend <0.001) of higher hrHPV prevalence with lower CD4 cell count, with the highest hrHPV prevalence among those with <200 CD4 cell counts (45.5%, 95% CI = 34.8-56.4%). In multivariate analysis of HIV [+] women, testing hrHPV positive was positively associated CD4 count of <200 cells/μL, history of 3 or more sexual partners, and history of using hormonal contraception, and negatively associated with older age. In HIV [-] women, testing hrHPV positive was negatively associated only with older age groups of 45-49 and 50-60 years and surprisingly was not associated with lifetime number of sexual partners.

CONCLUSION

hrHPV prevalence is high in HIV [+], especially in women with the lowest CD4 cell counts, which may have implications for utilizing hrHPV-based screening strategies such as screen-and-treat in these high-risk subgroups.

Building clinical trial priorities at the University of Rwanda

After the genocide in Rwanda, the country's healthcare system collapsed. Remarkable gains have since been made by the state to provide greater clinical service capacity and expand health policies that are grounded on locally relevant evidence. This commentary explores the challenges faced by Rwanda in building an infrastructure for clinical trials. Through local examples, we discuss how a clinical trial infrastructure can be constructed by (1) building educational capacity; (2) encouraging the testing of relevant interventions using appropriate and cost-effective designs; and, (3) promoting ethical and regulatory standards. The future is bright for clinical research in Rwanda and with a renewed appetite for locally generated evidence it is necessary that we discuss the challenges and opportunities in drawing up a clinical trials agenda.

Association of HIV and ART with cardiometabolic traits in sub-Saharan Africa: a systematic review and meta-analysis

Background Sub-Saharan Africa (SSA) has the highest burden of HIV in the world and a rising prevalence of cardiometabolic disease; however, the interrelationship between HIV, antiretroviral therapy (ART) and cardiometabolic traits is not well described in SSA populations.

Methods We conducted a systematic review and meta-analysis through MEDLINE and EMBASE (up to January 2012), as well as direct author contact. Eligible studies provided summary or individual-level data on one or more of the following traits in HIV+ and HIV-, or ART+ and ART- subgroups in SSA: body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TGs) and fasting blood glucose (FBG) or glycated hemoglobin (HbA1c). Information was synthesized under a random-effects model and the primary outcomes were the standardized mean differences (SMD) of the specified traits between subgroups of participants.

Results Data were obtained from 49 published and 3 unpublished studies which reported on 29 755 individuals. HIV infection was associated with higher TGs [SMD, 0.26; 95% confidence interval (CI), 0.08 to 0.44] and lower HDL (SMD, −0.59; 95% CI, −0.86 to −0.31), BMI (SMD, −0.32; 95% CI, −0.45 to −0.18), SBP (SMD, −0.40; 95% CI, −0.55 to −0.25) and DBP (SMD, −0.34; 95% CI, −0.51 to −0.17). Among HIV+ individuals, ART use was associated with higher LDL (SMD, 0.43; 95% CI, 0.14 to 0.72) and HDL (SMD, 0.39; 95% CI, 0.11 to 0.66), and lower HbA1c (SMD, −0.34; 95% CI, −0.62 to −0.06). Fully adjusted estimates from analyses of individual participant data were consistent with meta-analysis of summary estimates for most traits.

Conclusions Broadly consistent with results from populations of European descent, these results suggest differences in cardiometabolic traits between HIV-infected and uninfected individuals in SSA, which might be modified by ART use. In a region with the highest burden of HIV, it will be important to clarify these findings to reliably assess the need for monitoring and managing cardiometabolic risk in HIV-infected populations in SSA.

Effect of deworming on disease progression markers in HIV-1-infected pregnant women on antiretroviral therapy: a longitudinal observational study from Rwanda

BACKGROUND

Deworming human immunodeficiency virus (HIV)-infected individuals on antiretroviral therapy (ART) may be beneficial, particularly during pregnancy. We determined the efficacy of targeted and nontargeted antihelminth therapy and its effects on Plasmodium falciparum infection status, hemoglobin levels, CD4 counts, and viral load in pregnant, HIV-positive women receiving ART.

METHODS

Nine hundred eighty HIV-infected pregnant women receiving ART were examined at 2 visits during pregnancy and 2 postpartum visits within 12 weeks. Women were given antimalarials when malaria-positive whereas albendazole was given in a targeted (n = 467; treatment when helminth stool screening was positive) or nontargeted (n = 513; treatment at all time points, with stool screening) fashion.

RESULTS

No significant differences were noted between targeted and nontargeted albendazole treatments for the variables measured at each study visit except for CD4 counts, which were lower (P < .05) in the latter group at the final visit. Albendazole therapy was associated with favorable changes in subjects' hemoglobin levels, CD4 counts, and viral loads, particularly with helminth infections.

CONCLUSIONS

Antihelminthic therapy reduces detectable viral load, and increases CD4 counts and hemoglobin levels in pregnant HIV-infected women with helminth coinfections receiving ART.

Plasmodium falciparum Infection Does Not Affect Human Immunodeficiency Virus Viral Load in Coinfected Rwandan Adults

In contrast to prior studies, mild malaria infection had no impact on HIV Viral Loads(VL) in Rwanda. Over fifty percent of patients prescribed ARV had detectable VL; 25% had genotypic resistance. Eleven percent of patients with mild malaria were newly diagnosed with HIV.

Background

 Plasmodium falciparum infection has been reported to increase human immunodeficiency virus (HIV) viral load (VL), which can facilitate HIV transmission. We prospectively studied the impact of mild P falciparum coinfection on HIV VL in Rwanda.

Methods

 We measured plasma HIV VL at presentation with malaria infection and weekly for 4 weeks after artemether-lumefantrine treatment in Rwandan adults infected with HIV with P falciparum malaria. Regression analyses were used to examine associations between malaria infection and HIV VL changes. Samples with detectable virus underwent genotypic drug-resistance testing.

Results

 We enrolled 28 HIV-malaria coinfected patients and observed 27 of them for 5 weeks. Three patients (11%) were newly diagnosed with HIV. Acute P falciparum infection had no significant effect on HIV VL slope over 28 days of follow-up. Ten patients with VL <40 copies/mL at enrollment maintained viral suppression throughout. Seventeen patients had a detectable VL at enrollment including 9 (53%) who reported 100% adherence to ARVs; 3 of these had detectable genotypic drug resistance.

Conclusions

 Unlike studies from highly malaria-endemic areas, we did not identify an effect of P falciparum infection on HIV VL; therefore, malaria is not likely to increase HIV-transmission risk in our setting. However, routine HIV testing should be offered to adults presenting with acute malaria in Rwanda. Most importantly, we identified a large percentage of patients with detectable HIV VL despite antiretroviral (ARV) therapy. Some of these patients had HIV genotypic drug resistance. Larger studies are needed to define the prevalence and factors associated with detectable HIV VL in patients prescribed ARVs in Rwanda.

Associations of HIV infection with insulin and glucose levels in antiretroviral-naive Rwandan women: a cross-sectional analysis

OBJECTIVES

The purpose of these analyses was to determine the associations of HIV infection and related immune dysfunction with a glucose homeostasis in the population of antiretroviral-naïve HIV-infected and uninfected Rwandan women. We hypothesise that insulin resistance and its consequences in the developing countries may be further elevated with HIV infection itself regardless of antiretroviral therapy.

STUDY DESIGN

Cross-sectional analysis of a longitudinal cohort.

SETTING

Community-based women's associations.

PARTICIPANTS

In 2005, 710 HIV-infected (HIV positive) antiretroviral naïve and 226 HIV-uninfected (HIV negative) women were enrolled in the Rwanda Women's Interassociation Study and Assessment (RWISA). Clinical and demographic parameters, CD4 count, fasting insulin and glucose levels, anthropometric measurements and Bioelectrical Impedance Analysis (BIA) were obtained. Linear models were fit to log-transformed Homeostasis Model Assessment (HOMA) with results exponentiated back to a multiplicative effect on the original scale.

PRIMARY OUTCOME MEASURES

The outcome, insulin resistance, was measured by the HOMA, calculated as fasting insulin (μU/mL)×fasting glucose (mmol/L)/22.5.

RESULTS

In adjusted models, HIV-positive women were less insulin resistant than HIV-negative; an HIV-positive woman tended to have 0.728 times as much (95% CI 0.681 to 0.861) HOMA than a comparable HIV-negative woman. Among the HIV-positive women, those with CD4 <200 cells/µL tended to have 0.741 times as much HOMA (95% CI 0.601 to 0.912) as did comparable women with CD4 >350 cells/µL. The older age was independently associated with a lower HOMA insulin resistance. After adjusting for body mass index, fat and fat-free mass were not independently associated with HOMA.

CONCLUSIONS

This study found that HIV infection and more advanced HIV infection (CD4 counts <200 cells/µL) were associated with greater insulin sensitivity in antiretroviral naïve African women. These findings provide baseline information for the interpretation of future studies on the effect of antiretroviral therapy on metabolic insulin sensitivity derangements in African population.

Helminthic infections rates and malaria in HIV-infected pregnant women on anti-retroviral therapy in Rwanda

Background

Within sub-Saharan Africa, helminth and malaria infections cause considerable morbidity in HIV-positive pregnant women and their offspring. Helminth infections are also associated with a higher risk of mother-to-child HIV transmission. The aim of this study was to determine the prevalence of, and the protective and risk factors for helminth and malaria infections in pregnant HIV-positive Rwandan women receiving anti-retroviral therapy (ART).

Methodology and principle findings

Pregnant females (n = 980) were recruited from health centres in rural and peri-urban locations in the central and eastern provinces of Rwanda. Helminth infection was diagnosed using the Kato Katz method whilst the presence of Plasmodium falciparum was identified from blood smears. The prevalence of helminth infections was 34.3%; of malaria 13.3%, and of co-infections 6.6%. Helminth infections were more common in rural (43.1%) than peri-urban (18.0%; p<0.0005) sites. A CD4 count ≤350 cells/mm³ was associated with a higher risk of helminth infections (odds ratio, 3.39; 95% CIs, 2.16–5.33; p<0.0005) and malaria (3.37 [2.11–5.38]; p<0.0005) whilst helminth infection was a risk factor for malaria infection and vice versa. Education and employment reduced the risk of all types of infection whilst hand washing protected against helminth infection (0.29 [0.19–0.46]; p<0.0005);). The TDF-3TC-NVP (3.47 [2.21–5.45]; p<0.0005), D4T-3TC-NVP (2.47 [1.27–4.80]; p<0.05) and AZT-NVP (2.60 [1.33–5.08]; p<0.05) regimens each yielded higher helminth infection rates than the AZT-3TC-NVP regimen. Anti-retroviral therapy had no effect on the risk of malaria.

Conclusion/significance

HIV-positive pregnant women would benefit from the scaling up of de-worming programs alongside health education and hygiene interventions. The differential effect of certain ART combinations (as observed here most strongly with AZT-3TC-NVP) possibly protecting against helminth infection warrants further investigation.

There is an overlap in the worldwide distribution of intestinal worms (helminths), malaria and HIV. Co-infections with helminth and malaria parasites cause a significant problem in the host, particularly in the presence of HIV infection. The aim of this study was to assess the prevalence of intestinal worm and malaria infection and co-infections and the associated risk factors among HIV-positive pregnant women that attended rural and peri-urban health centers in Rwanda. Our findings indicate that intestinal worms were more common among HIV-infected pregnant women in the rural than peri-urban settings. HIV-positive pregnant women who had lower CD4 cell counts were more at risk of being infected by intestinal worms and malaria. Malaria also increased the risk of being infected by intestinal worms and vice versa. Socio-economic factors such as lack of education and unemployment were among the risk factors for intestinal worm infections and malaria. Hand washing was found to reduce the risk for worm infections; whilst one particular ART combination (AZT-3TC-NVP) led to a reduced rate of helminth infections when compared to others.

Gender inequities in sexual risks among youth with HIV in Kigali, Rwanda

Understanding the experiences of youth living with HIV (YLH) is necessary for implementing interventions that mitigate HIV transmission. We conducted a survey of sexual behaviours and sources of knowledge among 107 youths aged 16-24 attending two HIV clinics in Kigali, Rwanda. Respondents were 72% women and 28% men, with median age 18 years. Of those sexually active in the past six months, 56% reported inconsistent condom use; 53% of sexually active respondents reported having sexually transmitted infection (STI) symptoms in the past six months. The median age difference between respondent and first sex partner was nine years for women, and 0.5 years for men (P = 0.006). Women more frequently reported being forced to have sex (29% girls versus 6.5% boys, P = 0.011) and exchanging sex for money (66% girls versus. 17% boys, P = 0.033). Strengthening female YLH's financial and material resources may reduce the number of sexual partners, asymmetries within partnerships and risk of HIV transmission.

The impact of HIV status, HIV disease progression, and post-traumatic stress symptoms on the health-related quality of life of Rwandan women genocide survivors

PURPOSE

We examined whether established associations between HIV disease and HIV disease progression on worse health-related quality of life (HQOL) were applicable to women with severe trauma histories, in this case Rwandan women genocide survivors, the majority of whom were HIV-infected. Additionally, this study attempted to clarify whether post-traumatic stress symptoms were uniquely associated with HQOL or confounded with depression.

METHODS

The Rwandan Women's Interassociation Study and Assessment was a longitudinal prospective study of HIV-infected and uninfected women. At study entry, 922 women (705 HIV+ and 217 HIV-) completed measures of symptoms of post-traumatic stress and HQOL as well as other demographic, clinical, and behavioral characteristics.

RESULTS

Even after controlling for potential confounders and mediators, HIV+ women, in particular those with the lowest CD4 counts, scored significantly worse on HQOL and overall quality of life (QOL) than did HIV- women. Even after controlling for depression and HIV disease progression, women with more post-traumatic stress symptoms scored worse on HQOL and overall QOL than women with fewer post-traumatic stress symptoms.

CONCLUSIONS

This study demonstrated that post-traumatic stress symptoms were independently associated with HQOL and overall QOL, independent of depression and other confounders or potential mediators. Future research should examine whether the long-term impact of treatment on physical and psychological symptoms of HIV and post-traumatic stress symptoms would generate improvement in HQOL.

Malaria and helminthic co-infection among HIV-positive pregnant women: prevalence and effects of antiretroviral therapy

The impact of malaria on anemia and the interplay with helminths underline the importance of addressing the interactions between HIV/AIDS, malaria and intestinal helminth infections in pregnancy. The aim of this study was to determine the prevalence of malaria-helminth dual infections among HIV positive pregnant mothers after 12 months of ART. A cross sectional study was conducted on intestinal helminths and malaria dual infections among HIV-positive pregnant women attending antenatal health centers in Rwanda. Stool and malaria blood slide examinations were performed on 328 women residing in rural (n=166) and peri-urban locations (n=162). BMI, CD4 cell count, hemoglobin levels, type of ART and viral load of participants were assessed. Within the study group, 38% of individuals harbored helminths, 21% had malaria and 10% were infected with both. The most prevalent helminth species were Ascaris lumbricoides (20.7%), followed by Trichuris trichiura (9.2%), and Ancylostoma duodenale and Necator americanus (1.2%). Helminth infections were characterized by low hemoglobin and CD4 counts. Subjects treated with a d4T, 3TC, NVP regimen had a reduced risk of T. trichiura infection (OR, 0.27; 95% CIs, 0.10-0.76; p<0.05) and malaria-helminth dual infection (OR, 0.29; 95% CI, 0.11-0.75; p<0.05) compared to those receiving AZT, 3TC, NVP. This study shows a high prevalence of malaria and helminth infection among HIV-positive pregnant women in Rwanda. The differential effect of ARTs on the risk of helminth infection is of interest and should be examined prospectively in larger patient groups.

'I think my future will be better than my past': examining support group influence on the mental health of HIV-infected Rwandan women

Urgent need exists for improved psychological services among HIV-infected women in post-genocide Rwanda. Psychological problems associated with trauma and sexual violence (i.e., depression, posttraumatic stress disorder [PTSD]) place women at increased risk for sexual risk behaviour, low health-seeking behaviour, delay of antiretroviral therapy (ART) and reduced ART adherence. We explored experiences of HIV-infected Rwandan women attending psychosocial support groups and their narratives about how participation affected their mental health and HIV treatment. Focus group discussions examined participants' reasons for support group attendance, perceived psychological benefit of support groups, influence on ART adherence, and other influences on health behaviors and attitudes. Rwandan women (aged 18-65) were randomly selected from 10 health clinic-facilitated support groups for HIV-infected trauma survivors in Kigali. Results identified positive psychological and physical changes as well as behaviour changes in relationships with men, which participants attributed to support group attendance. Data showed significant improvement in mental health, ART adherence and HIV serostatus disclosure resulting from group attendance. Participants acknowledged limitations of support groups with respect to addressing poverty and hunger. Implementing psychosocial support groups may leverage clinical outcomes and rejuvenate the well-being of HIV-infected women with interpersonal trauma and/or PTSD and depressive symptoms, particularly those from post-conflict countries.

Association of serum albumin with markers of nutritional status among HIV-infected and uninfected Rwandan women

Introduction

The objectives of this study are to address if and how albumin can be used as an indication of malnutrition in HIV infected and uninfected Africans.

Methods

In 2005, 710 HIV-infected and 226 HIV-uninfected women enrolled in a cohort study. Clinical/demographic parameters, CD4 count, albumin, liver transaminases; anthropometric measurements and Bioelectrical Impedance Analysis (BIA) were performed. Malnutrition outcomes were defined as body mass index (BMI), Fat-free mass index (FFMI) and Fat mass index (FMI). Separate linear predictive models including albumin were fit to these outcomes in HIV negative and HIV positive women by CD4 strata (CD4>350,200–350 and <200 cells/µl).

Results

In unadjusted models for each outcome in HIV-negative and HIV positive women with CD4>350 cells/µl, serum albumin was not significantly associated with BMI, FFMI or FMI. Albumin was significantly associated with all three outcomes (p<0.05) in HIV+ women with CD4 200–350 cells/µl, and highly significant in HIV+ women with CD4<200 cells/µl (P<0.001). In multivariable linear regression, albumin remained associated with FFMI in women with CD4 count<200 cells/µl (p<0.01) but not in HIV+ women with CD4>200.

Discussion

While serum albumin is widely used to indicate nutritional status it did not consistently predict malnutrition outcomes in HIV- women or HIV+ women with higher CD4. This result suggests that albumin may measure end stage disease as well as malnutrition and should not be used as a proxy for nutritional status without further study of its association with validated measures.

Structural determinants of food insufficiency, low dietary diversity and BMI: a cross-sectional study of HIV-infected and HIV-negative Rwandan women

OBJECTIVES

In Sub-Saharan Africa, the overlapping epidemics of undernutrition and HIV infection affect over 200 and 23 million people, respectively, and little is known about the combined prevalence and nutritional effects. The authors sought to determine which structural factors are associated with food insufficiency, low dietary diversity and low body mass index (BMI) in HIV-negative and HIV-infected Sub-Saharan women.

STUDY DESIGN

Cross-sectional analysis of a longitudinal cohort.

SETTING

Community-based women's organisations.

PARTICIPANTS

161 HIV-negative and 514 HIV-infected Rwandan women.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes included food insufficiency (reporting 'usually not' or 'never' to 'Do you have enough food?'), low household dietary diversity (Household Dietary Diversity Score ≤3) and BMI <18.5 (kg/m(2)). The authors also measured structural and behavioural factors including: income, household size, literacy and alcohol use.

RESULTS

Food insufficiency was prevalent (46%) as was low dietary diversity (43%) and low BMI (15%). Food insufficiency and dietary diversity were associated with low income (adjusted odds ratio (aOR)=2.14 (95% CI 1.30 to 3.52) p<0.01), (aOR=6.51 (95% CI 3.66 to 11.57) p<0.001), respectfully and illiteracy (aOR=2.00 (95% CI 1.31 to 3.04) p<0.01), (aOR=2.10 (95% CI 1.37 to 3.23) p<0.001), respectfully and were not associated with HIV infection. Alcohol use was strongly associated with food insufficiency (aOR=3.23 (95% CI 1.99 to 5.24) p<0.001). Low BMI was inversely associated with HIV infection (aOR≈0.5) and was not correlated with food insufficiency or dietary diversity.

CONCLUSIONS

Rwandan women experienced high rates of food insufficiency and low dietary diversity. Extreme poverty, illiteracy and alcohol use, not HIV infection alone, may contribute to food insufficiency in Rwandan women. Food insufficiency, dietary diversity and low BMI do not correlate with one another; therefore, low BMI may not be an adequate screening tool for food insufficiency. Further studies are needed to understand the health effects of not having enough food, low food diversity and low weight in both HIV-negative and HIV-infected women.

Assessment of haematological parameters in HIV-infected and uninfected Rwandan women: a cross-sectional study

OBJECTIVES

Although haematological abnormalities are common manifestations of HIV infection, few studies on haematological parameters in HIV-infected persons have been undertaken in sub-Saharan Africa. The authors assessed factors associated with haematological parameters in HIV-infected antiretroviral-naïve and HIV-uninfected Rwandan women.

STUDY DESIGN

Cross-sectional analysis of a longitudinal cohort.

SETTING

Community-based women's associations.

PARTICIPANTS

710 HIV-infected (HIV+) antiretroviral-naïve and 226 HIV-uninfected (HIV-) women from the Rwanda Women's Interassociation Study Assessment. Haematological parameters categorised as (abnormal vs normal) were compared by HIV status and among HIV+ women by CD4 count category using proportions. Multivariate logistic regression models using forward selection were fit.

RESULTS

Prevalence of anaemia (haemoglobin (Hb) <12.0 g/dl) was higher in the HIV+ group (20.5% vs 6.3%; p<0.001), and increased with lower CD4 counts: ≥350 (7.6%), 200-349 (16%) and <200 cells/mm(3) (32.2%). Marked anaemia (Hb <10.0 g/dl) was found in 4.2% of HIV+ and none of the HIV- women (p<0.001), and was highest in HIV+ women with CD4 <200 cells/mm(3) (8.4%). The HIV+ were more likely than HIV- women (4.2 vs 0.5%, respectively, p=0.002) to have moderate neutropenia with white blood cells <2.0×10(3) cells/mm(3) and 8.4% of HIV+ women with CD4 <200 cells/mm(3) had moderate neutropenia. In multivariate logistic regression analysis, BMI (OR 0.87/kg/m(2), 95% CI 0.82 to 0.93; p<0.001), CD4 200-350 vs HIV- (OR 3.59, 95% CI 1.89 to 6.83; p<0.001) and CD4 <200 cells/mm(3) vs HIV- (OR 8.09, 95% CI 4.37 to 14.97; <0.001) had large independent associations with anaemia. There were large independent associations of CD4 <200 cells/mm(3) vs HIV- (OR 7.18, 95% CI 0.78 to 65.82; p=0.081) and co-trimoxazole and/or dapsone use (OR 5.69, 95% CI 0.63 to 51.45; p=0.122) with moderate neutropenia.

CONCLUSIONS

Anaemia was more common than neutropenia or thrombocytopenia in the HIV-infected Rwandan women. Future comparisons of haematological parameters in HIV-infected patients before and after antiretroviral therapy initiation are warranted.

Association of pre-treatment nutritional status with change in CD4 count after antiretroviral therapy at 6, 12, and 24 months in Rwandan women

BACKGROUND

Body mass index (BMI) independently predicts mortality in studies of HIV infected patients initiating antiretroviral therapy (ART). We hypothesized that poorer nutritional status would be associated with smaller gains in CD4 count in Rwandan women initiating ART.

METHODS AND FINDINGS

The Rwandan Women's Interassociation Study and Assessment, enrolled 710 ART-naïve HIV-positive and 226 HIV-negative women in 2005 with follow-up every 6 months. The outcome assessed in this study was change in CD4 count at 6, 12, and 24 months after ART initiation. Nutritional status measures taken prior to ART initiation were BMI; height adjusted fat free mass (FFMI); height adjusted fat mass (FMI), and sum of skinfold measurements. 475 women initiated ART. Mean (within 6 months) pre-ART CD4 count was 216 cells/µL. Prior to ART initiation, the mean (±SD) BMI was 21.6 (±3.78) kg/m(2) (18.3% malnourished with BMI<18.5); and among women for whom the following were measured, mean FFMI was 17.10 (±1.76) kg/m(2); FMI 4.7 (±3.5) kg/m(2) and sum of skinfold measurements 4.9 (±2.7) cm. FFMI was significantly associated with a smaller change in CD4 count at 6 months in univariate analysis (-6.7 cells/uL per kg/m(2), p=0.03) only. In multivariate analysis after adjustment for covariates, no nutritional variable was associated with change in CD4 count at any follow up visit.

CONCLUSION

In this cohort of African women initiating ART, no measure of malnutrition prior to ART was consistently associated with change in CD4 count at 6, 12, and 24 months of follow up, suggesting that poorer pre-treatment nutritional status does not prevent an excellent response to ART.

Adherence to highly active antiretroviral treatment in HIV-infected Rwandan women

BACKGROUND

Scale-up of highly active antiretroviral treatment therapy (HAART) programs in Rwanda has been highly successful but data on adherence is limited. We examined HAART adherence in a large cohort of HIV+ Rwandan women.

METHODS

The Rwanda Women's Interassociation Study Assessment (RWISA) was a prospective cohort study that assessed effectiveness and toxicity of ART. We analyzed patient data 12±3 months after HAART initiation to determine adherence rates in HIV+ women who had initiated HAART.

RESULTS

Of the 710 HIV+ women at baseline, 490 (87.2%) initiated HAART. Of these, 6 (1.2%) died within 12 months, 15 others (3.0%) discontinued the study and 80 others (19.0%) remained in RWISA but did not have a post-HAART initiation visit that fell within the 12±3 month time points leaving 389 subjects for analysis. Of these 389, 15 women stopped their medications without being advised to do so by their doctors. Of the remaining 374 persons who reported current HAART use 354 completed the adherence assessment. All women, 354/354, reported 100% adherence to HAART at the post-HAART visit. The high self-reported level of adherence is supported by changes in laboratory measures that are influenced by HAART. The median (interquartile range) CD4 cell count measured within 6 months prior to HAART initiation was 185 (128, 253) compared to 264 (182, 380) cells/mm(3) at the post-HAART visit. Similarly, the median (interquartile range) MCV within 6 months prior to HAART initiation was 88 (83, 93) fL compared to 104 (98, 110) fL at the 12±3 month visit.

CONCLUSION

Self-reported adherence to antiretroviral treatment 12±3 months after initiating therapy was 100% in this cohort of HIV-infected Rwandan women. Future studies should explore country-specific factors that may be contributing to high levels of adherence to HAART in this population.

Beneficial effects of physical activity in an HIV-infected woman with lipodystrophy: a case report

Introduction

Lipodystrophy is common in patients infected with human immunodeficiency virus receiving highly active antiretroviral therapy, and presents with morphologic changes and metabolic alterations that are associated with depressive behavior and reduced quality of life. We examined the effects of exercise training on morphological changes, lipid profile and quality of life in a woman with human immunodeficiency virus presenting with lipodystrophy.

Case presentation

A 31-year-old Latin-American Caucasian woman infected with human immunodeficiency virus participated in a 12-week progressive resistance exercise training program with an aerobic component. Her weight, height, skinfold thickness, body circumferences, femur and humerus diameter, blood lipid profile, maximal oxygen uptake volume, exercise duration, strength and quality of life were assessed pre-exercise and post-exercise training. After 12 weeks, she exhibited reductions in her total subcutaneous fat (18.5%), central subcutaneous fat (21.0%), peripheral subcutaneous fat (10.7%), waist circumference (WC) (4.5%), triglycerides (9.9%), total cholesterol (12.0%) and low-density lipoprotein cholesterol (8.6%). She had increased body mass (4.6%), body mass index (4.37%), humerus and femur diameter (3.0% and 2.3%, respectively), high-density lipoprotein cholesterol (16.7%), maximal oxygen uptake volume (33.3%), exercise duration (37.5%) and strength (65.5%). Quality of life measures improved mainly for psychological and physical measures, independence and social relationships.

Conclusions

These findings suggest that supervised progressive resistance exercise training is a safe and effective treatment for evolving morphologic and metabolic disorders in adults infected with HIV receiving highly active antiretroviral therapy, and improves their quality of life.

Prevalence of kidney disease in HIV-infected and uninfected Rwandan women

Background

In the United States, HIV-related kidney disease disproportionately affects individuals of African descent; however, there are few estimates of kidney disease prevalence in Africa. We evaluated the prevalence of kidney disease among HIV-infected and uninfected Rwandan women.

Methods

The Rwandan Women's Interassociation Study and Assessment prospectively enrolled 936 women. Associations with estimated glomerular filtration rate (eGFR)<60 mL/min/1.73 m² and proteinuria were assessed in separate logistic regression models.

Results

Among 891 non-pregnant women with available data, 2.4% had an eGFR<60 mL/min/1.73 m² (calculated by the Modification of Diet in Renal Disease equation, MDRD eGFR) and 8.7% had proteinuria ≥1+. The prevalence of decreased eGFR varied markedly depending on the estimating method used, with the highest prevalence by Cockcroft-Gault. Regardless of the method used to estimate GFR, the proportion with decreased eGFR or proteinuria did not differ significantly between HIV-infected and -uninfected women in unadjusted analysis. After adjusting for age and blood pressure, HIV infection was associated with significantly higher odds of decreased MDRD eGFR but not proteinuria.

Conclusion

In a well-characterized cohort of Rwandan women, HIV infection was associated with decreased MDRD eGFR. The prevalence of decreased eGFR among HIV-infected women in our study was lower than that previously reported in African-Americans and in other Central and East African HIV populations, although there was substantial variability depending on the equation used to estimate GFR. Future studies are needed to optimize GFR estimates and to determine the impact of antiretroviral therapy on kidney disease in this population.

Lipoprotein levels and cardiovascular risk in HIV-infected and uninfected Rwandan women

BACKGROUND

Lipoprotein profiles in HIV-infected African women have not been well described. We assessed associations of lipoprotein levels and cardiovascular risk with HIV-infection and CD4 count in Rwandan women.

METHODS

Cross-sectional study of 824 (218 HIV-negative, 606 HIV+) Rwandan women. Body composition by body impedance analysis, CD4 count, and fasting serum total cholesterol (total-C), triglycerides (TG) and high-density lipoprotein (HDL) levels were measured. Low-density lipoprotein (LDL) was calculated from Friedewald equation if TG < 400 and measured directly if TG ≥ 400 mg/dl.

RESULTS

BMI was similar in HIV+ and -negative women, < 1% were diabetic, and HIV+ women were younger. In multivariate models LDL was not associated with HIV-serostatus. HDL was lower in HIV+ women (44 vs. 54 mg/dL, p < 0.0001) with no significant difference by CD4 count (p = 0.13). HIV serostatus (p = 0.005) and among HIV+ women lower CD4 count (p = 0.04) were associated with higher TG. BMI was independently associated with higher LDL (p = 0.01), and higher total body fat was strongly associated with higher total-C and LDL. Framingham risk scores were < 2% in both groups.

CONCLUSIONS

In this cohort of non-obese African women HDL and TG, but not LDL, were adversely associated with HIV infection. As HDL is a strong predictor of cardiovascular (CV) events in women, this HIV-associated difference may confer increased risk for CV disease in HIV-infected women.

Effect of HIV infection on body composition and fat distribution in Rwandan women

OBJECTIVE

To assess the association of HIV infection with body weight and composition in Rwandan women.

DESIGN

Body weight and composition, the latter determined by bioelectrical impedance analysis (BIA) and by anthropometry, were compared in 620 HIV-positive and 211 HIV-negative participants. Associations of HIV with body composition were assessed, and t tests compared the groups.

RESULTS

HIV-positive women were younger (-7.0 years, P < .001) and shorter (-2.1 cm, P < .001). Mean body weight, body mass index (BMI), total body fat, and waist-to-hip ratio (WHR) were similar. Mean fat-free mass was 2.5% greater in HIV-negative participants, and 19% of HIV-positive group had BMI <18.5 kg/m(2) versus 26% of the HIV-negative group (P < .05). CD4 counts and body composition were not associated.

CONCLUSIONS

Malnutrition was common in this cohort of Rwandan women. However, HIV infection was not associated with nutritional status. Factors other than malnutrition may influence quality-of-life outcomes in HIV-infected Rwandan women. Initiatives to improve nutritional status should be population-wide and not restricted to the HIV-infected population.

Human papillomavirus infection and cervical cytology in HIV-infected and HIV-uninfected Rwandan women

BACKGROUND

Data on human papillomavirus (HPV) prevalence are essential for developing cost-effective cervical cancer prevention programs.

METHODS

In 2005, 710 human immunodeficiency virus (HIV)-positive and 226 HIV-negative Rwandan women enrolled in an observational prospective cohort study. Sociodemographic data, CD4+ cell counts, and cervical specimens were obtained. Cervicovaginal lavage specimens were collected from each woman and tested for >40 HPV types by a polymerase chain reaction assay; HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68 were considered primary carcinogenic HPV types.

RESULTS

The prevalence of HPV was higher in HIV-positive women than in HIV-negative women in all age groups. Among HIV-infected women, 69% were positive for >or=1 HPV type, 46% for a carcinogenic HPV type, and 10% for HPV-16. HPV prevalence peaked at 75% in the HIV-positive women aged 25-34 years and then declined with age to 37.5% in those >or=55 years old (Ptrend<.001). A significant trend of higher prevalence of HPV and carcinogenic HPV with lower CD4+ cell counts and increasing cytologic severity was seen among HIV-positive women.

CONCLUSIONS

We found a higher prevalence of HPV infection in HIV-positive than in HIV-negative Rwandan women, and the prevalence of HPV and carcinogenic HPV infection decreased with age.

Health promotion needs of physically disabled individuals with lower limb amputation in Rwanda

PURPOSE

The objectives of the study were to identify the health-related behaviors among physically disabled individuals with lower limb amputation resident in Rwanda, the factors that influenced these behaviors, and the major issues that should be targeted in health promotion programs for physically disabled individuals with lower limb amputation.

METHOD

A cross-sectional survey, utilizing a self-administered questionnaire, was carried out among 334 lower limb amputees who volunteered to take part in the study. In addition, a sub-sample of 15 participants was purposely selected for in-depth face-to-face interviews.

RESULTS

Many participants did not engage in physical exercises (64.7%). Others abused alcohol on daily basis (14.4%), smoked 11-20 cigarettes daily (13.2%), and used recreational drugs such as marijuana, opium and cocaine (9.6%). There were significant associations between the age group of the participants and participation in exercises (P=0.001), and consuming alcohol, tobacco and recreational drugs (P=0.001). In-depth interviews revealed factors influencing the behavior of participants.

CONCLUSIONS

Participants were found to be at risk of secondary complications because of poor lifestyle choices. There is a need to develop and promote wellness-enhancing behaviors in order to enhance the health status of physically disabled individuals in Rwanda who have lower limb amputations.

The human immunodeficiency virus and the cardiometabolic syndrome in the developing world: an African perspective

The advent of highly active antiretroviral therapy (HAART) has transformed human immunodeficiency virus (HIV)/AIDS into a manageable chronic disorder. Clinical care, however, needs to address the metabolic, anthropometric, and cardiovascular changes associated with HIV infection and HAART. Studies in developing countries suggest an increasing incidence of HIV-associated cardiometabolic syndrome (CMS), especially in urban settings. Predictions indicate that the greatest increase in the prevalence of diabetes will occur in Africa over the next 2 decades due to lifestyle changes. This, coupled with increased access to HAART, may exponentially increase the prevalence of CMS in developing countries, where HIV infection is prevalent. Appropriate evaluation and intervention programs need to be implemented in the developing world, especially sub-Saharan Africa, to curtail HIV-related CMS. This should include routine cardiovascular risk assessments, management of HIV infection with more "metabolically friendly" HAART, and encouragement of lifestyle modifications, particularly smoking cessation, weight management, regular exercise, and adherence to a healthy diet.

The effects of exercise training on quality of life in HAART-treated HIV-positive Rwandan subjects with body fat redistribution

OBJECTIVE

Our objective was to examine the effects of exercise training (EXS) on quality of life (QoL) in highly active antiretroviral therapy (HAART)-treated HIV-positive (HIV+) subjects with body fat redistribution (BFR) in Rwanda.

METHODS

The effects of a randomised controlled trial of EXS on QoL were measured using World Health Organisation Quality of Life (WHOQOL)-BREF in HIV+ subjects with BFR randomised to EXS (n = 50; BFR + EXS) or no exercise training (n = 50; BFR + noEXS).

RESULTS

At 6 months, scores on the psychological [1.3 (0.3) vs. 0.5 (0.1); P < 0.0001], independence [0.6 (0.1) vs. 0.0 (0.0); P < 0.0001], social relationships [0.6 (0.2) vs. 0.0 (0.0); P < 0.0001] and HIV HAART-specific QoL domains [1.4 (0.2) vs. -0.1 (0.2); P < 0.0001] improved more in BFR + EXS than BFR + noEXS group, respectively. Self-esteem [1.3 (0.8) vs. 0.1 (0.6); P < 0.001], body image [1.5 (0.6) vs. 0.0 (0.5); P < 0.001] and emotional stress [1.6 (0.7) vs. 0.2 (0.5); P < 0.001] improved more in the BFR + EXS group than BFR + noEXS group, respectively. Psychological [1.5 (0.2) vs. 1.1 (0.3); P < 0.0001], social relationship [0.8 (0.2) vs. 0.4 (0.2); P < 0.0001], and HIV HAART-specific well-being [1.8 (0.2) vs. 1.0 (0.0); P < 0.0001] improved more in BFR + EXS female than male subjects.

CONCLUSIONS

Exercise training improved several components of QoL in HAART-treated HIV+ African subjects with BFR. Exercise training is an inexpensive and efficacious strategy for improving QoL in HIV+ African subjects, which may improve HAART adherence and treatment initiatives in resource-limited areas of sub-Saharan Africa.

Exercise training reduces central adiposity and improves metabolic indices in HAART-treated HIV-positive subjects in Rwanda: a randomized controlled trial

As HAART becomes more accessible in sub-Saharan Africa, metabolic syndromes, body fat redistribution (BFR), and cardiovascular disease may become more prevalent. We conducted a 6-month, randomized controlled trial to test whether cardiorespiratory exercise training (CET), improves metabolic, body composition and cardiorespiratory fitness parameters in HAART-treated HIV(+) African subjects with BFR. Six months of CET reduced waist circumference (-7.13 +/- 4.4 cm, p < 0.0001), WHR (-0.10 +/- 0.1, p < 0.0001), sum skinfold thickness (-6.15 +/- 8.2 mm, p < 0.0001) and % body fat mass (-1.5 +/- 3.3, p < 0.0001) in HIV(+)BFR(+)EXS. Hip circumference was unchanged in non-exercise control groups. CET reduced fasting total cholesterol (-0.03 +/- 1.11 mM, p < 0.05), triglycerides (-0.22 +/-0.48 mM, p < 0.05) and glucose levels (-0.21 +/- 0.71 mM, p < 0.05) (p < 0.0001). HDL-, LDL-cholesterol and HOMA values were unchanged after CET. Interestingly, HIV(+) subjects randomized to non-exercising groups experienced increases in fasting plasma glucose levels, whereas HIV seronegative controls did not (p < 0.001). Predicted VO(2) peak increased more in the HIV(+)BFR(+)EXS than in all other groups (4.7 +/- 3.9 ml/kg/min, p < 0.0001). Exercise training positively modulated body composition and metabolic profiles, and improved cardiorespiratory fitness in HAART-treated HIV(+) Africans. These beneficial adaptations imply that exercise training is a safe, inexpensive, practical, and effective treatment for evolving metabolic and cardiovascular syndromes associated with HIV and HAART exposure in resource-limited sub-Saharan countries, where treatment is improving, morbidity and mortality rates are declining, but where minimal resources are available to manage HIVand HAART-associated cardiovascular and metabolic syndromes.

Assessment of quality of life in HAART-treated HIV-positive subjects with body fat redistribution in Rwanda

Background

The introduction of HAART has initially improved the quality of life (QoL) of HIV-positive (HIV+) patients, however body fat redistribution (BFR) and metabolic disorders associated with long-term HAART use may attenuate this improvement. As access to treatment improves in sub-Saharan Africa, the disfiguring nature of BFR (peripheral atrophy and/or central adiposity) may deter treatment adherence and initiatives and decrease QoL. We examined the relationship between BFR and domains of QoL in HAART-treated HIV+ African men and women with (HIV+BFR, n = 50) and without (HIV+noBFR, n = 50) BFR in Rwanda.

Results

HIV+ subjects with BFR were less satisfied with their body image (4.3 ± 0.1 versus 1.5 ± 0.2; p < .001), self-esteem and social life (4.1 ± 1.4 versus 2.1 ± 0.3; p = 0.003). HIV+BFR were more ashamed in public (4.5 ± 1.2 versus 1.1 ± 1.1), reported less confident about their health (4.6 ± 1.4 versus 1.5 ± 1.2) and were frequently embarrassed due to body changes (4.1 ± 1.1 versus 1.1 ± 0.9) (p < .001) than HIV+noBFR. HIV+ Rwandan women with BFR reported more dissatisfaction with psychological (8.3 ± 2.9 versus 13.7 ± 1.9), social relationships (6.9 ± 2.3 versus 11.1 ± 4.1) and HIV HAART-specific domain of wellbeing (3.1 ± 4.8 versus 6.3 ± 3.6) (p < .001). Age was associated with independence (r² = 0.691; p = 0.009) and marital status was associated with psychological (r² = 0.593; p = 0.019) and social relationships (r² = 0.493; p = 0.007). CD4 count (r² = 0.648; p = 0.003) and treatment duration (r² = 0.453; p = 0.003) were associated with HIV HAART-specific domain of wellbeing. HIV+ Rwandan women with BFR were significantly more affected by abdominal adiposity (p < .001), facial and buttocks atrophy (p < .05) than HIV+ men with BFR.

Conclusion

Body fat alterations negatively affect psychological and social domains of quality of life. These symptoms may result in stigmatization and marginalization mainly in HAART-treated African women, adversely affecting HAART adherence and treatment initiatives. Efforts to evaluate self-perceived body fat changes may improve patients' wellbeing, HAART adherence and treatment outcomes and contribute towards stability in quality of life continuum.

Hiv-associated lipodystrophy and exercise

As individuals affected by HIV/AIDS live longer due to the availability of HAART, the challenge to health care professionals is to manage and alleviate abnormalities associated with HAART. HIVlipodystrophy- altered body fat redistribution- is the most common stigmatising physical abnormality related to the use of HAART, which maybe alleviated by exercise participation. Currently, there is no reliable management standard care for HIV-associated lipodystrophy. However, there is sufficient evidence to support the benefits of exercise in adults with HIV infection. As various types of ARTs become available in the most HIV/AIDS stricken developing countries, there are inadequate studies to evaluate and promote exercise in alleviating HIV lipodystrophy and other related complications. The current paper reviews HIV-related lipodystrophy, related metabolic dysfunction, and the role of exercise in its management. The paper highlights the need to evaluate the effectiveness of exercise on HIV lipodystrophy syndrome. An emphasis needs to be put on raising awareness among health care professionals in Sub-Saharan Africa where the prevalence of HIV/AIDS is the  highest in the world.