Multiple cardiovascular risk factor care in 55 low- and middle-income countries: A cross-sectional analysis of nationally-representative, individual-level data from 280,783 adults.

The prevalence of multiple age-related cardiovascular disease (CVD) risk factors is high among individuals living in low- and middle-income countries. We described receipt of healthcare services for and management of hypertension and diabetes among individuals living with these conditions using individual-level data from 55 nationally representative population-based surveys (2009-2019) with measured blood pressure (BP) and diabetes biomarker. We restricted our analysis to non-pregnant individuals aged 40-69 years and defined three mutually exclusive groups (i.e., hypertension only, diabetes only, and both hypertension-diabetes) to compare individuals living with concurrent hypertension and diabetes to individuals with each condition separately. We included 90,086 individuals who lived with hypertension only, 11,975 with diabetes only, and 16,228 with hypertension-diabetes. We estimated the percentage of individuals who were aware of their diagnosis, used pharmacological therapy, or achieved appropriate hypertension and diabetes management. A greater percentage of individuals with hypertension-diabetes were fully diagnosed (64.1% [95% CI: 61.8-66.4]) than those with hypertension only (47.4% [45.3-49.6]) or diabetes only (46.7% [44.1-49.2]). Among the hypertension-diabetes group, pharmacological treatment was higher for individual conditions (38.3% [95% CI: 34.8-41.8] using antihypertensive and 42.3% [95% CI: 39.4-45.2] using glucose-lowering medications) than for both conditions jointly (24.6% [95% CI: 22.1-27.2]).The percentage of individuals achieving appropriate management was highest in the hypertension group (17.6% [16.4-18.8]), followed by diabetes (13.3% [10.7-15.8]) and hypertension-diabetes (6.6% [5.4-7.8]) groups. Although health systems in LMICs are reaching a larger share of individuals living with both hypertension and diabetes than those living with just one of these conditions, only seven percent achieved both BP and blood glucose treatment targets. Implementation of cost-effective population-level interventions that shift clinical care paradigm from disease-specific to comprehensive CVD care are urgently needed for all three groups, especially for those with multiple CVD risk factors.

Final 192-Week Efficacy and Safety Results of the ADVANCE Trial, Comparing 3 First-line Antiretroviral Regimens.

Background: ADVANCE compared 3 World Health Organization-recommended first-line regimens in participants with HIV who were antiretroviral naive. Methods: This randomized, open-label, noninferiority trial enrolled participants living with HIV with no antiretroviral exposure in the previous 6 months to 1 of the following arms: tenofovir alafenamide (TAF) / emtricitabine (FTC) + dolutegravir (DTG) (2 tablets), tenofovir disoproxil fumarate (TDF) / FTC + DTG (2 tablets), or a fixed-dose combination of TDF / FTC / efavirenz (EFV) (1 tablet). We report the final safety and efficacy data up to 192 weeks. Results: Repeat consent from the original 351 participants randomized to each arm was obtained from 230 participants (66%) in the TAF/FTC + DTG arm, 209 (60%) in the TDF/FTC + DTG arm, and 183 (52%) in the TDF/FTC/EFV arm. At 192 weeks, 213 (61%) of the original 351 participants in the TAF/FTC + DTG arm, 195 (56%) in the TDF/FTC + DTG arm, and 172 (49%) in the TDF/FTC/EFV arm had confirmed RNA <50 copies/mL, with low virologic failure in all groups and no significant integrase inhibitor mutations in any arm. Mean weight gain was 8.9 kg (SD, 7.1) in the TAF/FTC + DTG arm, 5.9 kg (SD, 7.1) in the TDF/FTC + DTG arm, and 3.2 kg (SD, 8.1) in the TDF/FTC/EFV arm at 192 weeks from baseline and was greatest among women, those taking TAF, and those with lower baseline CD4 counts. The weight trajectory slowed after week 96. There were few clinical events and minor laboratory changes and differences among arms after 96 weeks. There were no significant differences in treatment-emergent hypertension or pregnancy outcomes by arm. Conclusions: High viral suppression was seen across arms, with no resistance to DTG. Weight gain continued but slowed after 96 weeks, with few clinical events or laboratory changes.

Regional variation in weight change after the transition to dolutegravir: a prospective cohort study in Uganda and South Africa.

BACKGROUND: People with HIV (PWH) on integrase inhibitor-based regimens may be at risk of excess weight gain, but it is unclear if this risk is consistent across settings. We assessed weight change over 48 weeks among PWH who were transitioned to tenofovir disoproxil fumarate/lamivudine/dolutegravir (TLD). DESIGN: We conducted a prospective cohort study at public-sector HIV clinics in Uganda and South Africa. METHODS: Eligible participants were adults who were transitioned to TLD. Weight was measured at enrollment, 24-, and 48-weeks post TLD transition. Our outcomes were (1) weight change, (2) change in waist circumference, and (3) clinically significant weight gain, defined as ≥10% increase in weight from baseline, over 48 weeks. We used linear mixed-effects regression models, adjusted for demographic factors, to estimate weight gain and identify risk factors. RESULTS: Weight data were available for 428 participants in Uganda and 367 in South Africa. The mean weight change was 0.6 kg [95%CI: 0.1-1.0] in Uganda and 2.9 kg [2.3-3.4] in South Africa (p < 0.001). The mean change in waist circumference was 0.8 cm [95%CI: 0.0-1.5]) in Uganda and 2.3 cm [95%CI: 1.4-3.2] in South Africa (p = 0.012). Clinically significant weight gain occurred in 9.8% [7.0-12.6] of participants in Uganda and 18.0% [14.1-21.9] in South Africa (p < 0.001). After adjustment, PWH gained significantly less weight in Uganda than in South Africa. CONCLUSIONS: PWH in South Africa experienced significantly greater weight gain and increases in waist circumference compared to Uganda. Strategies to address weight gain in PWH should be carefully considered and may vary by region.

The prevalence of cardiovascular disease risk factors among adults living in extreme poverty.

Evidence on cardiovascular disease (CVD) risk factor prevalence among adults living below the World Bank's international line for extreme poverty (those with income <$1.90 per day) globally is sparse. Here we pooled individual-level data from 105 nationally representative household surveys across 78 countries, representing 85% of people living in extreme poverty globally, and sorted individuals by country-specific measures of household income or wealth to identify those in extreme poverty. CVD risk factors (hypertension, diabetes, smoking, obesity and dyslipidaemia) were present among 17.5% (95% confidence interval (CI) 16.7-18.3%), 4.0% (95% CI 3.6-4.5%), 10.6% (95% CI 9.0-12.3%), 3.1% (95% CI 2.8-3.3%) and 1.4% (95% CI 0.9-1.9%) of adults in extreme poverty, respectively. Most were not treated for CVD-related conditions (for example, among those with hypertension earning <$1.90 per day, 15.2% (95% CI 13.3-17.1%) reported taking blood pressure-lowering medication). The main limitation of the study is likely measurement error of poverty level and CVD risk factors that could have led to an overestimation of CVD risk factor prevalence among adults in extreme poverty. Nonetheless, our results could inform equity discussions for resource allocation and design of effective interventions.

Cytomegalovirus IgG is Associated With Physical Function But Not Muscle Density in People With HIV.

BACKGROUND: Cytomegalovirus (CMV) seropositivity is associated with poor outcomes, including physical function impairment, in people without HIV. We examined associations between CMV IgG titer and physical function in virologically suppressed people with HIV (PWH). METHODS: REPRIEVE is a double-blind randomized trial evaluating pitavastatin for primary prevention of atherosclerotic cardiovascular disease in PWH. This analysis focused on participants enrolled in a substudy with additional biomarker testing, imaging [coronary CT angiography], and physical function measures at entry. CMV IgG was measured using quantitative enzyme immunoassay, physical function by Short Physical Performance Battery, and muscle density and area by CT. Associations between CMV IgG (risk factor) and outcomes were evaluated using the partial Spearman correlation and linear and log-binomial regression. RESULTS: Among 717 participants, 82% male, the median CMV IgG was 2716 (Q1, Q3: 807, 6672) IU/mL, all above the limit of quantification. Among 631 participants with imaging, there was no association between CMV IgG and CT-based muscle density or area, controlling for age (r = -0.03 and r = -0.01, respectively; P ≥ 0.38). Among 161 participants with physical function data, higher CMV IgG was associated with poorer overall modified Short Physical Performance Battery score ( P = 0.02), adjusted for age, nadir CD4, and high-sensitivity C-reactive protein. CONCLUSIONS: Higher CMV IgG titer was associated with poorer physical function, not explained by previous immune compromise, inflammation, or muscle density or area. Further mechanistic studies are needed to understand this association and whether CMV-specific therapy can affect physical function in PWH.

The Association Between HIV-Related Stigma and the Uptake of HIV Testing and ART Among Older Adults in Rural South Africa: Findings from the HAALSI Cohort Study.

HIV testing and antiretroviral therapy (ART) remain critical for curbing the spread of HIV/AIDS, but stigma can impede access to these services. Using data from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI), we used a multivariable logistic regression to examine the correlation between HIV-related stigma, HIV testing and ART uptake in older adults. We used four questions to measure stigma, with three assessing social stigma (reflecting social distancing preferences) and one assessing anticipated stigma (disclosure concern). We combined the three social stigma questions to generate a social stigma score ranging from 0 to 3, with higher scores indicating higher stigma. Anticipated stigma was prevalent 85% (95% CI 0.84-0.86), and social stigma was also frequent 25% (95% CI 0.24-0.27). Higher social stigma scores correlated with decreased HIV testing for all participants with social stigma. Compared to those with a score of 0, odds of testing decreased with higher stigma scores (OR = 0.66, 95% CI 0.53-0.81, p = 0.000) for a score of 1 and (OR = 0.56, 95% CI 0.38-0.83, p = 0.004) for a score of 3. ART uptake also decreased with higher social stigma scores among people living with HIV (PLWH), although it was significant for those with a score of 2 (OR = 0.41, 95% CI 0.19-0.87, p = 0.020). These findings emphasize that HIV-related stigma hampers testing and ART uptake among older adults in rural South Africa. Addressing stigma is crucial for improving testing rates, early diagnosis, and treatment initiation among the older population and achieving UNAIDS 95-95-95 targets.

Hypertension care cascades and reducing inequities in cardiovascular disease in low- and middle-income countries.

Improving hypertension control in low- and middle-income countries has uncertain implications across socioeconomic groups. In this study, we simulated improvements in the hypertension care cascade and evaluated the distributional benefits across wealth quintiles in 44 low- and middle-income countries using individual-level data from nationally representative, cross-sectional surveys. We raised diagnosis (diagnosis scenario) and treatment (treatment scenario) levels for all wealth quintiles to match the best-performing country quintile and estimated the change in 10-year cardiovascular disease (CVD) risk of individuals initiated on treatment. We observed greater health benefits among bottom wealth quintiles in middle-income countries and in countries with larger baseline disparities in hypertension management. Lower-middle-income countries would see the greatest absolute benefits among the bottom quintiles under the treatment scenario (29.1 CVD cases averted per 1,000 people living with hypertension in the bottom quintile (Q1) versus 17.2 in the top quintile (Q5)), and the proportion of total CVD cases averted would be largest among the lowest quintiles in upper-middle-income countries under both diagnosis (32.0% of averted cases in Q1 versus 11.9% in Q5) and treatment (29.7% of averted cases in Q1 versus 14.0% in Q5) scenarios. Targeted improvements in hypertension diagnosis and treatment could substantially reduce socioeconomic-based inequalities in CVD burden in low- and middle-income countries.

Perceptions of Health, Body Size, and Nutritional Risk Factors for Obesity in People with HIV in South Africa.

Metabolic disease is increasing in people with HIV (PWH) in South Africa, but little is known about self-perceptions of body size, health, and nutritional behavior in this population. We performed a cross-sectional analysis of individual-level data from the 2016 South Africa Demographic and Health Survey. This survey measured HIV serostatus and body mass index (BMI). We categorized participants into six BMI groups: 18.5-22 kg/m2, 22-25 kg/m2, 25-27.5 kg/m2, 27.5-30 kg/m2, 30-35 kg/m2, and ≥ 35 kg/m2 and stratified them by HIV serostatus. Our outcomes were self-reported (1) body size and (2) health status among all participants, and intake of (3) chips and (4) sugar-sweetened beverages (SSB) in PWH. We described these metrics and used multivariable regression to evaluate the relationship between the nutritional behaviors and BMI ≥ 25 kg/m2 in PWH only, adjusting for age, sex, educational attainment, and household wealth quintile. Of 6138 participants, 1163 (19.7%) were PWH. Among PWH, < 10% with a BMI 25-30 kg/m2, < 20% with a BMI 30-35 kg/m2 and < 50% with a BMI ≥ 35 kg/m2 self-reported as overweight or obese. PWH reported being in poor health at higher rates than those without HIV at each BMI category except ≥ 35 kg/m2. In adjusted models, SSB consumption was associated with BMI ≥ 25 kg/m2 (1.13 [1.01-1.25], t-statistic = 2.14, p = 0.033) in PWH. Perceptions of body size may challenge efforts to prevent weight gain in PWH in South Africa. SSB intake reduction should be further explored as a modifiable risk factor for obesity.

From Evidence to Effectiveness: Implications of the Randomized Trial to Prevent Vascular Events in HIV Study for People With Human Immunodeficiency Virus in Low- and Middle-Income Settings.

The Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) study found a 35% reduction in major adverse cardiovascular events for people with human immunodeficiency virus who received daily pitavastatin. However, how this evidence will change practice is far from certain. Here, we outline evidence gaps and political and healthcare delivery challenges that will need to be addressed for REPRIEVE to offer public health benefits in low- and middle-income countries.

Identifying sex-specific anthropometric measures and thresholds for dysglycemia screening in an HIV-endemic rural South African population.

Valid screening and diagnostic algorithms are needed to achieve 2030 targets proposed by the WHO's Global Diabetes Compact. We explored anthropometric thresholds to optimally screen and refer individuals for diabetes testing in rural South Africa. We evaluated screening thresholds for waist circumference (WC), body mass index (BMI), and waist-hip ratio (WHR) to detect dysglycemia based on a glycated hemoglobin (HbA1C) ≥6.5% among adults in a population-based study in South Africa using weighted, non-parametric ROC regression analyses. We then assessed the diagnostic validity of traditional obesity thresholds, explored optimal thresholds for this population, and fit models stratified by sex, age, and HIV status. The prevalence of dysglycemia in the total study population (n = 17,846) was 7.7%. WC had greater discriminatory capacity than WHR to detect dysglycemia in men (p-value<0.001) and women (p<0.001). WC had greater discriminatory capacity than BMI to detect dysglycemia in women (p<0.001). However, BMI and WC performed similarly for men (p = 0.589). Whereas traditional WC thresholds for women (>81cm) performed well (sensitivity 91%, positive predictive value [PPV] 14.9%), substantially lower thresholds were needed to achieve acceptable sensitivity and PPV among men (traditional >94cm, derived >79.5cm). WC outperforms BMI as an anthropometric screening measure for dysglycemia in rural South Africa. Whereas WC guideline thresholds are appropriate for women, male-derived WC cutoffs performed better at lower thresholds. In this rural South African population, thresholds that maximize specificity and PPV for efficient resource allocation may be preferred.

Health service readiness to provide care for HIV and cardiovascular disease risk factors in low- and middle-income countries.

Cardiovascular disease risk factors (CVDRF), in particular diabetes and hypertension, are chronic conditions which carry a substantial disease burden in Low- and Middle-Income Countries. Unlike HIV, they were neglected in the Millenium Development Goals along with the health services required to manage them. To inform the level of health service readiness that could be achieved with increased attention, we compared readiness for CVDRF with that for HIV. Using data from national Service Provision Assessments, we describe facility-reported readiness to provide services for CVDRF and HIV, and derive a facility readiness score of observed essential components to manage them. We compared HIV vs CVDRF coverage scores by country, rural or urban location, and facility type, and by whether or not facilities reported readiness to provide care. We assessed the factors associated with coverage scores for CVDRF and HIV in a multivariable analysis. In our results, we include 7522 facilities in 8 countries; 86% of all facilities reported readiness to provide services for CVDRF, ranging from 77-98% in individual countries. For HIV, 30% reported of facilities readiness to provide services, ranging from 3-63%. Median derived facility readiness score for CVDRF was 0.28 (IQR 0.16-0.50), and for HIV was 0.43 (0.32-0.60). Among facilities which reported readiness, this rose to 0.34 (IQR 0.18-0.52) for CVD and 0.68 (0.56-0.76) for HIV. Derived readiness scores were generally significantly lower for CVDRF than for HIV, except in private facilities. In multivariable analysis, odds of a higher readiness score in both CVDRF or HIV care were higher in urban vs rural and secondary vs primary care; facilities with higher CVDRF scores were significantly associated with higher HIV scores. Derived readiness scores for HIV are higher than for CVDRF, and coverage for CVDRF is significantly higher in facilities with higher HIV readiness scores. This suggests possible benefits from leveraging HIV services to provide care for CVDRF, but poor coverage in rural and primary care facilities threatens Sustainable Development Goal 3.8 to provide high quality universal healthcare for all.

Diabetes risk and provision of diabetes prevention activities in 44 low-income and middle-income countries: a cross-sectional analysis of nationally representative, individual-level survey data.

BACKGROUND: The global burden of diabetes is rising rapidly, yet there is little evidence on individual-level diabetes prevention activities undertaken by health systems in low-income and middle-income countries (LMICs). Here we describe the population at high risk of developing diabetes, estimate diabetes prevention activities, and explore sociodemographic variation in these activities across LMICs. METHODS: We performed a pooled, cross-sectional analysis of individual-level data from nationally representative, population-based surveys conducted in 44 LMICs between October, 2009, and May, 2019. Our sample included all participants older than 25 years who did not have diabetes and were not pregnant. We defined the population at high risk of diabetes on the basis of either the presence of impaired fasting glucose (or prediabetes in countries with a haemoglobin A1c available) or overweight or obesity, consistent with the WHO Package of Essential Noncommunicable Disease Guidelines for type 2 diabetes management. We estimated the proportion of survey participants that were at high risk of developing diabetes based on this definition. We also estimated the proportion of the population at high risk that reported each of four fundamental diabetes prevention activities: physical activity counselling, weight loss counselling, dietary counselling, and blood glucose screening, overall and stratified by World Bank income group. Finally, we used multivariable Poisson regression models to evaluate associations between sociodemographic characteristics and these activities. FINDINGS: The final pooled sample included 145 739 adults (86 269 [59·2%] of whom were female and 59 468 [40·4%] of whom were male) across 44 LMICs, of whom 59 308 (40·6% [95% CI 38·5-42·8]) were considered at high risk of diabetes (20·6% [19·8-21·5] in low-income countries, 38·0% [37·2-38·9] in lower-middle-income countries, and 57·5% [54·3-60·6] in upper-middle-income countries). Overall, the reach of diabetes prevention activities was low at 40·0% (38·6-41·4) for physical activity counselling, 37·1% (35·9-38·4) for weight loss counselling, 42·7% (41·6-43·7) for dietary counselling, and 37·1% (34·7-39·6) for blood glucose screening. Diabetes prevention varied widely by national-level wealth: 68·1% (64·6-71·4) of people at high risk of diabetes in low-income countries reported none of these activities, whereas 49·0% (47·4-50·7) at high risk in upper-middle-income countries reported at least three activities. Educational attainment was associated with diabetes prevention, with estimated increases in the predicted probability of receipt ranging between 6·5 (3·6-9·4) percentage points for dietary fruit and vegetable counselling and 21·3 (19·5-23·2) percentage points for blood glucose screening, among people with some secondary schooling compared with people with no formal education. INTERPRETATION: A large proportion of individuals across LMICs are at high risk of diabetes but less than half reported receiving fundamental prevention activities overall, with the lowest receipt of these activities among people in low-income countries and with no formal education. These findings offer foundational evidence to inform future global targets for diabetes prevention and to strengthen policies and programmes to prevent continued increases in diabetes worldwide. FUNDING: Harvard T H Chan School of Public Health McLennan Fund: Dean's Challenge Grant Program and the EU's Research and Innovation programme Horizon 2020.

Health systems performance for hypertension control using a cascade of care approach in South Africa, 2011-2017.

Hypertension is a major contributor to global morbidity and mortality. In South Africa, the government has employed a whole systems approach to address the growing burden of non-communicable diseases. We used a novel incident care cascade approach to measure changes in the South African health system's ability to manage hypertension between 2011 and 2017. We used data from Waves 1-5 of the National Income Dynamics Study (NIDS) to estimate trends in the hypertension care cascade and unmet treatment need across four successive cohorts with incident hypertension. We used a negative binomial regression to identify factors that may predict higher rates of hypertension control, controlling for socio-demographic and healthcare factors. In 2011, 19.6% (95%CI 14.2, 26.2) of individuals with incident hypertension were diagnosed, 15.4% (95%CI 10.8, 21.4) were on treatment and 7.1% had controlled blood pressure. By 2017, the proportion of individuals with diagnosed incident hypertension had increased to 24.4% (95%CI 15.9, 35.4). Increases in treatment (23.3%, 95%CI 15.0, 34.3) and control (22.1%, 95%CI 14.1, 33.0) were also observed, translating to a decrease in unmet need for hypertension care from 92.9% in 2011 to 77.9% in 2017. Multivariable regression showed that participants with incident hypertension in 2017 were 3.01 (95%CI 1.77, 5.13) times more likely to have a controlled blood pressure compared to those in 2011. Our data show that while substantial improvements in the hypertension care cascade occurred between 2011 and 2017, a large burden of unmet need remains. The greatest losses in the incident hypertension care cascades came before diagnosis. Nevertheless, whole system programming will be needed to sufficiently address significant morbidity and mortality related to having an elevated blood pressure.

Home-based HIV testing strategies for middle-aged and older adults in rural South Africa.

OBJECTIVE: More than one in four adults over 40 years with HIV in South Africa are unaware of their status and not receiving antiretroviral therapy (ART). HIV self-testing may offer a powerful approach to closing this gap for aging adults. Here, we report the results of a randomized comparative effectiveness trial of three different home-based HIV testing strategies for middle-aged and older adults in rural South Africa. DESIGN: Two thousand nine hundred and sixty-three individuals in the 'Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI)' cohort study were randomized 1 : 1 : 1 to one of three types of home-based and home-delivered HIV testing modalities: rapid testing with counseling; self-testing, and both rapid testing with counselling and self-testing. METHOD: In OLS regression analyses, we estimated the treatment effects on HIV testing and HIV testing frequency at about 1 year after delivery. Finally, we assessed the potential adverse effects of these strategies on the secondary outcomes of depressive symptom as assessed by the CESD-20, linkage to care, and risky sexual behavior. RESULTS: There were no significant differences in HIV testing uptake or testing frequency across groups. However, respondents in the self-testing treatment arms were more likely to shift from testing at home and a facility [self-testing (HIVST), -8 percentage points (pp); 95% confidence interval (CI) -14 to -2 pp; self-testing plus rapid testing and counselling (ST+RT+C); -9 pp, 95% CI -15 to -3 pp] to testing only at home (HIVST 5 pp; 95% CI 2 to 9 pp; ST+RT+C: 5 pp, 95% CI 1 to 9 pp) - suggesting a revealed preference for self-testing in this population. We also found no adverse effects of this strategy on linkage to care for HIV and common comorbidities, recent sexual partners, or condom use. Finally, those in the self-testing only arm had significantly decreased depressive symptom scores by 0.58 points (95% CI -1.16 to -0.01). CONCLUSION: We find HIV self-testing to be a well tolerated and seemingly preferred home-based testing option for middle-aged and older adults in rural South Africa. This approach should be expanded to achieve the UNAIDS 95-95-95 targets.

Correlates of physical activity among people living with and without HIV in rural Uganda.

Background: Antiretroviral therapy (ART) has led to diminishing AIDS-related mortality but a concomitant increase in non-communicable diseases (NCDs) for people with HIV (PWH). Whereas physical activity (PA) has been shown to help prevent NCDs and NCD outcomes in other settings, there are few data on PA and its correlates among PWH in high-endemic settings. We aimed to compare PA by HIV serostatus in rural Uganda. Methods: We analysed data from the UGANDAC study, an observational cohort including PWH in ambulatory HIV care in Mbarara, Uganda, and age- and gender-matched people without HIV (PWOH). Our primary outcome of interest was PA, which we assessed using the International Physical Activity Questionnaire and considered as a continuous measure of metabolic equivalents in minutes/week (MET-min/week). Our primary exposure of interest was HIV serostatus. We fit univariable and multivariable linear regression models to estimate the relationship between HIV and PA levels, with and without addition of sociodemographic and clinical correlates of PA (MET-min/week). In secondary analyses, we explored relationships restricted to rural residents, and interactions between gender and serostatus. Results: We enrolled 309 participants, evenly divided by serostatus and gender. The mean age of PWH was 52 [standard deviation (SD) 7.2] and 52.6 (SD 7.3) for PWOH. In general, participants engaged in high levels of PA regardless of serostatus, with 81.2% (251/309) meeting criteria for high PA. However, PWOH reported higher mean levels of PA met-minutes/week than PWH (9,128 vs 7,152, p ≤ 0.001), and a greater proportion of PWOH (88.3%; 136/154) met the criteria for high PA compared to PWH (74.2%; 115/155). In adjusted models, lower levels of PA persisted among PWH (ß = -1,734, 95% CI: -2,645, -824, p ≤ 0.001). Results were similar in a sensitivity analysis limited to people living in rural areas. Conclusion: In a rural Ugandan cohort, PWOH had higher levels of PA than PWH. Interventions that encourage PA among PWH may have a role in improving NCD risk profiles among PWH in the region.

Diagnostic testing for hypertension, diabetes, and hypercholesterolaemia in low-income and middle-income countries: a cross-sectional study of data for 994 185 individuals from 57 nationally representative surveys.

BACKGROUND: Testing for the risk factors of cardiovascular disease, which include hypertension, diabetes, and hypercholesterolaemia, is important for timely and effective risk management. Yet few studies have quantified and analysed testing of cardiovascular risk factors in low-income and middle-income countries (LMICs) with respect to sociodemographic inequalities. We aimed to address this knowledge gap. METHODS: In this cross-sectional analysis, we pooled individual-level data for non-pregnant adults aged 18 years or older from nationally representative surveys done between Jan 1, 2010, and Dec 31, 2019 in LMICs that included a question about whether respondents had ever had their blood pressure, glucose, or cholesterol measured. We analysed diagnostic testing performance by quantifying the overall proportion of people who had ever been tested for these cardiovascular risk factors and the proportion of individuals who met the diagnostic testing criteria in the WHO package of essential noncommunicable disease interventions for primary care (PEN) guidelines (ie, a BMI >30 kg/m2 or a BMI >25 kg/m2 among people aged 40 years or older). We disaggregated and compared diagnostic testing performance by sex, wealth quintile, and education using two-sided t tests and multivariable logistic regression models. FINDINGS: Our sample included data for 994 185 people from 57 surveys. 19·1% (95% CI 18·5-19·8) of the 943 259 people in the hypertension sample met the WHO PEN criteria for diagnostic testing, of whom 78·6% (77·8-79·2) were tested. 23·8% (23·4-24·3) of the 225 707 people in the diabetes sample met the WHO PEN criteria for diagnostic testing, of whom 44·9% (43·7-46·2) were tested. Finally, 27·4% (26·3-28·6) of the 250 573 people in the hypercholesterolaemia sample met the WHO PEN criteria for diagnostic testing, of whom 39·7% (37·1-2·4) were tested. Women were more likely than men to be tested for hypertension and diabetes, and people in higher wealth quintiles compared with those in the lowest wealth quintile were more likely to be tested for all three risk factors, as were people with at least secondary education compared with those with less than primary education. INTERPRETATION: Our study shows opportunities for health systems in LMICs to improve the targeting of diagnostic testing for cardiovascular risk factors and adherence to diagnostic testing guidelines. Risk-factor-based testing recommendations rather than sociodemographic characteristics should determine which individuals are tested. FUNDING: Harvard McLennan Family Fund, the Alexander von Humboldt Foundation, and the National Heart, Lung, and Blood Institute of the US National Institutes of Health.

Aspirin for Secondary Prevention of Cardiovascular Disease in 51 Low-, Middle-, and High-Income Countries.

Importance: Aspirin is an effective and low-cost option for reducing atherosclerotic cardiovascular disease (CVD) events and improving mortality rates among individuals with established CVD. To guide efforts to mitigate the global CVD burden, there is a need to understand current levels of aspirin use for secondary prevention of CVD. Objective: To report and evaluate aspirin use for secondary prevention of CVD across low-, middle-, and high-income countries. Design, Setting, and Participants: Cross-sectional analysis using pooled, individual participant data from nationally representative health surveys conducted between 2013 and 2020 in 51 low-, middle-, and high-income countries. Included surveys contained data on self-reported history of CVD and aspirin use. The sample of participants included nonpregnant adults aged 40 to 69 years. Exposures: Countries' per capita income levels and world region; individuals' socioeconomic demographics. Main Outcomes and Measures: Self-reported use of aspirin for secondary prevention of CVD. Results: The overall pooled sample included 124 505 individuals. The median age was 52 (IQR, 45-59) years, and 50.5% (95% CI, 49.9%-51.1%) were women. A total of 10 589 individuals had a self-reported history of CVD (8.1% [95% CI, 7.6%-8.6%]). Among individuals with a history of CVD, aspirin use for secondary prevention in the overall pooled sample was 40.3% (95% CI, 37.6%-43.0%). By income group, estimates were 16.6% (95% CI, 12.4%-21.9%) in low-income countries, 24.5% (95% CI, 20.8%-28.6%) in lower-middle-income countries, 51.1% (95% CI, 48.2%-54.0%) in upper-middle-income countries, and 65.0% (95% CI, 59.1%-70.4%) in high-income countries. Conclusion and Relevance: Worldwide, aspirin is underused in secondary prevention, particularly in low-income countries. National health policies and health systems must develop, implement, and evaluate strategies to promote aspirin therapy.

National Estimates of the Adult Diabetes Care Continuum in India, 2019-2021.

Importance: Diabetes is widespread and treatable, but little is known about the diabetes care continuum (diagnosis, treatment, and control) in India and how it varies at the national, state, and district levels. Objective: To estimate the adult population levels of diabetes diagnosis, treatment, and control in India at national, state, and district levels and by sociodemographic characteristics. Design, Setting, and Participants: In this cross-sectional, nationally representative survey study from 2019 to 2021, adults in India from 28 states, 8 union territories, and 707 districts were surveyed for India's Fifth National Family Health Survey (NFHS-5). The survey team collected data on blood glucose among all adults (18-98 years) who were living in the same household as eligible participants (pregnant or nonpregnant female individuals aged 15-49 years and male individuals aged 15-54 years). The overall sample consisted of 1 895 287 adults. The analytic sample was restricted to those who either self-reported having diabetes or who had a valid measurement of blood glucose. Exposures: The exposures in this survey study were district and state residence; urban vs rural residence; age (18-39 years, 40-64 years, or ≥65 years); sex; and household wealth quintile. Main Outcomes and Measures: Diabetes was defined by self-report or high capillary blood glucose (fasting: ≥126 mg/dL [to convert to mmol/L, multiply by 0.0555]; nonfasting: ≥220 mg/dL). Among respondents who had previously been diagnosed with diabetes, the main outcome was the proportion treated based on self-reported medication use and the proportion controlled (fasting: blood glucose <126 mg/dL; nonfasting: ≤180 mg/dL). The findings were benchmarked against the World Health Organization (WHO) Global Diabetes Compact targets (80% diagnosis; 80% control among those diagnosed). The variance in indicators between and within states was partitioned using variance partition coefficients (VPCs). Results: Among 1 651 176 adult respondents (mean [SD] age, 41.6 [16.4] years; 867 896 [52.6%] female) with blood glucose measures, the proportion of individuals with diabetes was 6.5% (95% CI, 6.4%-6.6%). Among adults with diabetes, 74.2% (95% CI, 73.3%-75.0%) were diagnosed. Among those diagnosed, 59.4% (95% CI, 58.1%-60.6%) reported taking medication, and 65.5% (95% CI, 64.5%-66.4%) achieved control. Diagnosis and treatment were higher in urban areas, older age groups, and wealthier households. Among those diagnosed in the 707 districts surveyed, 246 (34.8%) districts met the WHO diagnosis target, while 76 (10.7%) districts met the WHO control target. Most of the variability in diabetes diagnosis (VPC, 89.1%), treatment (VPC, 85.9%), and control (VPC, 95.6%) were within states, not between states. Conclusions and Relevance: In this survey study, the diabetes care continuum in India is represented by considerable district-level variation, age-related disparities, and rural-urban differences. Surveillance at the district level can guide state health administrators to prioritize interventions and monitor achievement of global targets.