Management of rheumatic heart disease in uganda: the emerging epidemic of non-AIDS comorbidity in resource-limited settings

Exploring diseases burden in HIV population: Results from the CHAO (Comorbidities in HIV/AIDS outpatients) cross-sectional study in Kenya

Background

Africa is the epicenter of the HIV epidemic, with over two-thirds of the global population living with HIV. It is also facing a dramatic increase in non-communicable diseases (NCDs) amidst its aging population. This necessitates a healthcare approach that addresses both infectious diseases and NCDs in HIV-positive individuals. In Kenya, with 1.4 million HIV-positive people, efforts include widespread ART access and integrating HIV services into the health system. Challenges remain in healthcare infrastructure, particularly in rural areas. The Comorbidities in HIV/AIDS Outpatients (CHAO) Project, funded by the Italian Cooperation Agency, aims to improve understanding and management of comorbidities in HIV patients, highlighting the need for cost-effective healthcare strategies to address this dual burden.

Methods

The CHAO (Comorbidities in HIV/AIDS Outpatients) project conducted a cross-sectional epidemiological study across 25 clinics in Meru County, Kenya. The study included comprehensive surveys and screenings for various comorbidities among HIV-positive patients receiving treatment, utilizing both clinical evaluations and laboratory tests to assess the prevalence of infectious diseases and NCDs.

Results

A total of 1051 HIV-positive individuals were included in the study: 75 % females, 25 % males, median age 47 years, the majority (96 %) on long-term ART, mostly Dolutegravir-based (95 %). 55.4 % had at least one comorbidity, with NCDs such as dyslipidemia (21.22 %) and hypertension (20.17 %) being the most prevalent. The study also noted significant occurrences of communicable diseases, including syphilis (5.23 %), hepatitis B (2.19 %), and hepatitis C (0.29 %). The prevalence of comorbidities varied with age, highlighting the impact of aging on disease burden.

Discussion

The high prevalence of comorbidities among HIV-positive patients in Meru County underscores the need for integrated healthcare strategies that address both infectious diseases and NCDs. The findings advocate for systematic screening and management of comorbidities within HIV care programs, emphasizing the need for holistic health approaches to improve outcomes for this population.

Prevalence and characteristics of primary left-sided valve disease in a cohort of 15,000 patients undergoing echocardiography studies in a tertiary hospital in Uganda

BACKGROUND

Although rheumatic heart disease remains the leading cause of valve heart disease (VHD) in developing countries, other forms of valve disease have been over shadowed and not regarded as a public health problem. However, several facts suggest that the role of non-rheumatic VHD as a significant cardiovascular disease should be reconsidered. We aimed to assess the prevalence and characteristics of different forms of primary left sided valve diseases from a series of 15,009 echocardiographic studies.

METHODS

This was a retrospective review of echocardiographic reports for studies performed between January 2012 and December 2013 (24 months) at Uganda Heart Institute. All patients with primary left-sided valve disease were classified into one of five major diagnostic categories and in each diagnostic category; patients were sub-classified into stages A-D of primary valve disease as defined by the American College of Cardiology.

RESULTS

Three thousand five hundred eighty-two echocardiography reports qualified for final data analysis. The "sclerotic valve changes with normal valve function", a Stage A sub-class of "degenerative valve disease" overwhelmingly overshadowed all the other diagnostic categories in this stage. "Rheumatic Heart Disease", "Degenerative Valve Disease", "Bicuspid Aortic Valve", "Mitral Valve Prolapse" and "Endomyocardial Fibrosis" diagnostic categories accounted for 53.0%, 41.8%, 2.2%, 1.4% and 1.7% respectively in stages B-D of primary VHD. Rheumatic heart disease disproportionately affected the young, productive age groups. It was the major risk factor for infective endocarditis; and was the indication for valve surgery in 44 of 50 patients who had undergone valve replacement procedures.

CONCLUSIONS

We acknowledge that rheumatic heart disease remains a leading cause of progressive and severe primary left-sided valve disease among young adults in Uganda. But we bring to light the contemporary footprints of other forms of primary valve disease that require coordinated multidisciplinary approach to research, education and clinical management to ensure improved patient outcomes.

A Human-Centered Approach to CV Care: Infrastructure Development in Uganda

In this case study, we describe an ongoing approach to develop sustainable acute and chronic cardiovascular care infrastructure in Uganda that involves patient and provider participation. Leveraging strong infrastructure for HIV/AIDS care delivery, University Hospitals Harrington Heart and Vascular Institute and Case Western Reserve University have partnered with U.S. and Ugandan collaborators to improve cardiovascular capabilities. The collaboration has solicited innovative solutions from patients and providers focusing on education and advanced training, penicillin supply, diagnostic strategy (e.g., hand-held ultrasound), maternal health, and community awareness. Key outcomes of this approach have been the completion of formal training of the first interventional cardiologists and heart failure specialists in the country, establishment of 4 integrated regional centers of excellence in rheumatic heart disease care with a national rheumatic heart disease registry, a penicillin distribution and adherence support program focused on retention in care, access to imaging technology, and in-country capabilities to treat advanced rheumatic heart valve disease.

Prevention and control of rheumatic heart disease: Overcoming core challenges in resource-poor environments

Rheumatic heart disease (RHD) has long receded as a significant threat to public health in high-income countries. In low-resource settings, however, the specter of RHD remains unabated, as exemplified by recent data from the Global Burden of Diseases Study. There are many complex reasons for this ongoing global disparity, including inadequate data on disease burden, challenges in effective advocacy, ongoing poverty and inequality, and weak health systems, most of which predominantly affect developing nations. In this review, we discuss how each of these acts as a core challenge in RHD prevention and control. We then examine key lessons learnt from successful control programs in the past and highlight resources that have been developed to help create strong national RHD control programs.

Brief Report: Prevalence of Latent Rheumatic Heart Disease Among HIV-Infected Children in Kampala, Uganda

Rheumatic heart disease (RHD) remains highly prevalent in resource-constrained settings around the world, including countries with high rates of HIV/AIDS. Although both are immune-mediated diseases, it is unknown whether HIV modifies the risk or progression of RHD. We performed screening echocardiography to determine the prevalence of latent RHD in 488 HIV-infected children aged 5-18 in Kampala, Uganda. The overall prevalence of borderline/definite RHD was 0.82% (95% confidence interval: 0.26% to 2.23%), which is lower than the published prevalence rates of 1.5%-4% among Ugandan children. There may be protective factors that decrease the risk of RHD in HIV-infected children.

Health policy: Reducing rheumatic heart disease in Africa -- time for action

Rheumatic heart disease (RHD) key opinion leaders, health ministers, clinicians, and industry representatives gathered in Ethiopia in February 2015. The question: how to eradicate RHD in Africa. The response: the Addis Ababa communiqué, a practical document outlining seven major barriers to RHD control in Africa and seven strategies to address them.

Role of Natural Autoantibodies in Ugandans With Rheumatic Heart Disease and HIV

BACKGROUND

Rheumatic heart disease (RHD) and HIV are prevalent diseases in sub-Saharan Africa, but little is known about their potential interrelationships. The objective of this study was to assess the prevalence of protective natural autoantibodies among patients with RHD in Uganda, and to determine whether the levels of these autoantibodies are affected by HIV status.

METHODS

Participants were grouped according to RHD and HIV status. The three control groups (RHD - HIV -, RHD - HIV +, RHD + HIV -) were age-matched to the RHD + HIV + participants. All participants underwent HIV testing and echocardiography to evaluate for RHD. Natural autoantibody levels reactive with phosphorylcholine (PC) and malondialdehyde (MDA) were measured.

FINDINGS

We enrolled 220 participants; 21 with both RHD and HIV. Ages ranged from 10 to 60 years, with female predominance (144/220, 65%). After adjusting for age and gender, HIV infection and RHD were each associated with low IgM anti-PC (HIV: p < 0.0001 and RHD: p = 0.01). A distinct HIV ∗ RHD interaction was identified (p = 0.045) with increased IgG anti-MDA levels in HIV infected subjects without RHD, whereas IgG anti-MDA levels were decreased in HIV infected subjects with RHD.

INTERPRETATION

We found that HIV and RHD are associated with alterations in natural autoantibody responses previously linked to an increased risk for atherosclerosis and autoimmune inflammatory disease.

Proportion of patients in the Uganda rheumatic heart disease registry with advanced disease requiring urgent surgical interventions

INTRODUCTION

Since the establishment of the Uganda Rheumatic Heart Registry, over 900 patients have been enrolled. We sought to stratify the patients in the registry according to disease severity and optimal management strategy.

METHODS

We reviewed data of 618 patients who had enrolled in the Registry between March 2010 and February 2013. The 67 patients who had died were excluded leaving 551 patients who were recruited. The optimum management strategy was determined according to the 2012 European Society of Cardiology guidelines on the management of valvular heart disease.

RESULTS

Out of the 551 patient's records evaluated, 398 (72.3%) required invasive intervention, with 332(60.3%) patients requiring surgery and 66 (12.0%) requiring percutaneous mitral commissurotomy (PMC). This leaves only 27.7% of patients who required only medical management. Currently, majority of the patients (498, 90.4%) in the registry are on medical treatment. Of the 60.3% requiring surgical intervention, only 8.0% (44 patients) underwent valvular surgery and 5(1.0%) patients of the 66 (12.0%) underwent PMC successfully.

CONCLUSION

There is a high proportion of patients with severe disease that require surgical treatment yet they cannot access this therapy due to absence of local expertise.