Significant Improvement in Blood Pressure Levels Among Older Adults With Hypertension in Rural South Africa.

BACKGROUND: Sub-Saharan Africa is undergoing an epidemiologic transition from infectious diseases to cardiovascular diseases. From 2014 to 2019, sociodemographic surveillance was performed in a large cohort in rural South Africa. METHODS: Disease prevalence and incidence were calculated using inverse probability weights. Poisson regression was used to identify disease predictors. The percentage of individuals with controlled (<140/90 mm Hg) versus uncontrolled hypertension was compared between 2014 and 2019. RESULTS: Compared with 2014 (n=5059), study participants in 2019 (n=4176) had similar rates of obesity (mean body mass index, 27.5±10.0 versus 27.0±6.5) but higher smoking (9.1% versus 11.5%) and diabetes (11.1% versus 13.9%). There was no significant increase in hypertension prevalence (58.4% versus 59.8%; age adjusted, 64.3% versus 63.3%), and there was a significant reduction in mean systolic blood pressure (138.0 versus 128.5 mm Hg; P<0.001). Among hypertensive individuals who reported medication use in 2014 and 2019 (n=796), the proportion with controlled hypertension on medication increased from 44.5% to 62.3%. Hypertension incidence was 6.2 per 100 person-years, and age was the only independent predictor. Among normotensive individuals in 2014 (n=2257), 15.2% developed hypertension by 2019, with the majority already controlled on medications by 2019. CONCLUSIONS: The hypertension prevalence and incidence are plateauing in this aging cohort. There was a statistically and clinically significant decline in mean blood pressure and a substantial increase in individuals with controlled hypertension on medication. The prevalence of cardiometabolic risk factors did not decrease over time, suggesting that the blood pressure decrease is likely due to increased medication access and adherence, promoted by local health systems.

Incidence of Cognitive Impairment during Aging in Rural South Africa: Evidence from HAALSI, 2014 to 2019.

INTRODUCTION: Despite rapid population aging, there are currently limited data on the incidence of aging-related cognitive impairment in sub-Saharan Africa. We aimed to determine the incidence of cognitive impairment and its distribution across key demographic, social, and health-related factors among older adults in rural South Africa. METHODS: Data were from in-person interviews with 3,856 adults aged ≥40 who were free from cognitive impairment at baseline in the population-representative cohort, "Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI), in Agincourt sub-district, Mpumalanga province, South Africa (2014-19). Cognitive impairment was defined as scoring <1.5 standard deviations below the mean of the baseline distribution of orientation and episodic memory scores. Incidence rates and rate ratios for cognitive impairment were estimated according to key demographic, social, and health-related factors, adjusted for age, sex/gender, and country of birth. RESULTS: The incidence of cognitive impairment was 25.7/1,000 person-years (PY; 95% confidence interval [CI]: 23.0-28.8), weighted for mortality (12%) and attrition (6%) over the 3.5-year mean follow-up (range: 1.5-4.8 years). Incidence increased with age, from 8.9/1,000 PY (95% CI: 5.2-16.8) among those aged 40-44 to 93.5/1,000 PY (95% CI: 75.9-116.3) among those aged 80+, and age-specific risks were similar by sex/gender. Incidence was strongly associated with formal education and literacy, as well as marital status, household assets, employment, and alcohol consumption but not with history of smoking, hypertension, stroke, angina, heart attack, diabetes, or prevalent HIV. CONCLUSIONS: This study presents some of the first incidence rate estimates for aging-related cognitive impairment in rural South Africa. Social disparities in incident cognitive impairment rates were apparent in patterns similar to those observed in many high-income countries.

Cognitive function and cardiometabolic disease risk factors in rural South Africa: baseline evidence from the HAALSI study.

BACKGROUND: Evidence on cognitive function in older South Africans is limited, with few population-based studies. We aimed to estimate baseline associations between cognitive function and cardiometabolic disease risk factors in rural South Africa. METHODS: We use baseline data from "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI), a population-based study of adults aged 40 and above in rural South Africa in 2015. Cognitive function was measured using measures of time orientation, immediate and delayed recall, and numeracy adapted from the Health and Retirement Study cognitive battery (overall total cognitive score range 0-26). We used multiple linear regression to estimate associations between cardiometabolic risk factors (including BMI, hypertension, dyslipidemia, diabetes, history of stroke, alcohol frequency, and smoking status) and the overall cognitive function score, adjusted for potential confounders. RESULTS: In multivariable-adjusted analyses (n = 3018; male = 1520; female = 1498; median age 59 (interquartile range 50-67)), cardiometabolic risk factors associated with lower cognitive function scores included: diabetes (b = - 1.11 [95% confidence interval: - 2.01, - 0.20] for controlled diabetes vs. no diabetes); underweight BMI (b = - 0.87 [CI: - 1.48, - 0.26] vs. normal BMI); and current and past smoking history compared to never smokers. Factors associated with higher cognitive function scores included: obese BMI (b = 0.74 [CI: 0.39, 1.10] vs. normal BMI); and controlled hypertension (b = 0.53 [CI: 0.11, 0.96] vs. normotensive). CONCLUSIONS: We provide an important baseline from rural South Africa on the associations between cardiometabolic disease risk factors and cognitive function in an older, rural South African population using standardized clinical measurements and cut-offs and widely used cognitive assessments. Future studies are needed to clarify temporal associations as well as patterns between the onset and duration of cardiometabolic conditions and cognitive function. As the South African population ages, effective management of cardiometabolic risk factors may be key to lasting cognitive health.

The association between perceived household educational support and HIV risk in young women in a rural South African community (HPTN 068): A cross sectional study.

OBJECTIVE: To characterise perceived household support for female education and the associations between educational support and HIV prevalence, HSV-2 prevalence and sexual risk behaviours. METHODS: This cross-sectional study used baseline survey data from the Swa Koteka HPTN 068 trial undertaken in Mpumalanga, South Africa. The study included 2533 young women aged 13-20, in grades 8-11 at baseline. HIV and HSV-2 status were determined at baseline. Information about patterns of sexual behaviour and household support for education was collected during the baseline survey. Linear regression and binary logistic regression were used to determine associations between household support for education and both biological and behavioural outcomes. RESULTS: High levels of educational support were reported across all measures. HIV prevalence was 3.2% and HSV-2 prevalence was 4.7%, both increasing significantly with age. Over a quarter (26.6%) of young women reported vaginal sex, with 60% reporting condom use at last sex. The median age of sexual debut was 16 years. Household educational support was not significantly associated with HIV or HSV-2; however, the odds of having had vaginal sex were significantly lower in those who reported greater homework supervision (OR 0.82, 95%CI: 0.72-0.94), those who engaged in regular discussion of school marks with a caregiver (OR 0.82, 95%CI: 0.71-0.95) and when caregivers had greater educational goals for the young woman (OR 0.82, 95%CI: 0.71-0.96). In contrast, greater caregiver disappointment at dropout was significantly associated with reported vaginal sex (OR 1.29, 95%CI: 1.14-1.46). CONCLUSION: Young women in rural South Africa report experiencing high levels of household educational support. This study suggests that greater household educational support is associated with lower odds of having vaginal sex and engaging in risky sexual behaviour, though not with HIV or HSV-2 prevalence.

Education modifies the relationship between height and cognitive function in a cross-sectional population-based study of older adults in Rural South Africa.

We aimed to estimate the relationship between height (a measure of early-life cumulative net nutrition) and later-life cognitive function among older rural South African adults, and whether education modified this relationship. Data were from baseline in-person interviews with 5059 adults ≥ 40 years in the population-based "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI) study in Agincourt sub-district, South Africa, in 2015. Linear regression was used to estimate the relationship between height quintile and latent cognitive function z-score (representing episodic memory, time orientation, and numeracy), with adjustment for life course covariates and a height-by-education interaction. Mean (SD) height was 162.7 (8.9) cm. Nearly half the sample had no formal education (46%; 2307/5059). Mean age- and sex-adjusted cognitive z-scores increased from - 0.68 (95% CI: - 0.76 to - 0.61) in those with no education in the shortest height quintile to 0.62 (95% CI: 0.52-0.71) in those with at least 8 years of education in the tallest height quintile. There was a linear height disparity in cognitive z-scores for those with no formal education (adjusted ß = 0.10; 95% CI: 0.08-0.13 per height quintile), but no height disparity in cognitive z-scores in those with any level of education. Short stature is associated with poor cognitive function and may be a risk factor for cognitive impairment among older adults living in rural South Africa. The height disparity in cognitive function was negated for older adults who had any level of education.

Sociodemographic, socioeconomic, clinical and behavioural predictors of body mass index vary by sex in rural South African adults-findings from the AWI-Gen study.

BACKGROUND: Despite increasing obesity in South African adults, data on the prevalence and determinants of body mass index (BMI) from rural communities, home to a significant proportion of the population, are scarce. OBJECTIVES: To investigate overall and sex-specific determinants of BMI in a rural adult South African population undergoing rapid social and epidemiological transitions. METHODS: Baseline cross-sectional demographic, socioeconomic, anthropometric, clinical and behavioural data were collected between 2015 and 2016 from 1388 individuals aged 40-60 years and resident in the Agincourt sub-district of Mpumalanga province, a setting typical of rural northeast South Africa. A Health and Socio-Demographic Surveillance System (HDSS) underpins the sub-district and contributes to the Africa Wits-INDEPTH partnership for Genomic Studies (AWI-Gen). Linear regression was used to investigate univariate associations between log-transformed BMI and individual variables and multiple linear regression was used to investigate independent predictors of BMI overall and in sex-stratified analyses. RESULTS: Median BMI was significantly higher in females (28.7 kg/m2[95% CI 24.2-33.2] vs 23.0 kg/m2[95% CI 20.3-26.8];p < 0.001) with male sex associated with 17% lower BMI. In sex-stratified multiple linear regression models, compared to those never married, BMI was 7% higher in currently married males and 6% in currently married females. Current smoking in men and former smoking in women were associated with reductions in BMI of 13% and 26% respectively, compared with non-smokers. Higher educational attainment in women and higher socioeconomic status in men were both associated with higher BMI, while being HIV-positive and alcohol consumption in women were associated lower BMI. CONCLUSIONS: Female sex strongly predicts higher BMI in this rural African population. While some predictors of higher BMI differ by sex, married individuals in both sexes had a higher BMI, suggesting that, in addition to developing sex-specific interventions to combat overweight and obesity, targeting married couples may result in reduction in population BMI.

Village community mobilization is associated with reduced HIV incidence in young South African women participating in the HPTN 068 study cohort.

INTRODUCTION: Adolescent girls and young women (AGYW) in South Africa bear a disproportionate burden of HIV. Community mobilization (CM), defined as community members taking collective action to achieve a common goal related to health, equity and rights, has been associated with increased HIV testing and condom use and has been called a 'critical enabler' for addressing the HIV epidemic. However, limited research has examined whether CM is associated with HIV incidence among AGYW. METHODS: We examine the association of CM with incident HIV among AGYW (ages 13 to 21) enrolled in the HPTN 068 cohort in the Agincourt Health and socio-Demographic Surveillance System, South Africa. This analysis includes 2292 participants residing in 26 villages where cross-sectional, population-based surveys were conducted to measure CM among 18- to 35-year-old residents in 2012 and 2014. HPTN 068 participants completed up to five annual visits that included an HIV test (2011 to 2016). Household-level data were collected from AGYW parents/guardians and census data is updated annually. Mean village-level CM scores were created using a validated community mobilization measure with seven components (social cohesion, social control, critical consciousness, shared concerns, organizations and networks, leadership and collective action). We used pooled generalized estimating equation regression with a Poisson distribution to estimate risk ratios (RR) for the association of village-level CM score and CM components with incident HIV infection, accounting for village-level clustering and adjusting for key covariates. RESULTS: There were 194 incident infections over the follow-up period. For every additional standard deviation of village-level CM there was 12% lower HIV incidence (RR: 0.88, 95% CI: 0.79, 0.98) after adjusting for individual, household and community characteristics. CM components associated with lower HIV incidence included critical consciousness (RR: 0.88; CI: 0.79, 0.97) and leadership (RR: 0.87; CI: 0.79, 0.95); while not statistically significant, social cohesion (RR: 0.91; CI: 0.81, 1.01), shared concerns (RR: 0.90; CI: 0.81, 1.00), and organizations and networks (RR: 0.91; CI: 0.79, 1.03) may also play a protective role. CONCLUSIONS: These results suggest that having strong community social resources will reduce AGYW's risk of HIV acquisition. Work to mobilize communities, focusing on building social cohesion, shared concerns, critical consciousness, and effective and accountable leadership, can fortify prevention programming for AGYW.

Executive function associated with sexual risk in young South African women: Findings from the HPTN 068 cohort.

PURPOSE: Heightened sexual risk in adolescence and young adulthood may be partially explained by deficits in executive functioning, the set of cognitive processes used to make reasoned decisions. However, the association between executive function and sexual risk is understudied among adolescent girls and young women, particularly in low- and middle-income countries. METHODS: In a cohort of 853 young women age 18-25 in rural Mpumalanga province, South Africa, we evaluated executive function with three non-verbal cognitive tests: I. a rule-finding test, II. a trail-making test, and III. a figure drawing test. Using log-binomial regression models, we estimated the association between lower executive function test scores and indicators of sexual risk (unprotected sex acts, concurrent partnerships, transactional sex, and recent HSV-2 infection). RESULTS: In general, young women with lower executive function scores reported higher frequencies of sexual risk outcomes, though associations tended to be small with wide confidence intervals. Testing in the lowest quintile of Test I was associated with more unprotected sex [aPR (95% CI): 1.4 (1.0, 1.8)]. Testing in the lowest quintile of Test II was associated with more concurrent relationships and transactional sex [aPR (95% CI): 1.6 (1.1, 2.5) and 1.7 (1.3, 2.4), respectively], and testing in the lowest four quintiles of Test III was associated with more concurrent relationships [aPR (95% CI): 1.7 (1.0, 2.7)]. CONCLUSIONS: These results demonstrate an association between low executive function and sexual risk in South African young women. Future work should seek to understand the nature of this association and whether there is promise in developing interventions to enhance executive function to reduce sexual risk.

Regional and sex-specific variation in BMI distribution in four sub-Saharan African countries: The H3Africa AWI-Gen study.

BACKGROUND: African populations are characterised by diversity at many levels including: demographic history, genetic ancestry, language, wealth, socio-political landscape, culture and behaviour. Several of these have a profound impact on body fat mass. Obesity, a key risk factor for cardiovascular and metabolic diseases, in the wake of the epidemiological and health transitions across the continent, requires detailed analysis together with other major risk factors. OBJECTIVE: To compare regional and sex-specific body mass index (BMI) distributions, using a cross-sectional study design, in adults aged 40-60 years across six study sites in four sub-Saharan African (SSA) countries and to compare the determinants of BMI at each. METHODS: Anthropometric measurements were standardised across sites and BMI calculated. Median BMI and prevalence of underweight, lean, overweight and obesity were compared between the sexes and across sites. Data from multivariable linear regression models for the principal determinants of BMI were summarised from the site-specific studies. RESULTS: BMI was calculated in 10,702 participants (55% female) and was significantly higher in women than men at nearly all sites. The highest prevalence of obesity was observed at the three South African sites (42.3-66.6% in women and 2.81-17.5% in men) and the lowest in West Africa (1.25-4.22% in women and 1.19-2.20% in men). Across sites, higher socio-economic status and educational level were associated with higher BMI. Being married and increased dietary intake were associated with higher BMI in some communities, whilst smoking and alcohol intake were associated with lower BMI, as was HIV infection in the regions where it was prevalent. CONCLUSION: In SSA there is a marked variation in the prevalence of obesity both regionally and between men and women. Our data suggest that the drive for social upliftment within Africa will be associated with rising levels of obesity, which will require the initiation of targeted sex-specific intervention programmes across specific African communities.

Changing use of traditional healthcare amongst those dying of HIV related disease and TB in rural South Africa from 2003 - 2011: a retrospective cohort study.

BACKGROUND: In 2011 there were 5.5 million HIV infected people in South Africa and 71% of those requiring antiretroviral therapy (ART) received it. The effective integration of traditional medical practitioners and biomedical providers in HIV prevention and care has been demonstrated. However concerns remain that the use of traditional treatments for HIV-related disease may lead to pharmacokinetic interactions between herbal remedies and ART drugs and delay ART initiation. Here we analyse the changing prevalence and determinants of traditional healthcare use amongst those dying of HIV-related disease, pulmonary tuberculosis and other causes in a rural South African community between 2003 and 2011. ART was made available in this area in the latter part of this period. METHODS: Data was collected during household visits and verbal autopsy interviews. InterVA-4 was used to assign causes of death. Spatial analyses of the distribution of traditional healthcare use were performed. Logistic regression models were developed to test associations of determinants with traditional healthcare use. RESULTS: There were 5929 deaths in the study population of which 47.7% were caused by HIV-related disease or pulmonary tuberculosis (HIV/AIDS and TB). Traditional healthcare use declined for all deaths, with higher levels throughout for those dying of HIV/AIDS and TB than for those dying of other causes. In 2003-2005, sole use of biomedical treatment was reported for 18.2% of HIV/AIDS and TB deaths and 27.2% of other deaths, by 2008-2011 the figures were 49.9% and 45.3% respectively. In bivariate analyses, higher traditional healthcare use was associated with Mozambican origin, lower education levels, death in 2003-2005 compared to the later time periods, longer illness duration and moderate increases in prior household mortality. In the multivariate model only country of origin, time period and illness duration remained associated. CONCLUSIONS: There were large decreases in reported traditional healthcare use and increases in the sole use of biomedical treatment amongst those dying of HIV/AIDS and TB. No associations between socio-economic position, age or gender and the likelihood of traditional healthcare use were seen. Further qualitative and quantitative studies are needed to assess whether these figures reflect trends in healthcare use amongst the entire population and the reasons for the temporal changes identified.