Perspectives Among Health Care Providers and People with HIV on the Implementation of Long-Acting Injectable Cabotegravir/Rilpivirine for Antiretroviral Therapy in Florida.

Long-acting injectable (LAI) cabotegravir/rilpivirine (CAB/RPV) for antiretroviral therapy (ART) could benefit many people with HIV (PWH). However, its impact will largely be determined by providers' willingness to prescribe it and PWH's willingness to take it. This study explores the perceived barriers and facilitators of LAI CAB/RPV implementation among PWH and HIV care providers in Florida, a high prevalence setting. Semi-structured qualitative interviews were conducted in English with 16 PWH (50% non-Hispanic White, 50% cis men, and 94% on oral ART) and 11 providers (27% non-Hispanic Black, 27% Hispanic, 73% cis women, and 64% prescribed LAI CAB/RPV) throughout the state. Recruitment occurred between October 2022 and October 2023 from HIV clinics. Interviews were recorded, professionally transcribed, and then double coded using thematic analysis. The Consolidated Framework for Implementation Research guided the interview guide and coding. While PWH viewed LAI CAB/RPV as effective, predominant barriers included administration via injection, challenges of attending more clinic visits, and a feeling that this made HIV the center of one's life. Providers additionally expressed concerns about the development of integrase resistance. Barriers noted by PWH and providers outside of the clinic included transportation, stigma, access inequities, and payor issues. Within clinics, providers identified the need for extra staffing and the increased burden on existing staff as barriers. These barriers decreased the perceived need for LAI CAB/RPV among PWH and providers, especially with the high effectiveness of oral ART. Many of the identified barriers occur outside of the clinic and will likely apply to other novel long-acting ART options.

Subarachnoid Neurocysticercosis Case Series Reveals a Significant Delay in Diagnosis-Requiring a High Index of Suspicion Among Those at Risk.

Subarachnoid neurocysticercosis can be challenging to recognize, which often leads to a delay in diagnosis. We report 3 cases presenting as chronic headache disorders that highlight the unique manifestations seen with this form of neurocysticercosis and the role that the infectious diseases consultant can play in ensuring a timely diagnosis.

Comorbidity Burden and Health Care Utilization by Substance use Disorder Patterns among People with HIV in Florida.

Substance use disorder (SUD), a common comorbidity among people with HIV (PWH), adversely affects HIV clinical outcomes and HIV-related comorbidities. However, less is known about the incidence of different chronic conditions, changes in overall comorbidity burden, and health care utilization by SUD status and patterns among PWH in Florida, an area disproportionately affected by the HIV epidemic. We used electronic health records (EHR) from a large southeastern US consortium, the OneFlorida + clinical research data network. We identified a cohort of PWH with 3 + years of EHRs after the first visit with HIV diagnosis. International Classification of Diseases (ICD) codes were used to identify SUD and comorbidity conditions listed in the Charlson comorbidity index (CCI). A total of 42,271 PWH were included (mean age 44.5, 52% Black, 45% female). The prevalence SUD among PWH was 45.1%. Having a SUD diagnosis among PWH was associated with a higher incidence for most of the conditions listed on the CCI and faster increase in CCI score overtime (rate ratio = 1.45, 95%CI 1.42, 1.49). SUD in PWH was associated with a higher mean number of any care visits (21.7 vs. 14.8) and more frequent emergency department (ED, 3.5 vs. 2.0) and inpatient (8.5 vs. 24.5) visits compared to those without SUD. SUD among PWH was associated with a higher comorbidity burden and more frequent ED and inpatient visits than PWH without a diagnosis of SUD. The high SUD prevalence and comorbidity burden call for improved SUD screening, treatment, and integrated care among PWH.

Predictors of prior HIV testing and acceptance of a community-based HIV test offer among male bar patrons in northern Tanzania.

Community-based HIV testing offers an alternative approach to encourage HIV testing among men in sub-Saharan Africa. In this study, we evaluated a community-based HIV testing strategy targeting male bar patrons in northern Tanzania to assess factors predictive of prior HIV testing and factors predictive of accepting a real-time HIV test offer. Participants completed a detailed survey and were offered HIV testing upon survey completion. Poisson regression was used to identify prevalence ratios for the association between potential predictors and prior HIV testing or real-time testing uptake. Of 359 participants analyzed, the median age was 41 (range 19-82) years, 257 (71.6%) reported a previous HIV test, and 321 (89.4%) accepted the real-time testing offer. Factors associated with previous testing for HIV (adjusted prevalence ratio [aPR], 95% CI) were wealth scores in the upper-middle quartile (1.25, 1.03-1.52) or upper quartile (1.35, 1.12-1.62) and HIV knowledge (1.04, 1.01-1.07). Factors that predicted real-time testing uptake were lower scores on the Gender-Equitable Men scale (0.99, 0.98-0.99), never testing for HIV (1.16, 1.03-1.31), and testing for HIV > 12 months prior (1.18, 1.06-1.31). We show that individual-level factors that influence the testing-seeking behaviors of men are not likely to impact their acceptance of an HIV offer.

Depression and Anxiety Symptoms and Treatment Utilization, and Associated HIV Outcomes among Adults with HIV in Rural Florida.

Persons living with HIV (PLWH) and depression or anxiety in the rural South may have suboptimal HIV outcomes. We sought to examine the proportion of PLWH from rural Florida with symptoms of depression or anxiety, the proportion who received depression or anxiety treatment, and the relationship between untreated and treated symptoms of depression or anxiety and HIV outcomes. Cross-sectional survey data collected between 2014 and 2018 were analyzed. Among 187 PLWH residing in rural Florida (median age 49 years, 61.5%, male 45.5% Black), 127 (67.9%) met criteria for symptoms of depression and/or anxiety. Among these 127 participants, 60 (47.2%) were not on depression or anxiety treatment. Participants with untreated symptoms of depression and anxiety (OR 3.2, 95% CI 1.2-9.2, p = 0.03) and treated depression and anxiety with uncontrolled symptoms (OR 1.4, 95% CI 0.5-4.0, p = 0.52) were more likely to have viral non-suppression compared to those without depression or anxiety in an unadjusted bivariate analysis. Only the association between untreated symptoms of depression and anxiety and viral non-suppression was statistically significant, and when adjusting for social and structural confounders the association was attenuated and was no longer statistically significant. This suggests that social and structural barriers impact both mental health and HIV outcomes. Our findings support the need for increased mental health services and resources that address the social and structural barriers to care for PLWH in the rural South.

Six month incidence of major adverse cardiovascular events among adults with HIV in northern Tanzania: a prospective observational study.

OBJECTIVES: We aimed to prospectively describe incident cardiovascular events among people living with HIV (PLWH) in northern Tanzania. Secondary aims of this study were to understand non-communicable disease care-seeking behaviour and patient preferences for cardiovascular care and education. DESIGN: A prospective observational study. SETTING: This study was conducted at the Majengo HIV Care and Treatment Clinic, an outpatient government-funded clinic in Moshi, Tanzania PARTICIPANTS: Adult patients presenting to an HIV clinic for routine care in northern Tanzania were enrolled from 1 September 2020 to 1 March 2021. INTERVENTIONS: At enrolment, participants completed a survey and a resting 12-lead ECG was obtained. At 6 month follow-up, a repeat survey regarding interim health events and repeat ECG was obtained. PRIMARY AND SECONDARY OUTCOME MEASURES: Interim major adverse cardiovascular events (MACE) were defined by: self-reported interim stroke, self-reported hospitalisation for heart failure, self-reported interim myocardial infarction, interim myocardial infarction by ECG criteria (new pathologic Q waves in two contiguous leads) or death due to cardiovascular disease (CVD). RESULTS: Of 500 enrolled participants, 477 (95.4%) completed 6 month follow-up and 3 (0.6%) died. Over the 6 month follow-up period, 11 MACE occurred (3 strokes, 6 myocardial infarctions, 1 heart failure hospitalisation and 1 cardiovascular death), resulting in an incidence rate of 4.58 MACE per 100 person-years. Of participants completing 6 month follow-up, 31 (6.5%) reported a new non-communicable disease diagnosis, including 23 (4.8%) with a new hypertension diagnosis. CONCLUSIONS: The incidence of MACE among PLWH in Tanzania is high. These findings are an important preliminary step in understanding the landscape of CVD among PLWH in Tanzania and highlight the need for interventions to reduce cardiovascular risk in this population.

Six-month incidence of hypertension and diabetes among adults with HIV in Tanzania: A prospective cohort study.

Data describing the incidence of hypertension and diabetes among people with HIV in sub-Saharan Africa remain sparse. In this study, adults with HIV were enrolled from a public clinic in Moshi, Tanzania (September 2020-March 2021). At enrollment, a survey was administered to collect information on comorbidities and medication use. Each participant's blood pressure and point-of-care glucose were measured. Baseline hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension at enrollment. Baseline diabetes was defined by self-reported diabetes or hyperglycemia (fasting glucose ≥126 mg/dl or random glucose ≥200 mg/dl) at enrollment. At 6-month follow-up, participants' blood pressure and point-of-care glucose were again measured. Incident hypertension was defined by self-report of new hypertension diagnosis or blood pressure ≥140/90 mmHg at follow-up in a participant without baseline hypertension. Incident diabetes was defined as self-report of new diabetes diagnosis or measured hyperglycemia at follow-up in a participant without baseline diabetes. During the study period, 477 participants were enrolled, of whom 310 did not have baseline hypertension and 457 did not have baseline diabetes. At six-month follow-up, 51 participants (95% CI: 38, 67) had new-onset hypertension, corresponding to an incidence of 33 new cases of hypertension per 100 person-years. Participants with incident hypertension at 6-month follow-up were more likely to have a history of alcohol use (90.2% vs. 73.7%, OR = 3.18, 95% CI:1.32-9.62, p = 0.008) and were older (mean age = 46.5 vs. 42.3, p = 0.027). At six-month follow-up, 8 participants (95% CI: 3, 16) had new-onset diabetes, corresponding to an incidence of 3 new cases of diabetes per 100 person-years. In conclusion, the incidence of elevated blood pressure and diabetes among Tanzanians with HIV is higher than what has been reported in high-income settings.

Mental health, substance use, and risky sexual behaviors among women living with HIV.

INTRODUCTION: Risky sexual behavior has been explored in women living with HIV (WLHIV) internationally but is not well studied in WLHIV in the United States (U.S.). This merits further investigation due to the negative reproductive and HIV health outcomes associated with risky sexual behavior, such as the increased risk for HIV transmission and infertility from sexually transmitted infections (STIs). The aims of this study are to (1) describe sexual behaviors in a cohort of WLHIV in Florida, (2) determine whether demographic characteristics, substance use, and mental health symptoms are associated with risky sexual behavior in a cohort of WLHIV in Florida, and (3) explore whether the relationship between substance use and mental health symptoms and risky sexual behavior differs in reproductive-age (age 18-49), compared to non-reproductive-age WLHIV (age 50+). DESIGN: This was a cross-sectional analysis of data from a multisite cohort study done in Florida. METHODS: Data were collected from a sample of 304 participants who were recruited into the Florida Cohort Study from 9 clinical and community sites in Florida between 2014 to 2017. The predictor variables of interest were mental health symptoms, substance use, and demographic variables. The outcome variable of interest was risky sexual behavior which was defined as reporting ≥1 of the following: (1) at least one STI diagnosis in the past 12 months, (2) two or more sexual partners in the past 12 months, or (3) any inconsistent condom use in the past 12 months. Descriptive statistics, bivariate analysis, and logistic regression (p < 0.1) were conducted on the variables of interest. RESULTS: The mean age of the sample was 47.8 years, and approximately half (51.6%) of the sample was of reproductive-age. Reporting ≥1 risky sexual behavior was reported in over half (51.6%) of the reproductive-age WLHIV in the sample and 32% of the non-reproductive-age WLHIV in the sample. Binge drinking, alcohol-related problems, marijuana use, and age were all significantly associated with self-reporting ≥1 risky sexual behaviors in all WLHIV. Self-reporting binge drinking, marijuana use, and a high alcohol-related problems score respectively were associated with increased odds of self-reporting ≥1 risky sexual behavior in all WLHIV. Neither mental health symptoms nor race/ethnicity or education were significantly associated with self-reporting ≥1 risky sexual behavior in all WLHIV. Self-reporting severe anxiety symptoms and high alcohol-related problems scores respectively were associated with increased odds of self-reporting ≥1 risky sexual behavior only in reproductive-age WLHIV from the sample. CONCLUSION: Marijuana use, binge drinking, and alcohol-related problems appear to have a relationship with risky sexual behavior in WLHIV regardless of age. Reproductive-age also appears to influence risky sexual behavior in WLHIV, and specific reporting severe anxiety symptoms and high alcohol-related problems in reproductive-age WLHIV increases the odds of engaging in risky sexual behavior. CLINICAL SIGNIFICANCE: This study holds clinical significance for nurses and other clinicians working in reproductive health settings and clinics with WLHIV. Results indicate that it could be beneficial to do more screening for mental health symptoms (particularly anxiety) and alcohol use in younger reproductive-age WLHIV.

Hypertension in an Emergency Department Population in Moshi, Tanzania; A Qualitative Study of Barriers to Hypertension Control.

BACKGROUND: Sub-Saharan Africa has a high prevalence of hypertension with a low rate of awareness, treatment adherence, and control. The emergency department (ED) may represent a unique opportunity to improve hypertension screening, awareness, and linkage to care. We conducted a qualitative study among hypertensive patients presenting to the ED and their healthcare providers to determine barriers to hypertension care and control. METHODS: In northern Tanzania, between November and December 2017, we conducted three focus group discussions among patients with hypertension presenting to the emergency department and three in-depth interviews among emergency department physicians. In our study, hypertension was defined as a single blood pressure of ≥160/100 mm Hg or a two-time average of ≥140/90 mm Hg. Barriers to care were identified by thematic analysis applying an inductive approach within the framework method. RESULTS: We enrolled 24 total patients into three focus groups and performed three in-depth interviews with individual providers. Thematic analysis identified two major domains: 1) patient knowledge, attitudes, and practices, and 2) structural barriers to hypertension care. Four major themes emerged within the knowledge, attitudes, and practices domain, including disease chronicity, provider communication, family support, and fear-based attitudes. Within the structural domain, several themes emerged that identified barriers that impeded hypertension follow-up care and self-management, including cost, access to care, and transportation and wait time. CONCLUSION: Patients and physicians identified multiple barriers and facilitators to hypertension care. These perspectives may be helpful to design emergency department-based interventions that target blood pressure control and linkage to outpatient care.

A community health worker delivered intervention to address hypertension among adults engaged in HIV care in northern Tanzania: Outcomes from a pilot feasibility study.

Current care models are inadequate to address the dual epidemic of hypertension and HIV in sub-Saharan Africa. We developed a community health worker (CHW)-delivered educational intervention, integrated into existing HIV care to address hypertension in persons living with HIV. A detailed educational curriculum was created with five sessions: three in-person clinic sessions and two telephone sessions. The intervention was piloted among hypertensive adults at one HIV clinic in northern Tanzania over a 4-week period. Primary outcomes were feasibility, fidelity, and acceptability of the intervention. Secondary outcomes included hypertension care engagement and systolic and diastolic blood pressure (SBP and DBP). Among 16 eligible participants, 14 (64% women, median age of 54.5 years) were recruited into the study, and 13 (92.9%) completed all five intervention sessions. The intervention was delivered with 98.8% fidelity to the curriculum content. Hypertension care engagement improved following the intervention. At baseline, two (15.4%) participants had seen a doctor previously for hypertension, compared to 11 (84.6%) participants post-intervention (P = .0027). No participant was using antihypertensives at baseline, compared to 10 (76.9%) post-intervention (P = .0016). Pre-intervention median SBP was 164 (IQR 152-170) mmHg, compared to post-intervention SBP of 146 (IQR 134-154) mmHg (P = .0029). Pre-intervention median DBP was 102 (IQR 86-109) mmHg, compared to post-intervention DBP of 89 (IQR 86-98) mmHg (P = .0023). A CHW-delivered educational intervention, integrated into existing HIV care, is feasible and holds promise in improving hypertension care engagement and reducing blood pressure. Further research is needed to evaluate the efficacy and scale-up of our intervention.

Hypertension among adults enrolled in HIV care in northern Tanzania: comorbidities, cardiovascular risk, and knowledge, attitudes and practices.

Cite this article: Preeti Manavalan et al. Hypertension among adults enrolled in HIV care in northern Tanzania: comorbidities, cardiovascular risk, and knowledge, attitudes and practices. Pan African Medical Journal. 2022;41(285). 10.11604/pamj.2022.41.285.26952. Introduction: the epidemiology of non-communicable diseases (NCDs) among people living with HIV (PLHIV) in sub-Saharan Africa is poorly described. In this observational study we examined a cohort of hypertensive PLHIV in northern Tanzania and described comorbidities, cardiovascular risk, and hypertension knowledge, attitudes and practices. Methods: consecutive patients attending an HIV clinic were screened for hypertension; those who met hypertension study criteria were enrolled. Participants completed a hypertension knowledge, attitudes and practices survey, and underwent height, weight, and waist circumference measurements and urine dipstick, fasting blood sugar, and lipid panel analyses. Kidney disease was defined as 1+ proteinuria, diabetes mellitus was defined as fasting glucose >126mg/dL, and 10-year atherosclerotic cardiovascular disease (ASCVD) risk was defined per the Pooled Cohorts Equations. Results: of 555 screened patients, 105 met hypertension criteria and 91 (86.7%) were enrolled. The prevalence of diabetes mellitus, kidney disease, and overweight or obesity was 8.8%, 28.6%, and 86.7%, respectively. Almost all participants (n=86, 94.5%) had two or more medical comorbidities. More than half (n=39, 52.7%) had intermediate or high 10-year risk for an ASCVD event. While only 3 (3.3%) participants were able to define hypertension correctly, most would seek care at a medical facility (n=89, 97.8%) and take medication chronically for hypertension (n=79, 87.8%). Conclusion: we found a high burden of medical comorbidity and ASCVD risk among hypertensive PLHIV in northern Tanzania. Integration of routine NCD screening in the HIV clinical setting, in combination with large-scale educational campaigns, has the potential to impact clinical outcomes in this high-risk population.

Prevalence and predictors of uncontrolled hypertension, diabetes, and obesity among adults with HIV in northern Tanzania.

HIV is associated with increased risk of cardiovascular disease, but there has been less study of cardiovascular comorbidities among people with HIV in sub-Saharan Africa. In a cross-sectional observational study, Tanzanian adults presenting for outpatient HIV care completed a questionnaire and underwent weight, height, blood pressure, and blood glucose measurement. Hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension. Uncontrolled hypertension was defined as measured blood pressure ≥140/90 mmHg. Diabetes was defined by fasting glucose ≥126 mg/dl, random glucose ≥200 mg/dl, or self-reported diabetes. Obesity was defined by body mass index ≥30 kg/m2. Multivariate logistic regression was performed to identify predictors of uncontrolled hypertension. Among 500 participants, 173 (34.6%) had hypertension, 21 (4.2%) had diabetes, and 99 (19.8%) were obese. Of those with hypertension, 116 (67.1%) were unaware of their hypertension, and 155 (89.6%) had uncontrolled hypertension. In multivariate analysis, uncontrolled hypertension was associated with older age (OR 1.07, 95% CI: 1.05-1.10, p < 0.001) and higher body mass index (OR 1.17, 95% CI: 1.11-1.22, p < 0.001). Interventions are needed to improve screening and treatment for hypertension, diabetes, and obesity among Tanzanians with HIV.

Hypertension Care for People With HIV in Tanzania: Provider Perspectives and Opportunities for Improvement.

One in three people with HIV (PWH) has hypertension. However, most hypertensive PWH in sub-Saharan Africa are unaware of their hypertension diagnosis and are not on treatment. To better understand barriers to hypertension care faced by PWH, we interviewed 15 medical providers who care for patients with HIV and hypertension in northern Tanzania. The data revealed barriers at the patient, provider, and system level and included: stress, depression, and HIV-related stigma; lack of hypertension knowledge; insufficient hypertension training; inefficient prescribing practices; challenges with counselling; capacity limitations in hypertension care; high costs of care; and lack of routine hypertension screening and follow-up. Opportunities for improvement focused on prioritizing resources and funding towards hypertension care. System-related challenges were the underlying cause of barriers at individual levels. Strategies that focus on strengthening capacity and utilize existing HIV platforms to promote hypertension care delivery are urgently needed to improve cardiovascular outcomes among PWH.

Increasing the Uptake of HIV Testing among Men in Tanzania: A Novel Intervention for Bar Patrons.

We investigated a novel community-based HIV testing and counseling (HTC) strategy by recruiting men from bars in northern Tanzania in order to identify new HIV infections. All bars in the town of Boma Ng'ombe were identified and male patrons were systematically invited to participate in a health study. HIV testing was offered to all enrolled participants. Outputs included HIV test yield, cost per diagnosis, and comparison of our observed test yield to that among male patients contemporaneously tested at five local facility-based HTC. We enrolled 366 participants and identified 17 new infections - providing a test yield of 5.3% (95% Confidence interval [CI] 3.3-8.4). The test yield among men contemporaneously tested at five local HTC centers was 2.1% (95% CI 1.6-2.8). The cost-per-diagnosis was $634. Our results suggest that recruiting male bar patrons for HIV testing is efficient for identifying new HIV infections. The scalability of this intervention warrants further evaluation.

RESUMEN: Investigamos una novedosa estrategia comunitaria de asesoramiento y pruebas de VIH (HTC) reclutando hombres de los bares del norte de Tanzania para identificar nuevas infecciones de VIH. Se identificaron todos los bares de la ciudad de Boma Ng'ombe y se invitó sistemáticamente a los clientes varones a participar en un estudio de salud. Se ofrecieron pruebas de VIH a todos los participantes inscritos. Los resultados incluyeron los resultados de las pruebas de VIH, el costo por diagnóstico y la comparación de nuestros resultados observados con los de los pacientes varones que simultáneamente se sometieron a pruebas en cinco centros locales de HTC. Se inscribieron 366 participantes y se identificaron 17 nuevas infecciones, proporcionando un resultado en las pruebas del 5.3% (intervalo de confianza [IC] del 95%: 3.3-8.4). Los resultados de las pruebas realizadas simultáneamente en cinco centros locales de HTC fue del 2.1% (IC del 95%: 1.6-2.8). El costo por diagnóstico fue de $634. Nuestros resultados sugieren que el reclutamiento de clientes masculinos para las pruebas de VIH fue eficiente para identificar nuevas infecciones de VIH. La escalabilidad de esta intervención merece una evaluación adicional.

"It's because I think too much": Perspectives and experiences of adults with hypertension engaged in HIV care in northern Tanzania.

BACKGROUND: Hypertension, a leading risk for cardiovascular mortality, is an important co-morbidity among people living with HIV (PLHIV). In Tanzania, hypertension prevalence among PLHIV approaches 20 to 30%. However, most patients are unaware of their diagnosis and are not receiving treatment. Understanding the barriers to hypertension care is a critical first step in developing interventions to improve cardiovascular outcomes among PLHIV in Tanzania and similar settings. METHODS: Between September 1st and November 26th, 2018 thirteen semi structured in-depth interviews were conducted with hypertensive patients engaged in HIV care in two HIV clinics located in government health facilities in northern Tanzania. Interviews were audio-recorded, translated into English, transcribed and thematically coded using NVivo. Data analysis was conducted using applied thematic analysis. RESULTS: Participants had a median age of 54 (IQR 41-65) years. Of the 13 participants, eight stated they had used antihypertensive medication previously, but only one participant described current use of antihypertensive therapy. All participants were currently using antiretroviral therapy. The data revealed a range of themes including limited hypertension knowledge. Universally, all participants believed that "thinking too much", i.e. stress, was the major contributor to hypertension and that by "reducing thoughts", one may control hypertension. Additional emerging themes included a perceived overlap between hypertension and HIV, delays in hypertension diagnosis and linkage to care, challenges with provider communication and counseling, reluctance towards antihypertensive medication, lack of integration of hypertension and HIV care, and additional structural barriers to hypertension care. CONCLUSIONS: Participants described multiple, intersecting challenges related to hypertension management. Barriers specific to PLHIV included siloed care, HIV-related stigma, and burden from multiple medical conditions. Multifaceted strategies that seek to address structural barriers, hypertension education, psychosocial stressors and stigma, and that are integrated within HIV care are urgently needed to improve cardiovascular outcomes among PLHIV in sub-Saharan Africa.

Hypertension burden and challenges across the hypertension treatment cascade among adults enrolled in HIV care in northern Tanzania.

Failure to address hypertension among people living with HIV (PLWH) may undermine the significant progress made toward reducing mortality among this high-risk population in sub-Saharan Africa (SSA). Here, the authors report hypertension prevalence, diagnosis, and treatment among patients enrolled in HIV care in Tanzania. Patients attending an HIV clinic were consecutively screened for hypertension. Hypertension was defined as follows: a single blood pressure measurement ≥160 mm Hg systolic or ≥100 mm Hg diastolic, two measurements at separate visits ≥140 mm Hg systolic or ≥90 mm Hg diastolic, or self-reported hypertension diagnosis. The authors screened 555 patients, and 19.6% met hypertension criteria. Among a subset of 91 hypertensive participants, 44 (48.4%) reported previous blood pressure measurements, 32 (35.2%) were aware of diagnosis, 10 (11.0%) reported current antihypertensive use, and none had controlled blood pressure. Addressing barriers along the hypertension treatment cascade must be a top priority to improve cardiovascular outcomes among PLWH in SSA.

Provider-perceived barriers to diagnosis and treatment of acute coronary syndrome in Tanzania: a qualitative study.

BACKGROUND: The incidence of acute coronary syndrome (ACS) is growing across sub-Saharan Africa and many healthcare systems are ill-equipped for this growing burden. Evidence suggests that healthcare providers may be underdiagnosing and undertreating ACS, leading to poor health outcomes. The goal of this study was to examine provider perspectives on barriers to ACS care in Tanzania in order to identify opportunities for interventions to improve care. METHODS: Semistructured in-depth interviews were conducted with physicians and clinical officers from emergency departments and outpatient departments in northern Tanzania. Thematic analysis was conducted using an iterative cycle of coding and consensus building. RESULTS: The 11 participants included six physicians and five clinical officers from health centers, community hospitals and one referral hospital. Providers identified barriers related to providers, systems and patients. Provider-related barriers included inadequate training regarding ACS and poor application of textbook-based knowledge. System-related barriers included lack of diagnostic equipment, unavailability of treatments, referral system delays, lack of data regarding disease burden, absence of locally relevant guidelines and cost of care. Patient-related barriers included inadequate ACS knowledge, inappropriate healthcare-seeking behavior and non-adherence. CONCLUSIONS: This study identified actionable barriers to ACS care in northern Tanzania. Multifaceted interventions are urgently needed to improve care.

The Burden of Hypertension and Diabetes in an Emergency Department in Northern Tanzania.

Introduction: Little is known about the burden of hypertension and diabetes on emergency department (ED) utilization and hospitalizations in sub-Saharan Africa. Methods: A retrospective review of adult ED patients in northern Tanzania was performed from September 2017 through March 2018. Hypertension was defined as documented diagnosis of hypertension or blood pressure ≥ 140/90 mm Hg. Diabetes was defined as documented diagnosis of diabetes mellitus or random glucose ≥ 200 mg/dL. Results: Of 3961 adult ED patients, 1359 (34.3%) had hypertension, 518 (13.1%) had diabetes, and 273 (6.9%) had both. Both hypertension (OR 1.42, 95% CI 1.23-1.63, P<.001) and diabetes (OR 2.05, 95% CI 1.66-2.54, P<.001) were associated with increased odds of admission. Of 2418 hospital admissions, 694 (28.7%) were for complications of hypertension or diabetes. Of 499 patients admitted for hypertensive complications, the most common admission diagnoses were: heart failure (163 patients, 32.7%); stroke (147 patients, 29.5%); and severe hypertension (139 patients, 27.9%). Of 278 patients admitted for diabetic complications, the most common admission diagnoses were: hyperglycemia (158 patients, 56.9%); infection (60 patients, 21.6%); and stroke (28 patients, 10.1%). Conclusions: The burden of hypertension and diabetes in a Tanzanian ED is high, and the ED may serve as an opportune location for case identification and linkage-to-care interventions. Given the large proportion of Africans with undiagnosed hypertension and diabetes, an ED-based screening program would likely identify many new cases of these diseases. The high burden of hypertension- and diabetes-related hospitalizations highlights the urgent need for improvements in primary preventative care in Tanzania.

Opportunities to Leverage Telehealth Approaches Along the Hypertension Control Cascade in Sub-Saharan Africa.

PURPOSE OF REVIEW: To review the current literature on use of telehealth at different stages of the hypertension control cascade in sub-Saharan Africa (SSA) and to discuss opportunities to harness technology infrastructure in SSA to improve population-level blood pressure control. RECENT FINDINGS: Despite the high burden of hypertension in SAA, strategies to improve awareness, diagnosis, and management are inadequate. In high-income countries, telehealth has increased patient access to high-quality care at reduced costs. Notwithstanding the limited evidence on the use of telehealth at the different stages of the hypertension control cascade in SSA, the few published interventions in this review reported reduction of blood pressure and increase in the proportion of individuals with controlled blood pressure. Telehealth use across the hypertension control cascade in SSA is promising. These under-resourced settings provide opportunity to better understand the demand for these interventions in order to achieve meaningful clinical outcomes.

Experiences of Fetal or Infant Loss among Tanzanian Women in HIV Care.

This study examined the impact of fetal or infant loss on HIV care engagement. We conducted semi-structured interviews with 15 HIV-infected women who experienced fetal or infant loss while enrolled in prevention of mother-to-child transmission (PMTCT) services in Tanzania. Women attributed the loss to delays in receiving healthcare. Provider communication about the cause of the loss was poor, and women reported substantial distress related to the loss. One-fifth reported gaps in HIV care or disengagement from care following their loss. Loss of a fetus or infant is not uncommon in HIV endemic settings, and should be integrated into PMTCT guidelines.