Characteristics and efficacy of physical activity interventions to improve cardiometabolic and psychosocial outcomes in people living with HIV in sub-Saharan Africa: a protocol for a systematic review

BACKGROUND: Antiretroviral therapy (ART) has led to an increased lifespan for people living with HIV (PWH). This increased lifespan, coupled with the effects of HIV and adverse effects of ART have resulted in an increasing burden of cardiometabolic disease (CMD) among PWH. Physical activity (PA) has been proposed as an effective strategy to reduce the risk of developing cardiometabolic disease and other health complications in PWH. The aim of this paper is to review the characteristics and efficacy of PA interventions to improve cardiometabolic and psychosocial outcomes among PWH in sub-Saharan Africa. METHODS: The review will follow the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P). Literature searches will be conducted in PubMed, Web of Science (WoS), African Index Medicus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase. Peer-reviewed publications will be included if they include adults (age 18 or older), PWH in sub-Saharan Africa, and a PA intervention to improve cardiometabolic outcomes and/or psychosocial outcomes. We will include randomized controlled trials and quasi-experimental study designs. Two independent reviewers will screen all abstracts and full-text articles. The study methodological quality (or bias) will be appraised using the Revised tool to assess risk of bias in randomized trials and the Downs and Black checklist. Certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation guidelines. Meta-analyses will be conducted if our results are adequate for meta-analysis. Outcomes will be analyzed as continuous or dichotomous and meta-analyses will be conducted using random effects models with Stata computer software. DISCUSSION: This review will identify and synthesize the current evidence regarding the characteristics and efficacy of PA interventions to improve cardiometabolic and psychosocial outcomes among PWH in sub-Saharan Africa. We also plan to identify the strengths and weaknesses of evaluated interventions. Based on the evidence, recommendations will be made to promote the design and further evaluate the most promising strategies to maximize the efficacy of PA interventions in improving cardiometabolic and psychosocial outcomes in PWH in sub-Saharan Africa. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration ID: CRD42021271937

BMI and All-Cause Mortality in a Population-Based Cohort in Rural South Africa

OBJECTIVE: This study evaluates the association between BMI and all-cause and cause-specific mortality in South Africa. METHODS: Prospective, population-based observational cohort data from rural South Africa were analyzed. BMI was measured in 2010. Demographic characteristics were recorded and deaths were verified with verbal autopsy interview. The InterVA-5 tool was used to assign causes of death. HIV testing was conducted annually. Cox proportional hazards models were fit to estimate the effect of BMI on all-cause and cause-specific mortality, accounting for the competing risk of death from other causes. Models were adjusted for sociodemographic characteristics and HIV status, and inverse probability weighting for survey nonparticipation was used. RESULTS: The cohort consisted of 9,728 individuals. In adjusted models, those with BMI of 25.0 to 29.9 kg/m2 or 30.0 to 34.9 kg/m2 had a lower hazard of death (adjusted hazard ratio: 0.80; 95% CI: 0.69-0.92 and adjusted hazard ratio: 0.75; 95% CI: 0.60-0.93, respectively) compared with those with BMI of 18.5 to 24.9 kg/m^{2}. CONCLUSIONS: Individuals in South Africa who meet clinically defined criteria for overweight or obesity had a lower risk of all-cause mortality than those with a normal BMI. These findings were stronger for women and communicable conditions

Non-fatal injuries in rural Burkina Faso amongst older adults, disease burden and health system responsiveness:a cross-sectional household survey

OBJECTIVES: This study aimed to evaluate the epidemiology of injury as well as patient-reported health system responsiveness following injury and how this compares with non-injured patient experience, in older individuals in rural Burkina Faso. DESIGN: Cross-sectional household survey. Secondary analysis of the CRSN Heidelberg Ageing Study dataset. SETTING: Rural Burkina Faso. PARTICIPANTS: 3028 adults, over 40, from multiple ethnic groups, were randomly sampled from the 2015 Nouna Health and Demographic Surveillance Site census. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was incidence of injury. Secondary outcomes were incidence of injury related disability and patient-reported health system responsiveness following injury. RESULTS: 7.7% (232/3028) of the population reported injury in the preceding 12 months. In multivariable analyses, younger age, male sex, highest wealth quintile, an abnormal Generalised Anxiety Disorder score and lower Quality of Life score were all associated with injury. The most common mechanism of injury was being struck or hit by an object, 32.8%. In multivariable analysis, only education was significantly negatively associated with odds of disability (OR 0.407, 95% CI 0.17 to 0.997). Across all survey participants, 3.9% (119/3028) reported their most recent care seeking episode was following injury, rather than for another condition. Positive experience and satisfaction with care were reported following injury, with shorter median wait times (10 vs 20 min, p=0.002) and longer consultation times (20 vs 15 min, p=0.002) than care for another reason. Injured patients were also asked to return to health facilities more often than those seeking care for another reason, 81.4% (95% CI 73.1% to 87.9%) vs 54.8% (95% CI 49.9% to 53.6%). CONCLUSIONS: Injury is an important disease burden in this older adult rural low-income and middle-income country population. Further research could inform preventative strategies, including safer rural farming methods, explore the association between adverse mental health and injury, and strengthen health system readiness to provide quality care

Change in clinical knowledge of diabetes among primary healthcare providers in Indonesia: repeated crosssectional survey of 5105 primary healthcare facilities

Introduction Indonesia is experiencing a rapid rise in the number of people with diabetes. There is limited evidence on how well primary care providers are equipped to deal with this growing epidemic. This study aimed to determine the level of primary healthcare providers' knowledge of diabetes, change in knowledge from 2007 to 2014/2015 and the extent to which changes in the diabetes workforce composition, geographical distribution of providers, and provider characteristics explained the change in diabetes knowledge. Research design and methods In 2007 and 2014/2015, a random sample of public and private primary healthcare providers who reported providing diabetes care across 13 provinces in Indonesia completed a diabetes clinical case vignette. A provider's diabetes vignette score represents the percentage of all correct clinical actions for a hypothetical diabetes patient that were spontaneously mentioned by the provider. We used standardization and fixed-effects linear regression models to determine the extent to which changes in diabetes workforce composition, geographical distribution of providers, and provider characteristics explained any change in diabetes knowledge between survey rounds, and how knowledge varied among provinces. Results The mean unadjusted vignette score decreased from 37.1% (95% CI 36.4% to 37.9%) in 2007 to 29.1% (95% CI 28.4% to 29.8%, p<0.001) in 2014/2015. Vignette scores were, on average, 6.9 (95% CI −8.2 to 5.6, p<0.001) percentage points lower in 2014/2015 than in 2007 after adjusting for provider cadre, geographical distribution, and provider experience and training. Physicians and providers with postgraduate diabetes training had the highest vignette scores. Conclusions Diabetes knowledge among primary healthcare providers in Indonesia decreased, from an already low level, between 2007 and 2014/2015. Policies that improve preservice training, particularly at newer schools, and investment in onthe-job training in diabetes might halt and reverse the decline in diabetes knowledge among Indonesia's primary healthcare workforce.This project has received funding from the European Research Council under the European Union’s Horizon 2020 research and innovation programme (grant agreement number 850896). JMG was supported by the National Institute of Allergy and Infectious Diseases (grant number T32 AI007433

Reaching for the 'first 95': a cross-country analysis of HIV self-testing in nine countries in sub-Saharan Africa

OBJECTIVES: HIV self-testing (HIVST) offers a promising approach to increase HIV diagnosis and advance progress towards the UNAIDS 95-95-95 targets. We aimed to understand patterns of HIVST awareness and utilization in nine sub-Saharan African (SSA) countries, with the goal of identifying populations to target in disseminating this technology. DESIGN: A cross-sectional study. METHODS: We pooled individual-level population-based data from nine Demographic and Health Surveys (DHS) in SSA conducted 2015-2019 (Burundi, Cameroon, Guinea, Malawi, Senegal, Sierra Leone, South Africa, Zambia, Zimbabwe). Primary outcomes were HIVST awareness and utilization. We used logistic regression with survey fixed effects to explore the relationship between sociodemographic characteristics and these outcomes. Models were adjusted for sex, age, rural/urban residence, education, wealth, and marital status. We accounted for complex survey design. RESULTS: The study sample included 177 572 people (66.0% women, mean age 29 ± 10 years), of whom 86.6% [95% confidence interval (95% CI) 86.4-86.7] were unaware of HIVST, 11.7% (95% CI 11.6-11.9) were aware of but never used HIVST, and 1.7% (95% CI 1.6-1.8) had used HIVST. In adjusted models, women were less likely to be aware of HIVST [odds ratio (OR) 0.75, 95% CI 0.71-0.79], but more likely to have used HIVST (OR 1.17, 95% CI 1.03-1.32) compared with men. Rural residents, those who were least educated, and poorest were less likely to have heard of or used HIVST. CONCLUSION: HIVST awareness and uptake were low. Rural, less educated, and lower income populations were least likely to have heard of or used HIVST. Efforts to scale-up HIVST in these settings should aim to reach these less advantaged groups

Frailty and physical performance in the context of extreme poverty: a population-based study of older adults in rural Burkina Faso [version 1; peer review: 2 approved]

Background: Little is known about the prevalence of frailty and about normal values for physical performance among older individuals in low-income countries, in particular those in sub-Saharan Africa. We describe the prevalence of phenotypic frailty, and values and correlates of several physical performance measures in a cohort of middle-aged and older people living in rural Burkina Faso, one of the world’s poorest communities. Methods: We analysed data collected from participants aged over 40 in Nouna district, Burkina Faso. We measured handgrip strength, four metre walk speed, chair rise time, and derived the Fried frailty score based on grip strength, gait speed, body mass index, self-reported exhaustion, and physical activity. Frailty and physical performance indicators were then correlated with health and sociodemographic variables including comorbid disease, marital status, age, sex, wealth and activity impairment. Results: Our sample included 2973 individuals (1503 women), mean age 54 years. 1207 (43%) were categorised as non-frail, 1324 (44%) as prefrail, 212 (7%) as frail, and 167 (6%) were unable to complete all five frailty score components. Lower grip strength, longer chair stand time, lower walk speed and prevalence of frailty rose with age. Frailty was more common in women than men (8% vs 6%, p=0.01) except in those aged 80 and over. Frailty was strongly associated with impairment of activities of daily living and with lower wealth, being widowed, diabetes mellitus, hypertension, and self-reported diagnoses of tuberculosis or heart disease. With the exception of grip strength, which was higher in women than prior international normative values, women had greater deficits than men in physical performance. Conclusions: Phenotypic frailty and impaired physical performance were associated as expected with female sex, co-morbidities, increasing age and impaired activities of daily living. These results support the use of frailty measurements for classification of ageing related syndromes in this setting

Correlates of physical activity among people living with and without HIV in rural Uganda

Background Antiretroviral therapy (ART) has led to diminishing AIDS-related mortality but a concomitant increase in non-communicable diseases (NCDs) for people with HIV (PWH). Whereas physical activity (PA) has been shown to help prevent NCDs and NCD outcomes in other settings, there are few data on PA and its correlates among PWH in high-endemic settings. We aimed to compare PA by HIV serostatus in rural Uganda. Methods We analysed data from the UGANDAC study, an observational cohort including PWH in ambulatory HIV care in Mbarara, Uganda, and age- and gender-matched people without HIV (PWOH). Our primary outcome of interest was PA, which we assessed using the International Physical Activity Questionnaire and considered as a continuous measure of metabolic equivalents in minutes/week (MET-min/week). Our primary exposure of interest was HIV serostatus. We fit univariable and multivariable linear regression models to estimate the relationship between HIV and PA levels, with and without addition of sociodemographic and clinical correlates of PA (MET-min/week). In secondary analyses, we explored relationships restricted to rural residents, and interactions between gender and serostatus. Results We enrolled 309 participants, evenly divided by serostatus and gender. The mean age of PWH was 52 [standard deviation (SD) 7.2] and 52.6 (SD 7.3) for PWOH. In general, participants engaged in high levels of PA regardless of serostatus, with 81.2% (251/309) meeting criteria for high PA. However, PWOH reported higher mean levels of PA met-minutes/week than PWH (9,128 vs 7,152, p ≤ 0.001), and a greater proportion of PWOH (88.3%; 136/154) met the criteria for high PA compared to PWH (74.2%; 115/155). In adjusted models, lower levels of PA persisted among PWH (β = −1,734, 95% CI: −2,645, −824, p ≤ 0.001). Results were similar in a sensitivity analysis limited to people living in rural areas. Conclusion In a rural Ugandan cohort, PWOH had higher levels of PA than PWH. Interventions that encourage PA among PWH may have a role in improving NCD risk profiles among PWH in the region

Triatomine Infestation in Guatemala: Spatial Assessment after Two Rounds of Vector Control

In 2000, the Guatemalan Ministry of Health initiated a Chagas disease program to control Rhodnius prolixus and Triatoma dimidiata by periodic house spraying with pyrethroid insecticides to characterize infestation patterns and analyze the contribution of programmatic practices to these patterns. Spatial infestation patterns at three time points were identified using the Getis-Ord Gi*(d) test. Logistic regression was used to assess predictors of reinfestation after pyrethroid insecticide administration. Spatial analysis showed high and low clusters of infestation at three time points. After two rounds of spray, 178 communities persistently fell in high infestation clusters. A time lapse between rounds of vector control greater than 6 months was associated with 1.54 (95% confidence interval = 1.07-2.23) times increased odds of reinfestation after first spray, whereas a time lapse of greater than 1 year was associated with 2.66 (95% confidence interval = 1.85-3.83) times increased odds of reinfestation after first spray compared with localities where the time lapse was less than 180 days. The time lapse between rounds of vector control should remain under 1 year. Spatial analysis can guide targeted vector control efforts by enabling tracking of reinfestation hotspots and improved targeting of resources

Frailty and physical performance in the context of extreme poverty:a population-based study of older adults in rural Burkina Faso

Background: Little is known about the prevalence of frailty and about normal values for physical performance among older individuals in low-income countries, in particular those in sub-Saharan Africa. We describe the prevalence of phenotypic frailty, and values and correlates of several physical performance measures in a cohort of middle-aged and older people living in rural Burkina Faso, one of the world's poorest communities. Methods: We analysed data collected from participants aged over 40 in Nouna district, Burkina Faso. We measured handgrip strength, four metre walk speed, chair rise time, and derived the Fried frailty score based on grip strength, gait speed, body mass index, self-reported exhaustion, and physical activity. Frailty and physical performance indicators were then correlated with health and sociodemographic variables including comorbid disease, marital status, age, sex, wealth and activity impairment. Results: Our sample included 2973 individuals (1503 women), mean age 54 years. 1207 (43%) were categorised as non-frail, 1324 (44%) as prefrail, 212 (7%) as frail, and 167 (6%) were unable to complete all five frailty score components. Lower grip strength, longer chair stand time, lower walk speed and prevalence of frailty rose with age. Frailty was more common in women than men (8% vs 6%, p=0.01) except in those aged 80 and over. Frailty was strongly associated with impairment of activities of daily living and with lower wealth, being widowed, diabetes mellitus, hypertension, and self-reported diagnoses of tuberculosis or heart disease. With the exception of grip strength, which was higher in women than prior international normative values, women had greater deficits than men in physical performance. Conclusions: Phenotypic frailty and impaired physical performance were associated as expected with female sex, co-morbidities, increasing age and impaired activities of daily living. These results support the use of frailty measurements for classification of ageing related syndromes in this setting.GH is supported by a Wellcome Trust/Royal Society Sir Henry Dale fellowship, award number 210479/Z/18/Z. Support for the CRSN Heidelberg Aging Study and for TB was provided by the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award to Till Bärnighausen, funded by the German Federal Ministry of Education and Research. JMG is supported by Grant Number T32 AI007433 from the National Institute of Allergy and Infectious Diseases. The contents of this study are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. MDW acknowledges support from the NIHR Newcastle Biomedical Research Centre. CFP acknowledges support from the ANU Futures Scheme