Publications by authors named "Alemayehu Amberbir"

47 Publications

The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity-Building Scale-Up Trial: Study Design and Protocol.

Psychiatr Serv 2020 Dec 9:appips202000003. Epub 2020 Dec 9.

Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh).

Background: Depression is a leading cause of death and disability worldwide, including in low- and middle-income countries (LMICs). Depression often coexists with chronic medical conditions and is associated with worse clinical outcomes. This confluence has led to calls to integrate mental health treatment with chronic disease care systems in LMICs. This article describes the rationale and protocol for a trial comparing the clinical effectiveness and cost-effectiveness of two different intervention packages to implement evidence-based antidepressant management and psychotherapy into chronic noncommunicable disease (NCD) clinics in Malawi.

Methods: Using constrained randomization, the Sub-Saharan Africa Regional Partnership (SHARP) for mental health capacity building will assign five Malawian NCD clinics to a basic implementation strategy via an internal coordinator, a provider within the chronic care clinic who champions depression services by providing training, supervision, operations, and reporting. Another five clinics will be assigned to depression services implementation via an internal coordinator along with an external quality assurance committee, which will provide a quarterly audit of intervention component delivery with feedback to providers and the health management team.

Results: The authors will compare key implementation outcomes (fidelity to intervention), clinical effectiveness outcomes (patient health), and cost-effectiveness and will assess characteristics of clinics that may influence uptake and fidelity.

Next Steps: This trial will provide key information to guide the Malawi Ministry of Health in scaling up depression management in existing NCD settings. The SHARP trial is anticipated to substantially contribute to enhancing both mental health treatment and implementation science research capacity in Malawi and the wider region.
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http://dx.doi.org/10.1176/appi.ps.202000003DOI Listing
December 2020

A comparison of the associations between adiposity and lipids in Malawi and the United Kingdom.

BMC Med 2020 07 16;18(1):181. Epub 2020 Jul 16.

MRC Integrated Epidemiology Unit, University of Bristol, Bristol, UK.

Background: The prevalence of excess adiposity, as measured by elevated body mass index (BMI) and waist-hip ratio (WHR), is increasing in sub-Saharan African (SSA) populations. This could add a considerable burden of cardiovascular and metabolic diseases for which these populations are currently ill-prepared. Evidence from white, European origin populations shows that higher adiposity leads to an adverse lipid profile; whether these associations are similar in all SSA populations requires further exploration. This study compared the association of BMI and WHR with lipid profile in urban Malawi with a contemporary cohort with contrasting socioeconomic, demographic, and ethnic characteristics in the United Kingdom (UK).

Methods: We used data from 1248 adolescents (mean 18.7 years) and 2277 Malawian adults (mean 49.8 years), all urban-dwelling, and from 3201 adolescents (mean 17.8 years) and 6323 adults (mean 49.7 years) resident in the UK. Adiposity measures and fasting lipids were assessed in both settings, and the associations of BMI and WHR with total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) were assessed by sex and age groups in both studies.

Results: Malawian female adults were more adipose and had more adverse lipid profiles than their UK counterparts. In contrast, Malawian adolescent and adult males were leaner and had more favourable lipid profiles than in the UK. Higher BMI and WHR were associated with increased TC, LDL-C and TG and reduced HDL-C in both settings. The magnitude of the associations of BMI and WHR with lipids was mostly similar or slightly weaker in the Malawian compared with the UK cohort in both adolescents and adults. One exception was the stronger association between increasing adiposity and elevated TC and LDL-C in Malawian compared to UK men.

Conclusions: Malawian adult women have greater adiposity and more adverse lipid profiles compared with their UK counterparts. Similar associations of adiposity with adverse lipid profiles were observed for Malawian and UK adults in most age and sex groups studied. Sustained efforts are urgently needed to address the excess adiposity and adverse lipid profiles in Malawi to mitigate a future epidemic of cardio-metabolic disease among the poorest populations.
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http://dx.doi.org/10.1186/s12916-020-01648-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364601PMC
July 2020

Leveraging routine viral load testing to integrate diabetes screening among patients on antiretroviral therapy in Malawi.

Int Health 2021 Feb;13(2):135-142

Dignitas International, Zomba, Malawi.

Background: People living with HIV are at an increased risk of diabetes mellitus due to HIV infection and exposure to antiretroviral therapy (ART). Despite this, integrated diabetes screening has not been implemented commonly in African HIV clinics. Our objective was to explore the feasibility of integrating diabetes screening into existing routine HIV viral load (VL) monitoring and to determine a group of HIV patients that benefit from a targeted screening for diabetes.

Methods: A mixed methods study was conducted from January to July 2018 among patients on ART aged≥18 y and healthcare workers at an urban HIV clinic in Zomba Central Hospital, Malawi. Patients who were due for routine VL monitoring underwent a finger-prick for simultaneous point-of-care glucose measurement and dried blood spot sampling for a VL test. Diabetes was diagnosed according to WHO criteria. We collected demographic and medical history information using an interviewer-administered questionnaire and electronic medical records. We conducted focus group discussions among healthcare workers about their experience and perceptions regarding the integrated diabetes screening program.

Results: Of patients undergoing routine VL monitoring, 1316 of 1385 (95%) had simultaneous screening for diabetes during the study period. The median age was 44 y (IQR: 38-53); 61% were female; 28% overweight or obese; and median ART duration was 83 mo (IQR: 48-115). At baseline, median CD4 count was 199 cells/mm3 (IQR: 102-277) and 50% were in WHO clinical stages I or II; 45% were previously exposed to stavudine and 88% were virologically suppressed (<1000 copies/mL).  Diabetes prevalence was 31/1316 (2.4%). Diabetes diagnosis was associated with age ≥40 y (adjusted OR [aOR] 7.44; 95% CI: 1.74 to 31.80), being overweight and/or obese (aOR 2.46; 95% CI: 1.13 to 5.38) and being on a protease inhibitor-based ART regimen (aOR 5.78; 95% CI: 2.30 to 14.50). Healthcare workers appreciated integrated diabetes screening but also reported challenges including increased waiting time, additional workload and inadequate communication of results to patients.

Conclusions: Integrating diabetes screening with routine VL monitoring (every 2 y) seems feasible and was valued by healthcare workers. The additional cost of adding diabetes screening into VL clinics requires further study and could benefit from a targeted approach prioritizing patients aged ≥40 y, being overweight/obese and on protease inhibitor-based regimens.
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http://dx.doi.org/10.1093/inthealth/ihaa030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7902676PMC
February 2021

The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity Building: a program protocol for building implementation science and mental health research and policymaking capacity in Malawi and Tanzania.

Int J Ment Health Syst 2019 9;13:70. Epub 2019 Nov 9.

2103C McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC 27599 USA.

Background: Mental health (MH) disorders in low and middle-income countries (LMICs) account for a large proportion of disease burden. While efficacious treatments exist, only 10% of those in need are able to access care. This treatment gap is fueled by structural determinants including inadequate resource allocation and prioritization, both rooted in a lack of research and policy capacity. The goal of the Sub-Saharan Africa Regional Partnership for Mental Health Capacity Building (SHARP), based in Malawi and Tanzania, is to address those research and policy-based determinants.

Methods: SHARP aims to (1) build implementation science skills and expertise among Malawian and Tanzanian researchers in the area of mental health; (2) ensure that Malawian and Tanzanian policymakers and providers have the knowledge and skills to effectively apply research findings on evidence-based mental health programs to routine practice; and (3) strengthen dialogue between researchers, policymakers, and providers leading to efficient and sustainable scale-up of mental health services in Malawi and Tanzania. SHARP comprises five capacity building components: introductory and advanced short courses, a multifaceted dialogue, on-the-job training, pilot grants, and "mentor the mentors" courses.

Discussion: Program evaluation includes measuring dose delivered and received, participant knowledge and satisfaction, as well as academic output (e.g., conference posters or presentations, manuscript submissions, grant applications). The SHARP Capacity Building Program aims to make a meaningful contribution in pursuit of a model of capacity building that could be replicated in other LMICs. If impactful, the SHARP Capacity Building Program could increase the knowledge, skills, and mentorship capabilities of researchers, policymakers, and providers regarding effective scale up of evidence-based MH treatment.
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http://dx.doi.org/10.1186/s13033-019-0327-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6842238PMC
November 2019

Sex and area differences in the association between adiposity and lipid profile in Malawi.

BMJ Glob Health 2019 11;4(5):e001542. Epub 2019 Sep 11.

Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi.

Background: Evidence from high-income countries shows that higher adiposity results in an adverse lipid profile, but it is unclear whether this association is similar in Sub-Saharan African (SSA) populations. This study aimed to assess the association between total and central adiposity measures and lipid profile in Malawi, exploring differences by sex and area of residence (rural/urban).

Methods: In this cross-sectional study, data from 12 096 rural and 12 847 urban Malawian residents were used. The associations of body mass index (BMI) and waist to hip ratio (WHR) with fasting lipids (total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C), high-density lipoprotein-cholesterol (HDL-C) and triglycerides (TG)) were assessed by area and sex.

Results: After adjusting for potential confounders, higher BMI and WHR were linearly associated with increased TC, LDL-C and TG and reduced HDL-C. BMI was more strongly related to fasting lipids than was WHR. The associations of adiposity with adverse lipid profile were stronger in rural compared with urban residents. For instance, one SD increase in BMI was associated with 0.23 mmol/L (95% CI 0.19 to 0.26) increase in TC in rural women and 0.13 mmol/L (95% CI 0.11 to 0.15) in urban women. Sex differences in the associations between adiposity and lipids were less evident.

Conclusions: The consistent associations observed of higher adiposity with adverse lipid profiles in men and women living in rural and urban areas of Malawi highlight the emerging adverse cardio-metabolic epidemic in this poor population. Our findings underline the potential utility of BMI in estimating cardiovascular risk and highlight the need for greater investment to understand the long-term health outcomes of obesity and adverse lipid profiles and the extent to which lifestyle changes and treatments effectively prevent and modify adverse cardio-metabolic outcomes.
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http://dx.doi.org/10.1136/bmjgh-2019-001542DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6747887PMC
September 2019

The Malawi NCD BRITE Consortium: Building Research Capacity, Implementation, and Translation Expertise for Noncommunicable Diseases.

Glob Heart 2019 06;14(2):149-154

Research Support Center, University of Malawi, College of Medicine, Mahatma Gandhi Road, Blantyre, Malawi.

Africa is experiencing an increasing prevalence of noncommunicable diseases (NCD). However, few reliable data are available on their true burden, main risk factors, and economic impact that are needed to inform implementation of evidence-based interventions in the local context. In Malawi, a number of initiatives have begun addressing the NCD challenge, which have often utilized existing infectious disease infrastructure. It will be crucial to carefully leverage these synergies to maximize their impact. NCD-BRITE (Building Research Capacity, Implementation, and Translation Expertise) is a transdisciplinary consortium that brings together key research institutions, the Ministry of Health, and other stakeholders to build long-term, sustainable, NCD-focused implementation research capacity. Led by University of Malawi-College of Medicine, University of North Carolina, and Dignitas International, NCD-BRITE's specific aims are to conduct detailed assessments of the burden and risk factors of common NCD; assess the research infrastructure needed to inform, implement, and evaluate NCD interventions; create a national implementation research agenda for priority NCD; and develop NCD-focused implementation research capacity through short courses, mentored research awards, and an internship placement program. The capacity-building activities are purposely designed around the University of Malawi-College of Medicine and Ministry of Health to ensure sustainability. The NCD BRITE Consortium was launched in February 2018. In year 1, we have developed NCD-focused implementation research capacity. Needs assessments will follow in years 2 and 3. Finally, in year 4, the generated research capacity, together with findings from the needs assessments, will be used to create a national, actionable, implementation research agenda for NCD prioritized in this consortium, namely cardiovascular disease, diabetes mellitus, and asthma and chronic obstructive pulmonary disease.
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http://dx.doi.org/10.1016/j.gheart.2019.05.004DOI Listing
June 2019

Systematic Review of Hypertension and Diabetes Burden, Risk Factors, and Interventions for Prevention and Control in Malawi: The NCD BRITE Consortium.

Glob Heart 2019 06;14(2):109-118

Dignitas International, Zomba, Malawi; College of Medicine, University of Malawi, Blantyre, Malawi.

Recent studies have found an increasing burden of noncommunicable diseases in sub-Saharan Africa. A compressive search of PubMed, Medline, EMBASE, and the World Health Organization Global Health Library databases was undertaken to identify studies reporting on the prevalence, risk factors, and interventions for hypertension and diabetes in Malawi. The findings from 23 included studies revealed a high burden of hypertension and diabetes in Malawi, with estimates ranging from 15.8% to 32.9% and from 2.4% to 5.6%, respectively. Associated risk factors included old age, tobacco smoking, excessive alcohol consumption, obesity, physical inactivity, high salt and sugar intake, low fruit and vegetable intake, high body mass index, and high waist-to-hip ratio. Certain antiretroviral therapy regimens were also associated with increased diabetes and hypertension risk in human immunodeficiency virus patient populations. Nationwide, the quality of clinical care was generally limited and demonstrated a need for innovative and targeted interventions to prevent, control, and treat noncommunicable diseases in Malawi.
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http://dx.doi.org/10.1016/j.gheart.2019.05.001DOI Listing
June 2019

The challenge of worldwide tuberculosis control: and then came diabetes.

Lancet Glob Health 2019 04 25;7(4):e390-e391. Epub 2019 Feb 25.

Dignitas International, Zomba, Malawi. Electronic address:

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http://dx.doi.org/10.1016/S2214-109X(19)30053-1DOI Listing
April 2019

HIV Disclosure: HIV-positive status disclosure to sexual partners among individuals receiving HIV care in Addis Ababa, Ethiopia.

PLoS One 2019 15;14(2):e0211967. Epub 2019 Feb 15.

Western Sydney Sexual Health Centre, Western Sydney Local Health District, Sydney Medical School, Parramatta, New South Wales, Australia.

Introduction: Disclosure of HIV status to sexual partners can help HIV prevention efforts and enable HIV positive people to receive social support, as well as increasing access and adherence to treatment. This study was conducted to determine the rate, processes, outcomes, and correlates of HIV status disclosure to sexual partners among HIV positive individuals.

Method: A cross-sectional study was conducted between September and November 2015 at two HIV outpatient clinics in Addis Ababa, Ethiopia. Data were collected using an interviewer- administered semi-structured questionnaire. Logistic analysis was used to determine the independent correlates of serostatus disclosure.

Results: Of 742 participants, (371 men and 371 women), 727 (98%) were on antiretroviral therapy and 676 (91.1%) had at least one sexual partner since their HIV diagnosis, of whom 558 (82.5%) had disclosed their HIV status to their most recent sexual partner. Of those who reported having disclosed their status to their most recent sexual partner, 82 (14.7%) had at least one unprotected sexual encounter with the partner, after HIV diagnosis but prior to disclosure. The most commonly reported initial outcome of disclosure was gaining emotional and/or financial support. Some (11.3%) also reported that their disclosure immediately initiated their partner for HIV testing. Negative outcomes to disclosure, such as stigma and discrimination, were more common among females (26.2%) compared to males (12.7%). In the multiple regression analysis, disclosure was associated with greater condom use, greater social support, knowing the partner's HIV status, having a good relationship with the partner, and cohabiting with the partner.

Conclusion: HIV disclosure was common amongst participants, although sometimes delayed, with possible consequences for onward transmission. Fear of negative outcomes, such as verbal abuse and physical violence, were major barriers to disclosure. Efforts to support disclosure have the potential to contribute to HIV control and prevention by encouraging safer sexual practice, initiating partners for HIV testing, and enhancing support for people living with HIV.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0211967PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6415764PMC
November 2019

Retention on antiretroviral therapy during Universal Test and Treat implementation in Zomba district, Malawi: a retrospective cohort study.

J Int AIDS Soc 2019 02;22(2):e25239

Dignitas International, Zomba, Malawi.

Introduction: Since June 2016, the national HIV programme in Malawi has adopted Universal Test and Treat (UTT) guidelines requiring that all persons who test HIV positive will be referred to start antiretroviral therapy (ART). Although there is strong evidence from clinical trials that early initiation of ART leads to reduced morbidity and mortality, the impact of UTT on retention on ART in real-life programmatic settings in Africa is not yet known.

Methods: We conducted a retrospective cohort study in Zomba district, Malawi to compare ART outcomes of patients who initiated ART under 2016 UTT guidelines and those who started ART prior to rollout of UTT (pre-UTT). We analysed data from 32 rural and urban health facilities of various sizes. Cox proportional hazards modelling was used to determine the independent risk factors of attrition from ART at 12 months. All analyses were adjusted for clustering by health facility using a robust standard errors approach.

Results: Among 1492 patients (mean age 34.4 years, 933 (63%) female) who initiated ART during the study period, 501 were enrolled in the pre-UTT cohort and 911 during UTT. At 12 months, retention on ART in the UTT cohort was higher than in the pre-UTT cohort 83.0% (95% confidence interval (CI): 81.0% to 85.0%) versus 76.2% (95% CI 73.9% to 78.5%). Adolescents, aged 10 to 19 years (adjusted hazard ratio (aHR) 1.53; 95% CI 1.01 to 2.32), and women who were pregnant or breastfeeding at ART initiation (aHR 1.87; 95% CI 1.30 to 2.38) were at higher risk of attrition in the combined pre-UTT and UTT cohort.

Conclusions: Retention on ART was nearly 6% higher after UTT introduction. Young adults and women who were pregnant or breastfeeding at the start of ART were at increased risk of attrition, emphasizing the need for targeted interventions for these groups to achieve the 90-90-90 UNAIDS targets in the UTT era.
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http://dx.doi.org/10.1002/jia2.25239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6367572PMC
February 2019

Effect of cardio-metabolic risk factors on all-cause mortality among HIV patients on antiretroviral therapy in Malawi: A prospective cohort study.

PLoS One 2019 17;14(1):e0210629. Epub 2019 Jan 17.

Dignitas International, Zomba, Malawi.

Background: Cardiovascular disease (CVD) risk among people living with HIV is elevated due to persistent inflammation, hypertension and diabetes comorbidity, lifestyle factors and exposure to antiretroviral therapy (ART). Data from Africa on how CVD risk affects morbidity and mortality among ART patients are lacking. We explored the effect of CVD risk factors and the Framingham Risk Score (FRS) on medium-term ART outcomes.

Methods: A prospective cohort study of standardized ART outcomes (Dead, Alive on ART, stopped ART, Defaulted and Transferred out) was conducted from July 2014-December 2016 among patients on ART at a rural and an urban HIV clinic in Zomba district, Malawi. The primary outcome was Dead. Active defaulter tracing was not done and patients who transferred out and defaulted were excluded from the analysis. At enrolment, hypertension, diabetes and dyslipidemia were diagnosed, lifestyle data collected and the FRS was determined. Cox-regression analysis was used to determine independent risk factors for the outcome Dead.

Results: Of 933 patients enrolled, median age was 42 years (IQR: 35-50), 72% were female, 24% had hypertension, 4% had diabetes and 15.8% had elevated total cholesterol. The median follow up time was 2.4 years. Twenty (2.1%) patients died, 50 (5.4%) defaulted, 63 (6.8%) transferred out and 800 (85.7%) were alive on ART care (81.7% urban vs. 89.9% rural). In multivariable survival analysis, male gender (aHR = 3.28; 95%CI: 1.33-8.07, p = 0.01) and total/HDL cholesterol ratio (aHR = 5.77, 95%CI: 1.21-27.32; p = 0.03) were significantly associated with mortality. There was no significant association between mortality and hypertension, body mass index, central obesity, diabetes, FRS, physical inactivity, smoking at enrolment, ART regimen and WHO disease stage.

Conclusions: Medium-term all-cause mortality among ART patients was associated with male gender and elevated total/HDL cholesterol ratio.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0210629PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6336397PMC
November 2019

Early experiences in integrating cervical cancer screening and treatment into HIV services in Zomba Central Hospital, Malawi.

Malawi Med J 2018 09;30(3):211-214

Dignitas International, Zomba, Malawi.

Background: Malawi has the highest rate of cervical cancer globally and cervical cancer is six to eight times more common in women with HIV. HIV programmes provide an ideal setting to integrate cervical cancer screening.

Methods: Tisungane HIV clinic at Zomba Central Hospital has around 3,700 adult women receiving treatment. In October 2015, a model of integrated cervical cancer screening using visual inspection with acetic acid (VIA) was adopted. All women aged 20 and above in the HIV clinic were asked if they had cervical cancer screening in the past three years and, if not, were referred for screening. Screening was done daily by nurses in a room adjacent to the HIV clinic. Cold coagulation was used to treat pre-cancerous lesions. From October 2016, a modification to the HIV programme's electronic medical record was developed that assisted in matching numbers of women sent for screening with daily screening capacity and alerted providers to women with pre-cancerous lesions who missed referrals or treatment.

Results: Between May 2016 and March 2017, cervical cancer screening was performed in 957 women from the HIV clinic. Of the 686 (71%) women who underwent first ever screening, 23 (3.4%) were found to have VIA positive lesions suggestive of pre-cancer, of whom 8 (35%) had a same-day cold coagulation procedure, seven (30%) deferred cold coagulation to a later date (of whom 4 came for treatment), and 8 (35%) were referred to surgery due to size of lesion; 5/686 (0.7%) women had lesions suspicious of cancer.

Conclusion: Incorporating cervical cancer screening into services at HIV clinics is feasible. A structured approach to screening in the HIV clinic was important.
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http://dx.doi.org/10.4314/mmj.v30i3.14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6307048PMC
September 2018

Early experiences integrating hypertension and diabetes screening and treatment in a human immunodeficiency virus clinic in Malawi.

Int Health 2018 11;10(6):495-501

Dignitas International, Zomba, Malawi.

Background: Human immunodeficiency virus (HIV) programmes can be leveraged to manage the growing burden of non-communicable diseases (NCDs).

Methods: In October 2015, a model of integrated HIV-NCD care was developed at a large HIV clinic in southeast Malawi. Blood pressure was measured in adults at every visit and random blood glucose was determined every 2 y. Uncomplicated antiretroviral therapy (ART)-only care was provided by nurses, integrated HIV-NCD management was provided by clinical officers. Waiting times were assessed using the electronic medical record system. The team met monthly to identify bottlenecks.

Results: All (n=6036) adult HIV patients were screened and 765 were diagnosed with hypertension (prevalence 12.7% [95% confidence interval {CI} 11.9-13.5). A total of 2979 adult HIV patients were screened and 25 were diagnosed with diabetes mellitus (prevalence 0.8% [95% CI 0.6-1.2]). The mean duration of ART visits by clinical officers increased from 80.5 to 90 min during the first quarter following HIV-NCD integration but returned to 75 min the following quarter. The mean number of patients seen per day by clinical officers increased from 6 to 11 and for nurses decreased from 92 to 82 in that time period. The robust vertical HIV system made the design of integrated tools demanding. Challenges of integrated HIV-NCD care were related to patient flow, waiting times, NCD drug availability, data collection, clinic workload and the timing of diabetes and hypertension screening.

Conclusions: Integrated HIV-NCD services provision was feasible in our clinic.
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http://dx.doi.org/10.1093/inthealth/ihy049DOI Listing
November 2018

Dietary sodium intake in urban and rural Malawi, and directions for future interventions.

Am J Clin Nutr 2018 09;108(3):587-593

Departments of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.

Background: High dietary sodium intake is a major risk factor for hypertension. Data on population sodium intake are scanty in sub-Saharan Africa, despite a high hypertension prevalence in most countries.

Objective: We aimed to determine daily sodium intake in urban and rural communities in Malawi.

Design: In an observational cross-sectional survey, data were collected on estimated household-level per capita sodium intake, based on how long participants reported that a defined quantity of plain salt lasts in a household. In a subset of 2078 participants, 24-h urinary sodium was estimated from a morning spot urine sample.

Results: Of 29,074 participants, 52.8% of rural and 50.1% of urban individuals lived in households with an estimated per capita plain salt consumption >5 g/d. Of participants with urinary sodium data, 90.8% of rural and 95.9% of urban participants had estimated 24-h urinary sodium >2 g/d; there was no correlation between household per capita salt intake and estimated 24-h urinary sodium excretion. Younger adults were more likely to have high urinary sodium and to eat food prepared outside the home than were those over the age of 60 y. Households with a member with previously diagnosed hypertension had reduced odds (OR: 0.59; 95% CI: 0.51, 0.68) of per capita household plain salt intake >5 g/d, compared with those where hypertension was undiagnosed.

Conclusions: Sodium consumption exceeds the recommended amounts for most of the population in rural and urban Malawi. Population-level interventions for sodium intake reduction with a wide focus are needed, targeting both sources outside the home as well as home cooking. This trial was registered at clinicaltrials.gov as NCT03422185.
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http://dx.doi.org/10.1093/ajcn/nqy125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6134286PMC
September 2018

Opportunities and challenges for evidence-informed HIV-noncommunicable disease integrated care policies and programs: lessons from Malawi, South Africa, Swaziland and Kenya.

AIDS 2018 07;32 Suppl 1:S21-S32

Research and Medical Department, Dignitas International, Zomba, Malawi.

Introduction: Countries in sub-Saharan Africa (SSA) are recognizing the growing dual burden of HIV and noncommunicable diseases (NCDs). This article explores the availability, implementation processes, opportunities and challenges for policies and programs for HIV/NCD integration in four SSA countries: Malawi, Kenya, South Africa and Swaziland.

Methods: We conducted a cross-sectional analysis of current policies and programs relating to HIV/NCD care integration from January to April 2017 using document review and expert opinions. The review focussed on availability and content of relevant policy documents and processes towards implementating national HIV/NCD integration policies.

Results: All four case study countries had at least one policy document including aspects of HIV/NCD care integration. Apart from South Africa that had a phased nation-wide implementation of a comprehensive integrated chronic disease model, the three other countries - Malawi, Kenya and Swaziland, had either pilot implementations or nation-wide single-disease integration of NCDs and HIV. Opportunities for HIV/NCD integration policies included: presence of overarching health policy documents that recognize the need for integration, and coordinated action by policymakers, researchers and implementers. Evidence gaps for cost-effectiveness, effects of integration on key HIV and NCD outcomes and funding mechanisms for sustained implementation of integrated HIV/NCD care strategies, were among challenges identified.

Conclusion: Policymakers in Malawi, Kenya, South Africa and Swaziland have considered integration of NCD and HIV care but a lack of robust evidence hampers large-scale implementation of HIV/NCD integration. It is crucial for SSA Ministries of Health and throughout low-and-middle-income countries to utilize existing opportunities and advocate for evidence-informed HIV/NCD integration strategies.
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http://dx.doi.org/10.1097/QAD.0000000000001885DOI Listing
July 2018

Dyslipidemia among rural and urban HIV patients in south-east Malawi.

PLoS One 2018 21;13(5):e0197728. Epub 2018 May 21.

Dignitas International, Zomba, Malawi.

Background: While dyslipidemia importantly contributes to increased cardiovascular disease risk among patients on antiretroviral therapy (ART), data on lipid patterns among African adults on ART are limited. We describe the prevalence of lipid abnormalities and associated factors in two HIV clinics in Malawi.

Methods: We conducted a cross-sectional study in 2014 and enrolled adult patients at a rural and an urban HIV clinic in Zomba district, Malawi. We recorded patient characteristics, CVD risk factors and anthropometric measurements, using the WHO STEPS validated instrument. Non-fasting samples were taken for determination of total cholesterol (TC), triglyceride (TG) and HDL-cholesterol (HDL-c) levels. Logistic regression analysis was used to determine factors associated with elevated TC and elevated TC/HDL-c ratio.

Results: 554 patients were enrolled, 50% at the rural HIV clinic, 72.7% were female, the median (IQR) age was 42 years (36-50); 97.3% were on ART, 84.4% on tenofovir/lamivudine/efavirenz, 17.5% were overweight/obese and 27.8%% had elevated waist/hip ratio. 15.5% had elevated TC, 15.9% reduced HDL-c, 28.7% had elevated TG and 3.8% had elevated TC/HDL-c ratio. Lipid abnormalities were similar in rural and urban patients. Women had significantly higher burden of elevated TC and TG whereas men had higher prevalence of reduced HDL-c. Waist-to-hip ratio was independently associated with elevated TC (aOR = 1.90; 95% CI: 1.17-3.10, p = 0.01) and elevated TC/HDL-c ratio (aOR = 3.50; 95% CI: 1.38-8.85, p = 0.008). Increasing age was independently associated with elevated TC level (aOR = 1.54, 95% CI 0.51-4.59 for age 31-45; aOR = 3.69, 95% CI 1.24-10.95 for age >45 years vs. ≤30 years; p-trend <0.01).

Conclusions: We found a moderate burden of dyslipidemia among Malawian adults on ART, which was similar in rural and urban patients but differed significantly between men and women. High waist-hip ratio predicted elevated TC and elevated TC/HDL-c ratio and may be a practical tool for CVD risk indication in resource limited settings.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0197728PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5962094PMC
December 2018

Prevalence of obesity, hypertension, and diabetes, and cascade of care in sub-Saharan Africa: a cross-sectional, population-based study in rural and urban Malawi.

Lancet Diabetes Endocrinol 2018 03 19;6(3):208-222. Epub 2018 Jan 19.

Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Malawi Epidemiology and Intervention Research Unit, Lilongwe and Karonga, Malawi.

Background: Sub-Saharan Africa is in rapid demographic transition, and non-communicable diseases are increasingly important causes of morbidity and mortality. We investigated the burden of diabetes, overweight and obesity, hypertension, and multimorbidity, their treatment, and their associations with lifestyle and other factors in Malawi, a very poor country with a predominantly rural-but rapidly growing urban-population, to identify high-risk populations and inform appropriate interventions.

Methods: In this cross-sectional, population-based study, we enrolled all adults (≥18 years) residing in two defined geographical areas within Karonga District and Lilongwe city. All adults self-defining as usually resident in the study areas were eligible, and recruited at household level. Participants were interviewed, had anthropometry and blood pressure measured, and had fasting blood samples collected. The study outcomes were prevalence estimates and risk ratios for diabetes (defined as fasting blood glucose of at least 7·0 mmol/L or self-report of a previous diagnosis of diabetes), hypertension (systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, or self-report of current antihypertensive medication), overweight (BMI of 25·0-29·9 kg/m) and obesity (BMI of 30·0 kg/m or more), and multimorbidity (two or more of the above conditions) by location-specific (urban vs rural), age-specific, and sex-specific groups, calculated using negative binomial regression. We used χ likelihood ratio tests to assess heterogeneity by age, location, and sex.

Findings: Between May 16, 2013, and Feb 8, 2016, we enrolled 15 013 (62%) of 24 367 eligible urban adults in Lilongwe and 13 878 (88%) of 15 806 eligible rural adults in Karonga District. Overweight and obesity, hypertension, and diabetes were highly prevalent, more so in urban residents, the less poor, and better educated than in rural, the poorest, and least educated participants. 18% of urban men (961 of 5211 participants) and 44% (4115 of 9282) of urban women, and 9% (521 of 5834) of rural men and 27% (2038 of 7497) of rural women were overweight or obese; 16% (859 of 5212), 14% (1349 of 9793), 13% (787 of 5847), and 14% (1101 of 8025) had hypertension; and 3% (133 of 3928), 3% (225 of 7867), 2% (84 of 5004), and 2% (124 of 7116) had diabetes, respectively. Of 566 participants with diabetes, 233 (41%) were undiagnosed, and of 4096 participants with hypertension, 2388 (58%) were undiagnosed. Fewer than half the participants on medication for diabetes or hypertension had well controlled diabetes (84 [41%] of 207 participants) or blood pressure (440 [37%] of 1183 participants). Multimorbidity was highest in urban women (n=519, 7%).

Interpretation: Overweight and obesity, hypertension, and diabetes are highly prevalent in urban and rural Malawi, yet many patients are undiagnosed and management is limited. Local-evidence-informed multisectoral, innovative, and targeted interventions are needed urgently to manage the already high burden.

Funding: Wellcome Trust.
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http://dx.doi.org/10.1016/S2213-8587(17)30432-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5835666PMC
March 2018

The burden of gynecomastia among men on antiretroviral therapy in Zomba, Malawi.

PLoS One 2017 20;12(11):e0188379. Epub 2017 Nov 20.

Dignitas International, Zomba, Malawi.

Background: Many Africans who are on life-saving ART face challenges from a variety of toxicities. After the introduction of a standardized first-line efavirenz-containing ART regimen, reports of gynecomastia appeared in Malawian popular media, however data on the prevalence and risk factors of gynecomastia from Africa are lacking.

Methods: We conducted a cross-sectional study in males ≥18 years registered on ART at the HIV clinic in Zomba Central Hospital. Men who reported to have ever experienced breast or nipple enlargement received a standard questionnaire and underwent physical examination. Questions included perceptions and concerns about gynecomastia. Clinicians confirmed the presence and severity of gynecomastia. Routinely collected data on current and previous ART regimens, CD4 count, WHO clinical stage, anthropometric measurements and history of tuberculosis were extracted from the electronic database.

Results: We enrolled 1,027 men with median age 44 years (IQR: 38-52). The median ART duration was 57 months (IQR: 27-85); 46.7% were in WHO stage III/IV at ART initiation, 88.2% had exposure to efavirenz and 9% were overweight or obese. The prevalence of self-reported gynecomastia was 6.0% (62/1027) (95%-CI: 4.7-7.7%). Of men with gynecomastia 83.6% reported nipple enlargement and 98.4% enlarged breasts (85.5% bilateral). One-third said they had not reported gynecomastia to a health care worker. Over three-quarters mentioned that gynecomastia was an important or very important problem for them, while more than half were embarrassed by it. On examination gynecomastia was present in 90% (confirmed gynecomastia prevalence 5.5%; 95%-CI: 4.2-7.0%) and 51.8% had severity grade III or IV. History of tuberculosis treatment was independently associated with self-reported gynecomastia, adjusted OR 2.10 (95%-CI: 1.04-4.25).

Conclusions: The burden of gynecomastia among men on ART in Malawi was higher than previously reported, and was associated with adverse psychological consequences, calling for increased awareness, a proactive diagnostic approach and diligent clinical management.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0188379PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5695797PMC
December 2017

Virological outcomes of antiretroviral therapy in Zomba central prison, Malawi; a cross-sectional study.

J Int AIDS Soc 2017 08;20(1):21623

Dignitas International, Zomba, Malawi.

Introduction: Antiretroviral therapy (ART) outcomes that include viral suppression rates are rarely reported among African prison populations. Prisoners deal with specific challenges concerning adherence to ART. We aimed to describe virological outcomes of ART in a large prison in Malawi.

Methods: A cross-sectional study of ART outcomes was conducted at the Zomba Central Prison HIV clinic, Malawi, following the introduction of routine viral load monitoring. All prisoners on ART for at least 6 months were eligible for a viral load test. Patients with ≥1,000 copies/ml received adherence support for 3 months, after which a second VL sample was taken. Patients with ≥5,000 copies/ml on the second sample had virological failure and started 2nd line ART. We describe demographics and patient characteristics and report prevalence of potential- and documented virological failure. In the potential virological failure rate, those who could not be sampled after 3 months adherence support are included as virological failures. Logistic regression analysis was used to determine factors associated with potential ART failure.

Results And Discussion: Viral load testing was started at the end of 2014, when 1054 patients had ever registered on ART. Of those, 501 (47.5%) had transferred out to another clinic, 96 (9.1%) had died, 11 defaulted (1.0%) and 3 (0.3%) stopped ART. Of 443 (42.0%) remaining alive in care, an estimated 322 prisoners were on ART >6 months, of whom 262 (81.4%) were sampled. Their median age was 35 years (IQR 31-40) and 257 (98.1%) were male. Self-reported adherence was good in 258 (98.5%). The rate of potential ART failure was 8.0%, documented ART failure was 4.6% and documented HIV suppression 95.0%. No patient characteristics were independently associated with potential ART failure, possibly due to low numbers with this outcome.

Conclusions: Good virological suppression rates can be achieved among Malawian prisoners on ART, under challenging circumstances.
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http://dx.doi.org/10.7448/IAS.20.1.21623DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5577730PMC
August 2017

Incidence, prevalence and mortality rates of malaria in Ethiopia from 1990 to 2015: analysis of the global burden of diseases 2015.

Malar J 2017 07 4;16(1):271. Epub 2017 Jul 4.

Institute of Health Metrics and Evaluation, University of Washington, Seattle, USA.

Background: In Ethiopia there is no complete registration system to measure disease burden and risk factors accurately. In this study, the 2015 global burden of diseases, injuries and risk factors (GBD) data were used to analyse the incidence, prevalence and mortality rates of malaria in Ethiopia over the last 25 years.

Methods: GBD 2015 used verbal autopsy surveys, reports, and published scientific articles to estimate the burden of malaria in Ethiopia. Age and gender-specific causes of death for malaria were estimated using cause of death ensemble modelling.

Results: The number of new cases of malaria declined from 2.8 million [95% uncertainty interval (UI) 1.4-4.5 million] in 1990 to 621,345 (95% UI 462,230-797,442) in 2015. Malaria caused an estimated 30,323 deaths (95% UI 11,533.3-61,215.3) in 1990 and 1561 deaths (95% UI 752.8-2660.5) in 2015, a 94.8% reduction over the 25 years. Age-standardized mortality rate of malaria has declined by 96.5% between 1990 and 2015 with an annual rate of change of 13.4%. Age-standardized malaria incidence rate among all ages and gender declined by 88.7% between 1990 and 2015. The number of disability-adjusted life years lost (DALY) due to malaria decreased from 2.2 million (95% UI 0.76-4.7 million) in 1990 to 0.18 million (95% UI 0.12-0.26 million) in 2015, with a total reduction 91.7%. Similarly, age-standardized DALY rate declined by 94.8% during the same period.

Conclusions: Ethiopia has achieved a 50% reduction target of malaria of the millennium development goals. The country should strengthen its malaria control and treatment strategies to achieve the sustainable development goals.
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http://dx.doi.org/10.1186/s12936-017-1919-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496144PMC
July 2017

Health Effects of Overweight and Obesity in 195 Countries over 25 Years.

Authors:
Ashkan Afshin Mohammad H Forouzanfar Marissa B Reitsma Patrick Sur Kara Estep Alex Lee Laurie Marczak Ali H Mokdad Maziar Moradi-Lakeh Mohsen Naghavi Joseph S Salama Theo Vos Kalkidan H Abate Cristiana Abbafati Muktar B Ahmed Ziyad Al-Aly Ala’a Alkerwi Rajaa Al-Raddadi Azmeraw T Amare Alemayehu Amberbir Adeladza K Amegah Erfan Amini Stephen M Amrock Ranjit M Anjana Johan Ärnlöv Hamid Asayesh Amitava Banerjee Aleksandra Barac Estifanos Baye Derrick A Bennett Addisu S Beyene Sibhatu Biadgilign Stan Biryukov Espen Bjertness Dube J Boneya Ismael Campos-Nonato Juan J Carrero Pedro Cecilio Kelly Cercy Liliana G Ciobanu Leslie Cornaby Solomon A Damtew Lalit Dandona Rakhi Dandona Samath D Dharmaratne Bruce B Duncan Babak Eshrati Alireza Esteghamati Valery L Feigin João C Fernandes Thomas Fürst Tsegaye T Gebrehiwot Audra Gold Philimon N Gona Atsushi Goto Tesfa D Habtewold Kokeb T Hadush Nima Hafezi-Nejad Simon I Hay Masako Horino Farhad Islami Ritul Kamal Amir Kasaeian Srinivasa V Katikireddi Andre P Kengne Chandrasekharan N Kesavachandran Yousef S Khader Young-Ho Khang Jagdish Khubchandani Daniel Kim Yun J Kim Yohannes Kinfu Soewarta Kosen Tiffany Ku Barthelemy Kuate Defo G Anil Kumar Heidi J Larson Mall Leinsalu Xiaofeng Liang Stephen S Lim Patrick Liu Alan D Lopez Rafael Lozano Azeem Majeed Reza Malekzadeh Deborah C Malta Mohsen Mazidi Colm McAlinden Stephen T McGarvey Desalegn T Mengistu George A Mensah Gert B M Mensink Haftay B Mezgebe Erkin M Mirrakhimov Ulrich O Mueller Jean J Noubiap Carla M Obermeyer Felix A Ogbo Mayowa O Owolabi George C Patton Farshad Pourmalek Mostafa Qorbani Anwar Rafay Rajesh K Rai Chhabi L Ranabhat Nikolas Reinig Saeid Safiri Joshua A Salomon Juan R Sanabria Itamar S Santos Benn Sartorius Monika Sawhney Josef Schmidhuber Aletta E Schutte Maria I Schmidt Sadaf G Sepanlou Moretza Shamsizadeh Sara Sheikhbahaei Min-Jeong Shin Rahman Shiri Ivy Shiue Hirbo S Roba Diego A S Silva Jonathan I Silverberg Jasvinder A Singh Saverio Stranges Soumya Swaminathan Rafael Tabarés-Seisdedos Fentaw Tadese Bemnet A Tedla Balewgizie S Tegegne Abdullah S Terkawi J S Thakur Marcello Tonelli Roman Topor-Madry Stefanos Tyrovolas Kingsley N Ukwaja Olalekan A Uthman Masoud Vaezghasemi Tommi Vasankari Vasiliy V Vlassov Stein E Vollset Elisabete Weiderpass Andrea Werdecker Joshua Wesana Ronny Westerman Yuichiro Yano Naohiro Yonemoto Gerald Yonga Zoubida Zaidi Zerihun M Zenebe Ben Zipkin Christopher J L Murray

N Engl J Med 2017 07 12;377(1):13-27. Epub 2017 Jun 12.

Background: Although the rising pandemic of obesity has received major attention in many countries, the effects of this attention on trends and the disease burden of obesity remain uncertain.

Methods: We analyzed data from 68.5 million persons to assess the trends in the prevalence of overweight and obesity among children and adults between 1980 and 2015. Using the Global Burden of Disease study data and methods, we also quantified the burden of disease related to high body-mass index (BMI), according to age, sex, cause, and BMI in 195 countries between 1990 and 2015.

Results: In 2015, a total of 107.7 million children and 603.7 million adults were obese. Since 1980, the prevalence of obesity has doubled in more than 70 countries and has continuously increased in most other countries. Although the prevalence of obesity among children has been lower than that among adults, the rate of increase in childhood obesity in many countries has been greater than the rate of increase in adult obesity. High BMI accounted for 4.0 million deaths globally, nearly 40% of which occurred in persons who were not obese. More than two thirds of deaths related to high BMI were due to cardiovascular disease. The disease burden related to high BMI has increased since 1990; however, the rate of this increase has been attenuated owing to decreases in underlying rates of death from cardiovascular disease.

Conclusions: The rapid increase in the prevalence and disease burden of elevated BMI highlights the need for continued focus on surveillance of BMI and identification, implementation, and evaluation of evidence-based interventions to address this problem. (Funded by the Bill and Melinda Gates Foundation.).
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http://dx.doi.org/10.1056/NEJMoa1614362DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5477817PMC
July 2017

A metabolomic analytical approach permits identification of urinary biomarkers for Plasmodium falciparum infection: a case-control study.

Malar J 2017 05 30;16(1):229. Epub 2017 May 30.

School of Medicine, University of Nottingham, Nottingham, UK.

Background: Currently available diagnostic techniques of Plasmodium falciparum infection are not optimal for non-invasive, population-based screening for malaria. It was hypothesized that a mass spectrometry-based metabolomics approach could identify urinary biomarkers of falciparum malaria.

Methods: The study used a case-control design, with cases consisting of 21 adults in central Ethiopia with a diagnosis of P. falciparum infection confirmed with microscopy, and 25 controls of adults with negative blood smears for malaria matched on age and sex. Urinary samples were collected from these individuals during presentation at the clinic, and a second sample was collected from both cases and controls 4 weeks later, after the cases had received anti-malarial medication. The urine samples were screened for small molecule urinary biomarkers, using mass spectrometry-based metabolomics analyses followed by multivariate analysis using principal component analysis and orthogonal partial least square-discriminant analysis. The chemical identity of statistically significant malaria biomarkers was confirmed using tandem mass spectrometry.

Results: The urinary metabolic profiles of cases with P. falciparum infection were distinct from healthy controls. After treatment with anti-malarial medication, the metabolomic profile of cases resembled that of healthy controls. Significantly altered levels of 29 urinary metabolites were found. Elevated levels of urinary pipecolic acid, taurine, N-acetylspermidine, N-acetylputrescine and 1,3-diacetylpropane were identified as potential biomarkers of falciparum malaria.

Conclusion: The urinary biomarkers of malaria identified have potential for the development of non-invasive and rapid diagnostic test of P. falciparum infection.
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http://dx.doi.org/10.1186/s12936-017-1875-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5450092PMC
May 2017

Prevalence and risk factors for anemia severity and type in Malawian men and women: urban and rural differences.

Popul Health Metr 2017 03 29;15(1):12. Epub 2017 Mar 29.

London School of Hygiene and Tropical Medicine, London, United Kingdom.

Background: The global burden of anemia is large especially in sub-Saharan Africa, where HIV is common and lifestyles are changing rapidly with urbanization. The effects of these changes are unknown. Studies of anemia usually focus on pregnant women or children, among whom the burden is greatest. We describe prevalence and risk factors for anemia among rural and urban men and women of all ages in Malawi.

Methods: We analyzed data from a population-wide cross-sectional survey of adults conducted in two sites, Karonga (rural) and Lilongwe (urban), commencing in May 2013. We used multinomial logistic regression models, stratified by sex to identify risk factors for mild and moderate-to-severe anemia.

Results: Anemia prevalence was assessed among 8,926 men (age range 18-100 years) and 14,978 women (age range: 18-103 years). Weighted prevalence levels for all, mild, and moderate-to-severe anemia were 8.2, 6.7 and 1.2% in rural men; 19.4, 12.0 and 7.4% in rural women; 5.9, 5.1 and 0.8% in urban men; and 23.4, 13.6 and 10.1% in urban women. Among women, the odds of anemia were higher among urban residents and those with higher socioeconomic status. Increasing age was associated with higher anemia prevalence in men. Among both men and women, HIV infection was a consistent risk factor for severity of anemia, though its relative effect was stronger on moderate-to-severe anemia.

Conclusions: The drivers of anemia in this population are complex, include both socioeconomic and biological factors and are affecting men and women differently. The associations with urban lifestyle and HIV indicate opportunities for targeted intervention.
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http://dx.doi.org/10.1186/s12963-017-0128-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5371260PMC
March 2017

The burden of hypertension, diabetes mellitus, and cardiovascular risk factors among adult Malawians in HIV care: consequences for integrated services.

BMC Public Health 2016 12 12;16(1):1243. Epub 2016 Dec 12.

Dignitas International, PO Box 1071, Zomba, Malawi.

Background: Hypertension and diabetes prevalence is high in Africans. Data from HIV infected populations are limited, especially from Malawi. Integrating care for chronic non-communicable co-morbidities in well-established HIV services may provide benefit for patients by preventing multiple hospital visits but will increase the burden of care for busy HIV clinics.

Methods: Cross-sectional study of adults (≥18 years) at an urban and a rural HIV clinic in Zomba district, Malawi, during 2014. Hypertension and diabetes were diagnosed according to stringent criteria. Proteinuria, non-fasting lipids and cardio/cerebro-vascular disease (CVD) risk scores (Framingham and World Health Organization/International Society for Hypertension) were determined. The association of patient characteristics with diagnoses of hypertension and diabetes was studied using multivariable analyses. We explored the additional burden of care for integrated drug treatment of hypertension and diabetes in HIV clinics. We defined that burden as patients with diabetes and/or stage II and III hypertension, but not with stage I hypertension unless they had proteinuria, previous stroke or high Framingham CVD risk.

Results: Nine hundred fifty-two patients were enrolled, 71.7% female, median age 43.0 years, 95.9% on antiretroviral therapy (ART), median duration 47.7 months. Rural and urban patients' characteristics differed substantially. Hypertension prevalence was 23.7% (95%-confidence interval 21.1-26.6; rural 21.0% vs. urban 26.5%; p = 0.047), of whom 59.9% had stage I (mild) hypertension. Diabetes prevalence was 4.1% (95%-confidence interval 3.0-5.6) without significant difference between rural and urban settings. Prevalence of proteinuria, elevated total/high-density lipoprotein-cholesterol ratio and high CVD risk score was low. Hypertension diagnosis was associated with increasing age, higher body mass index, presence of proteinuria, being on regimen zidovudine/lamivudine/nevirapine and inversely with World Health Organization clinical stage at ART initiation. Diabetes diagnosis was associated with higher age and being on non-standard first-line or second-line ART regimens.

Conclusion: Among patients in HIV care 26.6% had hypertension and/or diabetes. Close to two-thirds of hypertension diagnoses was stage I and of those few had an indication for antihypertensive pharmacotherapy. According to our criteria, 13.0% of HIV patients in care required drug treatment for hypertension and/or diabetes.
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http://dx.doi.org/10.1186/s12889-016-3916-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5153818PMC
December 2016

Accessing clinical services and retention in care following screening for hypertension and diabetes among Malawian adults: an urban/rural comparison.

J Hypertens 2016 11;34(11):2172-9

aMalawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe, Malawi bLondon School of Hygiene and Tropical Medicine (LSHTM), London, UK cMinistry of Health, Lilongwe, Malawi.

Objective: Interventions to impact on the burden of chronic noncommunicable diseases, such as hypertension and diabetes, include screening of asymptomatic adults, but little is known about the subsequent course of clinical care. We report on the uptake of referral for clinical assessment and retention in care, following a large urban/rural population screening program in Malawi.

Methods: Adult residents were screened for raised blood pressure and raised fasting blood glucose at a demographic surveillance site in rural Karonga District and in urban Area 25, Lilongwe with well supported chronic care clinics. Successful uptake was defined as presenting for clinical assessment within 6 weeks of referral, and nonattenders were followed at home. Logistic regression was used to examine association of uptake with demographic and clinical factors. Retention was assessed using survival analysis techniques.

Results: A total of 27 305 participants were screened for hypertension and diabetes between May 2013 and September 2015. Of these, 4075 (14.9%) were referred for suspected hypertension (3640), diabetes (172), or both (263). Among those referred, 2480 (60.9%), reported for clinical assessment. Factors associated with uptake of care included being female, rural residency, older age, unemployment, prior medication, and diabetes. Retention, for those enrolled in care following a formal clinical assessment, was associated with the final diagnosis following clinical assessment, rural residency, and older age.

Conclusion: Screening for hypertension and diabetes identifies large numbers of individuals who need further clinical assessment, but strategies are needed to ensure better linkage and retention into care.
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http://dx.doi.org/10.1097/HJH.0000000000001070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5790170PMC
November 2016

Effect of Helicobacter pylori infection on growth trajectories in young Ethiopian children: a longitudinal study.

Int J Infect Dis 2016 Sep 12;50:57-66. Epub 2016 Aug 12.

Wellcome Trust Centre for Global Health Research, Brighton and Sussex Medical School, Brighton, UK.

Background: Helicobacter pylori infection has been associated with early childhood growth impairment in high- and middle-income countries; however, few studies have examined this relationship within low-income countries or have used a longitudinal design. The possible effects of H. pylori infection on growth trajectories were examined in a cohort of young Ethiopian children.

Methods: In 2011/12, 856 children (85.1% of the 1006 original singletons in a population-based birth cohort) were followed up at age 6.5 years. An interviewer-led questionnaire administered to mothers provided information on demographic and lifestyle variables. Height and weight were measured twice, and the average of the two measurements was used. Exposure to H. pylori infection was assessed using a rapid H. pylori stool antigen test. The independent associations of positive H. pylori infection status (measured at ages 3 and 6.5 years) with baseline height and weight (age 3 years) and height and weight growth trajectory (from age 3 to 6.5 years) were modelled using hierarchical linear models.

Results: At baseline (age 3 years), the children's mean height was 85.7cm and their mean weight was 11.9kg. They gained height at a mean rate of 8.7cm/year, and weight at a mean rate of 1.76kg/year. H. pylori infection was associated with lower baseline measurements and linear height trajectory (β=-0.74cm and -0.79cm/year, respectively), after controlling for demographics and markers of socio-economic status. However, the positive coefficient was associated with quadratic growth in height among H. pylori-infected children (β=0.28, 95% confidence interval 0.07 to 0.49, p<0.01), and indicated an increase in height trajectory as the child increased in age. A non-significant difference in baseline and trajectory of weight was observed between H. pylori-infected and non-infected children.

Conclusions: These findings add to the growing body of evidence supporting that H. pylori infection is inversely associated with childhood growth trajectory, after controlling for a range of factors associated with reduced growth and H. pylori status. Further follow-up will be important to confirm possible catch-up in height trajectory among H. pylori-infected children as they grow older.
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http://dx.doi.org/10.1016/j.ijid.2016.08.005DOI Listing
September 2016

Hypertension and diabetes in Africa: design and implementation of a large population-based study of burden and risk factors in rural and urban Malawi.

Emerg Themes Epidemiol 2016 1;13. Epub 2016 Feb 1.

Karonga Prevention Study, Karonga, Malawi ; London School of Hygiene and Tropical Medicine, London, UK.

Background: The emerging burden of cardiovascular disease and diabetes in sub-Saharan Africa threatens the gains made in health by the major international effort to combat infectious diseases. There are few data on distribution of risk factors and outcomes in the region to inform an effective public health response. A comprehensive research programme is being developed aimed at accurately documenting the burden and drivers of NCDs in urban and rural Malawi; to design and test intervention strategies. The programme includes population surveys of all people aged 18 years and above, linking individuals with newly diagnosed hypertension and diabetes to healthcare and supporting clinical services. The successes, challenges and lessons learnt from the programme to date are discussed.

Results: Over 20,000 adults have been recruited in rural Karonga and urban Lilongwe. The urban population is significantly younger and wealthier than the rural population. Employed urban individuals, particularly males, give particular recruitment challenges; male participation rates were 80.3 % in the rural population and 43.6 % in urban, whilst female rates were 93.6 and 75.6 %, respectively. The study is generating high quality data on hypertension, diabetes, lipid abnormalities and risk factors.

Conclusions: It is feasible to develop large scale studies that can reliably inform the public health approach to diabetes, cardiovascular disease and other NCDs in Sub-Saharan Africa. It is essential for studies to capture both rural and urban populations to address disparities in risk factors, including age structure. Innovative approaches are needed to address the specific challenge of recruiting employed urban males.
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http://dx.doi.org/10.1186/s12982-015-0039-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4736489PMC
February 2016

Effect of early and current Helicobacter pylori infection on the risk of anaemia in 6.5-year-old Ethiopian children.

BMC Infect Dis 2015 Jul 14;15:270. Epub 2015 Jul 14.

Brighton & Sussex Medical School, Nottingham, UK.

Background: Epidemiological and clinical studies in high income countries have suggested that Helicobacter pylori (H. pylori) may cause anaemia, but evidence is lacking from low income countries.We examined associations between H. pylori infection in early childhood and anaemia at the age of 6.5 years in an Ethiopian birth cohort.

Methods: In 2011/12, 856 children (85.1 % of the 1006 original singletons in a population-based birth cohort) were followed up at age six and half. An interviewer-led questionnaire administered to mothers provided information on demographic and lifestyle variables. Haemoglobin level and red cell indices were examined using an automated haematological analyzer (Cell Dyn 1800, Abbott, USA), and stool samples analyzed for H. pylori antigen. The independent effects of H. pylori infection (measured at age 3.5 and 6.5 years) on anaemia, haemoglobin level, and red cell indices (measured at age 6.5 years) were determined using multiple logistic and linear regression.

Results: The prevalence of anemia was 34.8 % (257/739), and the mean (SD) haemoglobin concentration was 11.8 (1.1) gm/dl. Current H. pylori infection at age 6.5 years was positively, though not significantly related to prevalence of anaemia (adjusted OR, 95 % CI, 1.15; 0.69, 1.93, p = 0.59). Any H. pylori infection up to age 6.5 years was significantly associated with an increased risk of anaemia at age 6.5 (adjusted OR, 95 % CI, 1.68; 1.22, 2.32, p = 0.01). A significant reduction in haemoglobin concentration and red cell indices was also observed among children who had any H. pylori infection up to age 6.5 (Hb adjusted β = -0.19, 95 % CI, -0.35 to -0.03, p = 0.01; MCV adjusted β = -2.22, 95 % CI, -3.43 to -1.01, p = 0.01; MCH adjusted β = -0.63, 95 % CI, -1.15 to - 0.12, p = 0.01; and MCHC adjusted β = -0.67, 95 % CI, -1.21 to -0.14, p = 0.01), respectively.

Conclusion: This study provides further evidence from a low income country that any H. pylori infection up to age 6.5 is associated with higher prevalence of anaemia, and reduction of haemoglobin level and red cell indices at age 6.5.
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http://dx.doi.org/10.1186/s12879-015-1012-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501201PMC
July 2015