Benson Njuguna

Diabetes in sub-Saharan Africa: from clinical care to health policy

Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA (Prof R Atun FRCP, Prof T Bärnighausen MD, I Postolovska ScD, S Vollmer PhD, B Ammon, A Annamreddi, A Awasthi, S Bhadriraju, J Chai MPH, J Ho BS, S S Kakarmath MBBS MS, R Kharel, M A Kyle, S C Lee MD, A Lichtman MD, J Manne-Goehler MD, M Nair MPH, O L O Okafor MPH, O Okunade MD, D Sando, A Sharma MPH, A S Syed MPH); Harvard Medical School, Harvard University, Boston, MA, USA (Prof R Atun, A Binagwaho MD, P Chipendo MD, J Manne-Goehler); Centre for Global Health, King’s College London, Weston Education Centre, London, UK (J I Davies MD); MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Education Campus, University of Witwatersrand, Parktown, South Africa (J I Davies); University of Bristol, Bristol, UK (E A M Gale FRCP); Muhimbili University of Health and Allied Sciences, and Abbas Medical Centre, Dar es Salaam, Tanzania (Z G Abbas MMed); Institute of Public Health, Faculty of Diabetes in sub-Saharan Africa: from clinical care to health policy

Ensuring Patient-Centered Access to Cardiovascular Disease Medicines in Low-Income and Middle-Income Countries Through Health-System Strengthening

Cardiovascular disease (CVD) is the leading cause of global mortality and is expected to reach 23 million deaths by 2030. Eighty percent of CVD deaths occur in low-income and middle-income countries (LMICs). Although CVD prevention and treatment guidelines are available, translating these into practice is hampered in LMICs by inadequate health care systems that limit access to lifesaving medications. In this review article, we describe the deficiencies in the current LMIC supply chains that limit access to effective CVD medicines, and discuss existing solutions that are translatable to similar settings so as to address these deficiencies.

To address emerging infections, we must invest in enduring systems: The kinetics and dynamics of health systems strengthening

Clinical pharmacology uses foundational principles of pharmacokinetics (PK) and pharmacodynamics (PD) to address medication use spanning a continuum from molecules to the masses. In the realm of infectious diseases, PK/PD attributes are considered especially important, because subtherapeutic dosing of antibiotics has been associated with poorer clinical outcomes in patients and increased incidences of drug resistance in populations. In consideration of these PK/PD principles, we will describe the analogous relationship between health systems strengthening, including for educating healthcare providers about emerging infections, and the tenets of therapeutic drug monitoring.

Problems and Obstacles of Poorest Countries in Having Good Governance and Quality and Effective Pharmaceutical Policy

Abstract Pharmaceutical policy is the framework, which guides the practice of global and regional health organizations, country governments, and hospitals in their quest to promote access to and rational use of quality-assured medicines to the populations they serve. Good governance, which is defined as a fundamental need to have in place laws, regulations, policies, and procedures based on ethical principles to improve the management of pharmaceutical systems and create a corrupt-free environment, is crucial to promote effective pharmaceutical policies. In most low-income and lower-middle-income countries, corruption, lack of implementation framework, and implementation gaps present as barriers to effective policies and good governance. This chapter explores these challenges and obstacles in detail. The chapter will conclude with a practical assessment of the interaction of policy, governance, and implementation as seen through the ongoing fight to address the ongoing HIV epidemic in sub-Saharan Africa.

Leveraging peer-based support to facilitate HIV care in Kenya

Rakhi Karwa and colleagues discuss a program in which peer navigators support care for people with HIV at a Kenyan hospital.

Infective endocarditis prophylaxis: a review.

ABSTRACT Introduction: Guidelines for prophylaxis against infective endocarditis (IE) have changed significantly due to a lack of evidence for its efficacy and increasing concerns about safety and antibiotic resistance. The impact of these changes on clinical practice and IE hospitalisation trends and outcomes has become a focus of research. Areas covered: We review the rationale for and against IE prophylaxis, highlight significant changes in guidelines since 2002, and discuss literature examining the impact of these changes on antibiotic prescription rates for IE prophylaxis, IE incidence, morbidity, and mortality. We included English articles published since 2002 relevant to IE prophylaxis. Expert commentary: Existing guidelines recommend limited to no prophylaxis against IE but differ on which patient populations would benefit most. Antibiotic prescription rates for IE prophylaxis have declined as a result of newer restrictive guidelines, most significantly in the UK where IE prophylaxis is not recommended. However, conflicting data exists on the impact of these changes on the trends of IE hospitalisation and clinical outcomes. Definitive studies to resolve this controversy do not seem feasible in the near future but well designed prospective observational studies may provide novel information on the long term impact of the new guidelines.

Prevalence, Risk Factors, and Pathophysiology of Dysglycemia among People Living with HIV in Sub-Saharan Africa

Objective To review available literature on the prevalence, risk factors, pathophysiology, and clinical outcomes of dysglycemia among people living with HIV (PLHIV) in sub-Saharan Africa (SSA). Methods Database search on PUBMED for eligible studies describing the prevalence, risk factors, pathophysiology, or clinical outcomes of dysglycemia in SSA PLHIV. Results Prevalence of diabetes mellitus (DM) and pre-DM among SSA PLHIV ranged from 1% to 26% and 19% to 47%, respectively, in 15 identified studies. Older age and an elevated body mass index (BMI) were common risk factors for dysglycemia. Risk factors potentially more specific to PLHIV in SSA included exposure to older-generation thymidine analogues or protease inhibitors, malnutrition at ART initiation, a failure to gain fat mass on treatment, and elevated serum lipids. There is evidence of higher nephropathy and neuropathy rates among PLHIV in SSA with comorbid DM compared to HIV-negative individuals with DM. Conclusion There is a need for longitudinal studies to enhance understanding of the risk factors for dysglycemia among PLHIV in SSA, further research into optimal therapies to reduce pre-DM progression to DM among SSA PLHIV, and studies of the burden and phenotype of diabetic complications and other health outcomes among PLHIV with comorbid DM in SSA.

Diabetes in sub-Saharan Africa

Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA (Prof R Atun FRCP, Prof T Bärnighausen MD, I Postolovska ScD, S Vollmer PhD, B Ammon, A Annamreddi, A Awasthi, S Bhadriraju, J Chai MPH, J Ho BS, S S Kakarmath MBBS MS, R Kharel, M A Kyle, S C Lee MD, A Lichtman MD, J Manne-Goehler MD, M Nair MPH, O L O Okafor MPH, O Okunade MD, D Sando, A Sharma MPH, A S Syed MPH); Harvard Medical School, Harvard University, Boston, MA, USA (Prof R Atun, A Binagwaho MD, P Chipendo MD, J Manne-Goehler); Centre for Global Health, King’s College London, Weston Education Centre, London, UK (J I Davies MD); MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Education Campus, University of Witwatersrand, Parktown, South Africa (J I Davies); University of Bristol, Bristol, UK (E A M Gale FRCP); Muhimbili University of Health and Allied Sciences, and Abbas Medical Centre, Dar es Salaam, Tanzania (Z G Abbas MMed); Institute of Public Health, Faculty of Diabetes in sub-Saharan Africa: from clinical care to health policy

Find and Plug the Leak: Improving Adherence to Anti-Hypertensive Medicines

Elevated blood pressure is the leading preventable cause of cardiovascular disease (CVD) death and disability globally [1, 2]. Adherence to anti-hypertensive medicines is the cornerstone to blood pressure control and subsequent reductions in CVD related death and disability [3]. However, adherence to anti-hypertensive medicines remains suboptimal globally and in sub-Saharan Africa (SSA). A recent systematic review estimated rates of non-adherence to be 45% globally, rising to 63% among African and Asian populations [4]. Furthermore, non-adherence was noted in 84% of patients with uncontrolled hypertension. Hypertension prevalence is highest in Africa (46%) compared to other regions and is expected to increase by more than 65% by 2025 [5, 6]. Consequently, there is an urgent need to implement strategies to monitor and improve adherence to anti-hypertensive medicines in SSA. Chronic care delivery for hypertension and other noncommunicable diseases (NCDs) remains elusive to a majority of SSA countries where health systems have being designed primarily to address acute infective diseases, maternal and child health, and the HIV epidemic [7]. Where hypertension care is available, socio-economic barriers associated with receiving chronic care limit access and utilisation by patients, with a significant impact on decreasing adherence to medicines [8]. In recognition of this key barrier, some SSA countries have built universal healthcare delivery platforms that provide free or subsidised hypertension care and medicines to their population. However, even in these areas, adherence remains sub-optimal. In Namibia, where universal care for hypertension is provided through public health care (PHC) facilities, Nashilongo et al. assessed the levels and predictors of adherence to antihypertensive medication, and validated a modified version of the Hill-Bone scale for compliance [9]. Their study recruited 120 patients regularly receiving medication refills for hypertensive drugs in four semi-urban PHC facilities in Windhoek. The primary outcome measure was the proportion of patients with ≥80% adherence on the Hill-Bone compliance scale, predefined as acceptable adherence. The modified Hill-Bone Scale for compliance had reasonable internal consistency and construct validity for assessing adherence in this population. Mean adherence level was 77% which was lower than the pre-specified ≥80% level designating good adherence. 58% of patients had adherence levels ≤80%. Independent predictors of good adherence after multivariable logistical regression were having a treatment support buddy, never having missed a clinic appointment, and always attending follow-up visits. Although age and distance to the PHC facility were associated with good adherence on bivariate analysis, these associations were not sustained in the multivariable model. Finally, no association was found between sex, employment status, education level, presence of a comorbidity, and knowledge on hypertension medicines or complications with adherence. Several limitations of this work are important to note. The small sample size may have underpowered some associations. Indeed, it is surprising that knowledge of hypertensive medicines and the complications of hypertension had no effect on adherence considering results of prior SSA studies. A study assessing adherence to anti-hypertensive therapy among 395 * Rajesh Vedanthan rajesh.vedanthan@mssm.edu

Infective Endocarditis in Low- and Middle-Income Countries

Infective endocarditis (IE) is a rare, life-threatening disease with a mortality rate of 25% and significant debilitating morbidities. Although much has been reported on contemporary IE in high-income countries, conclusions on the state of IE in low- and middle-income countries (LMICs) are based on studies conducted before the year 2000. Furthermore, unique challenges in the diagnosis and management of IE persist in LMICs. This article reviews IE studies conducted in LMICs documenting clinical experiences from the year 2000 to 2016. Presented are the causes of IE, management of patients with IE, and prevailing challenges in diagnosis and treatment of IE in LMICs.