Faculty Bibliography

Background/UNASSIGNED:People living with HIV (PWH) in Africa have higher burden of cardiovascular diseases (CVD) compared to the general population, probably due to increased burden of hypertension (HTN). In this study, we explored nurses' perceptions of factors that may influence the integration of an evidence-based task-shifting/sharing strategy for hypertension control (TASSH) into routine HIV care in Lagos, Nigeria. Methods/UNASSIGNED:Using group concept mapping, we examined the perceptions of 22 nurses from HIV clinics in Lagos. Participants responded to a focused prompt on the barriers and facilitators of integrating TASSH into HIV care; next, separate focus groups generated relevant statements on these factors; and statements were then sorted and rated on their importance and feasibility of adoption to create cluster maps of related themes. The statements and cluster maps were categorized according to the Consolidated Framework for Implementation Research (CFIR) domains. Results/UNASSIGNED:All study participants were women and with 2 to 16 years' experience in the provision of HIV care. From the GCM activities, 81 statements were generated and grouped into 12 themes. The most salient statements reflected the need for ongoing training of HIV nurses in HTN management and challenges in adapting TASSH in HIV clinics. A synthesis of the cluster themes using CFIR showed that most clusters reflected intervention characteristics and inner setting domains. The potential challenges to implementing TASSH included limited hypertension knowledge among HIV nurses and the need for on-going supervision on implementing task-shifting/sharing. Conclusions/UNASSIGNED:Findings from this study illustrate a variety of opinions regarding the integration of HTN management into HIV care in Nigeria. More importantly, it provides critical, evidence-based support in response to the call to action raised by the 2018 International AIDS Society Conference regarding the need to implement more NCD-HIV integration interventions in low-and middle-income countries through strategies, which enhance human resources. This study provides insight into factors that can facilitate stakeholder engagement in utilizing study results and prioritizing next steps for TASSH integration within HIV care in Nigeria.

Persons living with human immunodeficiency virus (PLHIV) are at increased risk of atherosclerotic cardiovascular disease (ASCVD). In spite of this, uptake of evidence-based clinical interventions for ASCVD risk reduction in the HIV clinic setting is sub-optimal. METHODS: EXTRA-CVD is a 12-month randomized clinical effectiveness trial that will assess the efficacy of a multi-component nurse-led intervention in reducing ASCVD risk among PLHIV. Three hundred high ASCVD risk PLHIV across three sites will be randomized 1:1 to usual care with generic prevention education or the study intervention. The study intervention will consist of four evidence-based components: (1) nurse-led care coordination, (2) nurse-managed medication protocols and adherence support (3) home BP monitoring, and (4) electronic health records support tools. The primary outcome will be change in systolic blood pressure and secondary outcome will be change in non-HDL cholesterol over the course of the intervention. Tertiary outcomes will include change in the proportion of participants in the following extended cascade categories: (1) appropriately diagnosed with hypertension and hyperlipidemia (2) appropriately managed; (3) at treatment goal (systolic blood pressure <130 mm Hg and non-HDL cholesterol < National Lipid Association targets). CONCLUSIONS: The EXTRA-CVD trial will provide evidence appraising the potential impact of nurse-led interventions in reducing ASCVD risk among PLHIV, an essential extension of the HIV care continuum beyond HIV viral suppression.

BACKGROUND:Given the growing burden of cardiovascular diseases in sub-Saharan Africa, global donors and governments are exploring strategies for integrating evidence-based cardiovascular diseases prevention into HIV clinics. We assessed the capabilities, motivations and opportunities that exist for HIV clinics to apply evidence-based strategies for hypertension control among people living with HIV (PLHIV) in Nigeria. METHODS:We used a concurrent Quan-Qual- study approach (a quantitative first step using structured questionnaires followed by a qualitative approach using stakeholder meetings).We invited key stakeholders and representatives of HIV and non-communicable disease organizations in Lagos, Nigeria to 1) assess the capacity of HIV clinics (n = 29) to, and; 2) explore their attitudes and perceptions towards implementing evidence-based strategies for hypertension management in Lagos, Nigeria (n = 19)The quantitative data were analyzed using SPSS whereas responses from the stakeholders meeting were coded and analyzed using thematic approach and an implementation science framework, the COM-B (Capabilities, Opportunities, Motivations and Behavior) model, guided the mapping and interpretation of the data. RESULTS:Out of the 29 HIV clinics that participated in the study, 28 clinics were public, government-owned facilities with 394 HIV patients per month with varying capabilities, opportunities and motivations for integrating evidence-based hypertension interventions within their services for PLHIV. Majority of the clinics (n = 26) rated medium-to-low on the psychological capability domains, while most of the clinics (n = 25) rated low on the physical capabilities of integrating evidence-based hypertension interventions within HIV clinics. There was high variability in the ratings for the opportunity domains, with physical opportunities rated high in only eight HIV clinics, two clinics with a medium rating and nineteen clinics with a low rating. Social opportunity domain tended to be rated low in majority of the HIV clinics (n = 21). Lastly, almost all the HIV clinics (n = 23) rated high on the reflective motivation domain although automatic motivations tended to be rated low across the HIV clinics. CONCLUSION/CONCLUSIONS:In this study, we found that with the exception of motivations, the relative capabilities whether physical or psychological and the relative opportunities for integrating evidence-based hypertension intervention within HIV clinics in Nigeria were minimal. Thus, there is need to strengthen the HIV clinics in Lagos for the implementation of evidence-based hypertension interventions within HIV clinics to improve patient outcomes and service delivery in Southwest Nigeria.

BACKGROUND:Integrated cardiovascular disease (CVD) and HIV (CVD-HIV) care interventions are being adopted to tackle the growing burden of noncommunicable diseases (NCDs) in low-and middle-income countries (LMICs) but there is a paucity of studies on the feasibility of these interventions in LMICs. This scoping review aims to present evidence of the feasibility of integrated CVD-HIV care in LMICs, and the alignment of feasibility reporting in LMICs with the existing implementation science methodology. METHODS:A systematic search of published articles including systematic and narrative reviews that reported on integrated CVD-HIV care was conducted, using multiple search engines including PubMed/Medline, Global Health, and Web of Science. We examined the articles for evidence of feasibility reporting. Adopting the definition of Proctor and colleagues (2011), feasibility was defined as the extent to which an intervention was plausible in a given agency or setting. Evidence from the articles was synthesized by level of integration, the chronic care continuum, and stages of intervention development. RESULTS:Twenty studies, reported in 18 articles and 3 conferences abstracts, reported on feasibility of integrated CVD-HIV care interventions. These studies were conducted in Sub-Saharan Africa, Southeast Asia and South America. Four of these studies were conducted as feasibility studies. Eighty percent of the studies reported feasibility, using descriptive sentences that included words synonymous with feasibility terminologies in existing definition recommended by Proctor and colleagues. There was also an overlap in the use of descriptive phrases for feasibility amongst the selected studies. CONCLUSIONS:Integrating CVD and HIV care is feasible in LMICs, although methodology for reporting feasibility is inconsistent. Assessing feasibility based on settings and integration goals will provide a unique perspective of the implementation landscape in LMICs. There is a need for consistency in measures in order to accurately assess the feasibility of integrated CVD-HIV care in LMICs.

BACKGROUND:Sputum smear-positive tuberculosis (TB) patients have a high risk of transmission and are of great epidemiological and infection control significance. Little is known about the smear-positive populations in high TB burden regions, such as Kazakhstan. The objective of this study is to characterize the smear-positive population in Kazakhstan and identify associated modifiable risk factors. METHODS:Data on incident TB cases' (identified between April 2012 and March 2014) socio-demographic, risk behavior, and comorbidity characteristics were collected in four regions of Kazakhstan through structured survey and medical record review. We used multivariable logistic regression to determine factors associated with smear positivity. RESULTS:Of the total sample, 193 (34.3%) of the 562 study participants tested smear-positive. In the final adjusted multivariable logistic regression model, sex (adjusted odds ratio (aOR) = 2.0, 95% CI:1.3-3.1, p < 0.01), incarceration (aOR = 3.6, 95% CI:1.2-11.1, p = 0.03), alcohol dependence (aOR = 2.6, 95% CI:1.2-5.7, p = 0.02), diabetes (aOR = 5.0, 95% CI:2.4-10.7, p < 0.01), and physician access (aOR = 2.7, 95% CI:1.3-5.5p < 0.01) were associated with smear-positivity. CONCLUSIONS:Incarceration, alcohol dependence, diabetes, and physician access are associated with smear positivity among incident TB cases in Kazakhstan. To stem the TB epidemic, screening, treatment and prevention policies should address these factors.

BACKGROUND:This study examined the association between incident pulmonary tuberculosis (TB) and social and behavioral characteristics in Almaty Oblast, Kazakhstan from 2012 to 2013. METHODS:We used a matched case-control design to estimate the role of factors for acquiring pulmonary TB. Totally 324 individuals were recruited from Sep 2012 to Mar 2013. Participants included 110 TB index cases with newly detected pulmonary TB. Each case was matched with one household and one community control. A total of 107 household and 107 community controls were included to the study. Adjusted odds ratios measuring associations between TB and risk factors were calculated by using a conditional multiple logistic regression analysis. RESULTS:TB cases were more likely to be younger, recent smokers and have diabetes, when compared to household controls. Between TB cases and community controls, TB was significantly associated with age, non-married family status, living in a rented home, recent smoker, and having diabetes. Comparing TB cases with community controls, we found that foreign birth was marginally associated with incident TB case status. CONCLUSION/CONCLUSIONS:Our findings confirm the role of modifiable risk factors for TB in Kazakhstan; highlighting the importance of developing interventions addressing social determinants and proximate risk factors for high TB burden regions.

The aim of the current systematic review is to examine the relationship between trauma and HIV risk behaviors among both forced and unforced migrant populations from low and middle income countries (LMIC). We conducted a review of studies published from 1995 to 2014. Data were extracted related to (1) the relationship between trauma and HIV risk behaviors, (2) methodological approach, (3) assessment methods, and (4) differences noted between forced and unforced migrants. A total of 340 records were retrieved with 24 studies meeting inclusion criteria. Our review demonstrated an overall relationship between trauma and HIV risk behaviors among migrant populations in LMIC, specifically with sexual violence and sexual risk behavior. However, findings from 10 studies were not in full support of the relationship. Findings from the review suggest that additional research using more rigorous methods is critically needed to understand the nature of the relationship experienced by this key-affected population.

INTRODUCTION: Rates of tuberculosis in Central Asia are extremely high, and even more alarming are the very high rates of multidrug-resistant tuberculosis (MDR-TB) in Kazakhstan, Uzbekistan, Tajikistan and Kyrgyzstan. In addition, rates of HIV infection related to injection drug use seems to be rising as well, thus creating conditions for a potentially devastating co-epidemic of TB/HIV and MDR-TB/HIV which would have terrible consequences for public health in these countries. CURRENT STATUS: In many countries of Central Asia, diagnosis of tuberculosis still rests on clinical grounds or simple technologies such as chest radiograph and sputum smear examination. Modern molecular techniques such as GenExpert are being introduced in Kazakhstan and Uzbekistan, and perhaps soon in Kyrgyzstan. Treatment of TB is still often centered around prolonged inpatient stay at TB hospitals. Only a minority of patients with HIV infection are receiving ART, and TB and HIV services are not well integrated. Needle exchange programs are becoming increasingly available, but opioid substitution therapy is rarely used in Central Asia. TB, drug treatment and HIV services are generally not well-integrated. CONCLUSIONS: To combat this developing storm, integration of TB services, HIV care, and substance abuse treatment programs is needed urgently to allow efficient and effective diagnosis and treatment of these conditions in a coordinated manner.