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BackgroundSame-day HIV testing and antiretroviral therapy (ART) initiation is being widely implemented. However, the optimal timing of ART among patients with tuberculosis (TB) symptoms is unknown. We hypothesized that same-day treatment would be superior to standard care in this population.Methods and FindingsWe conducted an open-label randomized trial among adults with TB symptoms at initial HIV diagnosis at GHESKIO in Haiti. Participants were randomized in a 1:1 ratio to same-day treatment (same-day TB testing with same-day treatment [TB medication if TB; ART if no TB]) vs. standard care. In both groups, ART was initiated two weeks after TB treatment. The primary outcome was retention in care with 48-week HIV-1 RNA ConclusionsIn patients with TB symptoms at HIV diagnosis, same-day treatment is not associated with superior retention and viral suppression. A short delay in ART initiation, which facilitates more feasible TB testing, does not compromise outcomes.Trial RegistrationThis study is registered withClinicalTrials.govNCT03154320

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.

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: Cardiovascular diseases (CVD) are rapidly increasing in low-middle income countries. Accurate risk assessment is essential to reduce premature CVD by targeting primary prevention. Available CVD risk prediction models are built on predominantly Caucasian, high-income country populations, and have not been evaluated in lower-income countries. We aimed to compare six existing models for predicted 10-year risk of CVD and identify high-risk groups for targeted prevention in Haiti. Methods: We used cross-sectional data within the Haiti CVD Cohort Study, including 653 adults ≥ 40 years without known history of CVD. Six CVD risk prediction models were compared: pooled cohort equations (PCE), adjusted PCE with updated cohorts, Framingham CVD Lipids, Framingham CVD Body Mass Index (BMI), WHO Lipids, and WHO BMI. Risk factors were measured during clinical exams. Primary outcome was continuous and categorical predicted 10-year CVD risk. Secondary outcome was statin eligibility. Results: Seventy percent (460/653) were female, 65.5% (428/653) lived on a daily income of ≤1 USD, 57.0% (372/653) had hypertension, 14.5% (95/653) had hypercholesterolemia, 9.3% (61/653) had diabetes mellitus, and 5.5% (36/653) were current smokers. Predicted 10-year CVD risk ranged from 3.9% in adjusted PCE (IQR 1.7-8.4) to 9.8% in Framingham-BMI (IQR 5.0-17.8), and Spearman correlation coefficients ranged from 0.87 to 0.98. The percent of the cohort categorized as high risk using the uniform threshold of 10-year CVD risk ≥ 7.5% ranged from 28.8% in the adjusted PCE model to 62.0% in the Framingham-BMI model (χ 2 = 331, p value < 0.001). Statin eligibility also varied widely. Conclusions: In the Haiti CVD Cohort, there was substantial variation in the proportion identified as high-risk and statin eligible using existing models, leading to very different treatment recommendations and public health implications depending on model choice. There is a need to design and validate CVD risk prediction tools for low-middle income countries.

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.

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.

BackgroundCardiovascular diseases (CVD) are rapidly increasing in low-middle income countries (LMICs). Accurate risk assessment is essential to reduce premature CVD by targeting primary prevention and risk factor treatment among high-risk groups. Available CVD risk prediction models are built on predominantly Caucasian, high-income country populations, and have not been evaluated in LMIC populations.ObjectiveTo compare the predicted 10-year risk of CVD and identify high-risk groups for targeted prevention and treatment in Haiti.MethodsWe used cross-sectional data within the Haiti CVD Cohort Study, including 653 adults ≥ 40 years without known history of CVD and with complete data. Six CVD risk prediction models were compared: pooled cohort equations (PCE), adjusted PCE with updated cohorts, Framingham CVD Lipids, Framingham CVD Body Mass Index (BMI), WHO Lipids, and WHO BMI. Risk factors were measured during clinical exams. Primary outcome was continuous and categorical predicted 10-year CVD risk. Secondary outcome was statin eligibility.ResultsSeventy percent were female, 65.5% lived on a daily income of ≤1 USD, 57.0% had hypertension, 14.5% had hypercholesterolemia, 9.3% had diabetes mellitus, 5.5% were current smokers, and 2.0% had HIV. Predicted 10-year CVD risk ranged from 3.9% in adjusted PCE (IQR 1.7-8.4) to 9.8% in Framingham-BMI (IQR 5.0-17.8), and Spearman rank correlation coefficients ranged from 0.87 to 0.98. The percent of the cohort categorized as high risk using the uniform threshold of 10-year CVD risk ≥ 7.5% ranged from 28.8% in the adjusted PCE model to 62.0% in the Framingham-BMI model (χ2= 331, p value < 0.001). Statin eligibility also varied widely.ConclusionsIn the Haiti CVD Cohort, there was substantial variation in the proportion identified as high-risk and statin eligible using existing models, leading to very different treatment recommendations and public health implications depending on which prediction model is chosen. There is a need to design and validate CVD risk prediction tools for low-middle income countries that include locally relevant risk factors.Trial registrationclinicaltrials.govNCT03892265

HIV infection is associated with increased risk and progression of cardiovascular disease (CVD), yet little is known about the prevalence of CVD risk factors among long-term AIDS survivors in resource-limited settings. Using routinely collected data, we conducted a retrospective study to describe the prevalence of CVD risk factors among a cohort of HIV-infected patients followed for over 10 years in Port-au Prince, Haiti. This cohort includes 910 adults who initiated antiretroviral therapy (ART) between 2003 and 2004 and remained in care between 2014 and 2016 when routine screening for CVD risk factors was implemented at a large clinic in Haiti. A total of 397 remained in care ≥10 years and received screening. At ART initiation, 59% were female, median age was 38 years (IQR 33-44), and median CD4 count was 117 cells/mm3 (IQR 34-201). Median follow-up time from ART initiation was 12.1 years (IQR 11.7-12.7). At screening, median CD4 count was 574 cells/mm3 (IQR 378-771), and 84% (282 of 336 screened) had HIV-1 RNA < 1000 copies/mL. Seventy-four percent of patients had at least 1 risk factor including 58% (224/385) with hypertension, 8% (24/297) diabetes, 43% (119/275) hypercholesterolemia, 8% (20/248) active smoking, and 10% (25/245) obesity. Factors associated with hypertension were age (adjusted OR 1.06, P < .001) and weight at screening (adjusted OR 1.02, P = .019). Long-term AIDS survivors have a high prevalence of CVD risk factors, primarily hypertension. Integration of cardiovascular screening and management into routine HIV care is needed to maximize health outcomes among aging HIV patients in resource-limited settings.

Introduction Long‐term mortality among TB survivors appears to be higher than control populations without TB in many settings. However, data are limited among persons with HIV (PWH). We assessed the association between cured TB and long‐term mortality among persons with PWH in Haiti. Methods A prospective cohort of PWH from the CIPRA HT‐001 trial was followed from study enrolment (August 2005 to July 2008) to study closure (December 2018) to compare mortality between participants with and without TB. The index date for the survival analysis was defined as 240 days after TB diagnosis or randomization date. Time to death was described using Kaplan–Meier curves, and log‐rank tests were used to compare time to death between the TB and no‐TB cohorts. The association between TB and long‐term mortality was estimated with multivariable Cox models. Results Of the 816 participants in the CIPRA HT‐001 trial, 77 were excluded for a history of TB prior to study enrolment and 31 were excluded due to death or attrition prior to the index date, leaving 574 in the no‐TB and 134 in the TB cohort. Twenty‐four (17.9%) participants in the TB and 48 (8.4%) in the no‐TB cohort died during follow‐up. Five and 10‐year mortality rates were 14.2% and 17.9% respectively, in the TB cohort, and 6.1% and 8.4% in the no‐TB cohort. In Kaplan–Meier analysis, participants in the TB cohort had a significantly shorter time to death (log‐rank p

OBJECTIVE The objective of this study was to determine how baseline blood pressure and incident hypertension related to antiretroviral therapy (ART) initiation, HIV-related inflammation and mortality in HIV-infected adults in a low-income country. METHODS We conducted long-term follow-up of HIV-infected adults who had participated in a trial of early vs. delayed initiation of ART in Port-au-Prince, Haiti. Between 2005 and 2008, 816 HIV-infected adults were randomized to early (N = 408) vs. delayed ART (when CD4 cell count

Background Attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is high worldwide. We assessed whether same-day HIV testing and ART initiation improves retention and virologic suppression. Methods and findings We conducted an unblinded, randomized trial of standard ART initiation versus same-day HIV testing and ART initiation among eligible adults ≥18 years old with World Health Organization Stage 1 or 2 disease and CD4 count ≤500 cells/mm3. The study was conducted among outpatients at the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic infections (GHESKIO) Clinic in Port-au-Prince, Haiti. Participants were randomly assigned (1:1) to standard ART initiation or same-day HIV testing and ART initiation. The standard group initiated ART 3 weeks after HIV testing, and the same-day group initiated ART on the day of testing. The primary study endpoint was retention in care 12 months after HIV testing with HIV-1 RNA, In a randomized unblinded trial in Port-au-Prince, Haiti, Serena Koenig and colleagues investigate whether initiating ART on the day of HIV diagnosis improved retention in care and viral suppression., Author summary Why was this study done? Multiple visits for counseling, laboratory testing, and other procedures to prepare patients for initiation of antiretroviral therapy (ART) are burdensome and contribute to the high rate of attrition during the period from HIV testing to ART initiation. The World Health Organization (WHO) recently changed their guidelines to recommend ART for all persons living with HIV, facilitating ART initiation. This study was conducted to determine if ART initiation on the day of HIV diagnosis could improve treatment initiation rates, retention in care, and HIV viral suppression for patients with asymptomatic or minimally symptomatic HIV disease. What did the researchers do and find? We randomly assigned patients who presented for HIV testing at a clinic in Port-au-Prince, Haiti to standard ART initiation or same-day HIV testing and ART initiation (356 in the standard and 347 in the same-day groups). The standard group had 3 weekly visits with a social worker and physician and then started ART 21 days after the date of HIV diagnosis; the same-day ART group initiated ART on the day of HIV diagnosis. All participants in the same-day ART group and 92% of participants in the standard group initiated ART. At 12 months after HIV testing, a higher proportion of participants in the same-day ART group were retained in care (80% versus 72%), and a higher proportion were retained in care with viral load

BACKGROUND:High attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is widely reported. Though treatment guidelines have changed to broaden ART eligibility and services have been widely expanded over the past decade, data on the temporal trends in pre-ART outcomes are limited; such data would be useful to guide future policy decisions. METHODS:We evaluated temporal trends and predictors of retention for each step from HIV testing to ART initiation over the past decade at the GHESKIO clinic in Port-au-Prince Haiti. The 24,925 patients >17 years of age who received a positive HIV test at GHESKIO from March 1, 2003 to February 28, 2013 were included. Patients were followed until they remained in pre-ART care for one year or initiated ART. RESULTS:24,925 patients (61% female, median age 35 years) were included, and 15,008 (60%) had blood drawn for CD4 count within 12 months of HIV testing; the trend increased over time from 36% in Year 1 to 78% in Year 10 (p500 cells/mm3, respectively. The trend increased over time for each CD4 strata, and in Year 10, 94%, 95%, 79%, and 74% were retained in pre-ART care or initiated ART for each CD4 strata. Predictors of pre-ART attrition included male gender, low income, and low educational status. Older age and tuberculosis (TB) at HIV testing were associated with retention in care. CONCLUSIONS:The proportion of patients completing assessments for ART eligibility, remaining in pre-ART care, and initiating ART have increased over the last decade across all CD4 count strata, particularly among patients with CD4 count ≤350 cells/mm3. However, additional retention efforts are needed for patients with higher CD4 counts.

Background: Since HIV-1 RNA (viral load) testing is not routinely available in Haiti, HIV-infected patients receiving antiretroviral therapy (ART) are monitored using the World Health Organization (WHO) clinical and/or immunologic criteria. Data on survival and treatment outcomes for HIV-1 infected patients who meet criteria for ART failure are limited. We conducted a retrospective study to compare survival rates for patients who experienced failure on first-line ART by clinical and/or immunologic criteria and switched to second-line ART vs. those who failed but did not switch. Methods: Patients receiving first-line ART at the GHESKIO Center in Port-au-Prince, Haiti, who met WHO clinical and immunologic criteria for failure were identified. Survival and treatment outcomes were compared in patients who switched their ART regimen and those who did not. Cox regression analysis was used to determine predictors of mortality after failure of first-line ART. Results: Of 3126 patients who initiated ART at the GHESKIO Center between 1 March 2003 and 31 July 2008, 482 (15%) met WHO immunologic and/or clinical criteria for failure. Among those, 195 (41%) switched to second-line ART and 287 (59%) did not. According to Kaplan-Meier survival analysis, the probability of survival to 12 months after failure of first-line ART was 93% for patients who switched to second-line ART after failure and 88% for patients who did not switch. Predictors of mortality after failure of first-line ART were weight in the lowest quartile for sex, CD4 T cell count≤100, adherence