Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and care cascade for HIV infected individuals (SCALE SAIA-HTN): a stepped-wedge cluster randomized trial.

BACKGROUND: Undiagnosed and untreated hypertension is a main driver of cardiovascular disease and disproportionately affects persons living with HIV (PLHIV) in low- and middle-income countries. Across sub-Saharan Africa, guideline application to screen and manage hypertension among PLHIV is inconsistent due to poor service readiness, low health worker motivation, and limited integration of hypertension screening and management within HIV care services. In Mozambique, where the adult HIV prevalence is over 13%, an estimated 39% of adults have hypertension. As the only scaled chronic care service in the county, the HIV treatment platform presents an opportunity to standardize and scale hypertension care services. Low-cost, multi-component systems-level strategies such as the Systems Analysis and Improvement Approach (SAIA) have been found effective at integrating hypertension and HIV services to improve the effectiveness of hypertension care delivery for PLHIV, reduce drop-offs in care, and improve service quality. To build off lessons learned from a recently completed cluster randomized trial (SAIA-HTN) and establish a robust evidence base on the effectiveness of SAIA at scale, we evaluated a scaled-delivery model of SAIA (SCALE SAIA-HTN) using existing district health management structures to facilitate SAIA across six districts of Maputo Province, Mozambique. METHODS: This study employs a stepped-wedge design with randomization at the district level. The SAIA strategy will be "scaled up" with delivery by district health supervisors (rather than research staff) and will be "scaled out" via expansion to Southern Mozambique, to 18 facilities across six districts in Maputo Province. SCALE SAIA-HTN will be introduced over three, 9-month waves of intensive intervention, where technical support will be provided to facilities and district managers by study team members from the Mozambican National Institute of Health. Our evaluation of SCALE SAIA-HTN will be guided by the RE-AIM framework and will seek to estimate the budget impact from the payer's perspective. DISCUSSION: SAIA packages user-friendly systems engineering tools to support decision-making by frontline health workers and to identify low-cost, contextually relevant improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial will determine an effective strategy for national scale-up and inform program planning. TRIAL REGISTRATION: ClinicalTrials.gov NCT05002322 (registered 02/15/2023).

Earlier antiretroviral initiation is independently associated with better arterial stiffness in children living with perinatally acquired HIV with sustained viral suppression in Mozambique.

BACKGROUND: Cardiovascular disease is a major driver of morbidity and mortality in adults living with HIV. The drivers of cardiovascular disease in children living with perinatally acquired HIV (PHIV) with sustained HIV viral suppression are unclear. OBJECTIVES: We explored the contribution of HIV-specific risk factors to arterial stiffness independently of traditional risk factors (metabolic syndrome [MetS]) in prepubertal children with PHIV with sustained viral suppression in a low-income country in Africa. METHOD: For this cross-sectional analysis, arterial stiffness was assessed by pulse wave velocity z-score (PWVz), measured using a Vicorder device. Metabolic syndrome components were measured. We retrospectively collected the antiretroviral therapy (ART) exposures, HIV stage, CD4 count and HIV viral load. A multivariate linear regression model was constructed for MetS components, retaining age and gender as obligatory variables. We then added HIV-related metrics to assess whether these had an independent or additive effect. RESULTS: We studied 77 virally suppressed children with PHIV without evidence of cardiovascular disease (from medical history and physical examination). In the initial model, the PWVz was independently associated with each MetS component. The PWVz was higher in participants with proportionally greater visceral fat (waist/height ratio), elevated lipids (triglyceride/high-density lipoprotein ratio) and insulin resistance (log homeostatic model assessment [HOMA]). The addition of age at ART initiation increased the model R 2 value from 0.36 to 0.43. In the resulting model, younger age at ART initiation was independently associated with a better PWVz (P < 0.001). CONCLUSION: Earlier ART initiation was independently associated with lower large artery stiffness. This effect was independent of the effect of elevated lipids, visceral fat and insulin resistance.

Cardiovascular risk and D-dimer levels in HIV-infected ART-naïve Africans.

Anti-retroviral therapy (ART) has decreased morbidity and mortality in HIV-infected individuals. With the adoption of the 90-90-90 strategy prevention and control of non-communicable disease, particularly knowledge of the burden and profile of cardiovascular disease, will become increasingly important. Our study assessed cardiovascular risk among recently diagnosed HIV-infected ART-naïve patients in a first referral urban hospital in a low-income country in sub-Saharan Africa. HIV-positive ART-naïve patients were submitted to cardiovascular risk assessment, clinical history, physical examination and laboratory workout, including 12-lead electrocardiography, portable transthoracic echocardiography, glycemia, lipidemia, hemogram and D-dimers. Three years after the diagnosis their vital status and occurrence of major cardiovascular events was assessed. We recruited 70 patients, all of black ethnicity (41 females; mean age 37±10.7). CD4 levels were very low (mean 21.3 cells/mL; SD 10.4). Twenty-one (26.6%) were overweight, 13 (16.7%) were obese, 19 (20.5%) had hyperglycemia and 20 patients (25.6%) had hypercholesterolemia. The median blood pressure was 119.5/79 mmHg (IQR 107-141/67-83); 20 patients (25.6%) had hypertension. Four (5.7%) patients had signs of heart failure, and left ventricular ejection fraction was reduced in 17 (25%). High levels of circulating D-dimers were found in 44 (62.8%) patients; the mean levels were 725.9 (SD 555.1). We found high occurrence of cardiovascular risk factors, left ventricular dysfunction and evidence of a pro-coagulant state in these HIV-infected ART-naïve patients. Active cardiovascular risk screening and stratification, as well as management protocols tailored to low-income settings are needed to sustain the gains obtained with increased availability of ART in Africa.

Differential patterns of disease and injury in Mozambique: New perspectives from a pragmatic, multicenter, surveillance study of 7809 emergency presentations.

BACKGROUND: There is a paucity of primary data to understand the overall pattern of disease and injuries as well as related health-service utilization in resource-poor countries in Africa. OBJECTIVE: To generate reliable and robust data describing the pattern of emergency presentations attributable to communicable disease (CD), non-communicable disease (NCD) and injuries in three different regions of Mozambique. METHODS: We undertook a pragmatic, prospective, multicentre surveillance study of individuals (all ages) presenting to the emergency departments of three hospitals in Southern (Maputo), Central (Beira) and Northern (Nampula) Mozambique. During 24-hour surveillance in the seasonally distinct months of April and October 2016/2017, we recorded data on 7,809 participants randomly selected from 39,124 emergency presentations to the three participating hospitals. Applying a pragmatic surveillance protocol, data were prospectively collected on the demography, clinical history, medical profile and treatment of study participants. FINDINGS: A total of 4,021 males and 3,788 (48.5%) females comprising 630 infants (8.1%), 2,070 children (26.5%), 1,009 adolescents (12.9%) and, 4,100 adults (52.5%) were studied. CD was the most common presentation (3,914 cases/50.1%) followed by NCD (1,963/25.1%) and injuries (1,932/24.7%). On an adjusted basis, CD was more prevalent in younger individuals (17.9±17.7 versus 26.6±19.2 years;p<0.001), females (51.7% versus 48.7%-OR 1.137, 95%CI 1.036-1.247;p = 0.007), the capital city of Maputo (59.6%) versus the more remote cities of Beira (42.8%-OR 0.532, 95%CI 0.476-0.594) and Nampula (45.8%-OR 0.538, 95%CI 0.480-0.603) and, during April (51.1% versus 49.3% for October-OR 1.142, 95%CI 1.041-1.253;p = 0.005). Conversely, NCD was progressively more prevalent in older individuals, females and in the regional city of Beira, whilst injuries were more prevalent in males (particularly adolescent/young men) and the northern city of Nampula. On a 24-hour basis, presentation patterns were unique to each hospital. INTERPRETATION: Applying highly pragmatic surveillance methods suited to the low-resource setting of Mozambique, these unique data provide critical insights into the differential pattern of CD, NCD and injury. Consequently, they highlight specific health priorities across different regions and seasons in Southern Africa.

Massas quísticas intracardíacas: causa de distúrbios do ritmo e disfunção miocárdica / Intracardiac cystic masses: Cause of rhythm disturbances and myocardial dysfunction

As massas intracardíacas, consideradas raras antes do advento da ecografia, são actualmente um diagnóstico frequente em regiões tropicais com acesso a esta técnica de imagem. Podem ser causadas por malformações congénitas, doenças infecciosas, tumores ou complicações de estase. O caso aqui reportado descreve um paciente adulto com diagnóstico clínico inicial de miocardiopatia dilatada e descompensada, cuja ecocardiograma revelou imagens quísticas septais, murais e valvulares. São discutidos os achados clínicos, procedimentos diagnósticos e a evolução clinicadesta insufciência cardíaca de causa atípica

Cardiac masses, considered rare before the advent of ultrasound, are currently a usual diagnosis in tropical regions with access to this technique. They can be related to congenital malformations, infections, neoplasia and stasis.The case we here report describes an adult patient with initial diagnosis of decompensated dilated cardiomyopathy, in whom cardiac ultrasound revealed the presence of intracardiac cysts located in the interventricular septum, left ventricular free wall and anterior mitral valve leaflet. We discuss the clinical findings, diagnostic procedures and evolution of signs and symptoms in this atypical heart failure.