Medical Education Partnership Initiative (MEPI) in Zimbabwe: Outcomes and Challenges

The 5-year medical education and research strengthening initiative in Zimbabwe increased faculty retention and student enrollment, improved information technology infrastructure, provided mentoring for postgraduates and clinical training in specialty areas, instituted a competency-based curriculum reform process, and created new departments and centers to institutionalize health education and research implementation. A comprehensive review of the curriculum is still underway and uptake of technology-assisted teaching has been slower than expected.

Background:

Sub-Saharan Africa has an inadequate number of health professionals, leading to a reduced capacity to respond to health challenges, including HIV/AIDS. From 2010 to 2015, the Medical Education Partnership Initiative (MEPI)—sponsored by the U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR) and the National Institutes of Health (NIH)—was enthusiastically taken up by the University of Zimbabwe College of Health Sciences (UZCHS) and 12 other sub-Saharan African universities to develop models of training to improve medical education and research capacity. In this article, we describe the outcomes and challenges of MEPI in Zimbabwe.

Methods:

UZCHS in partnership with the University of Colorado, Denver; Stanford University; University of Cape Town; University College London; and King's College London designed the Novel Education Clinical Trainees and Researchers (NECTAR) program and 2 linked awards addressing cardiovascular disease and mental health to pursue MEPI objectives. A range of medical education and research capacity-focused programs were implemented, including faculty development, research support, mentored scholars, visiting professors, community-based education, information and technology support, cross-cutting curricula, and collaboration with partner universities and the ministries of health and education. We analyzed quantitative and qualitative data from several data sources, including annual surveys of faculty, students, and other stakeholders; workshop exit surveys; and key informant interviews with NECTAR administrators and leaders and the UZCHS dean.

Findings:

Improved Internet connectivity and electronic resource availability were early successes of NECTAR. Over the 5-year period, 69% (115 of 166) of faculty members attended at least 1 of 15 faculty development workshops. Forty-one faculty members underwent 1-year advanced faculty development training in medical education and leadership. Thirty-three mentored research scholars were trained under NECTAR, and 52 and 12 in cardiovascular and mental health programs, respectively. Twelve MEPI scholars had joined faculty by 2015. Full-time faculty grew by 36% (122 to 166), annual postgraduate and medical student enrollment increased by 61% (75 to 121) and 71% (123 to 210), respectively. To institutionalize and sustain MEPI innovations, the Research Support Center and the Department of Health Professions Education were established at UZCHS.

Conclusion:

MEPI has synergistically revitalized medical education, research capacity, and leadership at UZCHS. Investments in creating a new research center, health professions education department, and, programs have laid the foundation to help sustain faculty development and research capacity in the country.

The shifting epidemiology of colorectal cancer in sub-Saharan Africa

The perception that colorectal cancer is rare in sub-Saharan Africa is widely held; however, it is unclear whether this is due to poor epidemiological data or to lower disease rates. The quality of epidemiological data has somewhat improved, and there is an ongoing transition to western dietary and lifestyle practices associated with colorectal cancer. The impact of these changes on the incidence of colorectal cancer is not as evident as it is with other non-communicable diseases such as diabetes. In this Viewpoint, we discuss the epidemiology of colorectal cancer in sub-Saharan Africa. Colorectal cancer in this region frequently occurs at an early age, often with distinctive histological characteristics. We detail the crucial need for hypothesis-driven research on the risk factors for colorectal cancer in this population and identify key research gaps. Should colorectal cancer occur more frequently than assumed, then commensurate allocation of resources will be needed for diagnosis and treatment.

Peripartum cardiomyopathy among cardiovascular patients referred for echocardiography at Parirenyatwa Teaching Hospital, Harare, Zimbabwe

OBJECTIVES

The main aim was to evaluate the outcome of patients with peripartum cardiomyopathy (PPCM) within six months of diagnosis. The secondary aim was to describe demographic and clinical characteristics of patients with PPCM in Harare, Zimbabwe.

METHODS

This was a prospective cohort study in which patients recruited into a detailed PPCM registry were followed up for six months. Echocardiograms were performed at enrolment, and three and six months after diagnosis, to determine left ventricular function.

RESULTS

From 1 August 2012 to 31 July 2013, 43 patients with a new diagnosis of PPCM were recruited at Parirenyatwa Hospital in Harare. At six months, mean ejection fraction improved from 29.7 ± 9.8 to 44.9 ± 14.9%, p < 0.001 and New York Heart Association (NYHA) functional class improved significantly (p < 0.0001). Five (11.6%) patients died.

CONCLUSIONS

Left ventricular function improved in a substantial number of patients (42.9%) in this Zimbabwean cohort compared to other African cohorts. However the mortality rate remained high.

Prednisolone and Mycobacterium indicus pranii in tuberculous pericarditis

BACKGROUND

Tuberculous pericarditis is associated with high morbidity and mortality even if antituberculosis therapy is administered. We evaluated the effects of adjunctive glucocorticoid therapy and Mycobacterium indicus pranii immunotherapy in patients with tuberculous pericarditis.

METHODS

Using a 2-by-2 factorial design, we randomly assigned 1400 adults with definite or probable tuberculous pericarditis to either prednisolone or placebo for 6 weeks and to either M. indicus pranii or placebo, administered in five injections over the course of 3 months. Two thirds of the participants had concomitant human immunodeficiency virus (HIV) infection. The primary efficacy outcome was a composite of death, cardiac tamponade requiring pericardiocentesis, or constrictive pericarditis.

RESULTS

There was no significant difference in the primary outcome between patients who received prednisolone and those who received placebo (23.8% and 24.5%, respectively; hazard ratio, 0.95; 95% confidence interval [CI], 0.77 to 1.18; P=0.66) or between those who received M. indicus pranii immunotherapy and those who received placebo (25.0% and 24.3%, respectively; hazard ratio, 1.03; 95% CI, 0.82 to 1.29; P=0.81). Prednisolone therapy, as compared with placebo, was associated with significant reductions in the incidence of constrictive pericarditis (4.4% vs. 7.8%; hazard ratio, 0.56; 95% CI, 0.36 to 0.87; P=0.009) and hospitalization (20.7% vs. 25.2%; hazard ratio, 0.79; 95% CI, 0.63 to 0.99; P=0.04). Both prednisolone and M. indicus pranii, each as compared with placebo, were associated with a significant increase in the incidence of cancer (1.8% vs. 0.6%; hazard ratio, 3.27; 95% CI, 1.07 to 10.03; P=0.03, and 1.8% vs. 0.5%; hazard ratio, 3.69; 95% CI, 1.03 to 13.24; P=0.03, respectively), owing mainly to an increase in HIV-associated cancer.

CONCLUSIONS

In patients with tuberculous pericarditis, neither prednisolone nor M. indicus pranii had a significant effect on the composite of death, cardiac tamponade requiring pericardiocentesis, or constrictive pericarditis. (Funded by the Canadian Institutes of Health Research and others; IMPI ClinicalTrials.gov number, NCT00810849.).

Cardiac disease in adolescents with delayed diagnosis of vertically acquired HIV infection

BACKGROUND

At least one-third of human immunodeficiency virus (HIV)-infected infants survive to adolescence even without antiretroviral therapy (ART), but are at high risk of complications including cardiac disease. We investigated the characteristics of cardiac disease among adolescents with HIV infection diagnosed in late childhood who were receiving ambulatory HIV care in Harare, Zimbabwe.

METHODS

Consecutive adolescents with vertically acquired HIV attending 2 HIV outpatient treatment clinics were studied. Assessment included clinical history and examination, and 2-dimensional, M-mode, pulsed- and continuous-wave Doppler echocardiography.

RESULTS

Of 110 participants (47% male; median age, 15 years; interquartile range, 12-17 years), 78 (71%) were taking ART. Exertional dyspnea, chest pain, palpitations, and ankle swelling were reported by 47 (43%), 43 (39%), 10 (9%), and 7 (6%), respectively. The New York Heart Association score was ≥ 2 in 41 participants (37%). Echocardiography showed that 74 participants (67%) had left ventricular (LV; septal and/or free wall) hypertrophy and 27 (24%) had evidence of impaired LV relaxation or restrictive LV physiology. The estimated pulmonary artery systolic pressure (ePASP) was >30 mm Hg in 4 participants (3.6%); of these 2 also had right ventricular (RV) dilatation. Another 32 participants (29%), without elevated ePASP, had isolated RV dilatation.

CONCLUSIONS

A significant burden of cardiac disease was seen among adolescents with vertically acquired HIV infection. More than half were asymptomatic yet had significant echocardiographic abnormalities. These findings highlight the need to screen this population in order to better define the geography, natural history, etiopathogenic mechanisms, and management (including the timing and choice of optimal therapeutic ART and cardiac drug interventions) to prevent development and/or progression of HIV-associated cardiac disease.

Rationale and design of the Investigation of the Management of Pericarditis (IMPI) trial: a 2 × 2 factorial randomized double-blind multicenter trial of adjunctive prednisolone and Mycobacterium w immunotherapy in tuberculous pericarditis

BACKGROUND

In spite of antituberculosis chemotherapy, tuberculous (TB) pericarditis causes death or disability in nearly half of those affected. Attenuation of the inflammatory response in TB pericarditis may improve outcome by reducing cardiac tamponade and pericardial constriction, but there is uncertainty as to whether adjunctive immunomodulation with corticosteroids and Mycobacterium w (M. w) can safely reduce mortality and morbidity.

OBJECTIVES

The primary objective of the IMPI Trial is to assess the effectiveness and safety of prednisolone and M. w immunotherapy in reducing the composite outcome of death, constriction, or cardiac tamponade requiring pericardial drainage in 1,400 patients with TB pericardial effusion.

DESIGN

The IMPI trial is a multicenter international randomized double-blind placebo-controlled 2 × 2 factorial study. Eligible patients are randomly assigned to receive oral prednisolone or placebo for 6 weeks and M. w injection or placebo for 3 months. Patients are followed up at weeks 2, 4, and 6 and months 3 and 6 during the intervention period and 6-monthly thereafter for up to 4 years. The primary outcome is the first occurrence of death, pericardial constriction, or cardiac tamponade requiring pericardiocentesis. The secondary outcome is safety of immunomodulatory treatment measured by effect on opportunistic infections (eg, herpes zoster) and malignancy (eg, Kaposi sarcoma) and impact on measures of immunosuppression and the incidence of immune reconstitution disease.

CONCLUSIONS

IMPI is the largest trial yet conducted comparing adjunctive immunotherapy in pericarditis. Its results will define the role of adjunctive corticosteroids and M. w immunotherapy in patients with TB pericardial effusion.

Routine versus clinically driven laboratory monitoring of HIV antiretroviral therapy in Africa (DART): a randomised non-inferiority trial

BACKGROUND

HIV antiretroviral therapy (ART) is often managed without routine laboratory monitoring in Africa; however, the effect of this approach is unknown. This trial investigated whether routine toxicity and efficacy monitoring of HIV-infected patients receiving ART had an important long-term effect on clinical outcomes in Africa.

METHODS

In this open, non-inferiority trial in three centres in Uganda and one in Zimbabwe, 3321 symptomatic, ART-naive, HIV-infected adults with CD4 counts less than 200 cells per microL starting ART were randomly assigned to laboratory and clinical monitoring (LCM; n=1659) or clinically driven monitoring (CDM; n=1662) by a computer-generated list. Haematology, biochemistry, and CD4-cell counts were done every 12 weeks. In the LCM group, results were available to clinicians; in the CDM group, results (apart from CD4-cell count) could be requested if clinically indicated and grade 4 toxicities were available. Participants switched to second-line ART after new or recurrent WHO stage 4 events in both groups, or CD4 count less than 100 cells per microL (LCM only). Co-primary endpoints were new WHO stage 4 HIV events or death, and serious adverse events. Non-inferiority was defined as the upper 95% confidence limit for the hazard ratio (HR) for new WHO stage 4 events or death being no greater than 1.18. Analyses were by intention to treat. This study is registered, number ISRCTN13968779.

FINDINGS

Two participants assigned to CDM and three to LCM were excluded from analyses. 5-year survival was 87% (95% CI 85-88) in the CDM group and 90% (88-91) in the LCM group, and 122 (7%) and 112 (7%) participants, respectively, were lost to follow-up over median 4.9 years' follow-up. 459 (28%) participants receiving CDM versus 356 (21%) LCM had a new WHO stage 4 event or died (6.94 [95% CI 6.33-7.60] vs 5.24 [4.72-5.81] per 100 person-years; absolute difference 1.70 per 100 person-years [0.87-2.54]; HR 1.31 [1.14-1.51]; p=0.0001). Differences in disease progression occurred from the third year on ART, whereas higher rates of switch to second-line treatment occurred in LCM from the second year. 283 (17%) participants receiving CDM versus 260 (16%) LCM had a new serious adverse event (HR 1.12 [0.94-1.32]; p=0.19), with anaemia the most common (76 vs 61 cases).

INTERPRETATION

ART can be delivered safely without routine laboratory monitoring for toxic effects, but differences in disease progression suggest a role for monitoring of CD4-cell count from the second year of ART to guide the switch to second-line treatment.

FUNDING

UK Medical Research Council, the UK Department for International Development, the Rockefeller Foundation, GlaxoSmithKline, Gilead Sciences, Boehringer-Ingelheim, and Abbott Laboratories.

Correlates of blood pressure in an urban Zimbabwean population and comparison to other populations of African origin

We have evaluated the relationship between systolic blood pressure (SBP) and age, body mass index (BMI), waist circumference, sodium to potassium ratio (Na/K), and tobacco use in an urban African population. We conducted a random, population-based, cross-sectional survey of people 25 years and older in Marondera, Zimbabwe, with over-sampling in older age groups (n = 775), using a method comparable to that used in International Collaborative Study on Hypertension in Blacks (ICSHIB). The age-adjusted prevalences of hypertension in Marondera (SBP >/=140/DBP >/=90/antihypertensive medication) were 30% for women and 21% for men. The average BMI was 26.3 kg/m2 for women and 21.4 kg/m2 for men. The prevalence of hypertension had a steep association with age and in women ranged from 15% (25-34 years) to 63% (55 years and over) and in men from 9% to 47%. No tobacco use in women and greater Na/K ratio in spot urines in men were significantly associated with an increased SBP. In both men and women the levels of hypertension and SBP were strongly positively associated with BMI, although the relationship appeared to plateau in women with a BMI greater than >/=25 kg/m2. At a given BMI, men and women had similar SBPs and prevalences of hypertension. There is a very high prevalence of hypertension among urban Zimbabweans, particularly among women. Under the assumption the studies are comparable, the prevalence of hypertension in Zimbabwean women (41%) and men (26%) after age adjustment to the ICSHIB populations, appeared higher than almost all of the ICSHIB populations, including those with higher average body mass indexes. Journal of Human Hypertension (2000) 14, 65-73.

Variation in in-patient stroke management in ten centres in different countries: the INCLEN multicentre stroke collaboration

BACKGROUND AND PURPOSE

Large within-country variations have been described in stroke management and there have been a few studies of between-country variation (in the USA and the UK). We designed a study to examine stroke management across a wide range of countries representing different stages of economic development. Large variations would suggest the need to explore methods of increasing the uptake of evidence-based stroke practice.

METHODS

Members of the International Clinical Epidemiology Network (INCLEN) from 14 centres in ten countries agreed to review the records of the last 50 patients admitted to hospital with a clinical diagnosis of stroke. Information on demographic variables, the clinical diagnosis of stroke type, investigations performed and treatments given and the discharge destination of the patient were recorded and sent to the coordinating centre in Australia for analysis.

RESULTS

There were statistically significant between-centre differences in the proportions of patients cared for by a neurologist, staying in hospital for at least ten days and having CT or MRI scans. Significant between-centre differences were also seen for treatment, for example, the use of aspirin in non-haemorrhagic stroke varied from 11 to 79%. The variation (for all interventions studied) was no longer statistically significant when examined within strata according to availability of facilities.

CONCLUSIONS

The large variation between centres in the management of stroke is largely 'explained' by the availability of resources, even for interventions that do not depend on resource availability. It will be important to develop management guidelines that reflect evidence-based practice of relevance across a range of economic settings.

Cardiovascular reactivity in Zimbabwe

OBJECTIVE

In this study, we examined the effects of residency and gender on cardiovascular reactivity to a speech stressor in 50 rural Zimbabweans (24 males, 26 females) and 47 urban Zimbabweans (25 males and 22 females).

METHODS

Participants were engaged in 4 periods: pre-task rest period, speech preparatory period, speaking task period, and the final recovery period. During each period, systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were assessed.

RESULTS

There was a significant interaction between area of residence and period for SBP and HR. Urban residents exhibited greater SBP and HR during the speaking phase of the speech task than did rural residents. However, rural residents displayed more exaggerated HR reactivity during the speech preparatory phase as compared to the urban residents. No gender differences were observed on blood pressure or heart rate reactivity.

CONCLUSION

In conclusion, the more exaggerated SBP and HR reactivity to the speaking phase among urban residents as compared to rural residents may be influenced by factors associated with urbanization.

Effects of parental history of hypertension and urbanization on blood pressure in zimbabweans

The increasing prevalence of essential hypertension is a growing public health concern for Zimbabwe and other African countries. Two important risk factors for hypertension are urbanization and parental history of hypertension. The relations among parental history of hypertension, urbanization, and blood pressures (BPs) are poorly understood. The objective of this study is to clarify these relations in a population of urbanized, African, young adults. The relation between parental history of hypertension and urbanization on resting BP's and Bp responses to a mental arithmetic stressor was examined in a group of normotensive, Black medical students with (n = 36) and without (n = 34) a parental history of high BP, and with (n = 49) and without (n = 19) a parental history of urbanization. Results indicate that those with a positive parental history counterparts. Further, those with parents residing in urban areas had higher resting SBPs than those with parents residing in rural areas. However, no reactivity differences were apparent between the urban and rural parent groups. These data suggest that although parental history for hypertension influences both resting and reactivity BP's parental history of urbanization may influence only resting BP.

Stroke incidence rates among black residents of Harare--a prospective community-based study

OBJECTIVE

To estimate the crude incidence rates of cerebrovascular accidents among the black residents of Harare.

DESIGN

Prospective community-based study.

SETTING

Black residents of Harare, Zimbabwe.

PARTICIPANTS

Two hundred and seventy-three 'first-ever' strokes prospectively identified over a 12-month period. MAIN OUTCOME STUDY FACTORS: Cerebrovascular accident first-week fatality rate; age- and sex-related incidence.

RESULTS

The crude incidence rate was estimated to be 30.7 per 100000 (95% confidence interval 27.1-34.4) and the standardised rate was 68 per 100000. Fifty-one per cent of stroke victims were below the age of 54 years. Thirty-five per cent of patients died within 1 week of the stroke. Overall, the age-specific rates for both sexes rose with age, with the rates for women being higher at all age strata except for the group 45-54 years.

CONCLUSION

With a standardised rate of 68 per 100000 and a first-week mortality rate of 35%, stroke must now be considered an important cause of morbidity and mortality in the population.

Acute myocardial infarction in Zimbabwe: the changing scene of coronary artery disease

From 1988 to 1993 (six years), 127 suspected cases of acute myocardial infarction (AMI) were admitted to the Parirenyatwa Hospital coronary care unit. AMI was confirmed in 76 cases, 37 were Black, 27 White, six Indian and six Coloured. For Blacks the male to female ratio was 5:1. The clinical and laboratory features and complications of AMI were similar in all ethnic groups. Compared to other groups, Blacks presented to hospital late, an observation which has important implications for thrombolytic therapy. With the increasing number of cases of AMI now being seen among Black Zimbabweans, the time has come for the evaluation of the changing risk factor profile and the initiation of education and intervention programmes which could contain this rise before it spirals into a major health problem.

Blood pressure response to acute changes in dietary sodium in young Zimbabwean men

OBJECTIVE

The primary objective of this study was to determine the effect of acute alterations in sodium intake upon the blood pressure and hormone levels of young Zimbabwean men.

DESIGN

Blood pressure, 24-h urinary electrolyte excretion and plasma concentrations of angiotensin II, aldosterone, and atrial natriuretic peptide were measured in normotensive black medical students. Three sets of measurements were taken: (1) during free access to sodium (baseline); (2) after 4 days on a low-sodium diet (10 mmol/day); and (3) after 4 days on a high-sodium diet (800 mmol/day).

METHODS

Blood pressure was measured by random zero sphygmomanometry, hormone levels by radioimmunoassay, and urinary electrolytes by flame photometry.

RESULTS

The low-sodium diet caused the range of pulse pressure to narrow, with a decrease in systolic blood pressure (SBP) and an increase in diastolic blood pressure (DBP). With the introduction of the high-sodium diet, SBP increased and DBP decreased. Mean arterial pressure did not change. At the same time, angiotensin II and aldosterone decreased. Plasma atrial natriuretic peptide did not change. A subgroup of the men on the high-sodium diet also received 100 mmol potassium/day. The increase in SBP associated with high sodium was significantly attenuated by the presence of added potassium.

CONCLUSIONS

SBP of young black Zimbabwean men is lowered by dietary sodium restriction and rises with a large increase in dietary sodium for a short duration, but mean arterial pressure does not change due to the opposing decreases in DBP.

Misdiagnosis of aneurysms: a case report

Three cases in which aneurysms were misdiagnosed to less serous lesions are described. Attention is drawn to the possibility of these errors whose consequences can be fatal. Some of the problems associated with the handling of an inadvertently opened aneurysm are discussed.

Strokes among black people in Harare, Zimbabwe: results of computed tomography and associated risk factors

Computed tomography was performed and risk factors evaluated in 100 consecutive adult patients presenting to the two teaching hospitals in Harare with a clinical diagnosis of stroke. The mean age of the patients was 52; only 28 were 65 or older. Non-stroke lesions were found in seven patients and were predicted by a recent history of convulsions (p less than 0.0001). Five lesions (four subdural haematomas and one cerebral cysticercosis) were remediable. Hypertension was present in 27 (93%) of the 29 patients with cerebral haemorrhage and in 49 (53%) of the 93 patients with stroke lesions. In 22 (45%) of these patients the hypertension had not been diagnosed, and another 22 had defaulted from treatment. All 13 patients who died before computed tomography had hypertension, and over half showed evidence of haemorrhagic stroke. There was a cardiac source for all 12 cases of cerebral embolism. In eight of the 100 patients cerebral infarction was attributed to neurosyphilis. None of the patients had clinical evidence of atherosclerosis. Smoking and oral contraceptives did not seem important risk factors for stroke. Detection and control of hypertension remain the most important measures needed to reduce the incidence of and mortality from stroke in Zimbabwe.

Investigations of long-term treatment with perhexiline maleate using therapeutic monitoring and electromyography

Experience is reported with 41 patients taking perhexiline maleate for angina pectoris for periods of up to 70 months, while serum concentrations of the drug were monitored, and liver function tests and electromyographic tests were made before and during treatment. Severe side effects did not occur unless serum perhexiline levels were greater than 1.5 mg/L. The drug seems effective for prolonged dosage, and the monitoring of weight, liver function test results, and serum concentrations should prevent or reduce toxicity. A starting dose of 100 mg daily is recommended. The drug is not recommended for routine use in angina pectoris.

Plasma disopyramide concentrations following a 300-mg oral loading dose in acute myocardial infarction

Plasma disopyramide concentrations were measured in 19 patients with suspected myocardial infarction (MI) following an oral loading dose of 300 mg. Infarction was confirmed in 17 patients. In 10 patients blood samples were collected frequently over a period of 6 h, and in the remaining nine, blood samples were collected for 60 h whilst they were receiving a maintenance dose of 100 mg six hourly. There was a wide variation in the absorption of the drug, and only 8 patients achieved plasma concentrations in the range 2-4 mg/L within one hour of ingestion; 8 of the patients on maintenance therapy were within this range 24 h following the start of therapy. Although only 2 noninfarct patients were observed, they achieved the highest plasma disopyramide concentrations--above the therapeutic range--within 1 h of receiving the loading dose. Narcotic analgesia was associated with poor absorption of the drug, but this does not exclude severity of infarction or vomiting after the loading dose from contributing to the wide variation in plasma concentrations in the early stages following the loading dose. It is concluded that this regime is unsuitable for prophylactic use in acute MI.