Chidozie U. Nduka

Prevalence of Hypertension in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.

AbstractWe aimed to obtain overall and regional estimates of hypertension prevalence, and to examine the pattern of this disease condition across different socio-demographic characteristics in low-and middle-income countries.We searched electronic databases from inception to August 2015. We included population-based studies that reported hypertension prevalence using the current definition of blood pressure ≥140/90 mm Hg or self-reported use of antihypertensive medication. We used random-effects meta-analyses to pool prevalence estimates of hypertension, overall, by World Bank region and country income group. Meta-regression analyses were performed to explore sources of heterogeneity across the included studies.A total of 242 studies, comprising data on 1,494,609 adults from 45 countries, met our inclusion criteria. The overall prevalence of hypertension was 32.3% (95% confidence interval [CI] 29.4–35.3), with the Latin America and Caribbean region reporting the highest estimates (39.1%, 95% CI 33.1–45.2). Pooled prevalence estimate was also highest across upper middle income countries (37.8%, 95% CI 35.0–40.6) and lowest across low-income countries (23.1%, 95% CI 20.1–26.2). Prevalence estimates were significantly higher in the elderly (≥65 years) compared with younger adults (<65 years) overall and across the geographical regions; however, there was no significant sex-difference in hypertension prevalence (31.9% vs 30.8%, P = 0.6). Persons without formal education (49.0% vs 24.9%, P < 0.00001), overweight/obese (46.4% vs 26.3%, P < 0.00001), and urban settlers (32.7% vs 25.2%, P = 0.0005) were also more likely to be hypertensive, compared with those who were educated, normal weight, and rural settlers respectively.This study provides contemporary and up-to-date estimates that reflect the significant burden of hypertension in low- and middle-income countries, as well as evidence that hypertension remains a major public health issue across the various socio-demographic subgroups. On average, about 1 in 3 adults in the developing world is hypertensive. The findings of this study will be useful for the design of hypertension screening and treatment programmes in low- and middle-income countries.

Evidence of increased blood pressure and hypertension risk among people living with HIV on antiretroviral therapy: a systematic review with meta-analysis

Owing to antiretroviral drug-induced endothelial dysfunction, HIV-infected patients on antiretroviral therapy (ART) may have elevated blood pressure. We conducted a systematic review and meta-analysis to estimate the effects of ART on blood pressure levels and hypertension risk among HIV-infected populations worldwide. We sought articles that compared the mean blood pressure measurements and hypertension prevalence between HIV-infected adults naive and exposed to ART. Thirty-nine studies comprising 44 903 participants met the inclusion criteria. Overall, systolic (mean difference (MD) 4.52 mm Hg, 95% confidence interval (CI) 2.65–6.39, I2=68.1%, 19 studies) and diastolic blood pressure levels (MD 3.17 mm Hg, 95% CI 1.71–4.64, I2=72.5%, 16 studies) were significantly higher among ART-exposed patients compared with treatment-naive patients. Similarly, the risk of hypertension was significantly higher among ART-exposed patients, such that among 28 908 ART-exposed patients, 4195 (14.5%) had hypertension compared with 950 of 9086 (10.5%) in those who were treatment-naive (odds ratio 1.68, 95% CI 1.35–2.10, I2=81.5%, 32 studies). In summary, exposure to ART is significantly associated with increased systolic and diastolic blood pressure levels, and increased risk of hypertension, regardless of study-level sociodemographic differences. This meta-analysis supports the need for population-based strategies to reduce the risk of high blood pressure among people living with HIV on ART.

Impact of antiretroviral therapy on serum lipoprotein levels and dyslipidemias: A systematic review and meta-analysis

BACKGROUND Antiretroviral drugs increase biosynthesis and reduce hepatic clearance of serum cholesterol. It is thus important to evaluate the impact of antiretroviral treatment on serum lipoprotein levels and the risk of dyslipidemia. METHODS We searched EMBASE and PubMed for articles comparing lipid profiles between HIV-infected adult patients naïve and exposed to antiretroviral therapy (ART). Eligible studies were pooled by performing random-effects meta-analyses of mean serum lipoprotein levels and prevalence estimates of dyslipidemias. RESULTS 51 observational studies comprising 37,110 patients were included in the meta-analyses. ART-exposed patients had significantly higher concentrations of total cholesterol (45 studies, mean difference [MD]=29.4mg/dL, 95% confidence interval [CI] 26.5 to 32.4, I(2)=82.2%), low density lipoprotein-cholesterol (37 studies, MD=14.9mg/dL, 95% CI 11.2 to 18.5, I(2)=86.1%), and triglycerides (43 studies, MD=46.8mg/dL, 95% CI 37.8 to 55.8, I(2)=97.1%), compared with ART-naïve patients. The risks of hypercholesterolemia (25 studies, pooled odds ratio [OR] 3.8, 95% CI 3.1 to 4.7, I(2)=60.0%) and hypertriglyceridemia (21 studies, OR 2.2, 95% CI 1.7 to 2.9, I(2)=81.7%) were also significantly higher among ART-exposed patients, compared with ART-naïve patients. CONCLUSION Antiretroviral therapy is significantly associated with increase in serum lipid levels and increased risk of dyslipidemia. Whether or not these associations are causal should be investigated by future studies.

A plausible causal link between antiretroviral therapy and increased blood pressure in a sub-Saharan African setting: A propensity score-matched analysis.

BACKGROUND The transition from association to causation could represent a fundamental step for taking preventive action against hypertension and its complications, especially among HIV-infected persons on antiretroviral therapy in sub-Saharan African countries. METHODS 406 consecutive HIV-infected adults attending a tertiary HIV clinic in semi-urban Nigeria were prospectively recruited between August and November 2014. These participants were stratified by antiretroviral treatment status. A propensity score matching model was fitted to examine the causal average treatment effects on the treated (ATT) of antiretroviral therapy on blood pressure. Propensity score matching entailed using nearest neighbour matching with a calliper width of 0.2 to achieve similarity in the baseline characteristics between participants naïve and exposed to antiretroviral therapy. RESULTS Matching HIV-infected patients naïve and exposed to antiretroviral therapy on the propensity score yielded a total of 303 participants - 229 antiretroviral-exposed and 74 antiretroviral-naïve - matched without any residual differences in the baseline characteristics between both groups of patients. In this propensity score-matched sample, the estimated ATT for the effects of antiretroviral therapy on systolic (7.85mmHg, 95% CI 3.72 to 15.68) and diastolic blood pressure (7.45mmHg, 95% CI 4.99 to 13.61) were statistically significant (P<0.001 for each). CONCLUSIONS There is a high probability that the epidemiological association between antiretroviral therapy and increased blood pressure be causal in nature among people living with HIV in sub-Saharan African settings. HIV-infected patients commencing antiretroviral treatment in these settings may require regular hypertension screening and other cardiovascular risk assessments.

Adherence to antiretroviral therapy among HIV-infected prisoners : a systematic review and meta-analysis

ABSTRACT Data on antiretroviral therapy (ART) adherence among prison inmates are limited and not previously synthesized in a systematic manner. The objective of this study was to provide accurate and up-to-date ART adherence estimates among prison inmates. We searched electronic databases for all studies reporting adherence as a primary or secondary outcome among prison inmates. A random-effects model was used to pool adherence rates; sensitivity, heterogeneity and publication bias were assessed. Eleven studies involving 2895 HIV-infected prison inmates were included. The studies were carried out between 1992 and 2011 and reported between 1998 and 2013. A pooled analysis of all studies indicated a pooled estimate of 54.6% (95% confidence interval 48.1–60.9%) of prison inmates had adequate (≥95%) ART adherence. The adherence estimates were significantly higher among cross-studies and studies that used self-reported measures. In summary, our findings indicate that optimal adherence remains a challenge among prison inmates. It is crucial to monitor ART adherence and develop appropriate interventions to improve adherence among these population.

Is There Sufficient Evidence for a Causal Association between Antiretroviral Therapy and Diabetes in HIV-infected Patients? A Meta-analysis.

The association of antiretroviral therapy (ART) with diabetes is inconsistent and varies widely across primary epidemiological studies. A comprehensive and more precise estimate of this association is fundamental to establishing a plausible causal link between ART and diabetes. We identified epidemiological studies that compared mean fasting plasma glucose (FPG) concentrations and proportions of diabetes and metabolic syndrome between HIV‐infected patients naïve and exposed to ART. Mean difference in FPG concentrations and odds ratios of diabetes and metabolic syndrome were pooled using random‐effects meta‐analyses. Data on 20 178 participants from 41 observational studies were included in the meta‐analyses. Mean FPG concentrations (Pooled mean difference: 4.66 mg/dL; 95% confidence interval [CI], 2.52 to 6.80; 24 studies) and the odds of diabetes (Pooled odds ratios: 3.85; 95% CI, 2.93 to 5.07; 10 studies) and metabolic syndrome (Pooled odds ratios: 1.45; 95% CI, 1.03 to 2.03; 18 studies) were significantly higher among ART‐exposed patients, compared to their naïve counterparts. ART was also associated with significant increases in FPG levels in studies with mean ART duration ≥18 months (Pooled mean difference: 4.97 mg/dL; 95% CI, 3.10 to 6.84; 14 studies), but not in studies with mean ART duration <18 months (Pooled mean difference: 4.40 mg/dL, 95% CI, –0.59 to 9.38; 7 studies). ART may potentially be the single most consistent determinant of diabetes in people living with HIV worldwide. However, given the preponderance of cross‐sectional studies in the meta‐analysis, the association between ART and diabetes cannot be interpreted as cause and effect.

Drug Abuse in People Living with HIV in the Era of Highly Active Antiretroviral Therapy: A Systematic Review and Meta-Analysis

Objective: Little is known about the epidemiology of drug abuse in HIV-infected populations. Therefore, we aimed to estimate the prevalence of drug abuse among people living with HIV. We also sought to examine factors potentially associated with drug abuse in this high-risk population subgroup. Methods: We searched EMBASE and PubMed databases from 1997 to September 2015 for studies that reported crude prevalence estimates of drug abuse in people living with HIV. Using random-effects meta-analysis, we pooled prevalence estimates of all forms of drug abuse, including alcohol, crack/cocaine, methamphetamine, heroin, over-the-counter, tobacco/nicotine, and prescription drugs. We defined drug abuse strictly in terms of its accompanying self-damaging effects. Random-effects meta-regression analysis was performed on all study-level characteristics to identify factors that may be associated with drug abuse in HIV-infected persons. Results: Seventy two studies, comprising 153,711 HIV-infected participants, met our inclusion criteria. Majority (87%) of the study population was resident in the United States (US). Overall, the prevalence of drug abuse was 33.6% (95% confidence interval [CI] 28.2 to 39.3, I2=99.7%, 31 studies, 28,238 participants), with prescription drugs identified as the most abused (42.7%, 95% CI 25.7 to 60.6, I2=99.7%, 14 studies, 1775 participants). While HIV infection duration (coefficient 0.03, 95% CI 0.0003 to 0.05, P=0.49, explained variance [R2]=51.3%) and ethnicity (Hispanic/Latino) (coefficient 0.006, 95% CI 0.001 to 0.01, P=0.012, R2=23.2%) may be determinants of drug abuse in people living with HIV, exposure to antiretroviral treatment was a strong deterrent (coefficient -0.004, 95% CI -0.01 to -0.0001, P=0.048, R2=10.1%). Conclusion: One in three HIV-infected persons may be affected by drug abuse, with HIV infection duration and ethnicity (Hispanic) identified as predictors of this disorder. However, most of the available evidence comes from US studies. More studies originating from low- and middle-income countries are needed to obtain more precise estimates.

Statin use and all-cause mortality in people living with HIV: a systematic review and meta-analysis

BackgroundIt is unknown whether statin use among people living with HIV results in a reduction in all-cause mortality. We aimed to evaluate the effect of statin use on all-cause mortality among people living with HIV.MethodsWe conducted comprehensive literature searches of Medline, Embase, CINAHL, the Cochrane Library, and cross-references up to April 2018. We included randomised, quasi-randomised trials and prospective cohort studies that examined the association between statin use and cardio-protective and mortality outcomes among people living with HIV. Two reviewers independently abstracted the data. Hazard ratios (HRs) were pooled using empirical Bayesian random-effect meta-analysis. A number of sensitivity analyses were conducted.ResultsWe included seven studies with a total of 35,708 participants. The percentage of participants on statins across the studies ranged from 8 to 35%. Where reported, the percentage of participants with hypertension ranged from 14 to 35% and 7 to 10% had been diagnosed with diabetes mellitus. Statin use was associated with a 33% reduction in all-cause mortality (pooled HR = 0.67, 95% Credible Interval 0.39 to 0.96). The probability that statin use conferred a moderate mortality benefit (i.e. decreased risk of mortality of at least 25%, HR ≤ 0.75) was 71.5%. Down-weighting and excluding the lower quality studies resulted in a more conservative estimate of the pooled HR.ConclusionStatin use appears to confer moderate mortality benefits in people living with HIV.

Does mode of delivery matter for smoking cessation interventions? A meta-analysis of mHealth versus face-to-face interventions for smoking cessation among people living with HIV (Preprint)

Background The prevalence of smoking among people living with HIV (PLHIV) is higher than that reported in the general population, and it is a significant risk factor for noncommunicable diseases in this group. Mobile phone interventions to promote healthier behaviors (mobile health, mHealth) have the potential to reach a large number of people at a low cost. It has been hypothesized that mHealth interventions may not be as effective as face-to-face strategies in achieving smoking cessation, but there is no systematic evidence to support this, especially among PLHIV. Objective This study aimed to compare two modes of intervention delivery (mHealth vs face-to-face) for smoking cessation among PLHIV. Methods Literature on randomized controlled trials (RCTs) investigating effects of mHealth or face-to-face intervention strategies on short-term (4 weeks to <6 months) and long-term (≥6 months) smoking abstinence among PLHIV was sought. We systematically reviewed relevant RCTs and conducted pairwise meta-analyses to estimate relative treatment effects of mHealth and face-to-face interventions using standard care as comparison. Given the absence of head-to-head trials comparing mHealth with face-to-face interventions, we performed adjusted indirect comparison meta-analyses to compare these interventions. Results A total of 10 studies involving 1772 PLHIV met the inclusion criteria. The average age of the study population was 45 years, and women comprised about 37%. In the short term, mHealth-delivered interventions were significantly more efficacious in increasing smoking cessation than no intervention control (risk ratio, RR, 2.81, 95% CI 1.44-5.49; n=726) and face-to-face interventions (RR 2.31, 95% CI 1.13-4.72; n=726). In the short term, face-to-face interventions were no more effective than no intervention in increasing smoking cessation (RR 1.22, 95% CI 0.94-1.58; n=1144). In terms of achieving long-term results among PLHIV, there was no significant difference in the rates of smoking cessation between those who received mHealth-delivered interventions, face-to-face interventions, or no intervention. Trial sequential analysis showed that only 15.16% (726/1304) and 5.56% (632/11,364) of the required information sizes were accrued to accept or reject a 25% relative risk reduction for short- and long-term smoking cessation treatment effects. In addition, sequential monitoring boundaries were not crossed, indicating that the cumulative evidence may be unreliable and inconclusive. Conclusions Compared with face-to-face interventions, mHealth-delivered interventions can better increase smoking cessation rate in the short term. The evidence that mHealth increases smoking cessation rate in the short term is encouraging but not sufficient to allow a definitive conclusion presently. Future research should focus on strategies for sustaining smoking cessation treatment effects among PLHIV in the long term.

Features of cardiovascular disease in low-income and middle-income countries in adults and children living with HIV

Purpose of review The current article addresses crucial issues in identifying risk of cardiovascular disease (CVD) in people living with HIV in low-income and middle-income countries (LMICs). These issues are in need of urgent attention to advance our knowledge and inform actions to mitigate CVD in this population. We address CVDs in adults living with HIV as well as the unique aspects pertaining to children living with HIV (CLHIV), a group sorely under-represented in this field. Recent findings CVDs affecting adults such as hypertension, dyslipidemia, coronary artery disease, and heart failure, in addition to myocardial dysfunction, vascular diseases, and autoimmune phenomena are also being reported in CLHIV. In addition to the background disparity in prevalence of traditional CVD risk factors, it is also likely that differential access to antiretroviral treatment, the younger age of the HIV-infected population, and types of antiretroviral treatment commonly used in LMICs contribute to the observed differences. Summary Overall, the state of evidence for CVD in LMICs is limited and at times contradictory. We summarize the evidence with suggestions for high priorities for further scientific investigation. Now is the crucial time to intervene in modifying CVD risk in LMICs.