The converging burdens of infectious and non-communicable diseases in rural-to-urban migrant Sub-Saharan African populations: a focus on HIV/AIDS, tuberculosis and cardio-metabolic diseases

Africa has the unenviable challenge of dealing with a double burden of disease: infectious diseases (IDs) such as HIV/AIDS and tuberculosis are high while non-communicable diseases (NCDs) are rapidly rising in the region. Populations with increased susceptibility to both include migrants. This review highlights the susceptibility of rural-to-urban migrants in Sub-Saharan Africa to the IDs of HIV/AIDS and tuberculosis, and to NCDs, particularly cardiovascular diseases. The disruption that occurs with migration is often accompanied by unhealthy exposures and environments. These include partaking in risky sexual practices and a subsequent greater risk for HIV infection in migrants than the general populations which contributes to the spread of the disease. Migrants frequently work and live in conditions that are poorly ventilated and overcrowded with suboptimal sanitation which increases their risk for tuberculosis. Considering that migrants have an increased risk of acquiring both HIV/AIDS and tuberculosis, and in view of the interaction between these diseases, they are likely to be at high risk for co-infection. They are also likely to facilitate the geographical spread of these infections and serve as conduits of disease dissemination to rural areas. Changes in lifestyle behaviours that accompany migration and urbanisation are exemplified primarily by shifts in physical activity and dietary patterns which promote the development of obesity, diabetes, hypertension and cardiovascular diseases. Urban living and employment is generally less physically exerting than rural routines; when migrants relocate from their rural residence they adapt to their new environment by significantly reducing their physical activity levels. Also, nutritional patterns among migrants in urban centres change rapidly with a shift to diets higher in fat, sugar and salt. Consequently, increases in weight, blood pressure and glucose levels have been reported within a year of migration. Interactions between IDs and NCDs are common; considering that migrants have an increased susceptibility to IDs and demonstrate a rapid rise in their risk for NCDs, the concurrent prevalence of both is likely in this population. There is a need for a combined strategy to combat IDs and NCDs with screening and treatment programmes geared towards this high risk group

Cardiovascular disease risk factors in the urban black population in Cape Town

Includes abstract. Includes bibliographical references

Trends in adult tobacco use from two South African demographic and health surveys conducted in 1998 and 2003

Introduction: Since tobacco use peaked in the early 1990s in South Africa, it has declined significantly. This reduction has been attributed to the government’s comprehensive tobacco control policies that were introduced in the 1990s. Objective: To assess the pattern of tobacco use between the South African Demographic and Health Surveys in 1998 and 2003. Methods: Multi-stage sampling was used to select approximately 11 000 households in cross-sectional national surveys. Face-to-face interviews, conducted with 13 826 adults (41% men) aged ≥15 years in 1998 and 8 115 (42% men) in 2003, included questions on tobacco use according to the WHO STEP-wise surveillance programme. Logistic regression analysis was used to assess the independent effects of selected characteristics on smoking prevalence. Results: Daily or occasional smoking prevalence among women remained unchanged at 10-11%; among men it decreased from 42% (1998) to 35% (2003). The decline for men was significant among the poorest and those aged 25-44 years. Strong age patterns were observed, peaking at 35-44 years, which was reduced for men in 2003. Higher income and education were associated with low prevalence of smoking while living in urban areas was associated with higher rates. African men and women smoked significantly less than other population groups. Conclusion: Despite decreasing smoking rates in some subgroups, a gap exists in the efforts to reduce tobacco use as smoking rates have remained unchanged in women and young adults, aged 15-24 years

A high burden of hypertension in the urban black population of Cape Town: the cardiovascular risk in Black South Africans (CRIBSA) study

Objective To determine the prevalence, associations and management of hypertension in the 25-74-year-old urban black population of Cape Town and examine the change between 1990 and 2008/09 in 25-64-year-olds. METHODS: In 2008/09, a representative cross-sectional sample, stratified for age and sex, was randomly selected from the same townships sampled in 1990. Cardiovascular disease risk factors were determined by administered questionnaires, clinical measurements and fasting biochemical analyses. Logistic regression models evaluated the associations with hypertension. RESULTS: There were 1099 participants, 392 men and 707 women (response rate 86%) in 2008/09. Age-standardised hypertension prevalence was 38.9% (95% confidence interval (CI): 35.6-42.3) with similar rates in men and women. Among 25-64-year-olds, hypertension prevalence was significantly higher in 2008/09 (35.6%, 95% CI: 32.3-39.0) than in 1990 (21.6%, 95% CI: 18.6-24.9). In 2008/09, hypertension odds increased with older age, family history of hypertension, higher body mass index, problematic alcohol intake, physical inactivity and urbanisation. Among hypertensive participants, significantly more women than men were detected (69.5% vs. 32.7%), treated (55.7% vs. 21.9%) and controlled (32.4% vs. 10.4%) in 2008/09. There were minimal changes from 1990 except for improved control in 25-64-year-old women (1990∶14.1% vs. 2008/09∶31.5%). CONCLUSIONS: The high and rising hypertension burden in this population, its association with modifiable risk factors and the sub-optimal care provided highlight the urgent need to prioritise hypertension management. Innovative solutions with efficient and cost-effective healthcare delivery as well as population-based strategies are required

Metabolic Syndrome in People Living with Human Immunodeficiency Virus: An Assessment of the Prevalence and the Agreement between Diagnostic Criteria

Objectives. We determined metabolic syndrome (MetS) prevalence and assessed the agreement between different diagnostic criteria in HIV-infected South Africans. Method. A random sample included 748 HIV-infected adult patients (79% women) across 17 HIV healthcare facilities in the Western Cape Province. MetS was defined using the Joint Interim Statement (JIS 2009), International Diabetes Federation (IDF 2005), and Adult Treatment Panel III (ATPIII 2005) criteria. Results. Median values were 38 years (age), 5 years (diagnosed HIV duration), and 392 cells/mm3 (CD4 count), and 93% of the participants were on antiretroviral therapy (ART). MetS prevalence was 28.2% (95%CI: 25–31.4), 26.5% (23.3–29.6), and 24.1% (21–27.1) by the JIS, IDF, and ATPIII 2005 criteria, respectively. Prevalence was always higher in women than in men (all ), in participants with longer duration of diagnosed HIV (all ), and in ART users not receiving 1st-line regimens (all ). The agreement among the three criteria was very good overall and in most subgroups (all ). Conclusions. The three most popular diagnostic criteria yielded similarly high MetS prevalence in this relatively young population receiving care for HIV infection. Very good levels of agreement between criteria are unaffected by some HIV-specific features highlighting the likely comparable diagnostic utility of those criteria in routine HIV care settings

Rising prevalence, and improved but suboptimal management, of hypertension in South Africa : a comparison of two national surveys

Aim To examine the changes in prevalence, awareness, treatment and control of hypertension between 1998 and 2016 in ≥15-year-old South African men and women and the sociodemographic characteristics associated with those changes. Methods In nationally representative surveys in 1998 and 2016, multi-stage sampling was used to select, interview and collect blood pressure and anthropometric measurements in ≥15-year-old adults. Logistic regression analyses evaluated the independent effects of selected sociodemographic characteristics on hypertension management. Results Among 13,217 participants in 1998 and 7830 in 2016 (59–60% women in both surveys), hypertension prevalence increased from 27% to 45% in men and 31% to 48% in women. Hypertension increased equally in participants with and without obesity and in daily cigarette smokers vs. their counterparts. Prevalence of awareness among participants with hypertension increased from 7% to 18% (men) and from 17% to 29% (women). Among those aware, hypertension treatment improved markedly from 8% to 85% (men) and from 12% to 82% (women). Hypertension control among those on treatment increased from 17% to 26% (men) and from 21% to 30% (women). Increasing age and survey year were consistently associated with higher prevalence, awareness, treatment and control of hypertension. The richest vs. poorer women, and lower vs. higher educated women were more likely to be treated for hypertension. Conclusions The high and rising hypertension burden together with suboptimal awareness and control levels warrant greater attention to curb hypertension-related morbidity and mortality in South Africans. Novel strategies involving community-based or workplace hypertension programmes may overcome some barriers to optimal care

Differing patterns of overweight and obesity among black men and women in Cape Town: the CRIBSA study

Objectives To ascertain the prevalence and determinants of overweight/obesity in the 25-74-year-old urban black population of Cape Town and examine the changes between 1990 and 2008/09. METHODS: In 2008/09, a representative cross-sectional sample, stratified for age and sex, was randomly selected from the same townships sampled in 1990. Data were collected by questionnaires, clinical measurements and biochemical analyses. Gender-specific linear regression models evaluated the associations with overweight/obesity. RESULTS: There were 1099 participants, 392 men and 707 women (response rate 86%) in 2008/09. Mean body mass index (BMI) and waist circumference (WC) were 23.7 kg/m 2 (95% confidence interval (CI): 23.1-24.2) and 84.2 cm (95% CI: 82.8-85.6) in men, and 33.0 kg/m 2 (95% CI: 32.3-33.7) and 96.8 cm (95% CI: 95.5-98.1) in women. Prevalence of BMI ≥25 kg/m 2 and raised WC were 28.9% (95% CI: 24.1-34.3) and 20.1% (95% CI: 15.9-24.9) in men, and 82.8% (95% CI: 79.3-85.9) and 86.0% (95% CI: 82.9-88.6) in women. Among 25-64-year-olds, BMI ≥25 kg/m 2 decreased between 1990 (37.3%, 95% CI: 31.7-43.1) and 2008/09 (27.7%, 95% CI: 22.7-33.4) in men but increased from 72.7% (95% CI: 67.6-77.2) to 82.6% (95% CI: 78.8-85.8) in women. In the regression models for men and women, higher BMI was directly associated with increasing age, wealth, hypertension and diabetes but inversely related to daily smoking. Also significantly associated with rising BMI were raised low-density lipoprotein cholesterol and being employed compared to unemployed in men, and having >7 years of education in women. CONCLUSIONS: Overweight/obesity, particularly in urban black women, requires urgent action because of the associations with cardiovascular disease risk factors and their serious consequences

A meta-analysis of the Metabolic Syndrome prevalence in the global HIV-infected population

BACKGROUND: Cardio-metabolic risk factors are of increasing concern in HIV-infected individuals, particularly with the advent of antiretroviral therapy (ART) and the subsequent rise in longevity. However, the prevalence of cardio-metabolic abnormalities in this population and the differential contribution, if any, of HIV specific factors to their distribution, are poorly understood. Therefore, we conducted a systematic review and meta-analysis to estimate the global prevalence of metabolic syndrome (MS) in HIV-infected populations, its variation by the different diagnostic criteria, severity of HIV infection, ART used and other major predictive characteristics. METHODS: We performed a comprehensive search on major databases for original research articles published between 1998 and 2015. The pooled overall prevalence as well as by specific groups and subgroups were computed using random effects models. RESULTS: A total of 65 studies across five continents comprising 55094 HIV-infected participants aged 17-73 years (median age 41 years) were included in the final meta-analysis. The overall prevalence of MS according to the following criteria were: ATPIII-2001:16.7% (95%CI: 14.6-18.8), IDF-2005: 18% (95%CI: 14.0-22.4), ATPIII-2004-2005: 24.6% (95%CI: 20.6-28.8), Modified ATPIII-2005: 27.9% (95%CI: 6.7-56.5), JIS-2009: 29.6% (95%CI: 22.9-36.8), and EGIR: 31.3% (95%CI: 26.8-36.0). By some MS criteria, the prevalence was significantly higher in women than in men (IDF-2005: 23.2% vs. 13.4, p = 0.030), in ART compared to non-ART users (ATPIII-2001: 18.4% vs. 11.8%, p = 0.001), and varied significantly by participant age, duration of HIV diagnosis, severity of infection, non-nucleoside reverse transcriptase inhibitors (NNRTIs) use and date of study publication. Across criteria, there were significant differences in MS prevalence by sub-groups such as in men, the Americas, older publications, regional studies, younger adults, smokers, ART-naïve participants, NNRTIs users, participants with shorter duration of diagnosed infection and across the spectrum of HIV severity. Substantial heterogeneities across and within criteria were not fully explained by major study characteristics, while evidence of publication bias was marginal. CONCLUSIONS: The similar range of MS prevalence in the HIV-infected and general populations highlights the common drivers of this condition. Thus, cardio-metabolic assessments need to be routinely included in the holistic management of the HIV-infected individual. Management strategies recommended for MS in the general population will likely provide similar benefits in the HIV-infected