Utility of CD4 count measurement in the era of universal antiretroviral therapy: an analysis of routine laboratory data in Botswana.

OBJECTIVES: National guidelines in Botswana recommend baseline CD4 count measurement and both CD4 and HIV viral load (VL) monitoring post-antiretroviral therapy (ART) initiation. We evaluated the utility of CD4 count measurement in Botswana in the era of universal ART. METHODS: CD4 and VL data were analysed for HIV-infected adults undergoing CD4 count measurement in 2015-2017 at the Botswana Harvard HIV-Reference Laboratory. We determined (1) the proportion of individuals with advanced HIV disease (CD4 count < 200 cells/µL) at initial CD4 assessment, (2) the proportion with an initial CD4 count ≥ 200 cells/µL experiencing a subsequent decline in CD4 count to < 200 cells/µL, and (3) the proportion of these immunologically failing individuals who had virological failure. Logistic regression modelling examined factors associated with advanced HIV disease. CD4 count trajectories were assessed using locally weighted scatterplot smoothing (LOWESS) regression. RESULTS: Twenty-five per cent (3571/14 423) of individuals with an initial CD4 assessment during the study period had advanced HIV disease at baseline. Older age [≥ 35 years; adjusted odds ratio (aOR) 1.9; 95% confidence interval (CI) 1.8-2.1] and male sex were associated with advanced HIV disease. Fifty per cent (7163/14 423) of individuals had at least two CD4 counts during the study period. Of those with an initial CD4 count ≥ 200 cells/µL, 4% (180/5061) experienced a decline in CD4 count to < 200 cells/µL; the majority of CD4 count declines were in virologically suppressed individuals and transient. CONCLUSIONS: One-quarter of HIV-positive individuals in Botswana still present with advanced HIV disease, highlighting the importance of baseline CD4 count measurement to identify this at-risk population. Few with a baseline CD4 count ≥ 200 cells/µL experienced a drop below 200 cells/µL, suggesting limited utility for ongoing CD4 monitoring.

Developing an interprofessional transition course to improve team-based HIV care for sub-Saharan Africa.

BACKGROUND: With funding from the United States Health Resources Service Administration (HRSA), a consortium of health professional training institutions from Africa developed HIV-specific, interprofessional, team-based educational resources to better support trainees during the transition period between pre-service training and professional practice. METHODS: Ten faculty members representing nine medical and nursing schools in sub-Saharan Africa (SSA) developed a training package of modules focused on core clinical, public health, interprofessional education (IPE), and quality improvement (QI) domains related to HIV service delivery. Curriculum development was informed by a rapid needs assessment of existing tools and future needs for HIV education across 27 SSA health professions training institutions. A total of 17 modules were developed, targeted at newly qualified health care professionals to be taught in a series of two-day workshops meant to complement existing institution specific HIV-curricula. RESULTS: Between April and July 2019, a comprehensive case-based HIV training package was developed to support trainees in transition from pre-service training to independent professional practice. Each module, addressing different elements of interprofessional practice, was intended to be delivered in an interprofessional format. Thus far, 70 health professions training institutions in 14 countries have implemented the program; 547 educators facilitated STRIPE workshops, with a total of 5027 learners trained between September 2019 and September 2020. CONCLUSIONS: To our knowledge this is the first IPE HIV-specific curriculum explicitly focused on enhancing the quality of training provided to graduating health care professionals working in SSA. The collaborative, cross-institutional, interprofessional approach to curriculum development provides a benchmark for how best-practice approaches to education can be disseminated in SSA.

Cholesterol Screening and Statin Prescription is Low Among HIV-Infected Patients on Protease-Inhibitor Regimens in Botswana.

BACKGROUND: Little is known about the use of statin for cardiovascular disease (CVD) risk reduction among HIV-infected patients on protease inhibitors (PI`s) in sub-Saharan Africa (SSA). OBJECTIVE: Cholesterol screening and statin use were retrospectively assessed among HIV-infected participants on PI`s between 2008 and 2012 at a large urban HIV clinic in Botswana. METHODS: Proportion of participants screened per year was calculated and statin indication was assessed using atherosclerosis CVD (ASCVD) and Framingham risk (FRS) scores as of the year 2012 guidelines. RESULTS: Cholesterol screening ranged between 19% and 30% per year (2008-2011) but increased to 80% after study enrollment. The rate of hypercholesterolemia (> 5.0 mmol/L) was 31% in 2012. Fewer than 1% participants were on statin therapy but 14.3% and 9.4% had statins indicated by ASCVD and FRS respectively. CONCLUSION: The high proportion of participants indicated for, but not prescribed statins highlights a substantial gap in the care to reduce CVD risk among these patients.

Presentation and mortality of patients hospitalised with acute heart failure in Botswana

Introduction: Heart failure is a common cause of hospitalisation and therefore contributes to in-hospital outcomes such as mortality. In this study we describe patient characteristics and outcomes of acute heart failure (AHF) in Botswana.Methods: Socio-demographic, clinical and laboratory data were collected from 193 consecutive patients admitted with AHF at Princess Marina Hospital in Gaborone between February 2014 and February 2015. The length of hospital stay and 30-, 90- and 180-day in-hospital mortality rates were assessed.Results: The mean age was 54 ± 17.1 years, and 53.9% of the patients were male. All patients were symptomatic (77.5% in NYHA functional class III or IV) and the majority (64.8%) presented with significant left ventricular dysfunction. The most common concomitant medical conditions were hypertension (54.9%), human immuno-deficiency virus (HIV) (33.9%), anaemia (23.3%) and prior diabetes mellitus (15.5%). Moderate to severe renal dysfunction was detected in 60 (31.1%) patients. Peripartum cardiomyopathy was one of the important causes of heart failure in female patients. The most commonly used treatment included furosemide (86%), beta-blockers (72.1%), angiotensin converting enzyme inhibitors (67.4%), spironolactone (59.9%), digoxin (22.1%), angiotensin receptor blockers (5.8%), nitrates (4.7%) and hydralazine (1.7%). The median length of stay was nine days, and the in-hospital mortality rate was 10.9%. Thirty-, 90- and 180-day case fatality rates were 14.7, 25.8 and 30.8%, respectively. Mortality at 180 days was significantly associated with increasing age, lower haemoglobin level, lower glomerular filtration rate, hyponatraemia, higher N-terminal pro-brain natriuretic peptide levels, and prolonged hospital stay.Conclusions: AHF is a major public health problem in Botswana, with high in-hospital and post-discharge mortality rates and prolonged hospital stays. Late and symptomatic presentation is common, and the most common aetiologies are preventable and/or treatable co-morbidities, including hypertension, diabetes mellitus, renal failure and HIV

Addressing the challenge of the emerging NCD epidemic: lessons learned from Botswana's response to the HIV epidemic.

Botswana has the second highest prevalence of human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS) in the world, and yet it has built one of Africa's most progressive and comprehensive HIV programs. While public health infrastructure has responded remarkably to the HIV epidemic, the prevalence of non-communicable diseases (NCDs), particularly diabetes mellitus and cardiovascular disease, in both HIV-infected and non-infected individuals, is increasing rapidly. Applying lessons learned from the scale-up of HIV/AIDS services may help with the implementation of an effective response to the challenges of the emerging NCD epidemic. We suggest that a successful response should include integrated service delivery, capacity building to provide disease-specific care, and strong partnerships to mobilize communities.

C'est au Botswana que se trouve la deuxième prévalence la plus élevée du virus de l'immunodéficience humaine/syndrome d'immunodéficience acquise (VIH/SIDA) au monde, et pourtant il a élaboré les programmes les plus progressifs et complets du VIH de toute l'Afrique. Alors que l'infrastructure de santé publique a répondu remarquablement à l'épidémie de VIH, la prévalence des maladies non transmissibles (NCD), particulièrement du diabète sucré et des maladies cardiovasculaires, augmente rapidement à la fois chez les sujets infectés et non infectés par le VIH. L'application des leçons retenues de l'extension des services VIH/SIDA peut aider à la mise en œuvre d'une réponse efficiente au défi de l'émergence de l'épidémie des NCD. Nous suggérons qu'une réponse couronnée de succès comporte la fourniture de services intégrés, la formation des compétences à fournir des soins spécifiques à la maladie ainsi que de puissants partenariats pour mobiliser les collectivités.

Botsuana presenta la segunda prevalencia más alta de infección por el virus de la inmunodeficiencia humana (VIH) y síndrome de inmunodeficiencia adquirida (SIDA) en el mundo y sin embargo, ha establecido uno de los programas más progresistas e integrales contra el VIH en África. Si bien la infraestructura de salud pública ha respondido de manera sobresaliente a la epidemia de infección por el VIH, la prevalencia de enfermedades no transmisibles (NCD), en especial la diabetes y las enfermedades cardiovasculares, progresa rápidamente en todas las personas, ya sea que padezcan o no la infección por el virus. Las enseñanzas extraídas de la ampliación de escala de los servicios contra el VIH y el SIDA podrían contribuir a poner en práctica una respuesta eficaz frente a los retos que plantea la epidemia incipiente de NCD. En el presente artículo se propone que la eficacia de esta respuesta exige los siguientes elementos: la prestación de servicios integrados, el fortalecimiento de la capacidad de suministrar una atención orientada a enfermedades específicas y el establecimiento de colaboraciones dinámicas que movilicen las comunidades.