Relationship between combination antiretroviral therapy regimens and diabetes mellitus-related comorbidities among HIV patients in Gaborone Botswana.

BACKGROUND: Combination antiretroviral therapy (cARTs) regiments are known to prolong the recipients' life even though they are risk factors for diabetes mellitus-related comorbidities (DRCs). We sought to: (i) examine cART relationship with DRCs among patients attending HIV clinics in Gaborone, Botswana (which cART regimens are associated with shorter/longer time to the event), (ii) characterize patients' underlying biomedical and demographic risk factors of DRC and identify the most important, (iii) investigate survival of patients on different cART regimens in the presence of these risk factors. METHODS: Data from two major HIV clinics in Botswana were reviewed. Relationships between different cART regimens and DRCs were investigated among 531 recipients. Recipients' DRC risk factors were identified. Cox regression model was run. Unadjusted and adjusted hazard ratios were computed, and hazard and survival functions for different cART regimens were plotted. RESULTS: Major findings were: patients on second- and third-line cART were less likely to develop DRCs earlier than those on first-line cART. Patients with CD4 count ≤ 200 cells/mm3 at cART initiation were more likely to develop DRCs earlier than those who had CD4 count > 200 cells/mm3. Overweight patients at cART initiation had a higher risk of developing DRCs earlier than those who had normal body mass index. Males had a lower risk of developing DRCs earlier than females. CONCLUSION: The risk of new onset of DRC among cART recipients is a function of the type of cART regimen, duration of exposure and patients' underlying biomedical and demographic DRC risk factors. The study has provided a survival model highlighting DRCs' significant prognostic factors to guide clinical care, policy and management of recipients of cARTs. Further studies in the same direction will likely improve the survival to the development of DRC of every cART recipient in this community.

Incidence of Mortality among Under-Five-Year-Old Children Born to Women Living with HIV and Those Born to Women Not Living with HIV in Botswana: A 5-Year Retrospective Study.

BACKGROUND: Child mortality is a core indicator for child health and wellness. Botswana reported an under-five-year-old children (UFC) mortality rate of 48 deaths per 1000 live births in 2017 against 152 deaths per 1000 live births in 1971. This was a commendable accomplishment. However, given the current country situation whereby 23% of children are born to women living with HIV, the incidence of mortality among UFC born to women living with and not living with HIV and their survival are better health metrics to inform decision making. Nevertheless, such data are still very scarce in Botswana. The study's objective was to estimate the incidence of UFC mortality among children born to women living with and not living with HIV and to compare UFC survival between the two groups. METHODS: A retrospective cohort study of mortality among UFC was conducted in Botswana, including all UFC born between January 2014 and June 2018. Data were extracted from the National Under-Five Mortality Audit Committee (NUFMAC) database using a standardized data collection tool. The incidence rate of UFC death was estimated as a function of the duration from birth to death. Survival functions of UFC born to women living with and not living with HIV were plotted and compared using Kaplan-Meier survival analysis. RESULTS: The overall incidence of UFC death was 4.63/1000 child months (CM) (95% CI 4.36-4.90). The incidence of UFC death among children born to women living with HIV was 6.96/1000 CM (95% CI 6.47-7.45) and that of UFC born to women not living with HIV was 4.34/1000 CM (95% CI 4.03-4.65). The overall average and standard error (SE) time to event/death for UFC born to women living with and not living with HIV was 54.80 (0.18) months. The mean (SE) time to death for UFC born to women living with HIV was 52.79 (0.41) months and that of UFC born to women not living with HIV was 55.44 (0.19) months (log-rank X 2 = 37.59, p < 0.001). Prematurity or low birth weight was the leading cause of UFC death in both groups; but, it was higher in UFC born to women not living with HIV subgroup than their counterparts. Four cases only or 0.5% of the 806 death cases reported by reporting physicians were attributable to HIV-related complications. CONCLUSION: Despite the commendable efforts made in reducing UFC death, the incidence of UFC death among UFC born to women living with HIV in Botswana is still higher, and their survival is shorter compared to UFC born to women not living with HIV. Child survival interventions should prioritize UFC born to women living with HIV to improve their survival.

Sociodemographic Predictors of HIV Infection among Pregnant Women in Botswana: Cross-Sectional Study at 7 Health Facilities.

OBJECTIVES: To determine the prevalence and sociodemographic predictors of HIV among pregnant women in Botswana. METHODS: This was a cross-sectional study of randomly enrolled women aged 18 to 49 years, attending 7 health facilities in Botswana. Data were gathered from November 2017 to March 2018 and analyzed using SPSS version 24. RESULT: Of the 429 women enrolled, 407 (96.4%) were included in the analysis. The HIV prevalence was 17%; 69 of 407 (95% CI: 13.4- 21.0). Women aged 35 to 49 years had higher HIV prevalence than those 18 to 24 years (adjusted odds ratio [AOR] = 6.2; 95% CI: 2.7-14.4). Illiterate and elementary school educated women had higher HIV prevalence than those with a tertiary education (AOR = 8.5; 95% CI: 1.8-39.1). Those with a history of alcohol intake had a higher HIV prevalence than those without (AOR = 2.6; 95% CI: 1.3-5.3). CONCLUSION: HIV prevalence was lower than it was in 2011. Age, level of education, and history of alcohol intake were strong predictors for HIV infection calling for targeted behavioral change interventions.

Overweight and Obesity among Recipients of Antiretroviral Therapy at HIV Clinics in Gaborone, Botswana: Factors Associated with Change in Body Mass Index.

BACKGROUND: Factors associated with overweight/obesity among antiretroviral therapy (ART) recipients have not been sufficiently studied in Botswana. OBJECTIVES: To: (i) estimate the prevalence and trends in overweight/obesity by duration of exposure to ART among recipients, (ii) assess changes in BMI categories among ART recipients between their first clinic visit (BMI-1) and their last clinic visit (BMI-2), (iii) identify ART regimen that predicts overweight/obesity better than the others and factors associated with BMI changes among ART recipients. METHODS: A 12-year retrospective record-based review was conducted. Potential predictors of BMI change among patients after at least three years of ART exposure were examined using a multiple logistic regression model. Adjusted odds ratios (AOR) and their 95% confidence intervals (CIs) were computed. ART regimens, duration of exposure to ART, and recipients' demographic and biomedical characteristics including the presence or absence of diabetes mellitus-related comorbidities (DRC), defined as any morbidity associated with type 2 diabetes as described in the international statistical classification of diseases and related health problems (ICD-10-CM) codebook index, were investigated as potential predictors of overweight/obesity. RESULTS: Twenty-nine percent of recipients were overweight, 16.6% had obesity of whom 2.4% were morbidly-obese at the last clinic visit. Overweight/obese recipients were more likely to be female, to have DRC and less likely to have CD4 count between 201 and 249 cells/mm3. Neither the first-line nor the second-, third-line ART regimens predicted overweight/obesity better than the other and neither did the duration of exposure to ART. No significant linear trends were observed in the prevalence of overweight/obesity by the duration of exposure to ART. CONCLUSION: These results suggest that the ART regimens studied have a comparable effect on overweight/obesity and that the duration of exposure does not affect the outcome. This study calls for further research to elucidate the relative contribution of various factors to BMI change among recipients, including ART regimens.

Characteristics and 12-month outcome of patients with atrial fibrillation at a tertiary hospital in Botswana.

BACKGROUND: Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia associated with high morbidity and mortality rates. Notwithstanding the scale of the problem, there are sparse data on the characteristics and outcomes of both valvular and non-valvular AF patients in sub-Saharan Africa (SSA). OBJECTIVE: This study aimed at describing the clinical features and outcome of AF patients at a tertiary hospital in Botswana. METHODS: This prospective study was carried out in the Princess Marina Hospital in Gaborone, Botswana between August 2016 and July 2018. We consecutively enrolled 138 (97.8% black Africans) adult patients with electrocardiographically documented AF. Their baseline clinical and biomedical data were documented, and each patient was followed up for 12 months. The primary study outcome was 12-month all-cause mortality. RESULTS: The mean [standard deviation (SD) ] age of enrolled patients was 66.7 (17.2) years, and 63.8% were females. Common co-morbidities were hypertension (59.4%), rheumatic heart disease (37.7%) and heart failure (35.5%). Stroke/transient ischaemic attack (TIA) (21.7%) and obesity (34.8%) were also prevalent. Compared to patients with non-valvular AF, those with valvular AF were more likely to be female (82 vs 55%, p = 0.003), younger (60 vs 75 years, p < 0.001), on anticoagulation (88.6 vs 66% p = 0.005), or have a dilated left atrium (5.3 vs 4.5 cm, p < 0.001). They were also less likely to present with hypertension (33 vs 72%, p < 0.001), stroke/TIA (nine vs 27%, p < 0.017), chronic kidney disease (five vs 20%, p < 0.02), or history of cigarette smoking (two vs 13%, p = 0.049) than non-valvular AF patients. The mean (SD) CHA2DS2-VASc score in non-valvular AF patients was 3.6 (1.5), and the median HAS-BLED score was 2.0 [interquartile range (IQR) 1.0-3.0]. During the 12-month follow up, 20 (14.5%) patients died. Despite differences in baseline characteristics, there was no difference in mortality rate in patients with valvular compared to those with non-valvular AF (13.8 vs 15.9%; p = 0.746). CONCLUSIONS: In this study, hypertension, rheumatic heart disease and heart failure were the most prevalent co-morbidities. AF presented in young people and conferred high mortality rates in both valvular and non-valvular AF patients. Prevention and optimal management of AF and associated co-morbidities are of critical importance.

Glycaemic, blood pressure and low-density lipoprotein-cholesterol control among patients with diabetes mellitus in a specialised clinic in Botswana: a cross-sectional study.

OBJECTIVE: Control of glycaemic, hypertension and low-density lipoprotein-cholesterol (LDL-C) among patients with type 2 diabetes mellitus (T2DM) is vital for the prevention of cardiovascular diseases. The current study was an audit of glycaemic, hypertension and LDL-C control among ambulant patients with T2DM in Botswana. Also, the study aimed at assessing factors associated with attaining optimal glycaemic, hypertension and LDL-C therapeutic goals. DESIGN: A cross-sectional study. SETTING: A specialised public diabetes clinic in Gaborone, Botswana. PARTICIPANTS: Patients with T2DM who had attended the clinic for ≥3 months between August 2017 and February 2018. PRIMARY OUTCOME MEASURE: The proportion of patients with optimal glycaemic (HbA1c<7%), hypertension (blood pressure <140/90 mm Hg) and LDL-C (<1.8 mmol/L) control. RESULTS: The proportions of patients meeting optimal targets were 32.3% for glycaemic, 54.2% for hypertension and 20.4% for LDL-C. Age≥ 50 years was positively associated with optimal glycaemic control (adjusted OR [AOR] 5.79; 95% CI 1.08 to 31.14). On the other hand, an increase in diabetes duration was inversely associated with optimal glycemic control (AOR 0.91; 95% CI 0.85 to 0.98). Being on an ACE inhibitor was inversely associated with optimal hypertension control (AOR 0.35; 95% CI 0.14 to 0.85). Being female was inversely associated with optimal LDL-C control (AOR 0.24; 95% CI (0.09 - 0.59). CONCLUSION: Patients with T2DM in Gaborone, Botswana, presented with suboptimal control of recommended glycaemic, hypertension and LDL-C targets. These findings call for urgent individual and health systems interventions to address key determinants of the recommended therapeutic targets among patients with diabetes in this setting.

Incidence of diabetes mellitus-related comorbidities among patients attending two major HIV clinics in Botswana: a 12-year retrospective cohort study.

OBJECTIVES: Exposure to combination antiretroviral therapy (cART) is associated with the development of diabetes mellitus related comorbidities (DRCs). This study aims to: (i) estimate the incidence of DRCs among cART recipients, (ii) assess the time-to-event (development of DRC) and, (iii) compare survival function between recipients on first-line regimen and those on second-, third-line cART regimen. RESULTS: The incidence of DRCs was 26.8/1000 person-years, with total time of exposure of 3316 person-years. The average time to event for all the three regimens was 11.72 ± 0.20 years. The first-line cART regimen had a shorter mean ± SE of 10.59 ± 0.26 years to the event compared to 12.69 ± 0.24 years for the second-, third-line cART regimen. Recipients on the first-line had a shorter survival than recipients on second-, third-line cART (Log-rank X2 = 8.98, p < 0.003). Data from this study showed that the risk of developing DRCs per year of exposure was significantly greater for patients on first-line compared to those who were on second-, third-line regimen; which, suggests that monitoring of cART long-term side effects and regular reviewing of cART regimens is important. Meticulous selection of drug combinations is a key to improving recipients' survival.

Households that harbour zero-dose children after door-to-door national immunization campaigns.

Data from two consecutive rounds of national immunization days were analysed to identify households that harboured zero-dose children after door-to-door immunization campaigns, and to highlight settings and features associated with these households in Chad. The proportion of households harbouring zero-dose children were higher among rural than among urban dwellers and were prevalent among parents who did not know the benefit of polio immunization. These results show the need for more attention to be given to rural dwellers and parent awareness of the benefit of polio immunization.

Validity of the Finnish Diabetes Risk Score for Detecting Undiagnosed Type 2 Diabetes among General Medical Outpatients in Botswana.

This was a cross-sectional study designed to assess the validity of the Finnish Diabetes Risk Score for detecting undiagnosed type 2 diabetes among general medical outpatients in Botswana. Participants aged ≥20 years without previously diagnosed diabetes were screened by (1) an 8-item Finnish diabetes risk assessment questionnaire and (2) Haemoglobin A1c test. Data from 291 participants were analyzed (74.2% were females). The mean age of the participants was 50.1 (SD = ±11) years, and the prevalence of undiagnosed diabetes was 42 (14.4%) with no significant differences between the gender (20% versus 12.5%, P = 0.26). The area under curve for detecting undiagnosed diabetes was 0.63 (95% CI 0.55-0.72) for the total population, 0.65 (95% CI: 0.56-0.75) for women, and 0.67 (95% CI: 0.52-0.83) for men. The optimal cut-off point for detecting undiagnosed diabetes was 17 (sensitivity = 48% and specificity = 73%) for the total population, 17 (sensitivity = 56% and specificity = 66%) for females, and 13 (sensitivity = 53% and specificity = 77%) for males. The positive predictive value and negative predictive value were 20% and 89.5%, respectively. The findings indicate that the Finnish questionnaire was only modestly effective in predicting undiagnosed diabetes among outpatients in Botswana.

Prevalence and determinants of metabolic syndrome: a cross-sectional survey of general medical outpatient clinics using National Cholesterol Education Program-Adult Treatment Panel III criteria in Botswana.

BACKGROUND: Low- and middle-income countries, including Botswana, are facing rising prevalence of obesity and obesity-related cardiometabolic complications. Very little information is known about clustering of cardiovascular risk factors in the outpatient setting during routine visits. We aimed to assess the prevalence and identify the determinants of metabolic syndrome among the general outpatients' attendances in Botswana. METHODS: A cross-sectional study was conducted from August to October 2014 involving outpatients aged ≥20 years without diagnosis of diabetes mellitus. A precoded questionnaire was used to collect data on participants' sociodemographics, risk factors, and anthropometric indices. Fasting blood samples were drawn and analyzed for glucose and lipid profile. Metabolic syndrome was assessed using National Cholesterol Education Program-Adult Treatment Panel III criteria. RESULTS: In total, 291 participants were analyzed, of whom 216 (74.2%) were females. The mean age of the total population was 50.1 (±11) years. The overall prevalence of metabolic syndrome was 27.1% (n=79), with no significant difference between the sexes (female =29.6%, males =20%, P=0.11). A triad of central obesity, low high-density lipoprotein-cholesterol, and elevated blood pressure constituted the largest proportion (38 [13.1%]) of cases of metabolic syndrome, followed by a combination of low high-density lipoprotein, elevated triglycerides, central obesity, and elevated blood pressure, with 17 (5.8%) cases. Independent determinants of metabolic syndrome were antihypertensive use and increased waist circumference. CONCLUSION: Metabolic syndrome is highly prevalent in the general medical outpatients clinics. Proactive approaches are needed to screen and manage cases targeting its most important predictors.

Severity of outcomes associated to illnesses funded by GFATM initiative and socio demographic and economic factors associated with HIV/AIDS, TB and malaria mortality in Kinshasa Hospitals, DRC.

BACKGROUND: For the past decades, developing countries have received considerable support to fight infectious illnesses in their homelands. This global effort has tremendously reduced case fatality rates associated with illnesses such as HIV/AIDS, tuberculosis and malaria in many countries. However, this information is still missing in some developing countries, hindering international effort for control programs; we designed this study in effort to close this gap. METHODS: Data on 23,487 inpatients from Kinshasa hospitals were gathered and analyzed using EpiData and SPSS. Major illnesses affecting inpatients were identified; mortality and case fatality rates associated with each such illness were estimated. Case fatality rates associated with each illness were compared between consecutive years. Socio demographic and economic factors associated with mortality due to HIV/AIDS, TB and malaria were investigated using logistic regression. RESULTS: The outstanding findings were that case fatality rates associated with major illnesses were relatively higher in 2008 than in the previous year; inpatients hospitalized for HIV/AIDS, TB and malaria in 2008 were more likely to die than those hospitalized in the previous year. Low socioeconomic status inpatients hospitalized for malaria, HIV/AIDS or TB were more likely to die than high socioeconomic status inpatients (AOR 0.29, 95% CI 0.22-0.40; AOR 0.20, 95%CI0.12-0.33; AOR 0.33, 95%CI 0.21-0.53), even though both groups presumably had access to free life-saving treatment and care. CONCLUSION: These results indicate that while improvement in health indicators greatly depends on funds availability and sustainability, these alone might not be enough in resource poor developing countries. Other factors, i.e., population SES also need to be addressed before needed changes may occur.