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Background: Cardiovascular disease disproportionately affects persons living in low- and middle-income countries and heart failure (HF) is thought to be a leading cause. Population-based studies characterizing the epidemiology of HF in these settings are lacking. We describe the age-standardized prevalence, survival, subtypes, risk factors, and 1-year mortality of HF in the population-based Haiti Cardiovascular Disease Cohort. Methods: Participants were recruited using multistage cluster-area random sampling in Port-au-Prince, Haiti. A total of 2981 completed standardized history and exam, laboratory measures, and cardiac imaging. Clinical HF was defined by Framingham criteria. Kaplan-Meier and Cox proportional hazard regression assessed mortality among participants with and without HF; logistic regression identified associated factors. Results: Among all participants, the median age was 40 years (interquartile range, 27–55), and 58.2% were female. Median follow-up was 15.4 months (interquartile range, 9–22). The age-standardized HF prevalence was 3.2% (93/2981 [95% CI, 2.6–3.9]). The average age of participants with HF was 57 years (interquartile range, 45–65), and 67.7% were female. The first significant increase in HF prevalence occurred between 30 to 39 and 40 to 49 years (1.1% versus 3.7%, P =0.003). HF with preserved ejection fraction was the most common HF subtype (71.0%). Age (adjusted odds ratio, 1.36 [1.12–1.66] per 10-year increase), hypertension (2.14 [1.26–3.66]), obesity (3.35 [95% CI, 1.99–5.62]), poverty (2.10 [1.18–3.72]), and renal dysfunction (5.42 [2.94–9.98]) were associated with HF. One-year HF mortality was 6.6% versus 0.8% (hazard ratio, 7.7 [95% CI, 2.9–20.6]; P Conclusions: The age-standardized prevalence of HF in this low-income setting was alarmingly high at 3.2%—5-fold higher than modeling estimates for low- and middle-income countries. Adults with HF were two decades younger and 7.7× more likely to die at 1 year compared with those in the community without HF. Further research characterizing the population burden of HF in low- and middle-income countries can guide resource allocation and development of pragmatic HF prevention and treatment interventions, ultimately reducing global cardiovascular disease health disparities. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03892265.

Despite the increasing role of chronic kidney disease (CKD) as a major cause of global morbidity and mortality, there is limited understanding of its prevalence and risk factors in low-income countries, including Haiti. We hypothesized the prevalence of CKD is high in urban Haiti due to high rates of uncontrolled risk factors, primarily hypertension (HTN). We evaluated the prevalence and risk factors for CKD in a population-based cohort from Haiti. Among 2426 participants ≥18 years, serum creatinine and urinary albumin and creatinine were measured at time of study enrollment. Estimated glomerular filtration rate (eGFR) was dichotomized at 2 . Albuminuria was defined as an albumin to creatinine ratio (ACR) ≥30 mg/g. CKD was defined as reduced eGFR and/or albuminuria. HTN was defined as a systolic blood pressure (BP) ≥140 mmHg, diastolic BP ≥90 mmHg, or use of antihypertensive medication. Factors associated with CKD were assessed with logistic regression. National Health and Nutrition Examination Survey (NHANES) 2015-2018 data was used for cohort comparison. Median age was 41 years (IQR 28-55), 57% of participants were female, and 69% earned

BackgroundMultidrug therapy is a World Health Organization “best buy” for the prevention and control of noncommunicable diseases. CVD polypills, including ≥2 blood pressure medications, and a statin with or without aspirin, are an effective, scalable strategy to close the treatment gap that exists in many low- and middle-income countries, including Haiti. We estimated the number of Haitian adults eligible for an atherosclerotic CVD (ASCVD) polypill, and the number of potentially preventable CVD events if polypills were implemented nationally.MethodsWe used cross-sectional data from the Haiti CVD Cohort, a population-based cohort of 3,005 adults ≥18 years in Port-au-Prince, to compare two polypill implementation strategies: high-risk primary prevention and secondary prevention. High-risk primary prevention included three scenarios: (a) age ≥40 years, (b) hypertension, or (c) predicted 10-year ASCVD risk ≥7.5%. Secondary prevention eligibility included history of stroke or myocardial infarction. We then used the 2019 Global Burden of Disease database and published polypill trials to estimate preventable CVD events, defined as nonfatal MI, nonfatal stroke, and cardiovascular death over a 5-year timeline.ResultsAmong 2,880 participants, the proportion of eligible adults for primary prevention were: 51.6% for age, 32.5% for hypertension, 19.3% for high ASCVD risk, and 5.8% for secondary prevention. Based on current trends, an estimated 462,509 CVD events (95% CI: 369,089–578,475) would occur among adults ≥40 years in Haiti from 2019–2024. Compared with no polypill therapy, we found 32% or 148,003 CVD events (95% CI: 70,126–248,744) could be prevented by a combined primary and secondary prevention approach in Haiti if polypills were fully implemented over 5 years.ConclusionThese modeling estimates underscore the potential magnitude of preventable CVD events in low-income settings like Haiti. Model calibration using observed CVD events, costs, and implementation assumptions are future directions.Clinical trial registrationclinicaltrials.gov, identifier: NCT03892265.

Ending hunger and alleviating poverty are key goals for a sustainable future. Food security is a constant challenge for agrarian communities in low-income countries, especially in Madagascar. We investigated agricultural practices, household characteristics, and food security in northeast Madagascar. We tested whether agricultural practices, demographics, and socioeconomics in rural populations were related to food security. Over 70% of respondents reported times during the last three years during which food for the household was insufficient, and the most frequently reported cause was small land size (57%). The probability of food insecurity decreased with increasing vanilla yield, rice yield, and land size. There was an interaction effect between land size and household size; larger families with smaller land holdings had higher food insecurity, while larger families with larger land had lower food insecurity. Other socioeconomic and agricultural variables were not significantly related to food insecurity, including material wealth, education, crop diversity, and livestock ownership. Our results highlight the high levels of food insecurity in these communities and point to interventions that would alleviate food stress. In particular, because current crop and livestock diversity were low, agricultural diversification could improve outputs and mitigate food insecurity. Development of sustainable agricultural intensification, including improving rice and vanilla cultivation to raise yields on small land areas, would likely have positive impacts on food security and alleviating poverty. Increasing market access and off-farm income, as well as improving policies related to land tenure could also play valuable roles in mitigating challenges in food security. Supplementary Information The online version contains supplementary material available at 10.1007/s12571-021-01179-3.

Aims: Modeling estimates indicate that heart failure (HF) prevalence may be lowest in low-income (LICs). Conversely, HF has been shown to be the leading cause of hospital admission in hospitals in many LICs. This disconnect between estimates and hospital-based observations may be explained by the underlying data. Modeling studies may have selection bias reporting data on individuals presenting with symptomatic disease and may introduce ascertainment bias based on accessibility of care and other structural factors in these communities. Population-based studies are needed to identify the true clinical epidemiology of HF in order to improve HF-related health outcomes in these under-resourced settings where four billion persons live. Haiti is the poorest, most under-resourced country in the Western Hemisphere. We describe HF prevalence, survival, subtypes, risk factors, and one-year mortality in the population-based Haiti Cardiovascular Disease Study. Methods and Results: Multistage cluster-area random sampling identified 2,981 adults, who completed standardized history and exam, laboratory measures, and cardiac imaging. Kaplan-Meier and Cox proportional hazard regression assessed survival; logistic regression identified associated factors. Median follow-up was 15.4 months (IQR 9-22). Age-standardized HF prevalence was 3.2% (93/2,981 [CI:2.6-3.9]). One-year HF mortality was 6.6% versus 0.8% (HR: 7.7 [CI 2.9-20.6], p Conclusion: The age-standardized prevalence of HF in this low-income setting was alarmingly high at 3.2%--50% higher than rates in high-income countries and 5-fold higher than modeling estimates for LMICs. Adults with HF were two decades younger as compared to high-income settings and 7.7 times more likely to die at one year. These data serve as a warning sign and may have implications for policy makers and future HF interventions in LMICs.

Introduction: Cardiovascular disease is the leading cause of death in Haiti and many low-middle income countries. Environmental lead exposure is associated with higher blood pressure (BP) and cardiovascular disease mortality in high income countries but has not been systematically evaluated in lower income countries where 6.5 billion people reside. Hypothesis: We hypothesized higher lead levels would be associated with higher BP in Haiti. Methods: Blood lead levels (BLLs) were measured among 2,257 participants ≥18 years enrolled in a population-based longitudinal cohort study in Port-au-Prince (Haiti Cardiovascular Disease Cohort Study). BLL screening was conducted using LeadCare II (detection limit ≥3.3 μg/dL). BLLs below detection were imputed. Associations between BLLs (quartiles) and systolic BP (SBP) and diastolic BP (DBP) were assessed, adjusting for age, sex, obesity, smoking, physical activity, and income. BLLs were also categorized as ≥5 versus Results: The median age was 40 years; 62.6% were female. The geometric mean BLL was 4.60 μg/dL, 67.3% had detectable BLLs >3.3 μg/dL, and 40.9% had elevated BLLs ≥5 μg/dL. BLLs in quartile four (≥6.5 μg/dL) in both unadjusted and adjusted analyses were associated with higher SBP (adjusted 3.02 mmHg; 95%CI 0.80, 5.25) and DBP (adjusted 2.19 mmHg; 95%CI 0.70, 3.67). BLL ≥5 μg/dL were associated with a higher SBP (2.21 mmHg; 95%CI 0.15, 4.26) and DBP (1.50 mmHg; 95%CI 0.20, 2.81) in unadjusted analysis. After adjustment there was no difference in SBP (1.41; 95%CI -0.25, 3.09) and 1.15 mmHg (95%CI 0.01, 2.30) higher DBP. Conclusions: Widespread environmental lead exposure is evident in urban Haiti, with higher BLLs associated with higher SBP and DBP. Lead is a modifiable pollutant in low-income countries that warrants urgent public health remediation.

Introduction: Neighborhood social context including violence and cohesion may impact cardiovascular disease risk factors in countries like Haiti with high civil unrest. We describe these factors using validated instruments (Neighborhood Collective Efficacy, City Stress Inventory), and hypothesized higher cohesion and lower violence were associated with lower stress, depression, blood pressure (BP), and hypertension. Methods: We collected data from a population-representative cohort of adults in Port-au-Prince, Haiti between March 2019 to April 2021, including stress (Perceived Stress Scale), depression (PHQ-9), blood pressure, and hypertension (SBP ≥ 140 mmHg, DBP ≥ 90 mmHg, or on medications). Adjusting for age and sex, multivariable linear and Poisson regressions assessed the relationship between exposures (neighborhood violence, neighborhood cohesion) and outcomes (stress, depression, BP, hypertension). Results: Among 2,799 adults, 59.7% were female and median age was 41 years (IQR:28-55). Participants reported high cohesion (median 15/25, IQR:14-17) and moderate violence (9/20, IQR:7-11). Stress was moderate (8/16), 12.8% had at least moderate depression, and 30.4% had hypertension. In regressions, higher violence at all levels was associated with higher depressive symptoms (Q4 vs Q1: +2.94 score, 95%CI 2.51, 3.38). Violence was also weakly associated with slightly higher stress (Q4 vs Q1: +0.32 score, 95%CI 0.04, 0.59), and lower hypertension prevalence (Q2 vs Q1: PR 0.86, 95%CI 0.75, 0.99). Cohesion was weakly associated with lower stress (T3 vs T1: -0.43 score, 95%CI -0.71, -0.16), depression (T2 vs T1: -0.63 score, 95%CI -1.02, -0.24), and higher DBP (T2 vs T1: 1.23 mmHg, 95%CI 0.065, 2.39). Conclusions: In conclusion, we found high perceived cohesion and moderate violence. The strongest association was between higher violence and higher depression. Paradoxically, higher violence and lower cohesion were associated with lower hypertension and DBP, possibly due to unmeasured confounding.

Introduction: Stress is associated with multiple adverse health outcomes, including hypertension. The impact of stress on health may be moderated by social support. The distribution of stress, support, and their association with hypertension have not been well described in low-income countries that face severe poverty. Over the past decade, Haiti has suffered massive natural disasters including the 2010 earthquake, cholera outbreak, COVID-19 pandemic, and recurrent civil instability—all of which may act as prolonged stressors. Hypothesis: We assessed the hypotheses that 1) there are high levels of both stress and support in Haiti, and 2) high support would moderate the relationship between high stress and hypertension. Methods: We measured stress and social support using validated instruments in a population-representative cohort of adults living in urban Port-au-Prince, Haiti between March 2019 and April 2021. Stress was measured using the Perceived Stress Scale, while social support was measured using the Multidimensional Scale of Perceived Social Support. For visualization, continuous scores were categorized using equal-width groups (stress: low (1-5), moderate (6-10), high (11-16); support: low (7-21), low-moderate (22-35), moderate (36-49), moderate-high (50-64), high (65-77)). Linear regression models were used to quantify the associations between: 1) stress and support adjusting for age and sex, 2) blood pressure and stress adjusting for age and sex. A formal moderation analysis was conducted to assess if support moderated the relationship between stress and blood pressure. Results: Among 2,817 adults, 59.7% female and the median age was 40 years (IQR 28-55). The majority had an income of less than 1 US dollar a day (69.7%). The median stress score was 8 out of 16 points, and median support score was 61 out of 77 points. Stress was higher with older ages (60+ years versus 18-29 years: +0.79 points, 95% CI 0.51 to 1.08) and in females (+0.85 points, 95% CI +0.65 to +1.06). Support was higher in males (+3.29 points, 95% CI 2.19 to 4.39). Support was inversely associated with stress, adjusting for age and sex (-0.04 points, 95% CI -0.04 to -0.03). Stress was not associated with systolic or diastolic blood pressure after adjustment for age and sex. Support did not moderate the association between stress and blood pressure. Conclusion: In this urban cohort of Haitian adults living with chronic civil instability, stress was moderate and support was high. While support was associated with lower stress, it did not moderate the relationship between stress and blood pressure. Despite the high levels of instability in Haiti, participants displayed resiliency through high levels of support, which may be an underutilized resource in reducing stress and long-term negative health outcomes.

Poor diets are responsible for a large burden of noncommunicable disease (NCD). The prevalence of modifiable dietary risk factors is rising in lower-income countries such as Haiti, along with increasing urbanization and shifts to diets high in sugar, salt, and fat. We describe self-reported dietary patterns (intake of fruits, vegetables, fried food, sugar-sweetened beverages, and added salt and oil) among a population-based cohort of low-income adults in Port-au-Prince and assess for associated sociodemographic factors (age, sex, income, education, body mass index). Among 2989 participants, the median age was 40 years, and 58.0% were women. Less than 1% met the World Health Organization recommendation of at least five servings/day of fruits and vegetables. Participants consumed fried food on average 1.6 days/week and sugar-sweetened beverages on average 4.7 days/week; young males of low socioeconomic status were the most likely to consume these dietary risk factors. The vast majority of participants reported usually or often consuming salt (87.1%) and oil (86.5%) added to their meals eaten at home. Our findings underscore the need for public health campaigns, particularly those targeting young males and household cooks preparing family meals at home, to improve dietary patterns in Haiti in order to address the growing NCD burden.

To stem the increasing incidence of non-communicable diseases (NCDs) and obesity, front-of-pack labels (FOPLs) have been developed since 1989. Whereas several countries have already adopted one voluntarily, the European Community wants to harmonize an FOPL system that will be mandatory for all member states. The purpose of this narrative review is to describe what could be achieved or not by FOPLs, and to discuss if there is enough evidence to establish whether such labels are effective in modifying purchasing behavior, in directing individual dietary patterns towards a healthy and sustainable diet, and in reformulating food products by the food industry. Non-directive FOPLs, which are still under study, appear to be informative and well-accepted by consumers even if they require a cognitive effort. Conversely, directive FOPLs are supported by several studies, but they are mostly conducted in simulated scenarios and/or performed as retrospective studies. Nevertheless, directive FOPLs are rated as an intuitive tool, and they have demonstrated a high capacity to help consumers rank food products as more or less healthy. In conclusion, directive and non-directive FOPLs convey different messages. No FOPL individually can be considered exhaustive in relation to all the objectives outlined in this narrative review, and therefore, the development of a model synthesizing both messages is advisable. Many questions remain open, such as the possibility of reformulating pre-packaged products, how to deal with traditional products, and the impact on the incidence of NCDs and obesity. In the light of the complexity of factors that condition consumption choices and health, none of the current FOPLs can be considered a health policy tool on its own. The possibility of development remains open, but as the state of the art, these tools do not seem to be able to achieve all the European Community goals together. We can speculate that they could meet these goals only if they are integrated into a multi-tiered, structured health policy intervention.

IntroductionDiabetes mellitus is a chronic noncommunicable disease associated with death and major disability, with increasing prevalence in low- and middle-income countries. There is limited population-based data about diabetes in Haiti. The objective of this study was to assess the prevalence of diabetes and associated factors among adults in Port-au-Prince, Haiti using a population-based cohort.MethodsThis study analyzes cross-sectional enrollment data from the population-based Haiti Cardiovascular Disease Cohort Study, conducted using multistage sampling with global positioning system waypoints in census blocks in the metropolitan area of Port-au-Prince, Haiti. A total of 3,005 adults ≥18 years old were enrolled from March 2019 to August 2021. We collected socio-demographic data, health-related behaviors, and clinical data using standardized questionnaires. Diabetes was defined as any of the following criteria: enrollment fasting glucose value ≥ 126 mg/dL or non-fasting glucose ≥ 200 mg/dL, patient self-report of taking diabetes medications, or study physician diagnosis of diabetes based on clinical evaluation.ResultsAmong 2985 (99.3%) with complete diabetes data, median age was 40 years, 58.1% were female, and 17.2% were obese. The prevalence of diabetes was 5.4% crude, and 5.2% age standardized. In unadjusted analysis, older age, higher body mass index (BMI), low physical activity, low education were associated with a higher odds of diabetes. After multivariable logistic regression, older age [60+ vs 18-29, Odds Ratio (OR)17.7, 95% CI 6.6 to 47.9] and higher BMI (obese vs normal/underweight, OR 2.7, 95% CI 1.7 to 4.4) remained statistically significantly associated with higher odds of diabetes.ConclusionThe prevalence of diabetes was relatively low among adults in Port-au-Prince, but much higher among certain groups (participants who were older and obese). The Haitian health system should be strengthened to prevent, diagnose, and treat diabetes among high-risk groups.

Cardiovascular disease is the leading cause of death in lower-income countries including Haiti. Environmental lead exposure is associated with high blood pressure and cardiovascular mortality in high-income countries but has not been systematically measured and evaluated as a potential modifiable cardiovascular risk factor in lower-income countries where 6.5 billion people reside. We hypothesized lead exposure is high in urban Haiti and associated with higher blood pressure levels. Blood lead levels were measured in 2504 participants ≥18 years enrolled in a longitudinal population-based cohort study in Port-au-Prince. Lead screening was conducted using LeadCare II (detection limit ≥3.3 µg/dL). Levels below detection were imputed by dividing the level of detection by √2. Associations between lead (quartiles) and systolic blood pressure and diastolic blood pressure were assessed, adjusting for age, sex, obesity, smoking, alcohol, physical activity, income, and antihypertensive medication use. The median age of participants was 40 years and 60.1% were female. The geometric mean blood lead level was 4.73µg/dL, 71.1% had a detectable lead level and 42.3% had a blood lead level ≥5 µg/dL. After multivariable adjustment, lead levels in quartile four (≥6.5 µg/dL) compared with quartile 1 ( Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03892265.

Cardiovascular disease (CVD) is the number one cause of death in low-income countries including Haiti, with hypertension (HTN) being the leading risk factor. This study aims to identify gaps in the HTN continuum of screening, diagnosis, treatment, and blood pressure (BP) control. Sociodemographic and clinical data were collected from a population-based sample of adults ≥18 years in Port-au-Prince (PAP) from March 2019 to April 2021. HTN was defined as systolic BP ≥ 140 mmHg, diastolic BP ≥ 90 mmHg, or use of antihypertensive medication. Screening was defined as ever having had a BP measurement; diagnosis as previously being informed of a HTN diagnosis; treatment as having taken antihypertensives in the past 2 weeks; and controlled as taking antihypertensives and having BP 140/90 mmHg. Factors associated with attaining each step in the continuum were assessed using Poisson multivariable regressions. Among 2737 participants, 810 (29% age-standardized) had HTN, of whom 97% had been screened, 72% diagnosed, 45% treated, and 13% controlled. There were no significant differences across age groups or sex. Obesity (BMI ≥ 30) was a significant factor associated with receiving treatment compared to normal weight (BMI 25), with a prevalence ratio (PR) of 1.5 (95% CI 1.1-2.0). Having secondary or higher education was associated with higher likelihood of controlled BP (PR 1.9 [95% CI 1.1-3.3]). In this urban Haitian population, the greatest gaps in HTN care are treatment and control. Targeted interventions are needed to improve these steps, including broader access to affordable treatment, timely distribution of medications, and patient adherence to HTN medication.

Background People living with HIV (PLWH) are at increased risk of cardiovascular disease (CVD) and death, with greater burdens of both HIV and CVD in lower-middle income countries. Treating prehypertension in PLWH may reduce progression to hypertension, CVD risk and potentially mortality. However, no trial has evaluated earlier blood pressure treatment for PLWH. We propose a randomized controlled trial to assess the feasibility, benefits, and risks of initiating antihypertensive treatment among PLWH with prehypertension, comparing prehypertension treatment to standard of care following current WHO guidelines. Methods A total of 250 adults 18–65 years and living with HIV (PLWH) with viral suppression in the past 12 months, who have prehypertension will be randomized to prehypertension treatment versus standard of care. Prehypertension is defined as having a systolic blood pressure (SBP) 120–139 mmHg or diastolic blood pressure (DBP) 80–89 mmHg. In the prehypertension treatment arm, participants will initiate amlodipine 5 mg daily immediately. In the standard of care arm, participants will initiate amlodipine only if they develop hypertension defined as SBP ≥ 140 mmHg or DBP ≥ 90 mmHg. The primary outcome is the difference in mean change of SBP from enrollment to 12 months. Secondary outcomes include feasibility, acceptability, adverse effects, HIV viral suppression, and medication adherence. Qualitative in-depth interviews with providers and participants will explore attitudes about initiating amlodipine, satisfaction, perceived CVD risk, and implementation challenges. Discussion PLWH have a higher CVD risk and may benefit from a lower BP threshold for initiation of antihypertensive treatment. Trial registration Clinicaltrials.gov registration number NCT04692467, registration date December 15, 2020, protocol ID 20–03021735.