Paediatric hypertension in South Africa: An underestimated problem calling for action.

Hypertension is a major global health problem and the most prominent risk factor for cardiovascular diseases, which disproportionately affect low- and middle-income countries (LMICs). According to a recent report from the Word Health Organization/Strategic Advisory Group of Experts (WHO-SAGE) group, almost half of the South African (SA) adult population is living with hypertension. Although the condition occurs less frequently in children than in adults, evidence now supports the concept that adult essential hypertension has its roots in childhood. A systematic review reports that the prevalence of hypertension in SA children ranges from 7.5% to 22.3%. One in five children aged 5 years is hypertensive (≥95th percentile for age, height and sex), and 60% of children with elevated blood pressure (BP) (>90th percentile for age, height and sex) maintain that status into early adulthood. In addition, there are distinct BP trajectories set early in childhood that are mainly driven by patterns of early life growth and socioeconomic environment. We seek to raise awareness of paediatric hypertension, its risk factors and its consequences, and highlight the importance of action, which can inform early detection and intervention strategies in the context of an increasing burden of cardiovascular disease in SA

Improving viral load testing using a quality improvement approach in Blantyre, Malawi

Background Viral load (VL) testing coverage remains low particularly in resource limited countries despite recommendation by World Health Organization, and Malawi is no exception. A quality improvement (QI) approach was used to improve VL testing coverage from 27% to a target of 80% at an urban health facility in Malawi. Methods A QI study employing a time-series quasi-experimental design with no comparison group was conducted at Chilomoni health centre in Blantyre from April 2020 to July 2020. A retrospective record review of all patient records (257) from 8 weeks before the study was conducted to determine baseline VL testing coverage. Root cause analysis of low VL testing coverage was done using fish-bone tool and factors prioritized using a Pareto-chart. Priority factors included inadequate capacity to update electronic medical records and competing tasks. Change ideas were identified and prioritized using an effort-impact matrix. Two change ideas; re-orienting ART providers on VL test order in EMR and dedicated ART provider to serve VL tested patients were implemented and tested in 5 Plan-Do-Study-Act (PDSA) cycles from the Model for Improvement (MFI), each lasting one week. The latter was tested, and adapted in 3 cycles, and eventually adopted for monitoring for another 5 weeks. VL testing coverage was tracked throughout the study using run charts and p-charts. Results VL testing coverage increased from 27% to 71% by the end of the study, with children aged 0 to 14 years having the lowest coverage throughout the study. Conclusion The MFI as a QI approach improved VL testing coverage through implementation of contextualized change ideas. A reliable data system, leadership buy-in and commitment are important for sustained improvement. Future research should focus on evaluating sustainability of improved VL testing coverage at the health facility and assessing barriers to VL testing among the paediatric population

A longitudinal perspective on violence in the lives of South African children from the Birth to Twenty Plus cohort study in Johannesburg-Soweto

Background. Violence against children is a significant cause of personal suffering and long-term ill health, poor psychological adjustment, and a range of social difficulties, including adverse effects intergenerationally.Objectives. Using a large corpus of longitudinal data collected in the Birth to Twenty Plus cohort, to give an overview of exposure to and experience of violence, as well as perpetration of violence, across childhood, reported contemporaneously by several informants. This overcomes limitations of retrospectively recalled information collected from one person at one point in time.Methods. We identified 280 data points relating to exposure to and perpetration of violence in 14 of the 21 waves of data collection from birth to 22 years of age. Data were classified into four developmental stages (preschool, primary school years, adolescence and young adulthood) and seven categories (exposure to violence in the community, home and school; exposure to peer violence; being a victim of violence, excluding sexual violence; sexual violence; and perpetration of violence). Both descriptive and inferential statistics were employed to analyse the data.Results. Over the past two decades, only 1% of the sample had not been exposed to or experienced violence in their home, school and/or community. Two-thirds of children of schoolgoing age were reported as having been exposed to community violence, and more than half of all children to violence in their home. Reports of sexual violence increased from 10% among primary school-aged children to ~30% among adolescents and young adults. Over the course of their lives, ~40% of children were reported as having been exposed to or being victims of five or six of the categories of violence coded in this analysis. High levels of violence perpetration were reported across childhood. Age and gender differences in exposure to and experience and perpetration of violence were evident, and all categories of violence were more prevalent among poorer and more disadvantaged groups.Conclusions. Very high levels of violence were reported in all the settings of urban South African children’s lives: home, community, school, among peers and in their intimate relationships. Children and youth were also reported to perpetrate high levels of violence. The personal and social costs of violence are very high, resulting in major public health problems due to its avoidable effects on short- and long-term mental and physical health and social adjustment, and intergenerationally.

Transitioning to Dolutegravir in a Programmatic Setting: Virological Outcomes and Associated Factors Among Treatment-Naive Patients With HIV-1 in the Kilombero and Ulanga Antiretroviral Cohort in Rural Tanzania.

BACKGROUND Virological outcome data after programmatic transition from non-nucleoside reverse transcriptase inhibitor (NNRTI)-based to dolutegravir (DTG)-based antiretroviral therapy (ART) regimens in sub-Saharan Africa (SSA) outside of clinical trials are scarce. We compared viral suppression and associated factors in treatment-naïve people living with HIV (PLHIV) starting DTG- based versus NNRTI-based ART. METHODS We compared virological suppression at 12 months, after treatment initiation in the two cohorts of participants aged ≥15 years, initiating DTG- and NNRTI-based ART. Drug resistance was assessed among participants with viremia ≥50 copies/mL on DTG. RESULTS Viral suppression was achieved for 165/195 (85%) and 154/211 (73%) participants in the DTG- and NNRTI- cohorts, respectively (P = 0.003). DTG-based ART was associated with >2 times the odds of viral suppression versus NNRTI-based ART (adjusted odds ratio, 2.10 [95% confidence interval {CI}, 1.12-3.94]; adjusted risk ratio, 1.11 [95% CI, 1.00-1.24]). HIV-1 genotypic resistance testing (GRT) before ART initiation was done in 14 of 30 viremic participants on DTG, among whom nucleoside reverse transcriptase inhibitor (NRTI), NNRTI, and protease inhibitors resistance was detected in 0 (0%), 2 (14%) and 1 (7%), respectively. No resistance was found in the 2 of 30 participants with available GRT at the time of viremia ≥50 copies/mL. CONCLUSIONS Virological suppression at 1 year was higher in participants initiating DTG- versus NNRTI-based ART. In those with viremia ≥50 copies/mL on DTG-based ART, there was no pretreatment or acquired resistance to the DTG co-administered NRTIs, although the number of samples tested was small

The associations between adult body composition and abdominal adiposity outcomes, and relative weight gain and linear growth from birth to age 22 in the Birth to Twenty Plus cohort, South Africa.

BACKGROUND: The growing prevalence of overweight and obesity in low- or middle-income countries precipitates the need to examine early life predictors of adiposity. OBJECTIVES: To examine growth trajectories from birth, and associations with adult body composition in the Birth to Twenty Plus Cohort, Soweto, South Africa. METHODS: Complete data at year 22 was available for 1088 participants (536 males and 537 females). Conditional weight and height indices were generated indicative of relative rate of growth between years 0-2, 2-5, 5-8, 8-18, and 18-22. Whole body composition was measured at year 22 (range 21-25 years) using dual energy x-ray absorptiometry (DXA). Total fat free soft tissue mass (FFSTM), fat mass, and abdominal visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) were recorded. RESULTS: Birth weight was positively associated with FFSTM and fat mass at year 22 (β = 0.11, p<0.01 and β = 0.10, p<0.01 respectively). Relative weight gain from birth to year 22 was positively associated with FFSTM, fat mass, VAT, and SAT at year 22. Relative linear growth from birth to year 22 was positively associated with FFSTM at year 22. Relative linear growth from birth to year 2 was positively associated with VAT at year 22. Being born small for gestational age and being stunted at age 2 years were inversely associated with FFSTM at year 22. CONCLUSIONS: The importance of optimal birth weight and growth tempos during early life for later life body composition, and the detrimental effects of pre- and postnatal growth restriction are clear; yet contemporary weight-gain most strongly predicted adult body composition. Thus interventions should target body composition trajectories during childhood and prevent excessive weight gain in early adulthood

The associations between adult body composition and abdominal adiposity outcomes, and relative weight gain and linear growth from birth to age 22 in the Birth to Twenty Plus cohort, South Africa.

BACKGROUND: The growing prevalence of overweight and obesity in low- or middle-income countries precipitates the need to examine early life predictors of adiposity. OBJECTIVES: To examine growth trajectories from birth, and associations with adult body composition in the Birth to Twenty Plus Cohort, Soweto, South Africa. METHODS: Complete data at year 22 was available for 1088 participants (536 males and 537 females). Conditional weight and height indices were generated indicative of relative rate of growth between years 0-2, 2-5, 5-8, 8-18, and 18-22. Whole body composition was measured at year 22 (range 21-25 years) using dual energy x-ray absorptiometry (DXA). Total fat free soft tissue mass (FFSTM), fat mass, and abdominal visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) were recorded. RESULTS: Birth weight was positively associated with FFSTM and fat mass at year 22 (β = 0.11, p<0.01 and β = 0.10, p<0.01 respectively). Relative weight gain from birth to year 22 was positively associated with FFSTM, fat mass, VAT, and SAT at year 22. Relative linear growth from birth to year 22 was positively associated with FFSTM at year 22. Relative linear growth from birth to year 2 was positively associated with VAT at year 22. Being born small for gestational age and being stunted at age 2 years were inversely associated with FFSTM at year 22. CONCLUSIONS: The importance of optimal birth weight and growth tempos during early life for later life body composition, and the detrimental effects of pre- and postnatal growth restriction are clear; yet contemporary weight-gain most strongly predicted adult body composition. Thus interventions should target body composition trajectories during childhood and prevent excessive weight gain in early adulthood

Genetic risk score for adult body mass index associations with childhood and adolescent weight gain in an African population

Abstract Background Ninety-seven independent single nucleotide polymorphisms (SNPs) are robustly associated with adult body mass index (BMI kg/m2) in Caucasian populations. The relevance of such variants in African populations at different stages of the life course (such as childhood) is unclear. We tested whether a genetic risk score composed of the aforementioned SNPs was associated with BMI from infancy to early adulthood. We further tested whether this genetic effect was mediated by conditional weight gain at different growth periods. We used data from the Birth to Twenty Plus Cohort (Bt20+), for 971 urban South African black children from birth to 18 years. DNA was collected at 13 years old and was genotyped using the Metabochip (Illumina) array. The weighted genetic risk score (wGRS) for BMI was constructed based on 71 of the 97 previously reported SNPs. Results The cross-sectional association between the wGRS and BMI strengthened with age from 5 to 18 years. The significant associations were observed from 11 to 18 years, and peak effect sizes were observed at 13 and 14 years of age. Results from the linear mixed effects models showed significant interactions between the wGRS and age on longitudinal BMI but no such interactions were observed in sex and the wGRS. A higher wGRS was associated with an increased relative risk of belonging to the early onset obese longitudinal BMI trajectory (relative risk = 1.88; 95%CI 1.28 to 2.76) compared to belonging to a normal longitudinal BMI trajectory. Adolescent conditional relative weight gain had a suggestive mediation effect of 56% on the association between wGRS and obesity risk at 18 years. Conclusions The results suggest that genetic susceptibility to higher adult BMI can be tracked from childhood in this African population. This supports the notion that prevention of adult obesity should begin early in life. The genetic risk score combined with other non-genetic risk factors, such as BMI trajectory membership in our case, has the potential to be used to screen for early identification of individuals at increased risk of obesity and other related NCD risk factors in order to reduce the adverse health risk outcomes later

Association Between Early Life Growth and Blood Pressure Trajectories in Black South African ChildrenNovelty and Significance

Early growth is associated with blood pressure measured on one occasion, but whether early life growth patterns are associated with longitudinal blood pressure trajectories is under-researched. Therefore, we sought to examine the association between early growth and blood pressure trajectories from childhood to adulthood. Blood pressure was measured on 7 occasions between ages 5 and 18 years in the Birth to Twenty cohort study, and conditional variables for growth in infancy and mid-childhood were computed from anthropometric measures (n=1937, 52% girls). We used a group-based trajectory modeling approach to identify distinct height-adjusted blood pressure trajectories and then tested their association with growth between birth and mid-childhood adjusting for several covariates. Three trajectory groups were identified for systolic and diastolic blood pressure: lower, middle, and upper in boys and girls, separately. In boys, predictors of the middle or upper systolic blood pressure trajectories versus the lower trajectory were in birth weight (odds ratio 0.75 [95% confidence interval 0.58-0.96] per SD) and relative weight gain in infancy (4.11 [1.25-13.51] per SD). In girls, greater relative weight gain and linear growth in both infancy and mid-childhood were consistently associated with an almost 2-fold higher likelihood of being in the upper versus lower systolic blood pressure trajectory. The associations for the diastolic blood pressure trajectories were inconsistent. These findings emphasize the importance of identifying children at risk of progression to high blood pressure. Accelerated growth in infancy and mid-childhood may be a key target for early life intervention in prevention of elevated blood pressure progression