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Background/Objectives Adequate dietary intake for type 2 diabetes mellitus (T2DM) patients is central in preventing or delaying onset of diabetes related complications. This study used dietary serving scores (DSS) to determine the adequacy of dietary intake and associated factors among patients with T2DM in Kampala. Subjects/Methods A facility based cross-sectional study among adult T2DM patients attending diabetes clinics attached to health care facilities in Kampala was conducted. Semi structured demographic and 7-day Food Frequency Questionnaires (FFQ) were used to collect data on sociodemographic characteristics, environmental factors and dietary intake respectively. Dietary intake was computed using Dietary Serving Scores (DSS) and was grouped into two: 'adequate dietary intake (DSS of 78 and above)' and 'inadequate dietary intake (DSS below 78)'. Multiple linear regression was used to assess correlates of dietary intake. Results Out of the 400 participants, only 49 (12.25%; 95% CI: 9.04, 15.46) were classified as having adequate dietary intake. After adjusting for potential confounders, unmarried individuals ([beta] = -2.367; p = 0.024) and those who are salaried ([beta] = -3.162; p = 0.012) or self-employed ([beta] = -4.214; p = 0.001) had significantly lower mean DSS compared to their respective counterparts. T2DM patients who attended Nsambya hospital diabetes clinic had significantly higher mean DSS ([beta] = 3.698; p = 0.022) compared to those who receive treatment in Lubaga hospital. Conclusions The prevalence of adequate dietary intake among patients with T2DM attending health facilities in Kampala is very low. More efforts are needed to educate patients on better dietary choices aligned with disease management., Author(s): Susan Kisaakye [sup.1] , Nicholas Matovu [sup.1] [sup.2] , David Guwatudde [sup.3] , Richard Kajjura [sup.1] Author Affiliations: (1) Department of Community Health and Behavioural Sciences, School of Public [...]

Introduction: Despite growing enthusiasm for integrating treatment of non-communicable diseases (NCDs) into human immunodeficiency virus (HIV) care and treatment services in sub-Saharan Africa, there is little evidence on the potential health and financial consequences of such integration. We aim to study the cost-effectiveness of basic NCD-HIV integration in a Ugandan setting. Methods: We developed an epidemiologic-cost model to analyze, from the provider perspective, the cost-effectiveness of integrating hypertension, diabetes mellitus (DM) and high cholesterol screening and treatment for people living with HIV (PLWH) receiving antiretroviral therapy (ART) in Uganda. We utilized cardiovascular disease (CVD) risk estimations drawing from the previously established Globorisk model and systematic reviews; HIV and NCD risk factor prevalence from the World Health Organization's STEPwise approach to Surveillance survey and global databases; and cost data from national drug price lists, expert consultation and the literature. Averted CVD cases and corresponding disability-adjusted life years were estimated over 10 subsequent years along with incremental cost-effectiveness of the integration. Results: Integrating services for hypertension, DM, and high cholesterol among ART patients in Uganda was associated with a mean decrease of the 10-year risk of a CVD event: from 8.2 to 6.6% in older PLWH women (absolute risk reduction of 1.6%), and from 10.7 to 9.5% in older PLWH men (absolute risk reduction of 1.2%), respectively. Integration would yield estimated net costs between $1,400 and $3,250 per disability-adjusted life year averted among older ART patients. Conclusions: Providing services for hypertension, DM and high cholesterol for Ugandan ART patients would reduce the overall CVD risk among these patients; it would amount to about 2.4% of national HIV/AIDS expenditure, and would present a cost-effectiveness comparable to other standalone interventions to address NCDs in low- and middle-income country settings. Keywords: HIV; antiretroviral therapy; non-communicable diseases; hypertension; hypercholesterolaemia; diabetes; cardiovascular diseases; integration; sub-Saharan Africa; Uganda, 1 | INTRODUCTION Non-communicable diseases (NCDs) have become a major cause of disability and mortality among people living with HIV (PLWH) in sub-Saharan Africa (SSA) [1]. This is largely due [...]

Introduction: There is great interest for integrating care for non-communicable diseases (NCDs) into routine HIV services in sub-Saharan Africa (SSA) due to the steady rise of the number of people who are ageing with HIV. Suggested health system approaches for intervening on these comorbidities have mostly been normative, with little actionable guidance on implementation, and on the practical, economic and ethical considerations of favouring people living with HIV (PLHIV) versus targeting the general population. We summarize opportunities and challenges related to leveraging HIV treatment platforms to address NCDs among PLHIV. We emphasize key considerations that can guide integrated care in SSA and point to possible interventions for implementation. Discussion: Integrating care offers an opportunity for effective delivery of NCD services to PLHIV, but may be viewed to unfairly ignore the larger number of NCD cases in the general population. Integration can also help maintain the substantial health and economic benefits that have been achieved by the global HIV/AIDS response. Implementing interventions for integrated care will require assessing the prevalence of common NCDs among PLHIV, which can be achieved via increased screening during routine HIV care. Successful integration will also necessitate earmarking funds for NCD interventions in national budgets. Conclusions: An expanded agenda for addressing HIV-NCD comorbidities in SSA may require adding selected NCDs to conditions that are routinely monitored in PLHIV. Attention should be given to mitigating potential tradeoffs in the quality of HIV services that may result from the extra responsibilities borne by HIV health workers. Integrated care will more likely be effective in the context of concurrent health system reforms that address NCDs in the general population, and with synergies with other HIV investments that have been used to strengthen health systems. Keywords: HIV/AIDS; non-communicable diseases; antiretroviral therapy; integrated care; sub-Saharan Africa, 1 | INTRODUCTION The global response to the HIV epidemic in sub-Saharan Africa (SSA) has resulted in large declines in HIV-related deaths, and contributed to substantial increments in life expectancy [...]

Problem The burden oftrauma and injuries in Uganda is substantial and growing.Two important gaps that need addressing are the shortage of trained people and a lack of national data on noncommunicable diseases and their risk factors in Uganda. Approach We developed and implemented a new track within an existing master of public health programme, aimed at developing graduate-level capacity and promoting research on key national priorities for trauma and injuries. We also offered training opportunities to a wider audience and set up a high-level national injury forum to foster national dialogue on addressing the burden of trauma, injuries and disability. Local setting The Chronic Consequences of Trauma, Injuries and Disability in Uganda programme was implemented In 2012 at Makerere University School of Public Health in Kampala, Uganda, in conjunction with Johns Hopkins Bloomberg School of Public Health in Baltimore, United States of America. Relevant changes Over the years 2012 to 2017 we supported four cohorts of master's students, with a total of 14 students (9 females and 5 males; mean age 30 years). Over 1300 individuals participated in workshops and seminars of the short-term training component of the programme. The forum hosted three research symposia and two national injury forums. Lessons learnt Institutional support and collaborative engagement is important for developing and implementing successful capacity development programmes. Integration of training components within existing academic structures is key to sustainability. Appropriate mentorship for highly motivated and talented students is valuable for guiding students through the programme. Probleme La charge de morbidite liee aux traumatismes et aux blessures en Ouganda est importante et en augmentation. La penurie de personnes formees et le manque de donnees nationales sur les maladies non transmissibles et leurs facteurs de risque en Ouganda constituent deux lacunes importantes qui doivent etre comblees. Approche Nous avons elabore et mis en oeuvre un nouveau parcours au sein d'un master de sante publique existant, destine a developper des capacites de niveau universitaire et a promouvoir la recherche sur les principales priorites nationales relatives aux traumatismes et aux blessures. Nous avons egalement propose des possibilites deformation a un plus large public et organise un forum national de haut niveau sur les blessures pour encourager un dialogue national sur la charge induite par les traumatismes, les blessures et le handicap. Environnement local Le programme Consequences chroniques des traumatismes, des blessures et du handicap en Ouganda a ete mis en oeuvre en 2012 a l'Ecole de sante publique de l'Universite Makerere a Kampala, en Ouganda, en collaboration avec l'Ecole de sante publique Bloomberg de l'Universite Johns Hopkins a Baltimore, aux Etats-Unis d'Amerique. Changements significatifs Entre 2012 et 2017, nous avons soutenu quatre cohortes d'etudiants en master, pour un total de 14 etudiants (9 femmes et 5 hommes; age moyen 30 ans). Plus de 1300 personnes ont participe aux ateliers et seminaires du volet formation courte du programme. Le forum a accueilli trois symposiums de recherche et deux forums nationaux sur les blessures. Lecons tirees Le soutien institutionnel et l'engagement collaboratif sont importants pour elaborer et mettre en oeuvre avec succes des programmes de renforcement des capacites. L'integration des volets deformation aux structures universitaires existantes est essentielle pour leur viabilite. Un tutorat adapte pour les etudiants motives et brillants est utile pour les accompagner pendant toute la duree du programme. Problema La carga de traumatismos y lesiones en Uganda es notable y sigue creciendo. Dos deficiencias importantes que deben abordarse son la escasez de personal formado y la falta de datos nacionales sobre las enfermedades no contagiosas y sus factores de riesgo en Uganda. Enfoque Se ha desarrollado e implementado un nuevo curso dentro de un programa de master en salud publica existente, destinado a desarrollar la capacidad de nivel de postgrado y promover la investigacion sobre prioridades nacionales clave para traumatismos y lesiones. Tambien se ofrecieron oportunidades de formacion a un publico mas amplio y se establecio un foro nacional de alto nivel sobre lesiones para fomentar el dialogo nacional sobre la carga de los traumatismos, las lesiones y la discapacidad. Marco regional El programa Consecuencias cronicas de los traumatismos, las lesiones y la discapacidad en Uganda se implemento en 2012 en la Escuela de Salud Publica de la Universidad de Makerere en Kampala, Uganda, junto con la Escuela de Salud Publica Johns Hopkins Bloomberg en Baltimore, EE.UU. Cambios importantes Entre los anos 2012 y 2017 se respaldaron cuatro cohortes de estudiantes de master, con un total de 14 estudiantes (9 mujeres y 5 hombres, con una edad media de 30 anos). Mas de 1300 personas participaron en talleres y seminarios del componente de formacion a corto plazo del programa. El foro fue sede de tres simposios de investigacion y dos foros nacionales sobre lesiones. Lecciones aprendidas El apoyo institucional y el compromiso colaborativo son importantes para desarrollar e implementar programas de desarrollo de capacidades de exito. La integracion de los componentes de formacion dentro de las estructuras academicas actuales es clave para la sostenibilidad. Una tutoria apropiada para estudiantes muy motivados y con talento es valiosa para guiar a los estudiantes por el programa., Introduction Injuries are a leading cause of death in the African Region, where they claim over 900 000 lives annually, (1) and within Africa, Uganda has one of the highest [...]

Background Global cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population's median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines. Methods and findings We conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%-4.2%) and 1.6% (1.3%-2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%-37.2%) for males and 41.6% (23.9%-53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%-58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis. Conclusions This study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk., Author(s): David Peiris 1,*, Arpita Ghosh 2,3, Jennifer Manne-Goehler 4, Lindsay M. Jaacks 5, Michaela Theilmann 4, Maja E. Marcus 6, Zhaxybay Zhumadilov 7, Lindiwe Tsabedze 8, Adil Supiyev 9, [...]

Background Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care. Methods and findings We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01-1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12-2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01-1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09-1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01-1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes. Conclusion In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care., Author(s): Justine I. Davies 1,2,3,4,*, Sumithra Krishnamurthy Reddiar 5, Lisa R. Hirschhorn 6, Cara Ebert 7, Maja-Emilia Marcus 8, Jacqueline A. Seiglie 9, Zhaxybay Zhumadilov 10, Adil Supiyev 11, Lela [...]

Background The prevalence of diabetes is increasing rapidly in low- and middle-income countries (LMICs), urgently requiring detailed evidence to guide the response of health systems to this epidemic. In an effort to understand at what step in the diabetes care continuum individuals are lost to care, and how this varies between countries and population groups, this study examined health system performance for diabetes among adults in 28 LMICs using a cascade of care approach. Methods and findings We pooled individual participant data from nationally representative surveys done between 2008 and 2016 in 28 LMICs. Diabetes was defined as fasting plasma glucose [greater than or equal to] 7.0 mmol/l (126 mg/dl), random plasma glucose [greater than or equal to] 11.1 mmol/l (200 mg/dl), HbA1c [greater than or equal to] 6.5%, or reporting to be taking medication for diabetes. Stages of the care cascade were as follows: tested, diagnosed, lifestyle advice and/or medication given ('treated'), and controlled (HbA1c < 8.0% or equivalent). We stratified cascades of care by country, geographic region, World Bank income group, and individual-level characteristics (age, sex, educational attainment, household wealth quintile, and body mass index [BMI]). We then used logistic regression models with country-level fixed effects to evaluate predictors of (1) testing, (2) treatment, and (3) control. The final sample included 847,413 adults in 28 LMICs (8 low income, 9 lower-middle income, 11 upper-middle income). Survey sample size ranged from 824 in Guyana to 750,451 in India. The prevalence of diabetes was 8.8% (95% CI: 8.2%-9.5%), and the prevalence of undiagnosed diabetes was 4.8% (95% CI: 4.5%-5.2%). Health system performance for management of diabetes showed large losses to care at the stage of being tested, and low rates of diabetes control. Total unmet need for diabetes care (defined as the sum of those not tested, tested but undiagnosed, diagnosed but untreated, and treated but with diabetes not controlled) was 77.0% (95% CI: 74.9%-78.9%). Performance along the care cascade was significantly better in upper-middle income countries, but across all World Bank income groups, only half of participants with diabetes who were tested achieved diabetes control. Greater age, educational attainment, and BMI were associated with higher odds of being tested, being treated, and achieving control. The limitations of this study included the use of a single glucose measurement to assess diabetes, differences in the approach to wealth measurement across surveys, and variation in the date of the surveys. Conclusions The study uncovered poor management of diabetes along the care cascade, indicating large unmet need for diabetes care across 28 LMICs. Performance across the care cascade varied by World Bank income group and individual-level characteristics, particularly age, educational attainment, and BMI. This policy-relevant analysis can inform country-specific interventions and offers a baseline by which future progress can be measured., Author(s): Jennifer Manne-Goehler 1,*, Pascal Geldsetzer 2, Kokou Agoudavi 3, Glennis Andall-Brereton 4, Krishna K. Aryal 5, Brice Wilfried Bicaba 6, Pascal Bovet 7,8, Garry Brian 9, Maria Dorobantu 10, [...]