Linkage Case Management and Posthospitalization Outcomes in People With HIV: The Daraja Randomized Clinical Trial.

Importance: Despite the widespread availability of antiretroviral therapy (ART), people with HIV still experience high mortality after hospital admission. Objective: To determine whether a linkage case management intervention (named "Daraja" ["bridge" in Kiswahili]) that was designed to address barriers to HIV care engagement could improve posthospital outcomes. Design, Setting, and Participants: Single-blind, individually randomized clinical trial to evaluate the effectiveness of the Daraja intervention. The study was conducted in 20 hospitals in Northwestern Tanzania. Five hundred people with HIV who were either not treated (ART-naive) or had discontinued ART and were hospitalized for any reason were enrolled between March 2019 and February 2022. Participants were randomly assigned 1:1 to receive either the Daraja intervention or enhanced standard care and were followed up for 12 months through March 2023. Intervention: The Daraja intervention group (n = 250) received up to 5 sessions conducted by a social worker at the hospital, in the home, and in the HIV clinic over a 3-month period. The enhanced standard care group (n = 250) received predischarge HIV counseling and assistance in scheduling an HIV clinic appointment. Main Outcomes and Measures: The primary outcome was all-cause mortality at 12 months after enrollment. Secondary outcomes related to HIV clinic attendance, ART use, and viral load suppression were extracted from HIV medical records. Antiretroviral therapy adherence was self-reported and pharmacy records confirmed perfect adherence. Results: The mean age was 37 (SD, 12) years, 76.8% were female, 35.0% had CD4 cell counts of less than 100/µL, and 80.4% were ART-naive. Intervention fidelity and uptake were high. A total of 85 participants (17.0%) died (43 in the intervention group; 42 in the enhanced standard care group); mortality did not differ by trial group (17.2% with intervention vs 16.8% with standard care; hazard ratio [HR], 1.01; 95% CI, 0.66-1.55; P = .96). The intervention, compared with enhanced standard care, reduced time to HIV clinic linkage (HR, 1.50; 95% CI, 1.24-1.82; P < .001) and ART initiation (HR, 1.56; 95% CI, 1.28-1.89; P < .001). Intervention participants also achieved higher rates of HIV clinic retention (87.4% vs 76.3%; P = .005), ART adherence (81.1% vs 67.6%; P = .002), and HIV viral load suppression (78.6% vs 67.1%; P = .01) at 12 months. The mean cost of the Daraja intervention was about US $22 per participant including startup costs. Conclusions and Relevance: Among hospitalized people with HIV, a linkage case management intervention did not reduce 12-month mortality outcomes. These findings may help inform decisions about the potential role of linkage case management among hospitalized people with HIV. Trial Registration: ClinicalTrials.gov Identifier: NCT03858998.

Characterizing blood pressure trajectories in people living with HIV following antiretroviral therapy: A systematic review.

OBJECTIVES: The advent of antiretroviral therapy (ART) has reduced AIDS-related morbidity and mortality among people living with HIV (PLWH). Due to increased survival, PLWH have now been found to be at risk of chronic conditions related to ageing, such as cardiovascular disease (CVD). Hypertension is common in PLWH and is a major risk factor for the development of CVD. We conducted a systematic literature review to evaluate the research evidence on longitudinal blood pressure (BP) trajectories following ART initiation in PLWH. METHODS: We searched the following databases: PubMed, CINHAL, Scopus, and Web of Science (up to 15 March 2021) for peer-reviewed published studies that reported BP trajectories following ART initiation in PLWH. Three reviewers independently screened all studies by title and abstract. We included articles in English, published up to March 2021, that report office BP trajectories in PLWH initiating ART. A total of 10 publications met our inclusion criteria. Eight studies were prospective cohorts and two were retrospective. RESULTS: Nine out of 10 studies in the literature reported an increase in systolic BP (4.7-10.0 mmHg in studies with a follow-up range of 6 months to 8 years, and 3.0-4.7 mmHg/year in time-averaged studies). In addition, four out of 10 studies reported increases in diastolic BP (2.3-8.0 mmHg for a 6 month to 6.8-year follow-up range and 2.3 mmHg/year). CONCLUSION: Systolic BP consistently increases while diastolic BP changes are more heterogeneous following ART initiation in PLWH. However, the studies were highly variable with respect to population demographics, ART regimen and duration, and follow-up time. Nevertheless, given the risks of CVD complications, such as stroke, heart failure and myocardial infarction, associated with elevated BP, results highlight the importance of future research in this area. It will be important to better characterize BP trajectories over time, identify the most critical times for interventions to reduce BP, determine the long-term CVD consequences in PLWH with elevated BP, and understand how different ART regimens may or may not influence BP and CVD disease.

Hypertension: Do Inflammation and Immunity Hold the Key to Solving this Epidemic?

Elevated cardiovascular risk including stroke, heart failure, and heart attack is present even after normalization of blood pressure in patients with hypertension. Underlying immune cell activation is a likely culprit. Although immune cells are important for protection against invading pathogens, their chronic overactivation may lead to tissue damage and high blood pressure. Triggers that may initiate immune activation include viral infections, autoimmunity, and lifestyle factors such as excess dietary salt. These conditions activate the immune system either directly or through their impact on the gut microbiome, which ultimately produces chronic inflammation and hypertension. T cells are central to the immune responses contributing to hypertension. They are activated in part by binding specific antigens that are presented in major histocompatibility complex molecules on professional antigen-presenting cells, and they generate repertoires of rearranged T-cell receptors. Activated T cells infiltrate tissues and produce cytokines including interleukin 17A, which promote renal and vascular dysfunction and end-organ damage leading to hypertension. In this comprehensive review, we highlight environmental, genetic, and microbial associated mechanisms contributing to both innate and adaptive immune cell activation leading to hypertension. Targeting the underlying chronic immune cell activation in hypertension has the potential to mitigate the excess cardiovascular risk associated with this common and deadly disease.

Perceptions, facilitators and barriers of physical activity among people living with HIV: a qualitative study.

BACKGROUND: People living with HIV (PLWH) have low levels of physical activity. Using the social ecological model to understand perceptions, facilitators and barriers of physical activity in this population is of importance for developing contextualised interventions to improve physical activity in PLWH. METHOD: This was a qualitative sub-study conducted between august and November 2019 as part of a cohort study on diabetes and associated complications in HIV infected in Mwanza, Tanzania. Sixteen in-depth interviews and three focus groups with nine participants in each were conducted. The interviews and focus groups were audio recorded, transcribed and translated into English. The social ecological model was considered during the coding and interpretation of the results. Transcripts were discussed, coded and analyzed using deductive content analysis. RESULTS: Forty-three PLWH aged 23-61 years participated in this study. The findings showed that most PLWH perceived physical activity as beneficial to their health. However, their perceptions of physical activity were rooted within existing gender stereotypes and roles in the community. Running and playing football were perceived as activities for men while household chores activities were for women. Further, men were perceived to do more physical activity than women. For women, household chores and income-generating activities were perceived as sufficient physical activity. Social support and engagement of family members and friends in physical activity were reported as facilitators of physical activity. Reported barriers of physical activity were lack of time, money, availability of physical activity facilities and social support groups, and poor information on physical activity from health care providers in HIV clinics. Human-immunodeficiency virus (HIV) HIV infection was not perceived by PLWH as a barrier for doing physical activity but most family members did not support them to do physical activity, fearing that it might worsen their condition. CONCLUSION: The findings demonstrated differing perceptions, facilitators and barriers of physical activity among PLWH. Interventions addressing awareness, gender stereotypes and roles related to physical activity from individual to community level are needed. Supportive environment and infrastructures are needed to improve physical activity levels in PLWH in Tanzania.

A Cluster-Randomized Trial of Traditional Healer-Delivered Counseling and Rapid HIV Testing in Tanzania.

Collaborations with traditional healers have been proposed to improve HIV testing uptake. We hypothesized that healer-delivered HIV testing would improve HIV testing uptake, compared with referral to clinic-based HIV testing. We conducted a cluster randomized trial to determine the effectiveness of traditional healers delivering counseling and HIV testing in Mwanza, Tanzania (ClinicalTrials.gov NCT#04071873). Intervention arm healers provided counseling and offered point-of-care HIV tests to adult clients of unknown HIV serostatus. Control arm healers provided referral for clinic-based testing. Primary outcome was receipt of an HIV test within 90 days of enrollment. Secondary outcomes were new HIV diagnosis and linkage to care. In the intervention, 100 clients (100%) received an HIV test, compared with 73 (73%) of control participants (p < 0.001). Two intervention arm participants (2%) had a new diagnosis compared with zero in the control arm (p = 0.50). Engaging traditional healers might provide a culturally concordant opportunity to improve HIV testing uptake.

Prevalence and outcome of HIV infected children admitted in a tertiary hospital in Northern Tanzania.

BACKGROUND: Provider Initiated Testing and Counseling (PITC) among hospitalized children have shown to increase the probability of identifying HIV-infected children and hence be able to link them to HIV care. We aimed at determining the prevalence, clinical characteristics and outcome of HIV-infected children admitted at Bugando Medical Centre (BMC) after active provision of PITC services. METHODS: A cross-sectional study with follow up at three months post enrollment was done. Children with unknown HIV status were tested for HIV infection as per 2012 Tanzanian algorithm. Questionnaires were used to collect demographic, clinical and follow up information. Data was statistically analyzed in STATA v13. RESULTS: A total of 525 children were enrolled in the study. Median [IQR] age was 28 [15-54] months. Males consisted of 60.2% of all the participants. HIV prevalence was 9.3% (49/525). Thirty-three (67.3%) of HIV-infected children were newly diagnosed at enrolment. Thirty-nine (79.6%) of all HIV-infected patients had WHO HIV/AIDS clinical stage four disease, 10 (20.4%) had WHO clinical stage three and none qualified in stage one or two. About 84% (41/49) of HIV infected children had severe immunodeficiency at the time of the study. Factors that were independently associated with HIV infection were, cough (OR 2.40 [1.08-5.31], p = 0.031), oral thrush (OR 20.06[8.29-48.52], p < 0.001), generalized lymphadenopathy (OR 5.61 [1.06-29.56], p = 0.042), severe acute malnutrition (OR 6.78 [2.28-20.12], p = 0.001), severe stunting (OR 9.09[2.80-29.53], p = 0.034) and death of one or both parents (OR 3.62 [1.10-11.87], p = 0.034). The overall mortality (in-hospital and post-hospital) was 38.8% among HIV-infected children compared with 14.0% in HIV-uninfected children. Within three months period after discharge from the hospital, 71.4% (25/35) of discharged HIV-infected children reported to have attended HIV clinic at least once and 60.0% (21/35) were on antiretroviral medications. CONCLUSION: PITC to all admitted children identified significant number of HIV-infected children. Mortality among HIV-infected children is high compared to HIV-uninfected. At the time of follow up about 30% of discharged HIV-infected children did not attend to any HIV care and treatment clinics. Therefore effective efforts are needed to guarantee early diagnosis and linkage to HIV care so as to reduce morbidity and mortality among these children.

Human Immunodeficiency Virus-Associated Myocardial Diastolic Dysfunction and Soluble ST2 Concentration in Tanzanian Adults: A Cross-Sectional Study.

BACKGROUND: The aims of this study were (1) to compare the prevalence of myocardial diastolic dysfunction (DD) in antiretroviral therapy (ART)-naive people living with human immunodeficiency virus (PLWH) to human immunodeficiency virus (HIV)-uninfected adults in East Africa and (2) to determine the association between serum concentration of the cardiac biomarkers ST2 and DD. METHODS: In this cross-sectional study, we enrolled PLWH and uninfected adults at a referral HIV clinic in Mwanza, Tanzania. Standardized history, echocardiography, and serum were obtained. Regression models were used to quantify associations. RESULTS: We enrolled 388 ART-naive PLWH and 461 HIV-uninfected adults with an average age of 36.0 ± 10.2 years. Of PLWH in the third, fourth, and fifth decades of life, 5.0%, 12.5%, and 32.7%, respectively, had DD. PLWH had a higher prevalence of DD (adjusted odds ratio, 2.71 [95% confidence interval, 1.62-4.55]; P < .0001). PLWH also had a higher probability of dysfunction with one or fewer traditional risk factors present. Serum ST2 concentration was associated with dysfunction in PLWH but not uninfected participants (P = .04 and P = .90, respectively). CONCLUSIONS: In a large population of young adults in sub-Saharan Africa, DD prevalence increased starting in the third decade of life. HIV was independently associated with dysfunction. Serum ST2 concentration was associated with DD in PLWH but not HIV-uninfected participants. This pathway may provide insight into the mechanisms of HIV-associated dysfunction.

Linkage to Care Intervention to Improve Post-Hospital Outcomes Among Children with Sickle Cell Disease in Tanzania: A Pilot Study.

We conducted a pilot study to determine the effectiveness of a linkage to care intervention with social workers to improve 12-month post-hospital mortality for children in Tanzania with sickle cell disease. Comparison was done with a historical cohort. Mortality was 6.7% in the interventional cohort compared with 19.2% (adjusted Hazard Ratio, 0.26; 95% CI, 0.08-0.83).

Sex-dependent correlates of arterial stiffness in Tanzanian adults.

OBJECTIVE: Arterial stiffness is a known indicator for cardiovascular disease. However, the factors that lead to arterial stiffening have primarily been studied in participants from high-income countries. Here, we examine clinical and lifestyle metrics in relation to arterial stiffness in Tanzanian adults. METHODS: We performed pulse wave velocity (PWV), the gold standard measure of arterial stiffness, on 808 Tanzanian adults (ages 18-65) enrolled in a longitudinal cohort studying trends in blood pressure. RESULTS: As expected, PWV was strongly associated with age, blood pressure and sex. We controlled for these factors in our statistical analysis. Lifestyle metrics were compared across multiple PWV quantiles. We found that determinants of PWV varied by sex: in female participants, PWV was associated with common obesity metrics and menopause, while in male participants, PWV was associated with HIV status and duration of anti-retroviral therapy (ART). Further clinical and lifestyle factors such as marriage status and type of occupation were also significantly associated with PWV and moderated by sex. CONCLUSION: Together, our data demonstrate the importance of studying sex-specific causal pathways for arterial stiffness and of including under-represented populations in these studies.

The burden of HIV, syphilis and schistosome infection and associated factors among adults in the fishing communities in northwestern Tanzania.

OBJECTIVES: To quantify the burden of HIV, syphilis and schistosome infection and associated risk factors among adults living in seven fishing communities of Lake Victoria in northwest Tanzania. METHODS: Cross-sectional study conducted between 2015 and 2016 in the selected communities. In each community, we randomly selected a sample of adults from the general population and from three putative risk groups including the following: (i) fishermen, (ii) fish processors and traders, and (iii) women working in the recreational facilities. Participants were interviewed to obtain information about potential risk factors, and venous blood was collected for detection of HIV, syphilis and schistosome infections. We used logistic regression models to quantify the associations between potential risk factors and HIV, and also between schistosome infection and HIV. RESULTS: We enrolled 1128 people from selected fishing communities. The overall prevalence of HIV, syphilis and schistosome infection was 14.2%, 15.6% and 83.1%, respectively. Female recreational facility workers had the highest prevalence of HIV (30.4%) and syphilis (24%). The odds of being HIV infected were generally higher in all age categories. Transactional sex was commonly reported and especially receiving gifts for sex was found to be strongly associated with HIV (adjusted OR = 2.50; 95% CI: 1.44-4.34, P = 0.008). Confirmed serological syphilis was associated with increased odds of having HIV infection. HIV was not associated with schistosome infection in a combined dataset and when we examined this separately for men and women alone. CONCLUSIONS: We observed a high burden of HIV, syphilis and schistosome infections in the fishing communities. Targeted efforts to treat and control infections have the potential to improve health among their residents.

OBJECTIFS: Quantifier la charge du VIH, de la syphilis et de l'infection à schistosomes et les facteurs de risque associés chez les adultes vivant dans sept communautés de pêcheurs du lac Victoria dans le nord-ouest de la Tanzanie. MÉTHODES: Etude transversale menée entre 2015-2016 dans les communautés sélectionnées. Dans chaque communauté, nous avons sélectionné aléatoirement un échantillon d'adultes de la population générale et de trois groupes à risque présumés, notamment: 1) les pêcheurs, 2) les transformateurs et commerçants de poisson et 3) les femmes travaillant dans les établissements de loisirs. Les participants ont été interrogés pour obtenir des informations sur les facteurs de risque potentiels, et du sang veineux a été collecté pour la détection du VIH, de la syphilis et des infections à schistosome. Nous avons utilisé des modèles de régression logistique pour quantifier les associations entre les facteurs de risque potentiels et le VIH, ainsi qu'entre l'infection à schistosome et le VIH. RÉSULTATS: Nous avons recruté 1.128 personnes dans une sélection de communautés de pêcheurs. La prévalence globale de l'infection par le VIH, la syphilis et les schistosomes était de 14,2%, 15,6% et 83,1% respectivement. Les travailleuses des établissements de loisirs avaient la prévalence la plus élevée du VIH (30,4%) et de la syphilis (24%). Les chances d'être infecté par le VIH étaient généralement plus élevées dans toutes les catégories d'âge. Les rapports sexuels transactionnels étaient fréquemment rapportés et surtout le fait de recevoir des cadeaux pour le sexe était fortement associé au VIH (OR ajusté = 2,50; IC95%: 1,44-4,34 ; P = 0,008). La syphilis sérologique confirmée était associée à une probabilité accrue d'être infecté par le VIH. Le VIH n'était pas associé à une infection à schistosome dans un ensemble de données combinées et lorsque nous avons examiné cela séparément pour les hommes et les femmes. CONCLUSIONS: Nous avons observé une charge élevée d'infections par le VIH, la syphilis et les schistosomes dans les communautés de pêcheurs. Des efforts ciblés pour traiter et contrôler les infections ont le potentiel d'améliorer la santé des résidents.

Risk factors for impaired renal function in HIV-infected and HIV-uninfected adults: cross-sectional study in North-Western Tanzania.

BACKGROUND: Although the burden of impaired renal function is rising in sub-Saharan Africa (SSA), little is known about correlates of impaired renal function in the region. We determined factors associated with estimated glomerular filtration rate (eGFR) and impaired renal function in HIV-infected and HIV-uninfected adults. METHODS: We undertook cross-sectional analysis of data from 1947 adults at enrolment for a cohort study on diabetes and associated complications in HIV patients in Mwanza, north-western Tanzania. A structured questionnaire was used to collect data on sociodemography, smoking, alcohol, physical activity, antiretroviral therapy (ART) and anthropometry. We measured blood pressure, tested blood samples for creatinine, glucose and HIV, and performed Kato Katz for Schistosoma mansoni. Correlates of eGFR (mL/min/1.73 m2) and impaired renal function (eGFR< 60 mL/min/1.73 m2) were determined using linear regression and logistic regression, respectively. RESULTS: 655 (34%) participants were HIV-uninfected, 956 (49%) were ART-naive HIV-infected and 336 (17%) were HIV-infected adults on ART. The mean age was 41 years (SD12) and majority (59%) were females. Overall, the mean eGFR was 113.6 mL/min/1.73 m2 but 111.2 mL/min/1.73 m2 in HIV-uninfected, 109.7 mL/min/1.73 m2 in ART-naive HIV-infected and 129.5 mL/min/1.73 m2 in HIV-infected ART-experienced adults, and respective prevalence of impaired renal function was 7.0, 5.7, 8.1 and 6.3%. Correlates of lower eGFR were increasing age, higher socioeconomic status, unhealthy alcohol drinking, higher body mass index and diabetes mellitus. Anaemia was associated with 1.9 (95% Confidence Interval (CI):1.2, 2.7, p = 0.001) higher odds of impaired renal function compared to no anaemia and this effect was modified by HIV status (p value 0.02 for interaction). CONCLUSION: Impaired renal function is prevalent in this middle-aged study population. Interventions for prevention of impaired renal function are needed in the study population with special focus in HIV-infected adults and those with high socioeconomic status. Interventions targeting modifiable risk factors such as alcohol and weight reduction are warranted.

Retinopathy in adults with hypertension and diabetes mellitus in Western Tanzania: a cross-sectional study.

OBJECTIVE: Little is known about the retinal manifestations of arterial hypertension (HTN) and diabetes mellitus (DM) in Western Tanzania and how to maximise the utilisation of scarce eye health resources. To address this, we determined the prevalence of hypertensive and diabetic retinopathy (DR), associated risk factors and relevant patient knowledge. METHODS: Adults with HTN or DM attending outpatient clinics at Bugando Medical Center (BMC) from June to August 2017 were enrolled. Fundus photographs were obtained, and data were collected on blood pressure (BP), body mass index (BMI), blood sugar, visual acuity (VA) and responses to questions about the effects of HTN and DM on the eye. RESULTS: A total of 180 persons were screened. When only individuals with DR were considered, bivariate regression found systolic BP was significantly associated with severity of DR (P = 0.034). Receiver operating characteristic (ROC) curve analysis using the maximum Youden index revealed the optimum cut-off using duration of DM to predict any DR was 8 years (AUC = 0.75, 95% CI 0.65-0.85). Fewer persons with HTN were aware of the effect of high BP on the eye (61.6%) than persons with DM who were aware of the effect of high blood sugar on the eye (74.4%) (P = 0.048). CONCLUSION: Efforts should be made to vigorously treat HTN among adults with DM and refer adults with duration of DM of 8 years or more for a dilated retinal examination. Additional efforts should be made to promote awareness of the sight threatening potential of HTN in resource-limited settings.

OBJECTIF: On en sait peu sur les manifestations rétiniennes de l'hypertension artérielle (HTA) et du diabète sucré (DS) dans l'ouest de la Tanzanie et sur la manière de maximiser l'utilisation des rares ressources de la santé oculaire. Pour répondre à ceci, nous avons déterminé la prévalence de la rétinopathie hypertensive et diabétique (RD), les facteurs de risque associés et la connaissance du patient concerné. MÉTHODES: Les adultes atteints d'HTA ou de DS fréquentant les cliniques ambulatoires au Bugando Medical Center (BMC) de juin à août 2017 ont été inscrits. Des photos du fond de l'œil ont été obtenues et des données ont été recueillies sur la pression artérielle (TA), l'indice de masse corporelle (IMC), la glycémie, l'acuité visuelle (AV) et les réponses aux questions sur les effets de l'HTA et du DS sur l'œil. RÉSULTATS: Au total, 180 personnes ont été dépistées. Lorsque seules les personnes atteintes de RD étaient considérées, la régression bivariée a révélé que la TA systolique était significativement associée à la sévérité de la RD (P = 0,034). L'analyse de la courbe des caractéristiques de fonctionnement du récepteur (ROC) à l'aide de l'indice de Youden maximal a révélé que le seuil optimal utilisant la durée du DS pour prédire toute RD était de 8 ans (ASC = 0,75 ; IC95%: 0,65 à 0,85). Moins de personnes atteintes de HTA étaient conscientes de l'effet d'une TA élevée sur l'œil (61,6%) que les personnes atteintes de DS qui étaient conscientes de l'effet de l'hyperglycémie sur l'œil (74,4%) (P = 0,048). CONCLUSION: Des efforts doivent être faits pour traiter effectivement l'HTA chez les adultes atteints de DS et référer les adultes avec une durée de DS de 8 ans ou plus pour un examen de la rétine dilatée. Des efforts supplémentaires devraient être faits pour promouvoir la prise de conscience du potentiel de menace pour la vue de l'HTA dans les zones à ressources limitées.

High birth prevalence of sickle cell disease in Northwestern Tanzania.

BACKGROUND: Worldwide, hemoglobinopathies affect millions of children. Identification of hemoglobin disorders in most sub-Saharan African countries is delayed until clinical signs of the disease are present. Limited studies have been conducted to understand their prevalence and clinical presentation among newborns in resource-limited settings. METHODOLOGY: This was a prospective cohort study. Newborns (aged 0-7 days) at two hospitals in Northwestern Tanzania were enrolled and followed prospectively for 6 months. Clinical and laboratory information were collected at baseline. Participants were screened for hemoglobinopathies using high-performance liquid chromatography. Clinical and laboratory follow-up was performed at 3 and 6 months for those with hemoglobinopathies as well as a comparison group of participants without hemoglobinopathies. RESULTS: A total of 919 newborns were enrolled. Among these, 1.4% (13/919) had sickle cell anemia or Hb S/ß0 -thalassemia (Hb FS), and 19.7% (181/919) had sickle cell trait or Hb S/ß+ thalassemia (Hb FAS). Furthermore, 0.2% (two of 919) had ß+ -thalassemia. Red cell indices compared between Hb FS, Hb FAS, and Hb FA were similar at baseline, but hemoglobin was lower and red cell distribution width was higher in children with Hb FS at 3- and 6-month follow-up. Febrile episodes were more common for children with Hb FS at 3- and 6-month follow-up. CONCLUSION: The prevalence of sickle cell disease among neonates born in Northwestern Tanzania is one of the highest in the world. Newborn screening is needed early in life to identify neonates with hemoglobinopathies so that clinical management may commence and morbidity and mortality related to hemoglobinopathies be reduced.

The magnitude of antibiotic resistance to Helicobacter pylori in Africa and identified mutations which confer resistance to antibiotics: systematic review and meta-analysis.

BACKGROUND: Worldwide Helicobacter pylori (H.pylori) treatment is of great challenge due to increased antibiotic resistance. The burden of H. pylori antibiotic resistance in Africa is high with unclear information regarding the real magnitude. This systematic review and meta-analysis was conducted to investigate the magnitude of H.pylori antibiotic resistance in Africa to gain insight of the extent of the problem among H.pylori naïve treatment patients. METHOD: The search was performed in the academic databases, Embase, PubMed, Web of Science and Africa Wide Information. ProQuest Dissertation and Theses, Scopus, Ethos, Africa Index Medicus (WHO), BioMed Central Proceedings, BASE, British Library, Open grey, Library of Congress and the New York Academy of Grey Literature Report were additionally searched for grey literature. Published articles from Africa on H.pylori antibiotic resistance between 1986 and June 2017 were systematically reviewed to estimate the H. pylori extent of resistance to macrolides, quinolones, amoxicillin, tetracycline and metronidazole. RESULTS: In 26 articles a total of 2085 isolates were tested for metronidazole, 1530 for amoxicillin, 1277 for tetracycline, 1752 for clarithromycin and 823 for quinolones.The overall pooled proportion of H.pylori resistance to quinolones, clarithromycin, tetracycline, metronidazole and amoxicillin were: (17.4%, 95%CI 12.8 - 21.9), (29.2%, 95%CI:26.7-31.8), (48.7%, 95%CI: 44.5-52.9), (75.8%, 95% CI: 74.1-.77.4) and (72.6%, 95% CI: 68.6-76.6), respectively. The commonest mutation detected were A2143G (49/97) for clarithromycin, RdxA (41/56) for metronidazole and D87I (16/40) for quinolones. CONCLUSION: Prevalence of metronidazole, clarithromycin, and amoxicillin resistance is high in developing world including Africa. This could impair the first line triple therapy of the H.pylori infection. There is a need of conducting surveillance of H.pylori susceptibility pattern in Africa for dual and triple resistance which can be used for the empirical treatment.

Tetanus in adult males, Bugando Medical Centre, United Republic of Tanzania.

PROBLEM: In the United Republic of Tanzania, the incidence of non-neonatal circumcision-related tetanus is probably underreported. APPROACH: We analysed charts and extracted information on outcome and wound location for non-neonatal cases of tetanus admitted to the intensive care unit of Bugando Medical Centre between 2001 and 2016. LOCAL SETTING: Bugando Medical Centre, which is one of four teaching referral hospitals in the United Republic of Tanzania, has a 13-bed intensive care unit that manages all admitted patients with tetanus. Within the United Republic of Tanzania, formal programmes of tetanus immunization are targeted at infants or women. RELEVANT CHANGES: From our inpatient logs, we identified six patients with non-neonatal tetanus among male patients with a recent history of circumcision. Only one of these patients had been circumcised within a subnational programme of voluntary medical male circumcision. The other five had been circumcised outside of the programme - e.g. at small rural dispensaries or by a traditional provider with no formal medical training. The six patients were aged 11-55 years and five (83%) of them died in hospital - all of overwhelming sepsis. LESSONS LEARNT: Within the Tanzanian programme of voluntary medical male circumcision, education on wound hygiene probably helps to reduce the incidence of non-neonatal circumcision-related tetanus. The corresponding incidence among the boys and men who are circumcised beyond this subnational programme is probably higher. The training of all circumcision providers in wound care and a vaccination programme to ensure that male Tanzanians receive tetanus immunization post-infancy are recommended.

Dysglycemia associations with adipose tissue among HIV-infected patients after 2 years of antiretroviral therapy in Mwanza: a follow-up cross-sectional study.

BACKGROUND: Data on the burden of dysglycemia among HIV-infected patients on antiretroviral therapy (ART) in Africa are limited. We determined the prevalence of pre-diabetes and diabetes among HIV-infected patients who started ART when malnourished 2 to 3 years previously and investigated the association of dysglycemia with body composition. METHODS: Malnourished (body mass index (BMI) < 18.5 kg/m2) HIV-infected patients who were enrolled in the Nutritional Support for Africans Starting Antiretroviral Therapy (NUSTART) trial from 2011 to 2013 were followed-up from March to August 2015. Anthropometric, fat mass and fat-free mass by bioelectrical impedance, and C-reactive protein (CRP) data were collected at baseline and follow-up. At follow-up, we defined fasting glucose of 6.1-6.9 mmol/L as impaired fasting glucose (IFG) and 2-h oral glucose tolerance test (OGTT) glucose of ≥7.8 to <11.1 mmol/L as impaired glucose tolerance (IGT). Both of these were considered pre-diabetes. Fasting glucose of ≥7.0 mmol/L or impaired glucose tolerance of ≥11.1 mmol/L was defined as diabetes mellitus. The relation of pre-diabetes and diabetes with body composition was assessed using logistic regression. RESULTS: Two hundred seventy-three (57%) of 478 patients who were alive at trial conclusion were followed-up. The mean age was 41.5 (SD 9.8) years and 65.2% (178) were females. The mean follow-up BMI was 19.9 (SD 2.8) kg/m2, 12 (4.4%) were either overweight or obese, and 61 (22.3%) patients had pre-diabetes or diabetes. In multiple regression, upper tertiles of baseline hip circumference (OR: 0.41, 95% CI: 0.2, 0.8) and fat mass index (OR: 0.20 (0.1, 0.5), and upper tertiles of follow-up waist circumference (OR: 0.22 (0.1, 0.5), BMI (OR: 0.32 (0.1, 0.7), fat mass index (OR: 0.19 (0.1, 0.5) and the middle tertile of follow-up fat-free mass (OR: 0.36, 95% CI: 0.1, 0.8) were associated with lower risk of pre-diabetes and diabetes (P < 0.05 for all). Baseline and follow-up CRP were not predictors. CONCLUSIONS: Low rather than high measures of adipose tissue were associated with increased risk of pre-diabetes and diabetes. Additional studies are needed to further investigate the role of body composition and control of glucose metabolism in the pathogenesis of diabetes among persons living with HIV in Africa.

Decreased renal function and associated factors in cities, towns and rural areas of Tanzania: a community-based population survey.

OBJECTIVES: Data on renal dysfunction in sub-Saharan Africa, comparing urban and rural areas, have not yet been reported. Therefore, we aimed to determine the distribution of low estimated glomerular filtration rates (eGFRs) in urban and rural Tanzania, to describe factors associated with low eGFR and to quantify fractions attributable to common risk factors. METHODS: We conducted a community-based survey of 1095 randomly selected Tanzanian adults (≥18 years). A structured questionnaire and examinations were used to document sociodemographic characteristics, diet, physical activity, anthropomorphic measurements and blood pressure. Blood tests were performed for HIV infection, diabetes mellitus and creatinine. eGFR was calculated using two equations recommended for African adults. RESULTS: Serum creatinine was available for 1043 participants: 170 in Mwanza city, 326 in district towns and 547 in rural areas. Mean age was 35.5 years and 54% were females. The prevalence of eGFR < 60 ml/min/1.73 m(2) in these 3 strata was 2.3% (95% CI = 0.8-6.6%), 7.5% (4.7-11.8%) and 7.4% (5.1-10.6%), respectively. When age standardised to the WHO world population, prevalences were 3.8%, 10.1% and 8.1%. Factors associated with low eGFR included district town residence, older age, greater wealth, less physical activity and hypertension. Only 21% of cases with eGFR < 60 ml/min/1.73 m(2) were attributable to HIV, hypertension or diabetes. CONCLUSIONS: Decreased renal function is common in Tanzania, particularly in district towns, and unique risk factors for kidney disease may exist in this population. Population-specific strategies for prevention, early diagnosis and treatment of kidney disease are needed for Africa.

Hypertension Is a Key Feature of the Metabolic Syndrome in Subjects Aging with HIV.

With widespread and effective antiretroviral therapy, the life expectancy in the HIV population has dramatically improved over the last two decades. Consequently, as patients are aging with HIV, other age-related comorbidities, such as metabolic disturbances and cardiovascular disease (CVD), have emerged as important causes of morbidity and mortality. An overrepresentation of traditional cardiovascular risk factors (RF), toxicities associated with long exposure to antiretroviral therapy, together with residual chronic inflammation and immune activation associated with HIV infection are thought to predispose to these metabolic complications and to the excess risk of CVD observed in the HIV population. The metabolic syndrome (MS) represents a clustering of RF for CVD that includes abdominal obesity, hypertension, dyslipidemia and insulin resistance. Hypertension is a prevalent feature of the MS in HIV, in particular in the aging population, and constitutes an important RF for CVD. Physicians should screen their patients for metabolic and cardiovascular risk at the regular visits to reduce MS and the associated CVD risk among people aging with HIV, since many of RF are under-diagnosed and under-treated conditions. Interventions to reduce these RF can include lifestyle changes and pharmacological interventions such as antihypertensive and lipid-lowering therapy, and treatment of glucose metabolism disturbances. Changes in antiretroviral therapy to more metabolic neutral antiretroviral drugs may also be considered.

High prevalence of hypertension and of risk factors for non-communicable diseases (NCDs): a population based cross-sectional survey of NCDS and HIV infection in Northwestern Tanzania and Southern Uganda.

BACKGROUND: The burden of non-communicable diseases (NCDs) is increasing in sub-Saharan Africa, but data available for intervention planning are inadequate. We determined the prevalence of selected NCDs and HIV infection, and NCD risk factors in northwestern Tanzania and southern Uganda. METHODS: A population-based cross-sectional survey was conducted, enrolling households using multistage sampling with five strata per country (one municipality, two towns, two rural areas). Consenting adults (≥18 years) were interviewed using the WHO STEPS survey instrument, examined, and tested for HIV and diabetes mellitus (DM). Adjusting for survey design, we estimated population prevalences of hypertension, DM, obstructive pulmonary disease, cardiac failure, epilepsy and HIV, and investigated factors associated with hypertension using logistic regression. RESULTS: Across strata, hypertension prevalence ranged from 16 % (95 % confidence interval (CI): 12 % to 22 %) to 17 % (CI: 14 % to 22 %) in Tanzania, and from 19 % (CI: 14 % to 26 %) to 26 % (CI: 23 % to 30 %) in Uganda. It was high in both urban and rural areas, affecting many young participants. The prevalence of DM (1 % to 4 %) and other NCDs was generally low. HIV prevalence ranged from 6 % to 10 % in Tanzania, and 6 % to 12 % in Uganda. Current smoking was reported by 12 % to 23 % of men in different strata, and 1 % to 3 % of women. Problem drinking (defined by Alcohol Use Disorder Identification Test criteria) affected 6 % to 15 % men and 1 % to 6 % women. Up to 46 % of participants were overweight, affecting women more than men and urban more than rural areas. Most patients with hypertension and other NCDs were unaware of their condition, and hypertension in treated patients was mostly uncontrolled. Hypertension was associated with older age, male sex, being divorced/widowed, lower education, higher BMI and, inversely, with smoking. CONCLUSIONS: The high prevalence of NCD risk factors and unrecognized and untreated hypertension represent major problems. The low prevalence of DM and other preventable NCDs provides an opportunity for prevention. HIV prevalence was in line with national data. In Tanzania, Uganda and probably elsewhere in Africa, major efforts are needed to strengthen health services for the PREVENTION, early detection and treatment of chronic diseases.