Self-reported cardiovascular disease risk factor screening among people living with HIV vs. members of the general population in Botswana: a community-based study.

BACKGROUND: Morbidity and mortality due to cardiovascular diseases (CVDs) are high and increasing in low- and middle-income countries. People living with HIV (PLWH) are more likely to experience CVD than members of the general population. Therefore, we aimed to assess whether PLWH were more likely to have previously been screened for cardiovascular disease risk factors (CVDRFs) than people without HIV. METHODS: A population-based, cross-sectional study was conducted among individuals aged 16 to 68 years across 22 communities in Botswana from February to August 2017 as part of a larger community-based cluster randomized HIV treatment-as-prevention trial. Participants were asked if they had been screened for and counselled on cardiovascular disease risk factors (history of hypertension or blood pressure check, blood glucose and cholesterol measurements, weight check and weight control, tobacco smoking and cessation, alcohol use and physical activity) in the preceding 3 years. HIV testing was offered to those with an unknown HIV status. Multiple logistic regression analysis controlling for age and sex was used to assess the relationship between CVDRF screening and HIV status. RESULTS: Of the 3981 participants enrolled, 2547 (64%) were female, and 1196 (30%) were PLWH (93% already on antiretroviral therapy [ART]). PLWH were more likely to report previous screening for diabetes (25% vs. 19%, p < 0.001), elevated cholesterol (17% vs. 12%, p < 0.001) and to have had their weight checked (76% vs. 55%, p < 0.001) than HIV-uninfected participants. PLWH were also more likely to have received counselling on salt intake (42% vs. 33%, p < 0.001), smoking cessation (66% vs. 46%, p < 0.001), weight control (38% vs. 29%, p < 0.001), physical activity (46% vs. 34%, p < 0.001) and alcohol consumption (35% vs. 23%, p < 0.001) than their HIV-uninfected counterparts. Overall, PLWH were more likely to have received screening for and/or counselling on CVDRFs (adjusted odds ratio 1.84, 95% CI: 1.46-2.32, p < 0.001). CONCLUSION: PLWH were almost two times more likely to have been previously screened for CVDRFs than those without HIV, indicating a need for universal scale-up of integrated management and prevention of CVDs in the HIV-uninfected population.

The case for precision medicine in the prevention, diagnosis, and treatment of cardiometabolic diseases in low-income and middle-income countries.

Cardiometabolic diseases are the leading preventable causes of death in most geographies. The causes, clinical presentations, and pathogenesis of cardiometabolic diseases vary greatly worldwide, as do the resources and strategies needed to prevent and treat them. Therefore, there is no single solution and health care should be optimised, if not to the individual (ie, personalised health care), then at least to population subgroups (ie, precision medicine). This optimisation should involve tailoring health care to individual disease characteristics according to ethnicity, biology, behaviour, environment, and subjective person-level characteristics. The capacity and availability of local resources and infrastructures should also be considered. Evidence needed for equitable precision medicine cannot be generated without adequate data from all target populations, and the idea that research done in high-income countries will transfer adequately to low-income and middle-income countries (LMICs) is problematic, as many migration studies and transethnic comparisons have shown. However, most data for precision medicine research are derived from people of European ancestry living in high-income countries. In this Series paper, we discuss the case for precision medicine for cardiometabolic diseases in LMICs, the barriers and enablers, and key considerations for implementation. We focus on three propositions: first, failure to explore and implement precision medicine for cardiometabolic disease in LMICs will enhance global health disparities. Second, some LMICs might already be placed to implement cardiometabolic precision medicine under appropriate circumstances, owing to progress made in treating infectious diseases. Third, improvements in population health from precision medicine are most probably asymptotic; the greatest gains are more likely to be obtained in countries where health-care systems are less developed. We outline key recommendations for implementation of precision medicine approaches in LMICs.

Prevalence and control of hypertension in a high HIV-prevalence setting, insights from a population based study in Botswana.

In a population-based representative sample of adults residing in 22 communities in Botswana, a southern African country with high HIV prevalence, 1 in 4 individuals had high blood pressure. High blood pressure was less prevalent in adults with HIV than without HIV. Sixty percent of persons with high blood pressure had not previously been diagnosed. Among individuals with a prior diagnosis of high blood pressure who reported being prescribed anti-hypertension medications, almost half had elevated blood pressure, irrespective of HIV-status. One-third of adults in this setting (mainly men) declined free non-invasive blood pressure assessments in their households. In conclusion, our study highlights alarmingly high hypertension rates in the community, with low levels of awareness and control, emphasizing the urgent need for community level BP screening and active management to reach recommended targets.

Hypertension, a dementia polygenic risk score, APOE genotype, and incident dementia.

INTRODUCTION: There is inconsistent evidence on whether genetic risk for dementia modifies the association between hypertension and dementia. METHODS: In 198,965 dementia-free participants aged ≥60 years, Cox proportional-hazards models were used to investigate the association between hypertension and incident dementia. A polygenic risk score (PRS) based on 38 non-apolipoprotein E (APOE) single nucleotide polymorphisms and APOE ε4 status were used to determine genetic risk for dementia. RESULTS: Over 15 years follow-up, 6270 participants developed dementia. Hypertension was associated with a 19% increased risk of dementia (hazard ratio = 1.19, 95% confidence interval 1.11-1.27). The associations remained similar when stratifying by genetic risk, with no evidence for multiplicative interaction by dementia PRS (P = 0.20) or APOE ε4 status (P = 0.16). However, the risk difference between those with and without hypertension was larger among those at higher genetic risk. DISCUSSION: Hypertension was associated with an increased risk of dementia regardless of genetic risk for dementia.

Balancing adaptability and standardisation: insights from 27 routinely implemented ICHOM standard sets.

BACKGROUND: Healthcare systems around the world experience increasing pressure to control future growth of healthcare expenditures. Among other initiatives, quality and value-based benchmarking has become an important field to inform clinical evaluation and reimbursement questions. The International Consortium for Health Outcomes Measurement (ICHOM) has become one of the driving forces to translate scientific evidence into standardized assessments that are routinely applicable in day-to-day care settings. These aim to provide a benchmarking tool that allows the comparison and competition of health care delivery on the basis of value-based health care principles. METHODS: This work focuses on the consolidation of the ICHOM methodology and presents insights from 27 routinely implemented Standard Sets. The analysis is based on a literature review of the ICHOM literature repository, a process document review and key informant interviews with ICHOM's outcomes research and development team. RESULTS: Key findings are that the scope of ICHOM Standard Sets shifted from a more static focus on burden of disease and poorly standardized care pathways to a more dynamic approach that also takes into account questions about the setting of care, feasibility of implementing a benchmarking tool and compatibility of different Standard Sets. Although certain overlaps exist with other initiatives in the field of patient reported outcomes (PRO), their scopes differ significantly and they hence rather complement each other. ICHOM pursues a pragmatic approach to enable the benchmarking and the analysis of healthcare delivery following the principles of value-based healthcare. CONCLUSION: The ICHOM Standard Sets complement other initiatives in the field of patient-reported outcomes (PRO) and functional reporting by placing a particular focus on healthcare delivery, while other initiatives primarily focus on evaluation of academic endpoints. Although ICHOM promotes a pragmatic approach towards developing and devising its Standard Sets, the definition of standardized decision making processes emerged as one of the key challenges. Furthermore, the consolidation of core metrics across number of disease areas to enable the parallel implementation of different Standard Sets in the same care setting is an important goal that will enable the widespread implementation of patient-reported outcome measures (PROM).

Cervical cancer prevention in countries with the highest HIV prevalence: a review of policies.

INTRODUCTION: Cervical cancer (CC) is the leading cause of cancer-related death among women in sub-Saharan Africa. It occurs most frequently in women living with HIV (WLHIV) and is classified as an AIDS-defining illness. Recent World Health Organisation (WHO) recommendations provide guidance for CC prevention policies, with specifications for WLHIV. We systematically reviewed policies for CC prevention and control in sub-Saharan countries with the highest HIV prevalence. METHODS: We included countries with an HIV prevalence ≥ 10% in 2018 and policies published between January 1st 2010 and March 31st 2022. We searched Medline via PubMed, the international cancer control partnership website and national governmental websites of included countries for relevant policy documents. The online document search was supplemented with expert consultation for each included country. We synthesised aspects defined in policies for HPV vaccination, sex education, condom use, tobacco control, male circumcision,cervical screening, diagnosis and treatment of cervical pre-cancerous lesions and cancer, monitoring mechanisms and cost of services to women while highlighting specificities for WLHIV. RESULTS: We reviewed 33 policy documents from nine countries. All included countries had policies on CC prevention and control either as a standalone policy (77.8%), or as part of a cancer or non-communicable diseases policy (22.2%) or both (66.7%). Aspects of HPV vaccination were reported in 7 (77.8%) of the 9 countries. All countries (100%) planned to develop or review Information, Education and Communication (IEC) materials for CC prevention including condom use and tobacco control. Age at screening commencement and screening intervals for WLHIV varied across countries. The most common recommended screening and treatment methods were visual inspection with acetic acid (VIA) (88.9%), Pap smear (77.8%); cryotherapy (100%) and loop electrosurgical procedure (LEEP) (88.9%) respectively. Global indicators disaggregated by HIV status for monitoring CC programs were rarely reported. CC prevention and care policies included service costs at various stages in three countries (33.3%). CONCLUSION: Considerable progress has been made in policy development for CC prevention and control in sub Saharan Africa. However, in countries with a high HIV burden, there is need to tailor these policies to respond to the specific needs of WLHIV. Countries may consider updating policies using the recent WHO guidelines for CC prevention, while adapting them to context realities.

Improving identification of symptomatic cancer at primary care clinics: A predictive modeling analysis in Botswana.

In resource-limited settings, augmenting primary care provider (PCP)-based referrals with data-derived algorithms could direct scarce resources towards those patients most likely to have a cancer diagnosis and benefit from early treatment. Using data from Botswana, we compared accuracy of predictions of probable cancer using different approaches for identifying symptomatic cancer at primary clinics. We followed cancer suspects until they entered specialized care for cancer treatment (following pathologically confirmed diagnosis), exited from the study following noncancer diagnosis, or died. Routine symptom and demographic data included baseline cancer probability assessed by the primary care provider (low, intermediate, high), age, sex, performance status, baseline cancer probability by study physician, predominant symptom (lump, bleeding, pain or other) and HIV status. Logistic regression with 10-fold cross-validation was used to evaluate classification by different sets of predictors: (1) PCPs, (2) Algorithm-only, (3) External specialist physician review and (4) Primary clinician augmented by algorithm. Classification accuracy was assessed using c-statistics, sensitivity and specificity. Six hundred and twenty-three adult cancer suspects with complete data were retained, of whom 166 (27%) were diagnosed with cancer. Models using PCP augmented by algorithm (c-statistic: 77.2%, 95% CI: 73.4%, 81.0%) and external study physician assessment (77.6%, 95% CI: 73.6%, 81.7%) performed better than algorithm-only (74.9%, 95% CI: 71.0%, 78.9%) and PCP initial assessment (62.8%, 95% CI: 57.9%, 67.7%) in correctly classifying suspected cancer patients. Sensitivity and specificity statistics from models combining PCP classifications and routine data were comparable to physicians, suggesting that incorporating data-driven algorithms into referral systems could improve efficiency.

Are polygenic risk scores for systolic blood pressure and LDL-cholesterol associated with treatment effectiveness, and clinical outcomes among those on treatment?

AIMS: Many studies have investigated associations between polygenic risk scores (PRS) and the incidence of cardiovascular disease (CVD); few have examined whether risk factor-related PRS predict CVD outcomes among adults treated with risk-modifying therapies. We assessed whether PRS for systolic blood pressure (PRSSBP) and for low-density lipoprotein cholesterol (PRSLDL-C) were associated with achieving SBP and LDL-C-related targets, and with major adverse cardiovascular events (MACE: non-fatal stroke or myocardial infarction, CVD death, and revascularization procedures). METHODS AND RESULTS: Using observational data from the UK Biobank (UKB), we calculated PRSSBP and PRSLDL-C and constructed two sub-cohorts of unrelated adults of White British ancestry aged 40-69 years and with no history of CVD, who reported taking medications used in the treatment of hypertension or hypercholesterolaemia. Treatment effectiveness in achieving adequate risk factor control was ascertained using on-treatment blood pressure (BP) or LDL-C levels measured at enrolment (uncontrolled hypertension: BP ≥ 140/90 mmHg; uncontrolled hypercholesterolaemia: LDL-C ≥ 3 mmol/L). We conducted multivariable logistic and Cox regression modelling for incident events, adjusting for socioeconomic characteristics, and CVD risk factors. There were 55 439 participants using BP lowering therapies (51.0% male, mean age 61.0 years, median follow-up 11.5 years) and 33 787 using LDL-C lowering therapies (58.5% male, mean age 61.7 years, median follow-up 11.4 years). PRSSBP was associated with uncontrolled hypertension (odds ratio 1.70; 95% confidence interval: 1.60-1.80) top vs. bottom quintile, equivalent to a 5.4 mmHg difference in SBP, and with MACE [hazard ratio (HR) 1.13; 1.04-1.23]. PRSLDL-C was associated with uncontrolled hypercholesterolaemia (HR 2.78; 2.58-3.00) but was not associated with subsequent MACE. CONCLUSION: We extend previous findings in the UKB cohort to examine PRSSBP and PRSLDL-C with treatment effectiveness. Our results indicate that both PRSSBP and PRSLDL-C can help identify individuals who, despite being on treatment, have inadequately controlled SBP and LDL-C, and for SBP are at higher risk for CVD events. This extends the potential role of PRS in clinical practice from identifying patients who may need these interventions to identifying patients who may need more intensive intervention.

Prevalence and determinants of hypertension control among almost 100 000 treated adults in the UK.

OBJECTIVE: To identify factors associated with hypertension control among treated middle-aged UK adults. METHODS: A cross-sectional population-based study including 99 468 previously diagnosed, treated hypertensives enrolled in the UK Biobank. Hypertension control was defined as systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg. RESULTS: Median age was 62.3 years (IQR 57.3 to 66.0), 45.9% female, 92.0% white, 40.1% obese, 9.3% current smokers and 19.4% had prior cardiovascular disease. 38.1% (95% CI 37.8% to 38.4%) were controlled. In multivariable logistic regression, associations with lack of hypertension control included: older age (OR 0.61, 95% CI 0.58 to 0.64 for 60-69 years compared with age 40-50 years), higher alcohol use (OR 0.61, 95% CI 0.58 to 0.64, for consuming >30 units per week compared with none), black ethnicity (OR 0.73, 95% CI 0.65 to 0.82 compared with white), obesity (OR 0.73, 95% CI 0.71 to 0.76 compared with normal body mass index). The strongest positive association with control was having ≥3 comorbidities (OR 2.09, 95% CI 1.95 to 2.23). Comorbidities associated with control included cardiovascular disease (OR 2.11, 95% CI 2.04 to 2.19), migraines (OR 1.68, 95% CI 1.56 to 1.81), diabetes (OR 1.32, 95% CI 1.27 to 1.36) and depression (OR 1.27, 95% CI 1.20 to 1.34). CONCLUSIONS: In one of the largest population-based analyses of middle-aged adults with measured blood pressure, the majority of treated hypertensives were uncontrolled. Risk factors for hypertension were associated with a lower probability of control. Having a comorbidity was associated with higher probability of control, possibly due to more frequent interaction with the healthcare system and/or appropriate management of those at greater cardiovascular risk.

Impact of Community-Based Clinical Breast Examinations in Botswana.

PURPOSE: We evaluated a clinical breast examination (CBE) screening program to determine the prevalence of breast abnormalities, number examined per cancer diagnosis, and clinical resources required for these diagnoses in a middle-income African setting. METHODS: We performed a retrospective review of a CBE screening program (2015-2018) by Journey of Hope Botswana, a Botswana-based nongovernmental organization (NGO). Symptomatic and asymptomatic women were invited to attend. Screening events were held in communities throughout rural and periurban Botswana, with CBEs performed by volunteer nurses. Individuals who screened positive were referred to a private tertiary facility and were followed by the NGO. Data were obtained from NGO records. RESULTS: Of 6,120 screened women (50 men excluded), 452 (7.4%) presented with a symptom and 357 (5.83%) were referred for further evaluation; 257 ultrasounds, 100 fine-needle aspirations (FNAs), 58 mammograms, and 31 biopsies were performed. In total, 6,031 were exonerated from cancer, 78 were lost to follow-up (67 for ≤ 50 years and 11 for > 50 years), and 11 were diagnosed with cancer (five for 41-50 years and six for > 50 years, 10 presented with symptoms). Overall breast cancer prevalence was calculated to be 18/10,000 (95% CI, 8 to 29/10,000). The number of women examined per breast cancer diagnosis was 237 (95% CI, 126 to 1910) for women of age 41-50 years and 196 (95% CI, 109 to 977) for women of age > 50 years. Median time to diagnosis for all women was 17.5 [1 to 32.5] days. CBE-detected tumors were not different than tumors presenting through standard care. CONCLUSION: In a previously unscreened population, yield from community-based CBE screening was high, particularly among symptomatic women, and required modest diagnostic resources. This strategy has potential to reduce breast cancer mortality.

Prevalence and Determinants of Hypertension Awareness, Treatment, and Control in Botswana: A Nationally Representative Population-Based Survey.

INTRODUCTION: Hypertension is a leading risk factor for cardiovascular mortality and an emerging public health concern in sub-Saharan Africa. Few studies have examined performance on the management of hypertension in this region, where the context may be distinct from other developing regions. OBJECTIVES: We aimed to determine the prevalence and correlates of hypertension, awareness, treatment, and control among adults in Botswana, a middle-income African country undergoing rapid demographic transition and with high HIV burden. METHODS: In this 2014 cross-sectional survey of adults aged 15-69 years, information on sociodemographic characteristics, lifestyle behavior, and medical history was collected through in-person interviews and physical measurements (body mass index and triplicate blood pressure (BP)). Hypertension was defined as self-report of use of antihypertensives in the previous two weeks and/or having elevated BP (≥140/90 mmHg). Multivariable logistic regression was employed to explore factors associated with hypertension, awareness (report of previous diagnosis), treatment (antihypertensives), and control (BP < 140/90). RESULTS: Our analysis (N = 4,007) yielded an age-standardized hypertension prevalence of 30% (95% CI: 28%-32%, N = 1,393). Among hypertensives, 54% (50-58%) were unaware of their condition, 45% (40-50%) of those aware were untreated, and 63% (55-70%) of those on medications were suboptimally treated (BP ≥ 140/90 mmHg). A fifth of hypertensives who were diagnosed but not on medications had BP ≥ 180/110 mmHg. Diabetes was the strongest correlate of hypertension and awareness (aOR 4.00, 1.86-8.59; aOR 3.30, 1.44-7.55, respectively). Males were less likely to be aware (aOR 0.62, 0.41-0.94) or controlled (aOR 0.36, 0.16-0.83). Obese individuals were more likely to be treated (aOR 2.17, 1.12-4.22), yet less likely to be controlled (aOR 0.32, 0.15-0.66). CONCLUSIONS: We report the first nationally representative estimates of the hypertension care cascade performance in Botswana, which will support planning and future policy evaluations. Findings contribute to the relatively sparse evidence on this subject and may inform development of innovations that improve quality of hypertension management and adherence support in similar settings.

Medication Errors and Blood Pressure Control Among Patients Managed for Hypertension in Public Ambulatory Care Clinics in Botswana.

Background The prevalence of hypertension in low- and middle-income countries is rapidly increasing, with most cases undiagnosed and many poorly controlled among those diagnosed. Medication reconciliation studies from high-income countries have demonstrated a high occurrence of antihypertensive medication errors and a strong association between medication errors and inadequate blood pressure control, but data from low- and middle-income countries are lacking. Methods and Results We conducted a cross-sectional study from April to October 2018 of adult patients on pharmacologic management for known hypertension at 7 public health facilities in Kweneng East District, Botswana. Our aims included to evaluate the frequency of uncontrolled hypertension, the frequency and type of medication errors causing discrepancies between patient-reported and prescribed antihypertensive medications, and the association between medication errors and uncontrolled hypertension. Descriptive analyses and multivariable logistic regression were used. The prevalence of uncontrolled hypertension was 55% among 280 enrolled adult patients, and 95 (34%) had ≥1 medication error. The most common errors included patients taking medications incorrectly (11.1%; 31/280), patients omitting medications (7.9%; 22/280), and unfilled prescriptions caused by pharmacy stock outs (7.5%%; 21/280). Uncontrolled hypertension was significantly associated with having ≥1 medication error compared with no errors (adjusted odds ratio, 3.26; 95% CI, 1.75-6.06; P<0.001). Conclusions Medication errors are strongly associated with poor blood pressure control in this setting. Further research is warranted to assess whether medication reconciliation and other low-cost interventions addressing root causes of medication errors can improve the control of hypertension and other chronic conditions in low- and middle-income countries.

HIV-associated morbidity and mortality in a setting of high ART coverage: prospective surveillance results from a district hospital in Botswana.

INTRODUCTION: Antiretroviral therapy (ART) has significantly improved survival in Africa in recent years. In Botswana, where adult HIV prevalence is 21.9%, AIDS-related mortality is estimated to have declined by 58% between 2005 and 2013 following the initial wide-spread introduction of ART, and ART coverage has steadily increased reaching 84% in 2016. However, there remains little data about the burden of HIV and its impact on mortality in the hospital setting where most deaths occur. We aimed to describe the burden of HIV and related morbidity and mortality among hospitalized medical patients in a district hospital in southern Botswana in the era of widespread ART coverage. METHODS: We prospectively reviewed medical admissions to Scottish Livingstone Hospital from December 2015 to November 2017 and recorded HIV status, demographics, clinical characteristics and final diagnoses at discharge, death or transfer. We ascertained outcomes and determined factors associated with mortality. Results were compared with similar surveillance data collected at the same facility in 2011 to 2012. RESULTS: A total of 2316 admissions occurred involving 1969 patients; 42.4% were of HIV-positive patients, 46.9% of HIV-negative patients and 10.7% of patients with unknown HIV status. Compared to HIV-negative patients, HIV-positive patients had younger age (mean 42 vs. 64 years, p < 0.0001) and higher mortality (22.2% vs. 18.0%, p = 0.03). Tuberculosis was the leading diagnosis among mortality cases in both groups but accounted for a higher proportion of deaths among HIV-positive admissions (44.5%) compared with HIV-negative admissions (19.4%, p < 0.0001). Compared with similar surveillance in 2011 to 2012, HIV prevalence was lower (42.4% vs. 47.6%, p < 0.01), and among HIV-positive admissions: ART coverage was higher (72.2% vs. 56.2%, p < 0.0001), viral load suppression was similar (78.6% vs. 80.3%, p = 0.77), CD4 counts were higher (55.0% vs. 44.6% with CD4 ≥200 cells/mm3 , p < 0.001), mortality was similar (22.2 vs. 22.7%, p = 0.93), tuberculosis diagnoses increased (27.5% vs. 20.1%, p < 0.01) and tuberculosis-associated mortality was higher (35.9% vs. 24.7%, p = 0.05). CONCLUSIONS: Despite high ART-coverage in Botswana, HIV-positive patients continue to be disproportionately represented among hospital admissions and deaths. Deaths from tuberculosis may be contributing to lack of reduction in inpatient mortality. Our findings suggest that control of HIV and tuberculosis remain top priorities for reducing inpatient mortality in Botswana.

Explaining disparities in oncology health systems delays and stage at diagnosis between men and women in Botswana: A cohort study.

PURPOSE: Men in Botswana present with more advanced cancer than women, leading to poorer outcomes. We sought to explain sex-specific differences in time to and stage at treatment initiation. METHODS: Cancer patients who initiated oncology treatment between October 2010 and June 2017 were recruited at four oncology centers in Botswana. Primary outcomes were time from first visit with cancer symptom to treatment initiation, and advanced cancer (stage III/IV). Sociodemographic and clinical covariates were obtained retrospectively through interviews and medical record review. We used accelerated failure time and logistic models to estimate standardized sex differences in treatment initiation time and risk differences for presentation with advanced stage. Results were stratified by cancer type (breast, cervix, non-Hodgkin's lymphoma, anogenital, head and neck, esophageal, other). RESULTS: 1886 participants (70% female) were included. After covariate adjustment, men experienced longer excess time from first presentation to treatment initiation (8.4 months) than women (7.0 months) for all cancers combined (1.4 months, 95% CI: 0.30, 2.5). In analysis stratified by cancer type, we only found evidence of a sex disparity (Men: 8.2; Women: 6.8 months) among patients with other, non-common cancers (1.4 months, 95% CI: 0.01, 2.8). Men experienced an increased risk of advanced stage (Men: 67%; Women: 60%; aRD: 6.7%, 95% CI: -1.7%, 15.1%) for all cancers combined, but this disparity was only statistically significant among patients with anogenital cancers (Men: 72%; Women: 50%; aRD: 22.0%, 95% CI: 0.5%, 43.5%). CONCLUSIONS: Accounting for the types of cancers experienced by men and women strongly attenuated disparities in time to treatment initiation and stage. Higher incidence of rarer cancers among men could explain these disparities.

Integrating noncommunicable disease services into primary health care, Botswana.

Despite the rising burden of noncommunicable diseases, access to quality decentralized noncommunicable disease services remain limited in many low- and middle-income countries. Here we describe the strategies we employed to drive the process from adaptation to national endorsement and implementation of the 2016 Botswana primary healthcare guidelines for adults. The strategies included detailed multilevel assessment with broad stakeholder inputs and in-depth analysis of local data; leveraging academic partnerships; facilitating development of supporting policy instruments; and embedding noncommunicable disease guidelines within broader primary health-care guidelines in keeping with the health ministry strategic direction. At facility level, strategies included developing a multimethod training programme for health-care providers, leveraging on the experience of provision of human immunodeficiency virus care and engaging health-care implementers early in the process. Through the strategies employed, the country's first national primary health-care guidelines were endorsed in 2016 and a phased three-year implementation started in August 2017. In addition, provision of primary health-care delivery of noncommunicable disease services was included in the country's 11th national development plan (2017-2023). During the guideline development process, we learnt that strong interdisciplinary skills in communication, organization, coalition building and systems thinking, and technical grasp of best-practices in low- and middle-income countries were important. Furthermore, misaligned agendas of stakeholders, exaggerated by a siloed approach to guideline development, underestimation of the importance of having policy instruments in place and coordination of the processes initially being led outside the health ministry caused delays. Our experience is relevant to other countries interested in developing and implementing guidelines for evidence-based noncommunicable disease services.

Malgré la charge de morbidité croissante des maladies non transmissibles, l'accès à des services décentralisés de qualité pour lutter contre ces maladies reste limité dans de nombreux pays à revenu faible ou intermédiaire. Dans cet article, nous décrivons les stratégies qui ont été employées pour mener les étapes d'adaptation, de validation et de mise en œuvre à l'échelle nationale des Lignes directrices 2016 du Botswana sur les soins de santé primaires pour l'adulte. Ces stratégies ont inclus: une évaluation multiniveau détaillée avec une large implication des parties prenantes et une analyse approfondie des données locales; le recours à des partenariats universitaires; la promotion de l'élaboration d'instruments politiques propices; l'intégration de lignes directrices portant spécifiquement sur les maladies non transmissibles dans les lignes directrices générales sur les soins primaires, en écho à l'orientation stratégique du ministère de la Santé. Au niveau des établissements de santé, les stratégies ont inclus: la création d'un programme de formation multiméthode à destination des prestataires de soins; l'exploitation de l'expérience acquise dans la prise en charge du virus de l'immunodéficience humaine et l'implication des prestataires de soins très tôt dans le processus. Grâce aux stratégies employées, les premières lignes directrices nationales sur les soins de santé primaires ont été validées en 2016, et une étape de mise en œuvre graduelle, sur trois ans, a commencé en août 2017. De plus, la prestation de soins de santé primaires contre les maladies non transmissibles a été incluse dans le 11e plan national de développement du pays (2017-2023). Pendant la phase d'élaboration des lignes directrices, nous avons constaté toute l'importance, dans les pays à revenu faible et intermédiaire, de pouvoir compter sur de solides compétences interdisciplinaires en matière de communication, d'organisation, de création de coalitions et de réflexion systémique et d'obtenir une bonne compréhension technique des meilleures pratiques. Nous avons par ailleurs observé des retards provoqués par des problèmes d'incompatibilité d'agendas entre les différentes parties prenantes, exagérés par des approches cloisonnées lors de la phase d'élaboration des lignes directrices, par la sous-estimation de l'importance d'avoir des outils politiques déjà en place et par des difficultés de coordination des processus initialement pilotés hors du ministère de la Santé. Notre expérience peut être utile pour d'autres pays qui souhaiteraient élaborer et mettre en œuvre des lignes directrices pour des services de soins contre les maladies non transmissibles fondés sur des données probantes.

A pesar de la creciente carga de las enfermedades no transmisibles, el acceso a servicios de calidad descentralizados para estas enfermedades sigue siendo limitado en muchos países de bajos y medianos ingresos. A continuación, describimos las estrategias que empleamos para impulsar el proceso desde la adaptación a la aprobación nacional y la implementación de las directrices de atención primaria de la salud para adultos de Botswana de 2016. Las estrategias incluían una evaluación detallada a varios niveles con amplias aportaciones de las partes interesadas y un análisis a fondo de los datos locales; el aprovechamiento de las asociaciones académicas; la facilidad para elaborar instrumentos normativos de apoyo; la incorporación de directrices sobre las enfermedades no transmisibles en las directrices más amplias sobre la atención primaria de la salud, de conformidad con la dirección estratégica del Ministerio de Salud. A nivel de los centros de salud, las estrategias incluían la elaboración de un programa de capacitación multimétodo para los proveedores de servicios de salud, el aprovechamiento de la experiencia en la prestación de servicios de atención del virus de la inmunodeficiencia humana y la participación de los encargados de la ejecución de los servicios de salud en las primeras etapas del proceso. Gracias a las estrategias empleadas, en 2016 se aprobaron las primeras directrices nacionales de atención primaria de la salud del país y en agosto de 2017 se inició una aplicación por etapas de tres años. Además, la prestación de servicios de atención primaria de la salud para las enfermedades no transmisibles se incluyó en el 11º plan nacional de desarrollo del país (2017-2023). Durante el proceso de desarrollo de las directrices, aprendimos que eran importantes las buenas habilidades interdisciplinarias en comunicación, organización, formación de coaliciones y pensamiento sistémico, así como la comprensión técnica de las mejores prácticas en los países de ingresos bajos y medios. Por otra parte, las agendas desalineadas de las partes interesadas, exageradas por el enfoque aislado del desarrollo de las directrices, la subestimación de la importancia de contar con instrumentos de política y la coordinación de los procesos que inicialmente se llevaban a cabo fuera del ministerio de salud causaron retrasos. Nuestra experiencia es relevante para otros países interesados en desarrollar e implementar directrices para servicios de enfermedades no transmisibles basados en la evidencia.

Patient Characteristics, Early Outcomes, and Implementation Lessons of Cervical Cancer Treatment Services in Rural Rwanda.

PURPOSE: Low- and middle-income countries account for 86% of all cervical cancer cases and 88% of cervical cancer mortality globally. Successful management of cervical cancer requires resources that are scarce in sub-Saharan Africa, especially in rural settings. Here, we describe the early clinical outcomes and implementation lessons learned from the Rwanda Ministry of Health's first national cancer referral center, the Butaro Cancer Center of Excellence (BCCOE). We hypothesize that those patients presenting at earlier stage and receiving treatment will have higher rates of being alive. METHODS: The implementation of cervical cancer services included developing partnerships, clinical protocols, pathology services, and tools for monitoring and evaluation. We conducted a retrospective study of patients with cervical cancer who presented at BCCOE between July 1, 2012, and June 30, 2015. Data were collected from the electronic medical record system and by manually reviewing medical records. Descriptive, bivariable and multivariable statistical analyses were conducted to describe patient demographics, disease profiles, treatment, and clinical outcomes. RESULTS: In all, 373 patients met the study inclusion criteria. The median age was 53 years (interquartile rage, 45 to 60 years), and 98% were residents of Rwanda. Eighty-nine percent of patients had a documented disease stage: 3% were stage I, 48% were stage II, 29% were stage III, and 8% were stage IV at presentation. Fifty percent of patients were planned to be treated with a curative intent, and 54% were referred to chemoradiotherapy in Uganda. Forty percent of patients who received chemoradiotherapy were in remission. Overall, 25% were lost to follow-up. CONCLUSION: BCCOE illustrates the feasibility and challenges of implementing effective cervical cancer treatment services in a rural setting in a low-income country.

Cost of Treating Pediatric Cancer at the Butaro Cancer Center of Excellence in Rwanda.

PURPOSE: Improvements in childhood survival rates have been achieved in low- and middle- income countries that have made a commitment to improve access to cancer care. Accurate data on the costs of delivering cancer treatment in these settings will allow ministries of health and donors to accurately assess and plan for expansions of access to care. This study assessed the financial cost of treating two common pediatric cancers, nephroblastoma and Hodgkin lymphoma, at the Butaro Cancer Center of Excellence in rural Rwanda. METHODS: A microcosting approach was used to calculate the per-patient cost for Hodgkin lymphoma and nephroblastoma diagnosis and treatment. Costs were analyzed retrospectively from the provider perspective for the 2014 fiscal year. The cost per patient was determined using an idealized patient receiving a full course of treatment, follow-up, and recommended social support in accordance with the national treatment protocol for each cancer. RESULTS: The cost for a full course of treatment, follow-up, and social support was determined to be between $1,490 and $2,093 for a patient with nephroblastoma and between $1,140 and $1,793 for a pediatric patient with Hodgkin lymphoma. CONCLUSION: Task shifting, reduced labor costs, and locally adapted protocols contributed to significantly lower costs than those seen in middle- or high-income countries.

Cost of Providing Quality Cancer Care at the Butaro Cancer Center of Excellence in Rwanda.

PURPOSE: The cost of providing cancer care in low-income countries remains largely unknown, which creates a significant barrier to effective planning and resource allocation. This study examines the cost of providing comprehensive cancer care at the Butaro Cancer Center of Excellence (BCCOE) in Rwanda. METHODS: A retrospective costing analysis was conducted from the provider perspective by using secondary data from the administrative systems of the BCCOE. We identified the start-up funds necessary to begin initial implementation and determined the fiscal year 2013-2014 operating cost of the cancer program, including capital expenditures and fixed and variable costs. RESULTS: A total of $556,105 US dollars was assessed as necessary start-up funding to implement the program. The annual operating cost of the cancer program was found to be $957,203 US dollars. Radiotherapy, labor, and chemotherapy were the most significant cost drivers. Radiotherapy services, which require sending patients out of country because there are no radiation units in Rwanda, comprised 25% of program costs, labor accounted for 21%, and chemotherapy, supportive medications, and consumables accounted for 15%. Overhead, training, computed tomography scans, surgeries, blood products, pathology, and social services accounted for less than 10% of the total. CONCLUSION: This study is one of the first to examine operating costs for implementing a cancer center in a low-income country. Having a strong commitment to cancer care, adapting clinical protocols to the local setting, shifting tasks, and creating collaborative partnerships make it possible for BCCOE to provide quality cancer care at a fraction of the cost seen in middle- and high-income countries, which has saved many lives and improved survival. Not all therapies, though, were available because of limited financial resources.