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BackgroundIn Mozambique, human and financial resources for public mental health services are extremely limited. Understanding the mental health needs of those seeking healthcare can inform efficient targeting of mental health services. We examined if the frequency of mental disorders in a health facility varied based on the level of specialization of such facility, from primary care without mental health specialists (PrCMH-), to those with mental health specialists (PrCMH+) and tertiary care (TerC), where both inpatient and outpatient mental health services are available.MethodsParticipants were adults seeking health or mental health services at six facilities (2 PrCMH+, 3 PrCMH-, and 1 TerC) in the cities of Maputo and Nampula in Mozambique. Mental disorders were assessed by the MINI International Neuropsychiatric Interview (MINI) 4.0.0. We compared the sociodemographic characteristics and MINI diagnoses across the three types of health facilities. Multiple logistic regression models determined the likelihood that a person seeking services at each type of facility would have any mental disorder, common mental disorders (CMD), severe mental disorders (SMD), substance use disorders (SUD), and moderate-to-high suicide risk, adjusting for sociodemographic factors. ResultsOf the 612 total participants, 52.6% (n=322) were positive for at least one mental disorder: 37.1% were positive for CMD, 28.9% for SMD, 13.2% for SUD, and 10.5% had suicide risk. Presence of any mental disorder was highest in TerC (62.5%) and lowest in PrCMH- (48.4%). Adjusting for sociodemographic covariates, participants in PrCMH+ were significantly more likely to have SMD (OR: 1.85, 95%CI: 1.10-3.11) and SUD (OR: 2.79, 95%CI: 1.31-5.94) than participants in PrCMH-; participants in TerC were more likely to have CMD (OR: 1.70, 95%CI: 1.01-2.87) and SUD (OR: 2.57, 95%CI: 1.14-5.79) than in PrCMH-. Suicide risk was the only condition that did not differ across facility types.ConclusionsAs anticipated, people with mental disorders were more likely to be cared for at facilities with mental health specialists. However, our study suggests there is a remarkably high frequency of mental disorders across different types of facilities within the Mozambican healthcare system. These results suggest a need to increase mental health services at the primary care level.

The burden of depression and anxiety disorders is high in sub-Saharan Africa, especially for people with HIV (PWH). The Patient Health Questionnaire-4 (PHQ-4) and Electronic Mental Wellness Tool-3 (E-mwTool-3) are ultra-brief screening tools for these disorders. We compared the performance of PHQ-4 and E-mwTool-3 for screening MINI-International Neuropsychiatric Interview diagnoses of depression and anxiety among a sample of individuals with and without HIV in two primary care clinics and one general hospital in Maputo City, Mozambique. Areas-under-the-curve (AUC) were calculated along with sensitivities and specificities at a range of cutoffs. For PWH, at a sum score cutoff of ≥ 1, sensitivities were strong: PHQ-4:Depression = 0.843; PHQ-4:Anxiety = 0.786; E-mwTool-3:Depression = 0.843; E-mwTool-3:Anxiety = 0.929. E-mwTool-3 performance was comparable to PHQ-4 among people with and without HIV.

Background: Emotional Contagion Behavior (ECB), the synchronized expression of emotional symptoms among members of a group, has been observed globally. In Mozambique, there have been numerous reports of ECB in recent years. Since 2010 several girls from a secondary school in Maputo City, Mozambique exhibited ECB which involved repeated fainting spells, sometimes including verbal aggression and threats to colleagues and teachers. We conducted a study to analyze sociodemographic and clinical characteristics associated with ECB. Methods: This cross-sectional study included 154 females aged from 16 to 24 years old. We considered emotional contagion behavior as repeated fainting spells, sometimes including verbal aggression and threats to others (colleagues and teachers). Participants responded to a sociodemographic questionnaire, the Beck Anxiety Scale, and the revised Eysenck Personality Questionnaire (EPQ-R). Bivariate and multivariate logistic regression models analyzed sociodemographic and clinical characteristics associated with EBC. Results: Among study participants, 57 presented ECB and 97 did not. The likelihood of ECB was higher among those with previous history of ECB (OR = 8.28, 95% CI [2.51, 27.30]; p ⩽ .001) and extroverted personality profile (OR = 1.15, 95% CI [1.01, 1.30]; p = .038). Having a romantic relationship was related to lower likelihood of having ECB (OR = 0.04, 95% CI [0.01, 0.19]; p = .001). Conclusions: These results suggest that ECB may repeat over time and be related to challenges pertaining to personality development, the presence of sexual life, and close relationships with peers faced by adolescent girls.

INTRODUCTION: Hazardous drinking imposes a major public health burden worldwide, especially in low-income countries like Mozambique. Implementing Screening, Brief Intervention, Referral to Treatment (SBIRT) to address problem drinking is recommended; evidence regarding the best strategies to implement SBIRT at scale are needed. METHODS: Guided by the Reach Effectiveness Adoption Implementation Maintenance model, we will conduct a two-year, cluster-randomized, hybrid type 2 implementation-effectiveness trial in 12 districts in Mozambique evaluating implementation (reach, adoption, fidelity, and maintenance), clinical effectiveness (symptoms, functioining, co-morbidities) outcomes, and cost (ClinicalTrials.Gov: NCT03610815). Eight districts will be randomized to an application-based, mobile SBIRT condition and four to SBIRT Conventional Training and Supervision. Study arms will be delivered by clinic-based community health workers. The Consolidated Framework for Implementation Research will guide our mixed-methods assessments throughout the study. RESULTS: The arm showing the better cost-effectiveness, will be scaled up in the other arms’ districts. During this 12-month scale-up phase, Ministry of Health personnel will be charged with trainings, clinical activities, and supervision in all 12 districts without research team support. The scale-up phase is critical to identify real-world facilitators and barriers tracking internal and external factors in clinics that continue using the superior arm and those that switch to that condition. NEXT STEPS: Working in a multi-step process with stakeholders from multiple sectors, outcomes and lessons learned from our study will inform development of an implementation tool-kit to guide scaling-up SBIRT for community hazardous drinking services to other low-and middle-income countries and low resource settings in high income countries.

Rheumatic heart disease (RHD) is the result of episodes of acute rheumatic fever with valvular (and other cardiac) damage caused by an abnormal immune response to group A streptococcal infections, usually during childhood and adolescence. As a result of improved living conditions and the introduction of penicillin, RHD was almost eradicated in the developed world by the 1980s. However, being a disease of poverty, its burden remains disproportionately high in the developing world, despite being a fundamentally preventable disease. Rheumatic heart disease generates relatively little attention from the medical and science communities, in contrast to other common infectious problems (such as malaria, HIV, tuberculosis), despite the major cardiovascular morbidity/mortality burden imposed by RHD. This relative neglect and paucity of funding have probably contributed to limited fundamental medical advances in this field for over 50 years. Given the importance of prevention before the onset of major valvular damage, the main challenges for RHD prevention are improving social circumstances, early diagnosis, and effective delivery of antibiotic prophylaxis. Early identification through ultrasound of silent, subclinical rheumatic valve lesions could provide an opportunity for early intervention. Simple echocardiographic diagnostic criteria and appropriately trained personnel can be valuable aids in large-scale public health efforts. In addition, a better understanding of the immunogenic determinants of the disease may provide potential routes to vaccine development and other novel therapies.

BACKGROUND: Mental health conditions impose a major burden worldwide, especially in low- and middle-income countries (LMICs), where health specialists are scarce. A challenge to closing LMICs’ mental health treatment gap is determining the most cost-effective task-shifting pathway for delivering mental health services using evidence-based interventions (EBIs). This article discusses the protocol for the first study implementing comprehensive mental health services in LMICs. METHODS: In partnership with the Mozambican Ministry of Health, this cluster-randomized, hybrid implementation effectiveness type-2 trial will evaluate implementation, patient, and service outcomes of three task-shifting delivery pathways in 20 Mozambican districts (population 4.7 million). In pathway 1 (usual care), community health workers (CHWs) and primary care providers (PCPs) refer patients to district-level mental health clinics. In pathway 2 (screen, refer, and treat), CHWs screen and refer patients to PCPs for behavioral and pharmacological EBIs in community clinics. In pathway 3 (community mental health stepped care), CHWs screen patients and deliver behavioral EBIs in the community and refer medication management cases to PCPs in clinics. Mixed-methods process evaluation will be used to examine factors affecting pathway implementation, adoption, and sustainability. Clinical activities will occur without research team support. Ministry of Health personnel will coordinate training and supervision. RESULTS: The most cost-effective pathway will be scaled up in all districts for 12 months. NEXT STEPS: This novel study integrating comprehensive mental health services into primary care will inform a toolkit to help the Mozambican Ministry of Health scale up the most cost-effective pathway for mental health services and can be a template for other LMICs.

Background: Healthcare systems in low-resource settings need simple, low-cost interventions to improve services and address gaps in care. Though routine data provide opportunities to guide these efforts, frontline healthcare workers (HCW) are rarely engaged in analyzing them for facility-level decision making. The Systems Analysis and Improvement Approach (SAIA) is an evidence-based, multi-component implementation strategy that engages HCW in use of facility-level data to promote systems-level thinking and quality improvement (QI) efforts within multi-step care cascades. SAIA was originally developed to address HIV care in resource-limited settings, but has since been adapted to a variety of clinical care systems including cervical cancer screening, mental health treatment, and hypertension management, among others; and across a variety of settings in sub-Saharan Africa and the United States. We aimed to extend the growing body of SAIA research by defining the core elements of SAIA using established specification approaches, and thus improve reproducibility, guide future adaptations and lay the groundwork to define its mechanism of action. Methods: Specification of the SAIA strategy was undertaken over 12 months by an expert panel of SAIA-researchers, implementing agents and stakeholders using a three-round, modified nominal group technique approach to match core SAIA components to the Expert Recommendations for Implementing Change (ERIC) list of distinct implementation strategies. Core implementation strategies were then specified according to Proctor’s recommendation for specifying and reporting, followed by synthesis of data on related implementation outcomes linked to the SAIA strategy across projects.Results: Based on this review and clarification of the operational definitions of the components of the SAIA, the four components of SAIA were mapped to 13 ERIC strategies. SAIA strategy meetings encompassed external facilitation, organization of provider implementation meetings, and provision of ongoing consultation. Cascade analysis mapped to three ERIC strategies; facilitating relay of clinical data to providers, use of audit and feedback of routine data with healthcare teams, and modelling and simulation of change. Process mapping tied to local needs assessment, local consensus discussions and assessment of readiness and identification of barriers and facilitators. Finally, continuous quality improvement encompassed tailoring strategies, developing a formal implementation blueprint, cyclical tests of change and purposefully re-examining the implementation process.Conclusions: Specifying the components of SAIA provides improved conceptual clarity to enhance reproducibility for other researchers and practitioners interested in applying the SAIA across novel settings.

Background: The Systems Analysis and Improvement Approach (SAIA) is an evidence-based, multi-component implementation strategy that engages service providers in the use of routinely-available service data to optimize service delivery cascades and promote systems-level thinking. SAIA was originally developed to address bottlenecks in HIV care in low-and middle-income countries, but has since been adapted and applied to a variety of care systems including: cervical cancer screening, mental health treatment, hypertension management, family planning, and community-based naloxone distribution. These projects have been implemented across a variety of settings in sub-Saharan Africa and the United States. Given the diversity of implementation experience, our consortium aimed to define the core elements of SAIA, to improve reproducibility, guide future adaptations, and lay the groundwork to evaluate mechanisms of action. Methods: Specification of the SAIA strategy was undertaken over 12 months by an expert panel of SAIA researchers, implementing agents and stakeholders, using a three-round, modified nominal group technique approach to match core SAIA components to the Expert Recommendations for Implementing Change (ERIC) list of distinct implementation strategies. Core implementation strategies were then specified according to Proctor’s recommendation for specifying and reporting, followed by synthesis of data on related implementation outcomes linked to the SAIA strategy across projects.Results: The four components of the SAIA strategy: (1) SAIA strategy meetings; (2) cascade analysis; (3) process mapping; and (4) continuous quality improvement, mapped to 13 distinct ERIC strategies. The SAIA strategy meetings component mapped to external facilitation, organization of provider implementation meetings, and provision of ongoing consultation. Cascade analysis mapped to facilitating relay of clinical data to providers, use of audit and feedback, and modelling and simulation of change. Process mapping tied to local needs assessment, local consensus discussions, and assessment of readiness and identification of barriers and facilitators. Continuous quality improvement encompassed tailoring strategies, developing a formal implementation blueprint, cyclical tests of change and purposefully re-examining the implementation process.Conclusions: Formally specifying the core components of SAIA provides improved conceptual clarity to enhance reproducibility for other researchers and practitioners interested in applying the SAIA across novel settings. Furthermore, this work provides a structured framework to examine potential mechanisms of SAIA and its component implementation strategies.

ObjectiveTo report the interim results from the training of providers inevidence-based psychotherapies (EBPs) and use of mobile applications.Design and SettingThe Partnerships in Research to Implement and Disseminate Sustainable and Scalable Evidence (PRIDE) study is a cluster-randomised hybrid effectiveness-implementation trial comparing three delivery pathways for integrating comprehensive mental healthcare into primary care in Mozambique. Innovations include the use of EBPs and scaling-up of task-shifted mental health services using mobile applications.Main outcome measuresWe examined EBP training attendance, certification, knowledge and intentions to deliver each component. We collected qualitative data through rapid ethnography and focus groups. We tracked the use of the mobile applications to investigate early reach of a valid screening tool (Electronic Mental Wellness Tool) and the roll out of the EBPsParticipantsPsychiatric technicians and primary care providers trained in the EBPs.ResultsPRIDE has trained 110 EBP providers, supervisors and trainers and will train 279 community health workers in upcoming months. The trainings improved knowledge about the EBPs and trainees indicated strong intentions to deliver the EBP core components. Trained providers began using the mobile applications and appear to identify cases and provide appropriate treatment.ConclusionsThe future of EBPs requires implementation within existing systems of care with fidelity to their core evidence-based components. To sustainably address the vast mental health treatment gap globally, EBP implementation demands: expanding the mental health workforce by training existing human resources; sequential use of EBPs to comprehensively treat mental disorders and their comorbid presentations and leveraging digital screening and treatment applications.

Background Rheumatic heart disease (RHD) poses a threat to African women in their reproductive years, being an important cause of maternal mortality and poor foetal outcomes. Timely diagnosis and adequate management reduce significantly obstetric complications. Our study aimed to describe the knowledge of diagnosis and management of RHD in pregnant women among reproductive health professionals (RHP) working in a highly endemic area. Methods The study that took place in May/2017 in two conveniently selected health facilities. Doctors (residents and specialists) and mid-level (maternal and child health nurses/technicians, MLRHP) were invited to respond to an anonymous, self-administered and standardized survey (electronic and paper-based questionnaires), which contained closed and open-ended questions on pregnancy-related RHD diagnosis, treatment and complications. The responses were coded and analysed using SPSS version 20. Results Seventy-three RHP participated (27 doctors, 46 MLRHP). While RHP understand the fetal 49 (67%) and maternal 57 (53%) outcomes in presence of RHD, they are unprepared to diagnose, manage and refer them adequately. Conclusion RHP constitute a group that can be targeted for decentralization of diagnosis and management of RHD, a strategy that may be crucial to reduce maternal mortality by indirect causes in low-middle income countries.

Introduction With improved access to anti-retroviral therapy (ART) the focus of HIV treatment is changing to reducing chronic co-morbidities and their effects, but guidelines for HIV care in many African countries do not include screening for cardiac disease. Our study aimed to determine the pattern of cardiac abnormalities in HIV-positive patients on ART. Methods We implemented a prospective, observational study for 24 months on a random sample of adult patients seen at a dedicated HIV clinic in Mozambique. Demographic, clinical and full cardiovascular evaluations were performed on all participants. Results We enrolled 264 HIVvpositive patients (mean age 39.3 years; 186 female, 70.5%). The mean time on ART was 46 (SD 36) months and most had low viral load (174, 65%). Obesity (45, 17%), overweight (65, 24.6%), hypertension (54, 20.5%) and severe anaemia (21, 8.3%) were frequent. Diabetes was present in four patients (1.5%). The most important conditions in 252 patients submitted to echocardiography (88, 34.9% had cardiac abnormalities) were: severe rheumatic heart valve disease (six), severe dilated cardiomyopathy (five), aortic degenerative disease and congenital heart disease (in three patients each). At 24-month follow up, six of the 252 patients had died; of the 196 reviewed on echocardiography 29 had progressed and two had improved ventricular systolic function. Conclusion This young cohort of HIV-positive patients on ART showed lower occurrence of tuberculous pericarditis and dilated cardiomyopathy but high cardiovascular risk, as assessed by the presence of obesity, hypertension and anaemia. Cardiac abnormalities needing multidisciplinary care were also found. There is a need for tailored cardiovascular risk stratification and screening for cardiovascular disease in HIV-positive patients on ART in Africa.

Challenges and special aspects related to the management and prognosis of pulmonary hypertension (PH) in middle- to low-income regions (MLIRs) range from late presentation to comorbidities, lack of resources and expertise, cost, and rare options of lung transplantation. Expert consensus recommendations addressing the specific challenges for prevention and therapy of PH in MLIRs with limited resources have been lacking. To date, 6 MLIR-PH registries containing mostly adult patients with PH exist. Importantly, the global prevalence of PH is much higher in MLIRs compared with high-income regions: group 2 PH (left heart disease), pulmonary arterial hypertension associated with unrepaired congenital heart disease, human immunodeficiency virus, or schistosomiasis are highly prevalent. This consensus statement provides selective, tailored modifications to the current PH guidelines to address the specific challenges faced in MLIRs, resulting in the first pragmatic and cost-effective consensus recommendations for PH care providers, patients, and their families.

Endomyocardial fibrosis (EMF) is a poverty-related disease of unknown origin that afflicts predominantly young people of certain rural areas in low-income countries and can be used to expose global disparities in cardiovascular research. Despite affecting predominantly young people and causing high morbidity and mortality, efforts to understand its mechanisms and natural history have been hampered by the incapacity to detect the early stages of the disease in endemic areas. Dietary, environmental and infectious factors seem to combine in susceptible individuals to give rise to an inflammatory process that leads to endomyocardial damage and scar formation. Lack of awareness by health professionals and low access to health care determine late diagnosis, when complications such as chronic heart failure, thromboembolism and arrhythmia are already present. Open-heart surgery to detach the endocardial fibrous tissue and repair the atrioventricular valve, remains the last resource to prolong patients’ survival. Community-based research is therefore needed to understand the epidemiology of EMF, detect early disease, uncover its pathogenesis and explore new therapeutic targets. Our research has shown that echocardiographic screening using standard criteria adds sensitivity and precision to the diagnosis, particularly in asymptomatic disease, providing an opportunity for longitudinal community-based research. However, researchers face major constraints in rural settings where EMF is endemic, including socioeconomic, cultural, geographical and administrative barriers. In presenting our experience we aim to describe the challenges and discuss the lessons learned while implementing community-based research in a highly endemic area in southern Mozambique, one of the poorest countries in the world. Additionally, we discuss how recent advances in medicine—such as use of point-of-care diagnostics, heart failure biomarkers and new imaging techniques—may open new possibilities for high quality research through collaborative partnerships and regional initiatives.

Background Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement. Methods The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV. Results CAT has been adapted 7 times: to a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical-estimating denominators and structuring steps to be binary sequential steps-as well as logistical-identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW. Discussion CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.

Many parts of the developing world, especially Sub-Saharan Africa, completely lack access to cardiac pacing. The authors initiated a multinational program to implement cardiac pacing in 14 countries in Sub-Saharan Africa (1996 to 2018), aiming to eventually build self-sustainable capacity in each country. This was based on an "on-site training" approach of performing procedures locally and educating local health care teams to work within resource-limited settings, with prospective evaluation of the program. In 64 missions, a total of 542 permanent pacemakers were implanted. In 11 of these countries, the first pacemaker implant in the country was through the mission. More than one-half of those initially listed as suitable died before the mission(s) arrived. The proportion of implantations that were completely handled by local teams increased from 3% in 1996 to 98% in 2018. These findings demonstrate the feasibility and effectiveness of a proctorship-based approach to the development of local cardiac pacing capabilities in Sub-Saharan African nations.

Countries building sustainable, cardiac surgical care must ensure that the local health system has the capacity to support routine postoperative follow-up and generate the infrastructure required to provide timely diagnosis and management of common postoperative complications. Following valvular cardiac surgery, most patients will need management of residual symptoms of heart failure, adjustment and monitor of anticoagulation, administration of lifelong penicillin prophylaxis and guidance on how to navigate family planning. Anticoagulation has historically been seen as an insurmountable challenge in the rural poor; however, in this chapter, we present the PEN-Plus model for decentralized postoperative management—and provide insight into how its application can guide the way forward to support sustainable post-surgical capacity and appropriate patient follow-up in resource-constrained settings. Warfarin, for example, is a standard anticoagulant prescribed following most routine cardiovascular procedures, and its management requires careful consideration in under-resourced settings. Given its teratogenicity and associated untoward effects, if not managed properly, warfarin can present life threatening complications. As such, district hospitals must be equipped with the capacity to diagnose anticipated complications, to treat mild cases and to refer more severe cases of bleeding, valve thrombosis, or thromboembolic events toward tertiary levels of care in a timely and efficient manner. Patients must be counselled on the attendant risks of anticoagulation, and be provided education on how to maintain a consistent diet. Health systems must ensure that district hospitals have a reliable supply of both warfarin and INR testing supplies. Providers must be trained to diagnose and manage common ongoing complications including endocarditis, sternal wound infection and dehiscence, pericardial and pleural effusions, atrial fibrillation, valve thrombosis, valve dehiscence and hemolytic anemia. Furthermore, health systems need to set up comprehensive support systems for patients, including cardiac rehabilitation, nutritional, socioeconomic and mental health supports.

Cardiac surgery is an essential health service required to prevent mortality and morbidity among patients with valvular and other cardiac disease. Access to cardiac surgery has historically been limited in low and lower-middle income countries (LLMICs), especially among the rural poor. Decentralization of noncommunicable disease (NCD) care from national tertiary care hospitals to local district hospitals can help achieve equity and increase access to cardiac surgery. Within the described PEN-Plus model for NCD management, nurses at the district hospital level are trained to diagnose heart disease by simple physical examination and echocardiography, and manage heart disease using a locally validated protocol, with the assistance of cardiologists from large tertiary care hospitals. This decentralized model provides medical preoperative management and identifies patients eligible for cardiac surgery earlier in their natural history of disease. Case selection can be challenging in LLMICs, but must take into consideration the risks vs benefits of the cardiac surgery for each patient, age of the patient, disease severity, complexity of proposed surgery, local capacity in the operating room and intensive care unit, and likelihood of good surgical outcomes, all with an emphasis on equity. Decisions regarding types of interventions must be made with a patient-centered approach, taking into account not only medical information, but also social and cultural considerations. Cardiac surgery programs must have a national coordinator who is in close communication with local NCD nurses, national cardiologists, and cardiac surgery teams. This coordinator should maintain a dynamic database of patients eligible for surgery, as well as patients who have been operated on and require follow-up and anticoagulation.

On March 2–3, 2011—ahead of the first UN High-Level Meeting on NCDs—a conference hosted in Boston (MA, USA) focused on the NCDs of the world's poorest billion, whose poverty was embodied in young average age, low energy intake, and subsistence through physical labour.30 Participants at the Boston event argued that global thinking about NCDs had been too focused on a theory of epidemiological transition, which projected epidemics of chronic disease associated with development.31 This theory created a blind spot regarding the existence and pattern of non-infectious conditions before declines in infectious mortality (pre-transitional NCDIs). The poorest populations were still experiencing NCDIs as part of a nexus of hunger, toxic environments, infectious diseases, and lack of health care. The NCDIs that emerged under these circumstances were both more severe and more varied than could be captured by frameworks developed for other populations. In April, 2011, the WHO African Regional Office held a consultation of health ministers in Congo (Brazzaville).32 The Brazzaville Declaration on NCDs called for an expanded NCDI agenda addressing haemoglobinopathies (sickle cell disease), mental disorders, and violence and injury.32 Other prominent African health experts called for a 5 × 5 strategy inclusive of neuropsychiatric disorders and infectious risks.33, 34 In July, 2013, at a meeting in Rwanda, a group of NCD unit leaders from ten African ministries of health called for a complementary strategy for NCDIs.35 This NCDI equity agenda focused on policies and integrated health-sector interventions to eliminate deaths among the poorest children and young adults (aged

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 velocityz-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 modelR2value 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.

Summary: Background: Despite declines in deaths from rheumatic heart disease (RHD) in Africa over the past 30 years, it remains a major cause of cardiovascular morbidity and mortality on the continent. We present an investment case for interventions to prevent and manage RHD in the African Union (AU). Methods: We created a cohort state-transition model to estimate key outcomes in the disease process, including cases of pharyngitis from group A streptococcus, episodes of acute rheumatic fever (ARF), cases of RHD, heart failure, and deaths. With this model, we estimated the impact of scaling up interventions using estimates of effect sizes from published studies. We estimated the cost to scale up coverage of interventions and summarised the benefits by monetising health gains estimated in the model using a full income approach. Costs and benefits were compared using the benefit–cost ratio and the net benefits with discounted costs and benefits. Findings: Operationally achievable levels of scale-up of interventions along the disease spectrum, including primary prevention, secondary prevention, platforms for management of heart failure, and heart valve surgery could avert 74 000 (UI 50 000–104 000) deaths from RHD and ARF from 2021 to 2030 in the AU, reaching a 30·7% (21·6–39·0) reduction in the age-standardised death rate from RHD in 2030, compared with no increase in coverage of interventions. The estimated benefit–cost ratio for plausible scale-up of secondary prevention and secondary and tertiary care interventions was 4·7 (2·9–6·3) with a net benefit of $2·8 billion (1·6–3·9; 2019 US$) through 2030. The estimated benefit–cost ratio for primary prevention scale-up was low to 2030 (0·2

Introduction:Non-Communicable Diseases (NCD) are becoming a public health problem in Mozambique and wider sub-Saharan Africa, and are driving changes to guaranty lifelong follow up of patients within the health systems. Patient-Held Medical Records (PHMR) are an option for this follow-up in under-resourced health systems. We designed a study to assess the rate of retention and quality of conservation of the PHMR. Methods:we conducted a prospective observational study from November 2016 to October 2018 in a peri-urban hospital from in Mozambique. Consecutive newly diagnosed patients with cardiovascular disease were given PHMR. Data was collected after their first consultation and one year after. The retention and quality of conservation were assessed after 12 months. Results:overall 134 PHMR were given to patients (24;17.9% children and 77;57.5% female), of which 121 (90.3%) retained at 12 months (90.9% in good conservation state). Most patients had on average four visits to health facilities during the study, all registered in the PHMR. Retention could not be confirmed in 13 patients who did not return the PHMR. Conclusion:PHMR retention rates were high in an urban low-income setting in Africa, with high quality of conservation, thus supporting its use to replace hospital paper-based medical files. Specific research is recommended on acceptability, quality of information registered and patient´s perception.

[first paragraph of article]Avoidable deaths from pregnancy complications occur on a global scale, with the greatest burden of mortality among women in low-to-middle income countries [1]. Most countries record maternal death only up to 42 days postpartum because of the assumption that avoidable death in pregnant women occurs during pregnancy or shortly thereafter. Although limited, the available data suggest otherwise.

This case reports on the authors’ successes building a strong network among female cardiovascular clinician scientists and researchers in Africa…, This case reports on the authors’ successes building a strong network among female cardiovascular clinician scientists and researchers in Africa provides examples of collaborations and mentorship. (Level of Difficulty: Beginner.), Graphical abstract

This research aims to summarize evidence on the cardiovascular effects of indoor air pollution (IAP) from solid fuel and identify areas for research and policy for low- and middle-income countries. IAP affects people from low socioeconomic status in Latin America, Asia, and Africa, who depend upon biomass as a fuel for cooking, heating, and lighting. In these settings, IAP disproportionately affects women, children, the elderly, and people with cardiopulmonary disease. The health effects of IAP include acute respiratory infections, chronic obstructive pulmonary disease, pneumoconiosis, cataract and blindness, pulmonary tuberculosis, adverse effects to pregnancy, cancer, and cardiovascular and cerebrovascular disease. New methods for assessing individual IAP exposure, exposing pathways of IAP-related cardiovascular disease, and performing qualitative research focusing on population preferences regarding strategies to reduce IAP exposure have been the most important developments in tackling the burden of IAP. Unfortunately, major disparities exist regarding research into the cardiovascular effects of IAP, with only few studies coming from sub-Saharan Africa, despite this region having the highest proportion of households using solid fuels. Premature cardiovascular deaths and disability can be averted in low-middle income countries by addressing biomass fuel usage by the most disadvantaged settings. While research is needed to uncover the mechanisms involved in cardiovascular outcomes linked to IAP, immediate action is needed to educate the most affected populations on IAP health hazards and to reduce their exposure to this environmental risk through promoting improved housing and better ventilation, as well as increasing access to affordable clean cooking energy.

BACKGROUND In response to the call by the World Health Organisation to reduce premature deaths from non-communicable diseases by 25% by the year 2025 (25×25), the Pan-African Society of Cardiology (PASCAR), in partnership with several organisations, including the World Heart Federation, have developed an urgent 10-point action plan to improve detection, treatment and control of hypertension in Africa. Priority six of this action plan is to promote a task-shifting/task-sharing approach in the management of hypertension. AIM This capacity-building initiative aims to enhance the knowledge, skills and core competences of primary healthcare physicians in the management of hypertension and related complications. METHODS In a collaborative approach with the International Society of Hypertension, the British and Irish Hypertension Society, the Public Health Foundation of India and the Centre for Chronic Disease Control, the PASCAR hypertension taskforce held a continental faculty meeting in Kenya on 25 and 26 February 2018 to review and discuss a process of effective contextualisation and implementation of the Indian hypertension management course on the African continent. RESULTS A tailored African course in terms of evidence-based learning, up-to-date curriculum and on-the-job training was developed with a robust monitoring and evaluation strategy. The course will be offered on a modular basis with a judicious mix of case studies, group discussions and contact sessions, with great flexibility to accommodate participants' queries. CONCLUSIONS Hypertension affects millions of people in Africa and if left untreated is a major cause of heart disease, kidney disease and stroke. CCMH-Africa will train in the next 10 years, 25 000 certified general physicians and 50 000 nurses, capable of adequately managing uncomplicated hypertension, thereby freeing the few available specialists to focus on severe or complicated cases.

The epidemiology of pulmonary vascular disease (PVD) remains unclear in Africa, where health systems do not reach the majority of the population and heath information systems are poorly developed. In this context, registries are particularly important in gathering crucial information on PVD, aiming at improving knowledge of the epidemiology and/or quality of care. While population-based registries are the main tool to identify incident cases, and be a better indicator of pulmonary vascular disease burden, hospital-based registries can give an indication of the demand for specific care services, which is useful for health policy and planning.The only registry for pulmonary hypertension in Africa – the Pan African Pulmonary Hypertension Cohort (PAPUCO) – involved four countries, and was a pragmatic study that revealed a unique pattern of environmental risks, issues related to low access to health care,and ill-equipped health facilities for diagnosis and management of pulmonary hypertension. In addition, disease specific registries for conditions such as congenital heart disease and rheumatic heart disease uncovered high occurrence of PVD that can be managed and/or prevented with improvements in community awareness, surveillance, management and prevention.It is suggested that existing networks of experts and researchers develop regional registries to determine the epidemiology of PVD in Africa, assess geographic, environmental and seasonal differentials, as well as inform policy and care provision in the continent.