Patterns of uptake of HIV testing in sub‐Saharan Africa in the pre‐treatment era

Objectives To compare nationally representative trends in self‐reported uptake of HIV testing and receipt of results in selected countries prior to treatment scale‐up. Methods Demographic and Health Survey (DHS) data from 13 countries in sub‐Saharan Africa were used to describe the pattern of uptake of testing for HIV among sexually active participants. Univariate and multivariate logistic regression were used to analyse the associations between socio‐demographic and behavioural characteristics and the uptake of testing. Results Knowledge of serostatus ranged from 2.2% among women in Guinea (2005) to 27.4% among women in Rwanda (2005). Despite varied levels of testing, univariate analysis showed the profile of testers to be remarkably similar across countries, with respect to socio‐demographic characteristics such as area of residence and socio‐economic status. HIV‐positive participants were more likely to have tested and received their results than HIV‐negative participants, with the exception of women in Senegal and men in Guinea. Adjusted analyses indicate that a secondary or higher level of education was a key determinant of testing, and awareness that treatment exists was independently positively associated with testing, once other characteristics were taken into account. Conclusion This work provides a baseline for monitoring trends in testing and exploring changes in the profile of those who get tested after the introduction and scale‐up of treatment.     

How access to health care relates to under‐five mortality in sub‐Saharan Africa: systematic review

An estimated 9.7 million children under the age of five die every year worldwide, approximately 41% of them in sub‐Saharan Africa (SSA). Access to adequate health care is among the factors suggested to be associated with child mortality; improved access holds great potential for a significant reduction in under‐five death in developing countries. Theory and corresponding frameworks indicate a wide range of factors affecting access to health care, such as traditionally measured variables (distance to a health provider and cost of obtaining health care) and additional variables (social support, time availability and caregiver autonomy). Few analytical studies of traditional variables have been conducted in SSA, and they have significant limitations and inconclusive results. The importance of additional factors has been suggested by qualitative and recent quantitative studies. We propose that access to health care is multidimensional; factors other than distance and cost need to be considered by those planning health care provision if child mortality rates are to be reduced through improved access. Analytical studies that comprehensively evaluate both traditional and additional variables in developing countries are required.     

Antiretroviral therapy uptake and coverage in four HIV community cohort studies in sub‐Saharan Africa

Objective To compare socio‐demographic patterns in access to antiretroviral therapy (ART) across four community HIV cohort studies in Africa. Methods Data on voluntary counselling and testing and ART use among HIV‐infected persons were analysed from Karonga (Malawi), Kisesa (Tanzania), Masaka (Uganda) and Manicaland (Zimbabwe), where free ART provision started between 2004 and 2007. ART coverage was compared across sites by calculating the proportion on ART among those estimated to need treatment, by age, sex and educational attainment. Logistic regression was used to identify socio‐demographic characteristics associated with undergoing eligibility screening at an ART clinic within 2 years of being diagnosed with HIV, for three sites with information on diagnosis and screening dates. Results Among adults known to be HIV‐infected from serological surveys, the proportion who knew their HIV status was 93% in Karonga, 37% in Kisesa, 46% in Masaka and 25% in Manicaland. Estimated ART coverage was highest in Masaka (68%) and lowest in Kisesa (2%). The proportion of HIV‐diagnosed persons who were screened for ART eligibility within 2 years of diagnosis ranged from 14% in Kisesa to 84% in Masaka, with the probability of screening uptake increasing with age at diagnosis in all sites. Conclusions Higher HIV testing rates among HIV‐infected persons in the community do not necessarily correspond with higher uptake of ART, nor more equitable treatment coverage among those in need of treatment. In all sites, young adults tend to be disadvantaged in terms of accessing and initiating ART, even after accounting for their less urgent need.     

Do behavioural differences help to explain variations in HIV prevalence in adolescents in sub‐Saharan Africa?

Objective To compare adolescent risk factors for HIV infection in two countries with high adolescent HIV prevalence and two lower prevalence countries with the aim of identifying risk factors that may help explain differences in adolescent HIV prevalence. Methods Data were available from two nationally representative surveys (South Africa, Zimbabwe), two behavioural intervention trials (Tanzania, Zimbabwe) and one population‐based cohort (Uganda). Data on variables known or postulated to be risk factors for HIV infection were compared. Results Few risk behaviours were markedly more common in the high HIV prevalence populations. Risk factors more common in high HIV prevalence settings were genital ulcers and discharge, and women were more likely to report older male partners. Discussion Age mixing may be an important determinate of HIV prevalence in adolescents. Potential reasons for the general lack of association between other adolescent risk factors and adolescent HIV prevalence include adult HIV prevalence, misreported behaviour, different survey methods and other unmeasured adolescent behaviours. If adult factors dominate adolescent HIV risk, it would help explain the failure of behavioural interventions targeted at adolescents and suggests future interventions should include adults.     

Short‐term effects of perindopril‐amlodipine vs perindopril‐indapamide on blood pressure control in sub‐Saharan type 2 diabetic individuals newly diagnosed for hypertension: A double‐blinded randomized controlled trial

Poor blood pressure (BP) control contributes to complications in sub‐Saharan African (SSA) type 2 diabetic individuals. Experts have advocated the use of combination therapies for effective BP control in these patients. The suggested combinations should include a RAAS antagonist and either a CCB or a thiazide diuretic; however, their efficacy is yet to be established in SSA. We investigated the short‐term effects of two combination therapies on BP control in SSA type 2 diabetic individuals. This was a double‐blinded randomized controlled trial conducted at the Yaoundé Central Hospital (Cameroon) from October 2016 to May 2017. We included type 2 diabetic patients, newly diagnosed for hypertension. After baseline assessment and 24‐hour ABPM, participants were allocated to receive either a fixed combination of perindopril + amlodipine or perindopril + indapamide for 42 days. Data analyses followed the intention‐to‐treat principle. We included fifteen participants (8 being females) in each group. Both combinations provided good circadian BP control after 6 weeks with similar efficacy. Twenty‐four‐hour SBP dropped from 144 to 145 mm Hg vs 128 to 126 mm Hg with perindopril‐amlodipine and perindopril‐indapamide, respectively (P = 0.003 for both groups). Twenty‐four‐hour DBP dropped from 85 to 78 mm Hg (P = 0.013) vs 89 to 79 mm Hg (P = 0.006) in the same respective groups. No significant adverse effect was reported. A fixed initial combination of perindopril‐amlodipine or perindopril‐indapamide achieved similar effective BP control after 6 weeks in SSA type 2 diabetic individuals with newly diagnosed hypertension. Therefore, these combinations can be used interchangeably in this indication.     

Epidemiology of gestational diabetes mellitus and its association with Type 2 diabetes.

Gestational diabetes (GDM) is defined as carbohydrate intolerance that begins or is first recognized during pregnancy. Although it is a well-known cause of pregnancy complications, its epidemiology has not been studied systematically. Our aim was to review the recent data on the epidemiology of GDM, and to describe the close relationship of GDM to prediabetic states, in addition to the risk of future deterioration in insulin resistance and development of overt Type 2 diabetes. We found that differences in screening programmes and diagnostic criteria make it difficult to compare frequencies of GDM among various populations. Nevertheless, ethnicity has been proven to be an independent risk factor for GDM, which varies in prevalence in direct proportion to the prevalence of Type 2 diabetes in a given population or ethnic group. There are several identifiable predisposing factors for GDM, and in the absence of risk factors, the incidence of GDM is low. Therefore, some authors suggest that selective screening may be cost-effective. Importantly, women with an early diagnosis of GDM, in the first half of pregnancy, represent a high-risk subgroup, with an increased incidence of obstetric complications, recurrent GDM in subsequent pregnancies, and future development of Type 2 diabetes. Other factors that place women with GDM at increased risk of Type 2 diabetes are obesity and need for insulin for glycaemic control. Furthermore, hypertensive disorders in pregnancy and afterwards may be more prevalent in women with GDM. We conclude that the epidemiological data suggest an association between several high-risk prediabetic states, GDM, and Type 2 diabetes. Insulin resistance is suggested as a pathogenic linkage. It is possible that improving insulin sensitivity with diet, exercise and drugs such as metformin may reduce the risk of diabetes in individuals at high risk, such as women with polycystic ovary syndrome, impaired glucose tolerance, and a history of GDM. Large controlled studies are needed to clarify this issue and to develop appropriate diabetic prevention strategies that address the potentially modifiable risk factors.