A high burden of adverse life events and poor coping mechanisms experienced by urban-dwelling black South Africans.

AIM: In view of the current context of poverty and socio-economic inequalities and the high and rising burdens of HIV infection and non-communicable diseases in South Africa, this study aims to describe the distribution of adverse life events (ALEs) by age and gender, and examine the socio-demographic characteristics, psychosocial coping mechanisms, risky lifestyle behaviours and family burden of HIV-related ill-health associated with ALEs in 25-74-year-old black residents of Cape Town. MATERIALS AND METHODS: In a random cross-sectional sample, 12 ALEs, tobacco and alcohol use, sense of coherence (SOC), locus of control (LOC) and impact of HIV in the family were determined by administered questionnaires. Data analyses included descriptive statistics adjusted for the realised sample. Multivariable linear regression models assessed the independent associations of increasing number of ALEs. RESULTS: Among 1099 participants, mean lifetime score of ALE categories examined was 6.1 ±2.1 (range 0-12) with men reporting significantly higher number of events compared with women (p<0.001). The most frequent ALE was the death of a loved one (88.5%) followed by a major financial crisis (81.2%) with no trend across gender or age group. In the multivariable linear regression model, increasing ALEs were significantly associated with male gender, unemployment, having spent >50% of life in urban areas, >7 years of education, problematic alcohol use and poorer psychosocial coping mechanisms defined by low SOC and LOC. All four variables pertaining to HIV-related burden of ill-health in the family were significantly associated with increasing ALEs. CONCLUSIONS: Considering that lower SOC and LOC and problem drinking were significantly linked to ALEs, policymakers need to formulate strategies that improve coping mechanisms and promote problem-solving behaviours, target the high burden of alcohol misuse and address unemployment.

Prevalence, concordance and associations of chronic kidney disease by five estimators in South Africa.

BACKGROUND: To determine the prevalence, distribution, concordance and associations of chronic kidney disease (CKD) determined by five glomerular filtration rate (GFR) formulae in urban black residents of Cape Town. METHODS: Data collection in this cross-sectional study included interviews, clinical measurements and biochemical analyses, including serum creatinine and cystatin C levels. GFR was based on the CKD Epidemiology Collaboration (CKD-EPI) equations (CKD-EPI creatinine (CKD-EPIcr), CKD-EPI cystatin C (CKD-EPIcys), CKD-EPI creatinine-cystatins (CKD-EPIcr-cys)), Modification of Diet in Renal Disease (MDRD) and Cockcroft-Gault formula (CGF). GFR < 60 mL/min/1.73 m2 defined CKD. RESULTS: Among 392 men and 700 women, mean GFR, was between 114.0 (CKD-EPIcr) and 135.4 mL/min/1.73 m2 (CGF) in men, and between 107.5 (CKD-EPIcr-cys) and 173.4 mL/min/1.73 m2 (CGF) in women. CKD prevalence ranged from 2.3% (CKD-EPIcr and MDRD) to 5.1% (CKD-EPIcys) in men and 1.6% (CGF) to 6.7% (CKD-EPIcr-cys) in women. The kappa statistic was high between CKD-EPIcr and MDRD (0.934), and CKD-EPIcys and CKD-EPIcr-cys (0.815), but fair-to-moderate between the other eqs. (0.353-0.565). In the basic regressions, older age and body mass index ≥30 kg/m2, but not gender, were significantly associated with CKD-EPIcr-defined CKD. In the presence of these three variables, hypertension, heart rate ≥ 90 beats/minute, diabetes and low-density lipoprotein cholesterol were significant predictors of prevalent CKD. CONCLUSIONS: Varying CKD prevalence estimates, because of different GFR equations used, underscores the need to improve accuracy of CKD diagnoses. Furthermore, screening for CKD should be incorporated into the routine assessment of high-risk patients such as those with hypertension or diabetes.

Waist-to-height ratio is a useful indicator of cardio-metabolic risk in South Africa.

BACKGROUND: The use of waist-to-height ratio has been suggested as a better proxy indicator of central obesity. OBJECTIVE: To compare the utility of waist-to-height ratio with commonly used adiposity indices of body mass index, waist circumference and waist-to-hip ratio to identify cardio-metabolic diseases in 25-74-year-old black residents of Cape Town. METHODS: This cross-sectional study, stratified for age and gender, determined cardio-metabolic abnormalities by administered questionnaires, clinical measurements and biochemical analyses, including oral glucose tolerance tests. Correlations between adiposity indices with cardio-metabolic components were examined. Age- and gender-adjusted logistic regression analyses determined the associations of obesity by these adiposity indices with cardio-metabolic abnormalities. RESULTS: The study comprised 392 men and 707 women. Compared with other adiposity indices, waist-to-height ratio in men correlated most closely with fasting (0.360) and 2-hour (0.388) glucose levels, total cholesterol (0.267), low-density lipoprotein cholesterol (0.351) and triglycerides (0.400). In women, waist-to-height ratio correlated the best with systolic blood pressure (0.254) and diastolic blood pressure (0.287). Of the adiposity indices, waist circumference was most strongly associated with diabetes (odds ratio 4.27, 95% confidence interval: 2.39-7.62), low high-density lipoprotein cholesterol (2.84, 1.90-4.26) and hypertriglyceridaemia (3.60, 2.03-6.40), whereas raised waist-to-height ratio was most closely related to hypertension (1.61, 1.07-2.42), hypercholesterolaemia (1.72, 1.04-2.83) and raised low-density lipoprotein cholesterol (2.46, 1.70-3.55). CONCLUSIONS: Compared with other adiposity indices, the better correlation of waist-to-height ratio with many cardio-metabolic components, particularly in men, and the stronger association of raised waist-to-height ratio with hypertension, hypercholesterolaemia and raised low-density lipoprotein cholesterol support the utility of waist-to-height ratio in routine assessments of adiposity in this population, which may improve the identification of cardio-metabolic risk.

Monitoring the South African population's salt intake: spot urine v. 24 h urine.

OBJECTIVE: The present study set out to determine whether morning spot urine samples can be used to monitor Na (and K) intake levels in South Africa, instead of the 'gold standard' 24 h urine sample. DESIGN: Participants collected one 24 h and one spot urine sample for Na and K analysis, after which estimations using three different formulas (Kawasaki, Tanaka and INTERSALT) were calculated. SETTING: Between 2013 and 2015, urine samples were collected from different population groups in South Africa. SUBJECTS: A total of 681 spot and 24 h urine samples were collected from white (n 259), black (n 315) and Indian (n 107) subgroups, mostly women. RESULTS: The Kawasaki and the Tanaka formulas showed significantly higher (P≤0·001) estimated Na values than the measured 24 h excretion in the whole population (5677·79 and 4235·05 v. 3279·19 mg/d). The INTERSALT formula did not differ from the measured 24 h excretion for the whole population. The Kawasaki formula seemed to overestimate Na excretion in all subgroups tested and also showed the highest degree of bias (-2242 mg/d, 95 % CI-10 659, 6175) compared with the INTERSALT formula, which had the lowest bias (161 mg/d, 95 % CI-4038, 4360). CONCLUSIONS: Estimations of Na excretion by the three formulas should be used with caution when reporting on Na intake levels. More research is needed to validate and develop a specific formula for the South African context with its different population groups. The WHO's recommendation of using 24 h urine collection until more studies are carried out is still supported.

Evaluation of a Mass-Media Campaign to Increase the Awareness of the Need to Reduce Discretionary Salt Use in the South African Population.

The South African strategic plan to reduce cardiovascular disease (CVD) includes reducing population salt intake to less than 5 g/day. A mass media campaign was undertaken to increase public awareness of the association between high salt intake, blood pressure and CVD, and focused on the reduction of discretionary salt intake. Community based surveys, before and after the campaign, were conducted in a cohort of black women aged 18-55 years. Questions on knowledge, attitudes and beliefs regarding salt use were asked. Current interest in engaging with salt reduction behaviors was assessed using the "stage of change" model. Five hundred fifty women participated in the baseline study and 477 in the follow-up survey. Most of the indicators of knowledge, attitudes and behavior change show a significant move towards considering and initiating reduced salt consumption. Post intervention, significantly more participants reported that they were taking steps to control salt intake (38% increased to 59.5%, p < 0.0001). In particular, adding salt while cooking and at the table occurred significantly less frequently. The findings suggest that mass media campaigns may be an effective tool to use as part of a strategy to reduce discretionary consumption of salt among the population along with other methods.

Educational Outreach with an Integrated Clinical Tool for Nurse-Led Non-communicable Chronic Disease Management in Primary Care in South Africa: A Pragmatic Cluster Randomised Controlled Trial.

BACKGROUND: In many low-income countries, care for patients with non-communicable diseases (NCDs) and mental health conditions is provided by nurses. The benefits of nurse substitution and supplementation in NCD care in high-income settings are well recognised, but evidence from low- and middle-income countries is limited. Primary Care 101 (PC101) is a programme designed to support and expand nurses' role in NCD care, comprising educational outreach to nurses and a clinical management tool with enhanced prescribing provisions. We evaluated the effect of the programme on primary care nurses' capacity to manage NCDs. METHODS AND FINDINGS: In a cluster randomised controlled trial design, 38 public sector primary care clinics in the Western Cape Province, South Africa, were randomised. Nurses in the intervention clinics were trained to use the PC101 management tool during educational outreach sessions delivered by health department trainers and were authorised to prescribe an expanded range of drugs for several NCDs. Control clinics continued use of the Practical Approach to Lung Health and HIV/AIDS in South Africa (PALSA PLUS) management tool and usual training. Patients attending these clinics with one or more of hypertension (3,227), diabetes (1,842), chronic respiratory disease (1,157) or who screened positive for depression (2,466), totalling 4,393 patients, were enrolled between 28 March 2011 and 10 November 2011. Primary outcomes were treatment intensification in the hypertension, diabetes, and chronic respiratory disease cohorts, defined as the proportion of patients in whom treatment was escalated during follow-up over 14 mo, and case detection in the depression cohort. Primary outcome data were analysed for 2,110 (97%) intervention and 2,170 (97%) control group patients. Treatment intensification rates in intervention clinics were not superior to those in the control clinics (hypertension: 44% in the intervention group versus 40% in the control group, risk ratio [RR] 1.08 [95% CI 0.94 to 1.24; p = 0.252]; diabetes: 57% versus 50%, RR 1.10 [0.97 to 1.24; p = 0.126]; chronic respiratory disease: 14% versus 12%, RR 1.08 [0.75 to 1.55; p = 0.674]), nor was case detection of depression (18% versus 24%, RR 0.76 [0.53 to 1.10; p = 0.142]). No adverse effects of the nurses' expanded scope of practice were observed. Limitations of the study include dependence on self-reported diagnoses for inclusion in the patient cohorts, limited data on uptake of PC101 by users, reliance on process outcomes, and insufficient resources to measure important health outcomes, such as HbA1c, at follow-up. CONCLUSIONS: Educational outreach to primary care nurses to train them in the use of a management tool involving an expanded role in managing NCDs was feasible and safe but was not associated with treatment intensification or improved case detection for index diseases. This notwithstanding, the intervention, with adjustments to improve its effectiveness, has been adopted for implementation in primary care clinics throughout South Africa. TRIAL REGISTRATION: The trial is registered with Current Controlled Trials (ISRCTN20283604).

Sex differences in insulin sensitivity and insulin response with increasing age in black South African men and women.

AIMS: Black Africans are disproportionally affected by type 2 diabetes, but the pathophysiology is poorly understood. The study aimed to examine the effect of sex and age on insulin sensitivity and insulin response in black South African adults. METHODS: This cross-sectional study included a random sample of 179 men and 260 women aged 25-74years with normal glucose tolerance from 5 peri-urban townships in Cape Town, SA. Insulin sensitivity (insulin sensitivity index, ISI0,120) and response (insulinogenic index, IGI), and the disposition index (DI, ISI0,120×IGI), derived from an oral glucose tolerance test, were measured. RESULTS: Although men were older (median [interquartile range]: 39 [30-48] vs. 35 [29-44], P=0.021) and had significantly lower BMI than women (22.6 [20.0-25.3] vs. 31.0 [25.9-35.7] kg/m2, P=0.001), DI was not different (P=0.740), but ISI0,120 was higher (P=0.007) and IGI was lower (P=0.074) in men than women, adjusting for age and BMI. With increasing age, DI (ß (95%CI): -24.4 (-36.3 to -12.5), P<0.001) and IGI (ß (95%CI): -4.9 (-7.5 to -2.2), P<0.001) decreased similarly in both sexes, but ISI0,120 did not change (ß (95%CI): 0.005 (-0.20 to 0.03), P=0.675). CONCLUSION: Black South African women with normal glucose tolerance have lower insulin sensitivity than their male counterparts, but increase their insulin response to maintain normoglycemia. With increasing age, insulin sensitivity remains unchanged, but the insulin response decreases at a similar rate in men and women.

Sodium and potassium intake in South Africa: an evaluation of 24-hour urine collections in a white, black, and Indian population.

Limited number of studies on salt intake has been conducted in the South Africa. The present study established the sodium and potassium excretion (24-hour urine collection) of three different South African populations. In total, 692 successful 24-hour urine collections were analyzed for sodium, potassium, and iodine levels. The median sodium and potassium excretion was 122.9 and 33.5 mmol/d, respectively, and the median salt intake was 7.2 g/d. The majority (92.8%) of the population did not meet the recommended potassium intake/d, and 65.6% consumed more than 6 g of salt/d. Potassium excretion showed a linear relationship with salt intake (P-trend ≤ .001). The median sodium-to-potassium ratio was 3.5. These findings support the South African government's sodium reduction legislation, as well as global initiatives. More consideration should be given to promoting the intake of potassium-rich foods, as this may have a greater public health impact than focusing only on dietary sodium reduction.

Increased risk of dysglycaemia in South Africans with HIV; especially those on protease inhibitors.

AIMS: To compare dysglycaemia prevalence (impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or diabetes) in HIV-infected persons, stratified by antiretroviral therapy (ART), with a community-based survey (CBS) in Cape Town, South Africa. METHODS: Three groups of HIV-infected adults without known diabetes were conveniently sampled from community healthcare centres; ART-naïve, first-line ART (non-nucleoside reverse transcriptase inhibitor (NNRTI) plus dual NRTIs), and second-line ART (lopinavir/ritonavir-boosted protease inhibitor plus dual NRTIs). The CBS recruited a representative cross-sectional sample from urban townships. Participants reporting ART use or known diabetes were excluded. All participants underwent oral glucose tolerance testing. Multiple logistic regression determined independent associations with dysglycaemia. RESULTS: The samples comprised ART-naïve, first-line ART, second-line ART and CBS participants (n=393, 439, 108 and 880, respectively). Mean age was 34-40years. Dysglycaemia prevalence was as follows: CBS 18.0%, ART-naïve 21.6%, first-line ART 26.0% and second-line ART 37.0%. Diabetes was similar across groups, but IGT was 3-4-fold higher in second-line ART and CBS compared with ART-naïve and first-line ART groups. In contrast, IFG was 14.3-21.2% across HIV groups but only 1.5% in the CBS. Increased risk of dysglycaemia was associated with older age, female gender, and HIV status (ART-naïve: OR 2.31, 95% CI 1.65-3.24; first-line ART: OR 2.47, 95% CI 1.80-3.38; second-line ART: OR 4.10, 95% CI 2.54-6.61). Diabetes family history and central obesity were not related to dysglycaemia. CONCLUSIONS: In view of the increased risk of dysglycaemia in HIV-infected participants, screening for diabetes should be instituted in ART programmes.

Dietary Intake of the Urban Black Population of Cape Town: The Cardiovascular Risk in Black South Africans (CRIBSA) Study.

INTRODUCTION: To determine dietary intake of 19 to 64 years old urban Africans in Cape Town in 2009 and examine the changes between 1990 and 2009. METHODS: A representative cross-sectional sample (n = 544), stratified by gender and age was randomly selected in 2009 from the same areas sampled in 1990. Socio-demographic data and a 24-h dietary recall were obtained by trained field workers. The associations of dietary data with an asset index and degree of urbanization were assessed. RESULTS: Fat intakes were higher in 19-44-year-old men (32% energy (E)) and women (33.4%E) in 2009 compared with 1990 (men: 25.9%E, women: 27.0%E) while carbohydrate intakes were lower in 2009 (men 53.2%E, women: 55.5%E) than in 1990 (men: 61.3%E; women: 62%E) while sugar intake increased significantly (p < 0.01) in women. There were significant positive correlations between urbanization and total fat (p = 0.016), saturated fat (p = 0.001), monounsaturated fat (p = 0.002) and fat as a %E intake (p = 0.046). Urbanization was inversely associated with intake of carbohydrate %E (p < 0.001). Overall micronutrient intakes improved significantly compared with 1990. It should also be noted that energy and macronutrient intakes were all significant in a linear regression model using mean adequacy ratio (MAR) as a measure of dietary quality in 2009, as was duration of urbanization. DISCUSSION: The higher fat and lower carbohydrate %E intakes in this population demonstrate a transition to a more urbanized diet over last two decades. These dietary changes reflect the nutrition transitions that typically occur as a longer time is spent in urban centers.

Training and Capacity Building in LMIC for Research in Heart and Lung Diseases: The NHLBI-UnitedHealth Global Health Centers of Excellence Program.

Stemming the tide of noncommunicable diseases (NCDs) worldwide requires a multipronged approach. Although much attention has been paid to disease control measures, there is relatively little consideration of the importance of training the next generation of health-related researchers to play their important role in this global epidemic. The lack of support for early stage investigators in low- and middle-income countries interested in the global NCD field has resulted in inadequate funding opportunities for research, insufficient training in advanced research methodology and data analysis, lack of mentorship in manuscript and grant writing, and meager institutional support for developing, submitting, and administering research applications and awards. To address this unmet need, The National Heart, Lung, and Blood Institute-UnitedHealth Collaborating Centers of Excellence initiative created a Training Subcommittee that coordinated and developed an intensive, mentored health-related research experience for a number of early stage investigators from the 11 Centers of Excellence around the world. We describe the challenges faced by early stage investigators in low- and middle-income countries, the organization and scope of the Training Subcommittee, training activities, early outcomes of the early stage investigators (foreign and domestic) and training materials that have been developed by this program that are available to the public. By investing in the careers of individuals in a supportive global NCD network, we demonstrate the impact that an investment in training individuals from low- and middle-income countries can have on the preferred future of or current efforts to combat NCDs.

Prevalence of Pragmatically Defined High CV Risk and its Correlates in LMIC: A Report From 10 LMIC Areas in Africa, Asia, and South America.

BACKGROUND: Currently available tools for assessing high cardiovascular risk (HCR) often require measurements not available in resource-limited settings in low- and middle-income countries (LMIC). There is a need to assess HCR using a pragmatic evidence-based approach. OBJECTIVES: This study sought to report the prevalence of HCR in 10 LMIC areas in Africa, Asia, and South America and to investigate the profiles and correlates of HCR. METHODS: Cross-sectional analysis using data from the National Heart, Lung, and Blood Institute-UnitedHealth Group Centers of Excellence. HCR was defined as history of heart disease/heart attack, history of stroke, older age (≥50 years for men and ≥60 for women) with history of diabetes, or older age with systolic blood pressure ≥160 mm Hg. Prevalence estimates were standardized to the World Health Organization's World Standard Population. RESULTS: A total of 37,067 subjects ages ≥35 years were included; 53.7% were women and mean age was 53.5 ± 12.1 years. The overall age-standardized prevalence of HCR was 15.4% (95% confidence interval: 15.0% to 15.7%), ranging from 8.3% (India, Bangalore) to 23.4% (Bangladesh). Among men, the prevalence was 1.7% for the younger age group (35 to 49 years) and 29.1% for the older group (≥50); among women, 3.8% for the younger group (35 to 59 years) and 40.7% for the older group (≥60). Among the older group, measured systolic blood pressure ≥160 mm Hg (with or without other conditions) was the most common criterion for having HCR, followed by diabetes. The proportion of having met more than 1 criterion was nearly 20%. Age, education, and body mass index were significantly associated with HCR. Cross-site differences existed and were attenuated after adjusting for age, sex, education, smoking, and body mass index. CONCLUSIONS: The prevalence of HCR in 10 LMIC areas was generally high. This study provides a starting point to define targeted populations that may benefit from interventions combining both primary and secondary prevention strategies.

Comparison of Nonblood-Based and Blood-Based Total CV Risk Scores in Global Populations.

BACKGROUND: Cost-effective primary prevention of cardiovascular disease (CVD) in low- and middle-income countries requires accurate risk assessment. Laboratory-based risk tools currently used in high-income countries are relatively expensive and impractical in many settings due to lack of facilities. OBJECTIVES: This study sought to assess the correlation between a non-laboratory-based risk tool and 4 commonly used, laboratory-based risk scores in 7 countries representing nearly one-half of the world's population. METHODS: We calculated 10-year CVD risk scores for 47,466 persons with cross-sectional data collected from 16 different cohorts in 9 countries. The performance of the non-laboratory-based risk score was compared with 4 laboratory-based risk scores: Pooled Cohort Risk Equations (ASCVD [Atherosclerotic Cardiovascular Disease]), Framingham, and SCORE (Systematic Coronary Risk Evaluation) for high- and low-risk countries. Rankings of each score were compared using Spearman rank correlations. Based on these correlations, we measured concordance between individual absolute CVD risk as measured by the Harvard NHANES (National Health and Nutrition Examination Survey) risk score, and the 4 laboratory-based risk scores, using both the conventional Framingham risk thresholds of >20% and the recent ASCVD guideline threshold of >7.5%. RESULTS: The aggregate Spearman rank correlations between the non-laboratory-based risk score and the laboratory-based scores ranged from 0.915 to 0.979 for women and from 0.923 to 0.970 for men. When applying the conventional Framingham risk threshold of >20% over 10 years, 92.7% to 96.0% of women and 88.3% to 92.8% of men were equivalently characterized as "high" or "low" risk. Applying the recent ASCVD guidelines risk threshold of >7.5% resulted in risk characterization agreement for women ranging from 88.1% to 94.4% and from 89.0% to 93.7% for men. CONCLUSIONS: The correlation between non-laboratory-based and laboratory-based risk scores is very high for both men and women. Potentially large numbers of high-risk individuals could be detected with relatively simple tools.

Hypertension Prevalence, Awareness, Treatment, and Control in Selected LMIC Communities: Results From the NHLBI/UHG Network of Centers of Excellence for Chronic Diseases.

BACKGROUND: Hypertension is the leading cause of cardiovascular disease and premature death worldwide. The prevalence of this public health problem is increasing in low- and middle-income countries (LMICs) in both urban and rural communities. OBJECTIVE: The aim of this study was to examine hypertension prevalence, awareness, treatment, and control in adults 35 to 74 years of age from urban and rural communities in LMICs in Africa, Asia, and South America. METHODS: The authors analyzed data from 7 population-based cross-sectional studies in selected communities in 9 LMICs that were conducted between 2008 and 2013. Age- and sex-standardized prevalence rates of pre-hypertension and hypertension were calculated. The prevalence rates of awareness, treatment, and control of hypertension were estimated overall and by subgroups of age, sex, and educational level. RESULTS: In selected communities, age- and sex-standardized prevalence rates of hypertension among men and women 35 to 74 years of age were 49.9% (95% confidence interval [CI]: 42.3% to 57.4%) in Kenya, 54.9% (95% CI: 51.3% to 58.4%) in South Africa, 52.5% (95% CI: 50.1% to 54.8%) in China, 32.5% (95% CI: 31.7% to 33.3%) in India, 42.3% (95% CI: 40.4% to 44.2%) in Pakistan, 45.4% (95% CI: 43.6% to 47.2%) in Argentina, 39.9% (95% CI: 37.8% to 42.1%) in Chile, 19.2% (95% CI: 17.8% to 20.5%) in Peru, and 44.1% (95% CI: 41.6% to 46.6%) in Uruguay. The proportion of awareness varied from 33.5% in India to 69.0% in Peru, the proportion of treatment among those who were aware of their hypertension varied from 70.8% in South Africa to 93.3% in Pakistan, and the proportion of blood pressure control varied from 5.3% in China to 45.9% in Peru. CONCLUSIONS: The prevalence of hypertension varies widely in different communities. The rates of awareness, treatment, and control also differ in different settings. There is a clear need to focus on increasing hypertension awareness and control in LMICs.

A Multiethnic Study of Pre-Diabetes and Diabetes in LMIC.

BACKGROUND: Diabetes mellitus is one of the leading causes of death and disability worldwide. Approximately three-quarters of people with diabetes live in low- and middle-income countries, and these countries are projected to experience the greatest increase in diabetes burden. OBJECTIVES: We sought to compare the prevalence, awareness, treatment, and control of diabetes in 3 urban and periurban regions: the Southern Cone of Latin America and Peru, South Asia, and South Africa. In addition, we examined the relationship between diabetes and pre-diabetes with known cardiovascular and metabolic risk factors. METHODS: A total of 26,680 participants (mean age, 47.7 ± 14.0 years; 45.9% male) were enrolled in 4 sites (Southern Cone of Latin America = 7,524; Peru = 3,601; South Asia = 11,907; South Africa = 1,099). Detailed demographic, anthropometric, and biochemical data were collected. Diabetes and pre-diabetes were defined as a fasting plasma glucose ≥126 mg/dl and 100 to 125 mg/dl, respectively. Diabetes control was defined as fasting plasma glucose <130 mg/dl. RESULTS: The prevalence of diabetes and pre-diabetes was 14.0% (95% confidence interval [CI]: 13.2% to 14.8%) and 17.8% (95% CI: 17.0% to 18.7%) in the Southern Cone of Latin America, 9.8% (95% CI: 8.8% to 10.9%) and 17.1% (95% CI: 15.9% to 18.5%) in Peru, 19.0% (95% CI: 18.4% to 19.8%) and 24.0% (95% CI: 23.2% to 24.7%) in South Asia, and 13.8% (95% CI: 11.9% to 16.0%) and 9.9% (95% CI: 8.3% to 11.8%) in South Africa. The age- and sex-specific prevalence of diabetes and pre-diabetes for all countries increased with age (p < 0.001). In the Southern Cone of Latin America, Peru, and South Africa the prevalence of pre-diabetes rose sharply at 35 to 44 years. In South Asia, the sharpest rise in pre-diabetes prevalence occurred younger at 25 to 34 years. The prevalence of diabetes rose sharply at 45 to 54 years in the Southern Cone of Latin America, Peru, and South Africa, and at 35 to 44 years in South Asia. Diabetes and pre-diabetes prevalence increased with body mass index. South Asians had the highest prevalence of diabetes and pre-diabetes for any body mass index and normal-weight South Asians had a higher prevalence of diabetes and pre-diabetes than overweight and obese individuals from other regions. Across all regions, only 79.8% of persons with diabetes were aware of their diagnosis, of these only 78.2% were receiving treatment, and only 36.6% were able to attain glycemic control. CONCLUSIONS: The prevalence of diabetes and pre-diabetes is alarmingly high among urban and periurban populations in Latin America, South Asia, and South Africa. Even more alarming is the propensity for South Asians to develop diabetes and pre-diabetes at a younger age and lower body mass index compared with individuals from other low and middle income countries. It is concerning that one-fifth of all people with diabetes were unaware of their diagnosis and that only two-thirds of those under treatment were able to attain glycemic control. Health systems and policy makers must make concerted efforts to improve diabetes prevention, detection, and control to prevent long-term consequences.

Delivery of health care for cardiovascular and metabolic diseases among people living with HIV/AIDS in African countries: a systematic review protocol.

BACKGROUND: People living with HIV (PLHIV) in African countries are living longer due to the rollout of antiretroviral drug therapy programs, but they are at increasing risk of non-communicable diseases (NCDs). However, there remain many gaps in detecting and treating NCDs in African health systems, and little is known about how NCDs are being managed among PLHIV. Developing integrated chronic care models that effectively prevent and treat NCDs among PLHIV requires an understanding of the current patterns of care delivery and the major barriers and facilitators to health care. We present a systematic review protocol to synthesize studies of healthcare delivery for an important subset of NCDs, cardiovascular and metabolic diseases (CMDs), among African PLHIV. METHODS/DESIGN: We plan to search electronic databases and reference lists of relevant studies published in African settings from January 2003 to the present. Studies will be considered if they address one or both of our major objectives and focus on health care for one or more of six interrelated CMDs (ischemic heart disease, stroke, heart failure, hypertension, diabetes, and hyperlipidemia) in PLHIV. Our first objective will be to estimate proportions of CMD patients along the "cascade of care"-i.e., screened, diagnosed, aware of the diagnosis, initiated on treatment, adherent to treatment, and with controlled disease. Our second objective will be to identify unique barriers and facilitators to health care faced by PLHIV in African countries. For studies deemed eligible for inclusion, we will assess study quality and risk of bias using previously published criteria. We will extract study data using standardized instruments. We will meta-analyze quantitative data at each level of the cascade of care for each CMD (first objective). We will use meta-synthesis techniques to understand and integrate qualitative data on health-related behaviors (second objective). DISCUSSION: CMDs and other NCDs are becoming major health concerns for African PLHIV. The results of our review will inform the development of research into chronic care models that integrate care for HIV/AIDS and CMDs among PLHIV. Our findings will be highly relevant to health policymakers, administrators, and practitioners in African settings. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015029375.

Mobile Phone Text Messages to Support Treatment Adherence in Adults With High Blood Pressure (SMS-Text Adherence Support [StAR]): A Single-Blind, Randomized Trial.

BACKGROUND: We assessed the effect of automated treatment adherence support delivered via mobile phone short message system (SMS) text messages on blood pressure. METHODS AND RESULTS: In this pragmatic, single-blind, 3-arm, randomized trial (SMS-Text Adherence Support [StAR]) undertaken in South Africa, patients treated for high blood pressure were randomly allocated in a 1:1:1 ratio to information only, interactive SMS text messaging, or usual care. The primary outcome was change in systolic blood pressure at 12 months from baseline measured with a validated oscillometric device. All trial staff were masked to treatment allocation. Analyses were intention to treat. Between June 26, 2012, and November 23, 2012, 1372 participants were randomized to receive information-only SMS text messages (n=457), interactive SMS text messages (n=458), or usual care (n=457). Primary outcome data were available for 1256 participants (92%). At 12 months, the mean adjusted change in systolic blood pressure compared with usual care was -2.2 mm Hg (95% confidence interval, -4.4 to -0.04) with information-only SMS and -1.6 mm Hg (95% confidence interval, -3.7 to 0.6) with interactive SMS. Odds ratios for the proportion of participants with a blood pressure <140/90 mm Hg were 1.42 (95% confidence interval, 1.03-1.95) for information-only messaging and 1.41 (95% confidence interval, 1.02-1.95) for interactive messaging compared with usual care. CONCLUSIONS: In this randomized trial of an automated adherence support program delivered by SMS text message in a general outpatient population of adults with high blood pressure, we found a small reduction in systolic blood pressure control compared with usual care at 12 months. There was no evidence that an interactive intervention increased this effect. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02019823. South African National Clinical Trials Register, number SANCTR DOH-27-1212-386; Pan Africa Trial Register, number PACTR201411000724141.

Socioeconomic predictors and consequences of depression among primary care attenders with non-communicable diseases in the Western Cape, South Africa: cohort study within a randomised trial.

BACKGROUND: Socioeconomic predictors and consequences of depression and its treatment were investigated in 4393 adults with specified non-communicable diseases attending 38 public sector primary care clinics in the Eden and Overberg districts of the Western Cape, South Africa. METHODS: Participants were interviewed at baseline in 2011 and 14 months later, as part of a randomised controlled trial of a guideline-based intervention to improve diagnosis and management of chronic diseases. The 10-item Center for Epidemiologic Studies Depression Scale (CESD-10) was used to assess depression symptoms, with higher scores representing more depressed mood. RESULTS: Higher CESD-10 scores at baseline were independently associated with being less educated (p = 0.004) and having lower income (p = 0.003). CESD-10 scores at follow-up were higher in participants with less education (p = 0.010) or receiving welfare grants (p = 0.007) independent of their baseline scores. Participants with CESD-10 scores of ten or more at baseline (56 % of all participants) had 25 % higher odds of being unemployed at follow-up (p = 0.016), independently of baseline CESD-10 score and treatment status. Among participants with baseline CESD-10 scores of ten or more, antidepressant medication at baseline was independently more likely in participants who had more education (p = 0.002), higher income (p < 0.001), or were unemployed (p = 0.001). Antidepressant medication at follow up was independently more likely in participants with higher income (p = 0.023), and in clinics with better access to pharmacists (p = 0.053) and off-site drug delivery (p = 0.013). CONCLUSIONS: Socioeconomic disadvantage appears to be both a cause and consequence of depression, and may also be a barrier to treatment. There are opportunities for improving the prevention, diagnosis and treatment of depression in primary care in inequitable middle income countries like South Africa. TRIAL REGISTRATION: The trial is registered with Current Controlled Trials ( ISRCTN20283604 ).

Multimorbidity, control and treatment of noncommunicable diseases among primary healthcare attenders in the Western Cape, South Africa.

BACKGROUND: South Africa (SA) is facing a heavy burden of non-communicable diseases (NCDs). Few studies address multimorbidity, control and treatment of NCDs in patients attending primary healthcare (PHC) clinics. OBJECTIVES: To describe multimorbidity, related risk factors, disease severity and treatment status of patients with four important NCDs attending public sector PHC clinics in two districts in SA. METHODS: A cross-sectional sample of patients completed baseline data collection for a randomised controlled trial of a health systems intervention. The study population comprised adults attending PHC clinics in the Eden and Overberg districts of the Western Cape in 2011. Four subgroups of patients were identified: hypertension, diabetes, chronic respiratory disease and depression. A total of 4 393 participants enrolled from 38 clinics completed a baseline structured questionnaire and had measurements taken. Prescription data were recorded. RESULTS: Of participants with hypertension, diabetes, respiratory disease and depression, 80%, 92%, 88% and 80%, respectively, had at least one of the other three conditions. There were low levels of control and treatment: 59% of participants with hypertension had a blood pressure ≥140/90 mmHg, the mean haemoglobin A1c (HbA1c) value in participants with diabetes was 9%, 12% of participants in the depression group were prescribed an antidepressant at a therapeutic dose, and 48% of respiratory participants were prescribed a b2-agonist and 34% an inhaled corticosteroid. CONCLUSION: Considerable multimorbidity and unmet treatment needs exist among patients with NCDs attending public sector PHC clinics. Improved strategies are required for diagnosing and managing NCDs in this sector.

Increasing Prescription Length Could Cut Cardiovascular Disease Burden And Produce Savings In South Africa.

South Africa's rates of statin use are among the world's lowest, despite statins' demonstrated effectiveness for people with a high blood cholesterol level or history of cardiovascular disease. Almost 5 percent of the country's total mortality has been attributed to high cholesterol levels, fueled in part by low levels of statin adherence. Drawing upon experience elsewhere, we used a microsimulation model of cardiovascular disease to investigate the health and economic impacts of increasing prescription length from the standard thirty days to either sixty or ninety days, for South African adults on a stable statin regimen. Increasing prescription length to sixty or ninety days could save 1,694 or 2,553 lives per million adults, respectively. In addition, annual per patient costs related to cardiovascular disease would decrease by $152.41 and $210.29, respectively. Savings would largely accrue to patients in the form of time savings and reduced transportation costs, as a result of less frequent trips to the pharmacy. Increasing statin prescription length would both save resources and improve health outcomes in South Africa.