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Background: Similar to other African countries, life expectancy of people living with HIV infection has improved due to access to antiretroviral therapy (ART) in Rwanda. However, both HIV infection and use of ART are associated with cardiovascular disease (CVD) risks, due to adverse changes in some biomarkers, causing dyslipidemia and other metabolic imbalances. Biomarkers for CVD risk in HIV-infected individuals taking ART, has not been well characterized in Rwanda. We evaluated the association between the use and duration of ART and biomarkers of CVD risk among HIV infected adults in Rwanda. Methods: A total of 150 participants (18-45 years) from HIV clinics in public Health Center in Kigali included n=30 HIV-uninfected (HIV-) and n=120 HIV-infected (HIV+) adults. Among the HIV+ adults, n=40 participants were ART-naïve. Cross-sectional data were collected on healthrelated behaviors and biochemical markers of CVD risk. We compared CVD-related biomarkers between HIV-, HIV+ ART-naïve, and HIV+ on ART groups. Results: The majority of participants were women (60%) and HIV- were younger (35 ± 6 vs. 31 ± 6 years). Total cholesterol and triglycerides concentrations were associated with ART usage. Serum triglycerides concentrations were lower in HIV+ ART-naïve compared to HIV+ on ART (76.6 ± 38.9 mg/dl vs. 85.0 ± 38.3 mg/dl; p< 0.01). While total cholesterol concentrations were higher in HIV+ on ART than HIV+ ART-naïve (136.0 ± 45.1 mg/dl vs. 130.0 ± 36.5 mg/dl; p

Background: Similar to other African countries, life expectancy of people living with HIV infection has improved due to access to antiretroviral therapy (ART) in Rwanda. However, both HIV infection and use of ART are associated with cardiovascular disease (CVD) risks, due to adverse changes in some biochemical markers, causing dyslipidemia and other metabolic imbalances. Biomarkers for CVD risk in HIV-infected individuals taking ART, has not been well characterized in Rwanda. We evaluated the association between the use and duration of ART and biomarkers of CVD risk among HIV infected adults in Rwanda. Methods: A total of 150 participants (18-45 years) from HIV clinics in public Health Center in Kigali included n=30 HIV-uninfected (HIV-) and n=120 HIV-infected (HIV+) adults. Among the HIV+ adults, n=40 participants were ART-naïve. Cross-sectional data were collected on health-related behaviors and biochemical markers of CVD risk. We compared CVD-related biochemical markers between HIV-, HIV+ ART-naïve and HIV+ on ART groups. Results: The majority of participants were women (60%) and HIV- were younger (35±6 vs. 31±6 years). Total cholesterol and triglycerides concentrations were associated with ART usage. Serum triglycerides concentrations were lower in HIV+ ART-naïve compared to HIV+ on ART (76.6±38.9 mg/dl vs. 85.0±38.3 mg/dl; p< 0.01). While total cholesterol concentrations was higher in HIV+ on ART than HIV+ ART-naïve (136.0±45.1 mg/dl vs. 130.0±36.5 mg/dl; pConclusion: Higher serum total cholesterol and triglycerides were associated with use of ART in young adults with HIV. Although these values were within the upper limits of normal, our findings suggest early alterations in biomarkers of cardiac risk. These findings underscore the need for early evaluation of lipid profiles as biomarkers of cardiovascular disease risk, to effectively monitor how ART may contribute to cardiovascular disease and deter treatment programs in African countries.

Background Hypertension remains the major risk factor for cardiovascular diseases (CVDs) worldwide with a prevalence and mortality in low- and middle-income countries (LMICs) among the highest. The early detection of hypertension risk factors is a crucial pillar for CVD prevention. Design and method This cross-sectional study included 4284 subjects, mean age 46 ± 16SD, 56.4% females and mean BMI 26.6 ± 3.7 SD. Data were collected through a screening campaign in rural area of Kirehe District, Eastern of Rwanda, with the objective to characterize and examine the prevalence of elevated blood pressure (BP) and other CVD risk factors. An adapted tool from the World Health Organization STEPwise Approach was used for data collection. Elevated BP was defined as ≥ 140/90 mm/Hg and elevated blood glucose as blood glucose ≥ 100 mg/dL after a 6-h fast. Results Of the sampled population, 21.2% (n = 910) had an elevated BP at screening; BP was elevated among individuals not previously known to have HTN in 18.7% (n = 752). Among individuals with a prior diagnosis of HTN, 62.2% (n = 158 of 254) BP was uncontrolled. Age, weight, smoking, alcohol history and waist circumference were associated with BP in both univariate analyses and multivariate analysis. Conclusion High rates of elevated BP identified through a health screening campaign in this Rwandan district were surprising given the rural characteristics of the district and relatively low population age. These data highlight the need to implement an adequate strategy for the prevention, diagnosis, and control of HTN that includes rural areas of Rwanda as part of a multicomponent strategy for CVD prevention.

Background Life expectancy of people living with HIV infection has improved due to access to antiretroviral therapy (ART) in Rwanda like other African countries. However, both HIV infection and use of ART are associated with cardiovascular disease (CVD) risks, due to adverse changes in some biochemical markers, causing dyslipidemia and other metabolic imbalances. The CVD risk associated with metabolic biomarkers that may affect cardiac function with use of the ART, has not been well characterized in Rwanda. We evaluated the association between the use and duration of ART and abnormal changes in biochemical markers of CVD risk among HIV infected adults in Rwanda. Methods Participants were enrolled from HIV Clinics Public Health Centers in a cross-sectional study in Kigali. A total of 150 participants between 18-45 years included 30 HIV-Uninfected (HIV-) and 120 HIV-infected (HIV+) adults. Among the HIV+ adults, 40 participants were ART-naïve. Data were collected on health-related behaviors and biochemical markers of CVD risk. We compared changes in CVD-related biochemical markers between HIV-, HIV+ ART-naïve and HIV+ on ART treatment groups. Results Majority of participants were women (60%), and HIV- were younger (35±6 vs. 31±6 years). We observed differences in levels of cholesterol and triglycerides in HIV+ ART-treated and HIV+ ART-naïve groups. Total cholesterol and triglycerides were associated with use of ART. Serum triglycerides were lower in HIV+ ART-naïve compared to HIV+ on ART treatment (61.20±18.30 mg/dl vs. 85.00±38.30 mg/dl; p< 0.01). While total cholesterol was higher in HIV+ on ART than HIV+ ART-naïve (136.00±45.00 mg/dl vs. 119.00±36.00 mg/dl; p

ImportanceHypertension is the largest contributor to the Global Burden of Disease. In Rwanda, as in most low-income and middle-income countries, an increasing prevalence of hypertension and its associated morbidity and mortality is causing major healthcare and economic impact. Understanding healthcare systems context in hypertension care is necessary.ObjectiveTo study the hypertension healthcare context as perceived by healthcare providers using the Context Assessment for Community Health (COACH) tool.DesignA cross-sectional cohort responded to the COACH questionnaire and a survey about hypertension training.SettingThree tertiary care hospitals in Rwanda.ParticipantsHealthcare professionals (n=223).Primary outcome(s) and measure(s)The COACH tool consists of 49 items with eight subscales: resources, community engagement, commitment to work, informal payment, leadership, work culture, monitoring services for action (5-point Likert Scale) and sources of knowledge (on a 0–1 scale). Four questions surveyed training on hypertension.ResultsResponders (n=223, 75% women; 56% aged 20–35 years) included nurses (n=142, 64%, midwives (n=42, 19%), primary care physicians (n=28, 13%) and physician specialists (n=11, 5%)). The subscales commitment to work, leadership, work culture and informal payment scored between 4.7 and 4.1 and the community engagement, monitoring services for action and organizational resources scored between 3.1 and 3.5. Sources of knowledge had a mean score of 0.6±0.3. While 73% reported having attended a didactic hypertension seminar in the past year, only 28% had received long-term training and 51% had ConclusionsThere is a need for increased and continuous training in Rwanda. Healthcare responders stated a commitment to work and reported supportive leadership, while acknowledging limited resources and no monitoring systems. The COACH tool provides contextual guidance to develop training strategies prior to the implementation of a sustainable hypertension care programme.

Background Hypertension (HTN) affects nearly 1 billion people globally and is a major cause of morbidity and mortality. In low- and middle-income countries (LMICs), HTN represents an unmet health care gap that can be addressed by strengthening national health care systems. The National Heart, Lung, and Blood Institute recently funded the T4 Translation Research Capacity Building Initiative in Low Income Countries (TREIN) program to build capacity in dissemination and implementation (D&I) research in HTN in LMICs. The Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) recently developed a massive open online course (MOOC) to train in D&I. Herein, we report on the use of the TDR WHO MOOC in D&I for the TREIN program in Rwanda, assessing feasibility of the MOOC and D&I competencies after MOOC training. Methods Participants in one-group MOOC training completed pre- and post-training questionnaires to assess dissemination and implementation (D&I) competency outcomes and feasibility. D&I competencies were measured by use of a scale developed for a US-based training program, with the change in competency scores assessed by paired t test. Feasibility was measured by completion of homework and final project assignment and analyzed using descriptive statistics. Results Of the 92 trainees enrolled, 35 (38%) completed all MOOC components. D&I competency scores showed strong evidence of improvements from pre- to post-test. The full-scale average score improved by an average of 1.09 points, representing an effect size of 1.25 (CI 0.48-2.00); all four subscales also showed strong evidence of improvements. Trainees reported challenges to MOOC course completion that included technological issues (i.e., limited internet access) and competing demands (i.e., work, family). Conclusions In the context of LMIC training, the MOOC course was feasible and course completion showed improvement in D&I competency scores. While the program was designed with a focus on training for tropical diseases, there is potential for scalability to a wider audience of health care researchers, workers, administrators, and policymakers in LMIC interested in D&I research in non-communicable diseases.

In Rwanda, as in other sub-Saharan African (SSA) countries, life expectancy of people living with HIV (PLWH) has increased dramatically as a result of combined antiretroviral therapy (cART). People living with HIV can now live longer but with increasing rates of non-communicable diseases (NCDs). Thus, prevention of NCD comorbidities in PWLHI is crucial to maintain and gain health-related benefits and to maximise the health-related quality of life (HRQOL) in the long-term management of PLWH. This study determines the association between physical and mental health-related dimensions of quality of life (QOL) with behavioural and biological risk factors, after controlling socio-demographic and HIV-related factors in adults living with HIV in Rwanda. A cross-sectional study using the WHO STEPwise approach and Kinyarwanda version of the MOS-HIV Health Survey, risk factors for NCDs and HRQOL were analysed for 794 PLWH, both HIV+ on ART and ART-naive. Multiple regression analysis was used to examine the relationship between CMD risk factors and physical health and mental health summary scores. A total of 794 participants were interviewed. The mean age of the sample was 37.9 (±10.8) years and the majority of the participants were women ( n = 513; 64.6%). About 16.2% reported daily smoking, 31.4% reported harmful alcohol use and 95% reported insufficient consumption of vegetables and fruits while 26.1% reported being physically inactive. 18.4% were overweight 43.4% had abdominal obesity, i.e. waist-hip-ratio (WHR) ≥0.95 in males and 0.85 in females. High blood pressure (HBP), i.e. systolic blood pressure (SBP) of ≥140 mmHg, or diastolic blood pressure (DBP) ≥90 mmHg was 24.4%. The results reveal that mean physical health summary and mental health summary score values were 63.96 ± 11.68 and 53.43 ± 10.89, respectively. While participants indicated that tobacco users and those who had abdominal obesity reported poor mental HRQOL, physical inactivity and hypertension have a negative impact on physical HRQOL. In addition, certain sociodemographic and HIV-related variables – specifically being unmarried, lack of HIV disclosure and low CD4 count (less 350 cell counts /mm 3 ) – were associated with significantly lower mental and physical dimensions of quality of life. The results of this study reveal that behavioural and biological risk factors for NCDs were significantly associated with a lower HRQOL. These research findings also suggest that the assessment of the association between behavioural and biological risk factors for NCDs and a HRQOL provides opportunities for targeted counselling and secondary prevention efforts, so that health care providers can implement strategies that have a significant impact on the HRQOL. Keywords: Non-communicable diseases; risk factors; HIV; healthrelated quality of life; physical health; Rwanda

Highlights NCD represent a serious challenge globally, particularly in LMIC.Implementation research capacity building are critical to inform the prevention and control of NCD in LMIC.Sustainable evidence-based strategies can reduce mortality and prevent avoidable illness from NCD.Strategic change agents (i.e., key stakeholders, institutions, communities, health systems, patients, and families) should work collaboratively to make the necessary advancements to reducing the burden of NCD in LMIC. Fil: Aifah, Angela. No especifíca; Fil: Iwelunmor, Juliet. No especifíca; Fil: Akwanalo, Constantine. No especifíca; Fil: Allison, Jeroan. Massachusetts Institute of Technology; Estados Unidos Fil: Amberbir, Alemayehu. No especifíca; Fil: Asante, Kwaku P.. No especifíca; Fil: Baumann, Ana. Washington University in St. Louis; Estados Unidos Fil: Brown, Angela. Washington University in St. Louis; Estados Unidos Fil: Butler, Mark. No especifíca; Fil: Dalton, Milena. No especifíca; Fil: Davila Roman, Victor. Washington University in St. Louis; Estados Unidos Fil: Fitzpatrick, Annette L.. No especifíca; Fil: Fort, Meredith. State University of Colorado at Boulder; Estados Unidos Fil: Goldberg, Robert. No especifíca; Fil: Gondwe, Austrida. No especifíca; Fil: Ha, Duc. No especifíca; Fil: He, Jiang. University of Tulane; Estados Unidos Fil: Hosseinipour, Mina. No especifíca; Fil: Irazola, Vilma. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Kamano, Jemima. No especifíca; Fil: Karengera, Stephen. Washington University in St. Louis; Estados Unidos Fil: Karmacharya, Biraj M.. No especifíca; Fil: Koju, Rajendra. No especifíca; Fil: Maharjan, Rashmi. No especifíca; Fil: Mohan, Sailesh. No especifíca; Fil: Mutabazi, Vincent. No especifíca; Fil: Mutimura, Eugene. No especifíca; Fil: Muula, Adamson. No especifíca; Fil: Narayan, K.M.V.. University of Emory; Estados Unidos Fil: Nguyen, Hoa. No especifíca; Fil: Njuguna, Benson. No especifíca; Fil: Nyirenda, Moffat. No especifíca; Fil: Ogedegbe, Gbenga. No especifíca; Fil: van Oosterhout, Joep. No especifíca; Fil: Onakomaiya, Deborah. No especifíca; Fil: Patel, Shivani. University of Emory; Estados Unidos Fil: Paniagua-Ávila, Alejandra. No especifíca; Fil: Ramirez zea, Manuel. No especifíca; Fil: Plange Rhule, Jacob. No especifíca; Fil: Roche, Dina. No especifíca; Fil: Shrestha, Archana. No especifíca; Fil: Sharma, Hanspria. No especifíca; Fil: Tandon, Nikhil. No especifíca; Fil: Thu Cuc, Nguyen. No especifíca; Fil: Vaidya, Abhinav. No especifíca; Fil: Vedanthan, Rajesh. No especifíca; Fil: Weber, Mary Beth. University of Emory; Estados Unidos

Background: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide and in low- and middle-income countries, and hypertension (HTN) is a major risk factor for CVD. Although effective evidence-based interventions for control of HTN in high-income countries exist, implementation of these in low- and middle-income countries has been challenging due to limited capacity and infrastructure for latephase translational research. In Rwanda, the 2015 STEPS NCD (STEPwise Approach to Surveillance of Noncommunicable Diseases) risk survey reported an overall prevalence of HTN of 15% (95% confidence interval [CI]: 13.8 to 16.3) for those ages 15 to 64 years; prevalence increased with increasing age to 39% (95% CI: 35.7 to 43.1) for those ages 55 to 64 years; CVD was the third most common cause of mortality (7%). Suboptimal infrastructure and capacity in Rwanda hinders research and community knowledge for HTN control.Objectives: To address the issue of suboptimal capacity to implement evidence-based interventions in HTN, this project was designed with the following objectives: 1) to develop a regional needs assessment of infrastructure for dissemination and implementation (D & I) strategies for HTN-CVD control; 2) to develop HTNCVD research capacity through creation of countrywide resources such as core research facilities and training in the fields of HTN-CVD, D & I, and biostatistics; and 3) to engage and train multiple stakeholders in D & I and HTN-CVD evidence-based interventions.Methods: A weeklong training program in HTN-CVD, biostatistics, and D & I was conducted in Rwanda in August 2018, and pre- and post-D & I training competency questionnaires were administered.Results: Questionnaire results show a statistically significant increase in D & I knowledge and skills as a result of training (full scale pre- to post-test scores: 2.12 ± 0.78 vs. 3.94 ± 0.42; p < 0.0001).Conclusions: Using principles of community engagement and train-the-trainer methods, we will continue to adapt guidelines and treatments for HTN-CVD developed in high-income countries to the context of Rwanda with the goal of establishing a sustainable platform to address the burden of disease from HTN-CVD.HighlightsImplementation research in LMIC has been challenging due to limited capacity.A training program was developed to support implementation research strategies in Rwanda.Implementation research training resulted in significant increases in knowledge and skills.

Author(s): Ekoru, Kenneth; Young, Elizabeth H; Dillon, David G; Gurdasani, Deepti; Stehouwer, Nathan; Faurholt-Jepsen, Daniel; Levitt, Naomi S; Crowther, Nigel J; Nyirenda, Moffat; Njelekela, Marina A; Ramaiya, Kaushik; Nyan, Ousman; Adewole, Olanisun O; Anastos, Kathryn; Compostella, Caterina; Dave, Joel A; Fourie, Carla M; Friis, Henrik; Kruger, Iolanthe M; Longenecker, Chris T; Maher, Dermot P; Mutimura, Eugene; Ndhlovu, Chiratidzo E; Praygod, George; Pefura Yone, Eric W; Pujades-Rodriguez, Mar; Range, Nyagosya; Sani, Mahmoud U; Sanusi, Muhammad; Schutte, Aletta E; Sliwa, Karen; Tien, Phyllis C; Vorster, Este H; Walsh, Corinna; Gareta, Dickman; Mashili, Fredirick; Sobngwi, Eugene; Adebamowo, Clement; Kamali, Anatoli; Seeley, Janet; Smeeth, Liam; Pillay, Deenan; Motala, Ayesha A; Kaleebu, Pontiano; Sandhu, Manjinder S | Abstract: BackgroundAnti-retroviral therapy (ART) regimes for HIV are associated with raised levels of circulating triglycerides (TG) in western populations. However, there are limited data on the impact of ART on cardiometabolic risk in sub-Saharan African (SSA) populations.MethodsPooled analyses of 14 studies comprising 21 023 individuals, on whom relevant cardiometabolic risk factors (including TG), HIV and ART status were assessed between 2003 and 2014, in SSA. The association between ART and raised TG (g2.3 mmol/L) was analysed using regression models.FindingsAmong 10 615 individuals, ART was associated with a two-fold higher probability of raised TG (RR 2.05, 95% CI 1.51-2.77, I2=45.2%). The associations between ART and raised blood pressure, glucose, HbA1c, and other lipids were inconsistent across studies.InterpretationEvidence from this study confirms the association of ART with raised TG in SSA populations. Given the possible causal effect of raised TG on cardiovascular disease (CVD), the evidence highlights the need for prospective studies to clarify the impact of long term ART on CVD outcomes in SSA.

To evaluate the effectiveness of decentralizing ambulatory reproductive and intrapartum services to increase rates of antenatal care (ANC) utilization and skilled attendance at birth (SAB) in Rwanda. A prospective cohort study was implemented with one control and two intervention sites: decentralized ambulatory reproductive healthcare and decentralized intrapartum care. Multivariate logistic regression analysis was performed with primary outcome of lack of SAB and secondary outcome of ≥3 ANC visits. 536 women were entered in the study. Distance lived from delivery site significantly predicted SAB (p = 0.007), however distance lived to ANC site did not predict ≥3 ANC visits (p = 0.81). Neither decentralization of ambulatory reproductive healthcare (p = 0.10) nor intrapartum care (p = 0.40) was significantly associated with SAB. The control site had the greatest percentage of women receive ≥3 ANC visits (p < 0.001). Receiving

BACKGROUND Initiation of antiretroviral therapy (ART) in the advanced stages of HIV infection remains a major challenge in sub-Saharan Africa. This study was conducted to better understand barriers and enablers to timely ART initiation in Rwanda where ART coverage is high and national ART eligibility guidelines first expanded in 2007-2008. METHODS Using data on 6326 patients (≥15 years) at five Rwandan clinics, we assessed trends and correlates of CD4 cell count at ART initiation and the proportion initiating ART with advanced HIV disease (CD4

BACKGROUND Deworming human immunodeficiency virus (HIV)-infected individuals on antiretroviral therapy (ART) may be beneficial, particularly during pregnancy. We determined the efficacy of targeted and nontargeted antihelminth therapy and its effects on Plasmodium falciparum infection status, hemoglobin levels, CD4 counts, and viral load in pregnant, HIV-positive women receiving ART. METHODS Nine hundred eighty HIV-infected pregnant women receiving ART were examined at 2 visits during pregnancy and 2 postpartum visits within 12 weeks. Women were given antimalarials when malaria-positive whereas albendazole was given in a targeted (n = 467; treatment when helminth stool screening was positive) or nontargeted (n = 513; treatment at all time points, with stool screening) fashion. RESULTS No significant differences were noted between targeted and nontargeted albendazole treatments for the variables measured at each study visit except for CD4 counts, which were lower (P < .05) in the latter group at the final visit. Albendazole therapy was associated with favorable changes in subjects' hemoglobin levels, CD4 counts, and viral loads, particularly with helminth infections. CONCLUSIONS Antihelminthic therapy reduces detectable viral load, and increases CD4 counts and hemoglobin levels in pregnant HIV-infected women with helminth coinfections receiving ART.

It is not well understood how infection with HIV and prior experience of sexual violence affects sexual behavior in African women. We describe factors influencing current sexual practices of Rwandan women living with or without HIV/AIDS. By design, 75 % of participants were HIV positive and ~50 % reported having experienced genocidal rape. Univariate and multivariate logistic regression models were fit to describe demographic and clinical characteristics that influenced sexual behavior in the previous 6 months, condom use, history of transactional sex, and prior infection with a non-HIV sexually transmitted disease. Respondents' age, where they lived, whether or not they lived with a husband or partner, experience of sexual trauma, CD4 count, CES-D and PTSD scores were strongly associated with risky sexual behavior and infection with non-HIV STI. HIV positive women with a history of sexual violence in the contexts of war and conflict may be susceptible to some high-risk sexual behaviors.

Background: Sub-Saharan Africa (SSA) has the highest burden of HIV in the world and a rising prevalence of cardiometabolic disease; however, the interrelationship between HIV, antiretroviral therapy (ART) and cardiometabolic traits is not well described in SSA populations. Methods: We conducted a systematic review and meta-analysis through MEDLINE and EMBASE (up to January 2012), as well as direct author contact. Eligible studies provided summary or individuallevel data on one or more of the following traits in HIVþ and HIV-, or ARTþ and ART- subgroups in SSA: body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TGs) and fasting blood glucose (FBG) or glycated hemoglobin (HbA1c). Information was synthesized under a random-effects model and the primary outcomes were the standardized mean differences (SMD) of the specified traits between subgroups of participants. Results: Data were obtained from 49 published and 3 unpublished studies which reported on 29 755 individuals. HIV infection was associated with higher TGs [SMD, 0.26; 95% confidence interval (CI), 0.08 to 0.44] and lower HDL (SMD, 0.59; 95% CI, 0.86 to 0.31), BMI (SMD, 0.32; 95% CI, 0.45 to 0.18), SBP (SMD, 0.40; 95% CI, 0.55 to 0.25) and DBP (SMD, 0.34; 95% CI, 0.51 to 0.17). Among HIVþ individuals, ART use was associated with higher LDL (SMD, 0.43; 95% CI, 0.14 to 0.72) and HDL (SMD, 0.39; 95% CI, 0.11 to 0.66), and lower HbA1c (SMD, 0.34; 95% CI, 0.62 to 0.06). Fully adjusted estimates from analyses of individual participant data were consistent with meta-analysis of summary estimates for most traits. Conclusions: Broadly consistent with results from populations of European descent, these results suggest differences in cardiometabolic traits between HIV-infected and uninfected individuals in SSA, which might be modified by ART use. In a region with the highest burden of HIV, it will be important to clarify these findings to reliably assess the need for monitoring and managing cardiometabolic risk in HIV-infected populations in SSA. http://ije.oxfordjournals.org/ http://dx.doi.org/10.1093/ije/dyt198

We examined whether established associations between HIV disease and HIV disease progression on worse health-related quality of life (HQOL) were applicable to women with severe trauma histories, in this case Rwandan women genocide survivors, the majority of whom were HIV-infected. Additionally, this study attempted to clarify whether post-traumatic stress symptoms were uniquely associated with HQOL or confounded with depression.The Rwandan Women's Interassociation Study and Assessment was a longitudinal prospective study of HIV-infected and uninfected women. At study entry, 922 women (705 HIV+ and 217 HIV-) completed measures of symptoms of post-traumatic stress and HQOL as well as other demographic, clinical, and behavioral characteristics.Even after controlling for potential confounders and mediators, HIV+ women, in particular those with the lowest CD4 counts, scored significantly worse on HQOL and overall quality of life (QOL) than did HIV- women. Even after controlling for depression and HIV disease progression, women with more post-traumatic stress symptoms scored worse on HQOL and overall QOL than women with fewer post-traumatic stress symptoms.This study demonstrated that post-traumatic stress symptoms were independently associated with HQOL and overall QOL, independent of depression and other confounders or potential mediators. Future research should examine whether the long-term impact of treatment on physical and psychological symptoms of HIV and post-traumatic stress symptoms would generate improvement in HQOL.

The impact of malaria on anemia and the interplay with helminths underline the importance of addressing the interactions between HIV/AIDS, malaria and intestinal helminth infections in pregnancy. The aim of this study was to determine the prevalence of malaria-helminth dual infections among HIV positive pregnant mothers after 12 months of ART. A cross sectional study was conducted on intestinal helminths and malaria dual infections among HIV-positive pregnant women attending antenatal health centers in Rwanda. Stool and malaria blood slide examinations were performed on 328 women residing in rural (n = 166) and pen-urban locations (n = 162). BMI, CD4 cell count, hemoglobin levels, type of ART and viral load of participants were assessed. Within the study group, 38% of individuals harbored helminths, 21% had malaria and 10% were infected with both. The most prevalent helminth species were Ascaris lumbricoides (20.7%), followed by Trichuris trichiura (9.2%), and Ancylostoma duodenale and Necator americanus (1.2%). Helminth infections were characterized by low hemoglobin and CD4 counts. Subjects treated with a d4T, 3TC, NVP regimen had a reduced risk of T. trichiura infection (OR, 0.27; 95% Cls, 0.10-0.76; p

We determined the associations of HIV infection/CD4 count with markers of hepatocellular damage [elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT)] and liver synthetic function (decreased albumin) in HIV-infected (HIV+) antiretroviral therapy (ART)-naive and uninfected (HIV−) Rwandan women. In 2005, 710 HIV+ ART-naive and 226 HIV− women enrolled in the Rwanda Women's Interassociation Study and Assessment. Liver enzymes were measured with abnormality defined as either AST or ALT ≥1.25 times the upper limit of normal. Low serum albumin level was defined as 350 (p

BackgroundWe longitudinally assessed predictors of insulin resistance (IR) change among HIV-uninfected and HIV-infected (ART-initiators and ART-non-initiators) Rwandan women.MethodologyHIV-infected (HIV+) and uninfected (HIV-) women provided demographic and clinical measures: age, body mass index (BMI) in Kg/(height in meters)2, Fat-Mass (FMI) and Fat-Free-Mass (FFMI) index, fasting serum glucose and insulin. Homeostasis Model Assessment (HOMA) was calculated to estimate IR change over time in log10 transformed HOMA measured at study enrollment or prior to ART initiation in 3 groups: HIV- (n = 194), HIV+ ART-non-initiators (n=95) and HIV+ ART-initiators (n=371). ANCOVA linear regression models of change in log10-HOMA were fit with all models included the first log10 HOMA as a predictor.ResultsMean±SD log10-HOMA was -0.18±0.39 at the 1st and -0.21±0.41 at the 2nd measure, with mean change of 0.03±0.44. In the final model (all women) BMI at 1st HOMA measure (0.014; 95% CI=0.006-0.021 per kg/m2; pConclusionsBaseline BMI and change in BMI, and in particular fat mass and change in fat mass predicted insulin resistance change over ~3 years in HIV-infected and uninfected Rwandan women. Exposure to specific ART (d4T, AZT, EFV) did not predict insulin resistance change in ART-treated HIV-infected Rwandan women.

Objective To examine the prevalence of reported shingles in the last 6 months and its association with post-traumatic stress disorder (PTSD), depression and severity of HIV disease in Rwandan women with HIV. Settings This cross-sectional study was conducted as part of the Rwanda Women's Interassociation Study and Assessment (RWISA), an observational cohort study designed to assess the impact of HIV and residual factors from experiencing rape in the 1994 genocide in Rwandan women. Participants were recruited through grassroots women's associations of people living with HIV infection and clinical care sites for HIV infection. Most participants (58.5%, n=405/692) had PTSD. Participants This cross-sectional analysis was conducted in 710 HIV-infected women enrolled in RWISA. Inclusion criteria were: age >15 years, informed consent, HIV test, ability to complete the interview in the local language, travel to and from the research site and participate in a baseline outpatient visit, and being naive to antiretroviral therapy at enrolment. Primary and secondary outcome measures The outcome of interest was self-reported shingles in the past 6 months. The exposure was PTSD defined using the cross-culturally validated Harvard Trauma Questionnaire. Results Overall prevalence of reported shingles in the past 6 months was 12.5% (n=89/710). There was an inverse relationship between shingles prevalence and immunological status: 7.6%, 12.3% and 16.7% of women with CD4 >350, 200–350 and

HIV infected individuals in malaria endemic areas experience more frequent and severe malaria episodes compared to non HIV infected. This clinical observation has been linked to a deficiency in antibody responses to Plasmodium falciparum antigens; however, prior studies have only focused on the antibody response to

The global prevalence of gestational diabetes (GDM) in pregnant 20-49 year old women has increased to 16.9%, although data from Africa on GDM are scarce, and risk exposure to pregnant women is unknown. Among the 288 pregnant women screened in Rwanda, 8.3% of women with FPG >126 mg/dL (>6.9 mmol/L) had GDM. Age >41 years (45.8% vs. 18.9%; p

After the genocide in Rwanda, the country's healthcare system collapsed. Remarkable gains have since been made by the state to provide greater clinical service capacity and expand health policies that are grounded on locally relevant evidence. This commentary explores the challenges faced by Rwanda in building an infrastructure for clinical trials. Through local examples, we discuss how a clinical trial infrastructure can be constructed by (1) building educational capacity; (2) encouraging the testing of relevant interventions using appropriate and cost-effective designs; and, (3) promoting ethical and regulatory standards. The future is bright for clinical research in Rwanda and with a renewed appetite for locally generated evidence it is necessary that we discuss the challenges and opportunities in drawing up a clinical trials agenda.

SETTING: Drug resistance threatens tuberculosis (TB) control, particularly among human immunodeficiency virus (HIV) infected persons.OBJECTIVE: To describe practices in the prevention and management of drug-resistant TB under antiretroviral therapy (ART) programs in lower-income countries.DESIGN: We used online questionnaires to collect program-level data on 47 ART programs in Southern Africa (n = 14), East Africa (n = 8), West Africa (n = 7), Central Africa (n = 5), Latin America (n = 7) and the Asia-Pacific (n = 6 programs) in 2012. Patient-level data were collected on 1002 adult TB patients seen at 40 of the participating ART programs.RESULTS: Phenotypic drug susceptibility testing (DST) was available in 36 (77%) ART programs, but was only used for 22% of all TB patients. Molecular DST was available in 33 (70%) programs and was used in 23% of all TB patients. Twenty ART programs (43%) provided directly observed therapy (DOT) during the entire course of treatment, 16 (34%) during the intensive phase only, and 11 (23%) did not follow DOT. Fourteen (30%) ART programs reported no access to second-line anti-tuberculosis regimens; 18 (38%) reported TB drug shortages.CONCLUSIONS: Capacity to diagnose and treat drug-resistant TB was limited across ART programs in lower-income countries. DOT was not always implemented and drug supplies were regularly interrupted, which may contribute to the global emergence of drug resistance.

Plasmodium falciparum infection can result in severe disease that is associated with elevated inflammation and vital organ dysfunction; however, malaria-endemic residents gain protection from lethal outcomes and manifest only mild symptoms during infection. To characterize host responses associated with this more effective antimalarial response, we characterized whole-blood transcriptional profiles in Rwandan adults during a mild malaria episode and compared them with findings from a convalescence sample. We observed transcriptional up-regulation in many pathways, including type I interferon, interferon γ, complement activation, and nitric oxide during malaria infection, which provide benchmarks of mild disease physiology. Transcripts encoding negative regulators of T-cell activation, such as programmed death ligand 1 (PD-L1), programmed death 1 ligand 2 (PD-L2), and the butyrophilin family member butyrophilin-like 2 (BTNL2) were also increased. To support an important functional role for BTNL2 during malaria infection, we studied chimeric mice reconstituted with BTNL2(-/-) or wild-type hematopoietic cells that were inoculated with Plasmodium berghei ANKA, a murine model of cerebral malaria. We found that BTNL2(-/-) chimeric mice had a significant decrease in survival compared with wild-type counterparts. Collectively these data characterize the immune responses associated with mild malaria and uncover a novel role for BTNL2 in the host response to malaria.

In contrast to prior studies, mild malaria infection had no impact on HIV Viral Loads(VL) in Rwanda. Over fifty percent of patients prescribed ARV had detectable VL; 25% had genotypic resistance. Eleven percent of patients with mild malaria were newly diagnosed with HIV., Background Plasmodium falciparum infection has been reported to increase human immunodeficiency virus (HIV) viral load (VL), which can facilitate HIV transmission. We prospectively studied the impact of mild P falciparum coinfection on HIV VL in Rwanda. Methods We measured plasma HIV VL at presentation with malaria infection and weekly for 4 weeks after artemether-lumefantrine treatment in Rwandan adults infected with HIV with P falciparum malaria. Regression analyses were used to examine associations between malaria infection and HIV VL changes. Samples with detectable virus underwent genotypic drug-resistance testing. Results We enrolled 28 HIV-malaria coinfected patients and observed 27 of them for 5 weeks. Three patients (11%) were newly diagnosed with HIV. Acute P falciparum infection had no significant effect on HIV VL slope over 28 days of follow-up. Ten patients with VL

As individuals affected by HIV/AIDS live longer due to the availability of HAART, the challenge to health care professionals is to manage and alleviate abnormalities associated with HAART. HIVlipodystrophy- altered body fat redistribution- is the most common stigmatising physical abnormality related to the use of HAART, which maybe alleviated by exercise participation. Currently, there is no reliable management standard care for HIV-associated lipodystrophy. However, there is sufficient evidence to support the benefits of exercise in adults with HIV infection. As various types of ARTs become available in the most HIV/AIDS stricken developing countries, there are inadequate studies to evaluate and promote exercise in alleviating HIV lipodystrophy and other related complications. The current paper reviews HIV-related lipodystrophy, related metabolic dysfunction, and the role of exercise in its management. The paper highlights the need to evaluate the effectiveness of exercise on HIV lipodystrophy syndrome. An emphasis needs to be put on raising awareness among health care professionals in Sub-Saharan Africa where the prevalence of HIV/AIDS is the highest in the world.

Urgent need exists for improved psychological services among HIV-infected women in post-genocide Rwanda. Psychological problems associated with trauma and sexual violence (i.e., depression, posttraumatic stress disorder [PTSD]) place women at increased risk for sexual risk behaviour, low health-seeking behaviour, delay of antiretroviral therapy (ART) and reduced ART adherence. We explored experiences of HIV-infected Rwandan women attending psychosocial support groups and their narratives about how participation affected their mental health and HIV treatment. Focus group discussions examined participants' reasons for support group attendance, perceived psychological benefit of support groups, influence on ART adherence, and other influences on health behaviors and attitudes. Rwandan women (aged 18-65) were randomly selected from 10 health clinic-facilitated support groups for HIV-infected trauma survivors in Kigali. Results identified positive psychological and physical changes as well as behaviour changes in relationships with men, which participants attributed to support group attendance. Data showed significant improvement in mental health, ART adherence and HIV serostatus disclosure resulting from group attendance. Participants acknowledged limitations of support groups with respect to addressing poverty and hunger. Implementing psychosocial support groups may leverage clinical outcomes and rejuvenate the well-being of HIV-infected women with interpersonal trauma and/or PTSD and depressive symptoms, particularly those from post-conflict countries.

Introduction Lipodystrophy is common in patients infected with human immunodeficiency virus receiving highly active antiretroviral therapy, and presents with morphologic changes and metabolic alterations that are associated with depressive behavior and reduced quality of life. We examined the effects of exercise training on morphological changes, lipid profile and quality of life in a woman with human immunodeficiency virus presenting with lipodystrophy. Case presentation A 31-year-old Latin-American Caucasian woman infected with human immunodeficiency virus participated in a 12-week progressive resistance exercise training program with an aerobic component. Her weight, height, skinfold thickness, body circumferences, femur and humerus diameter, blood lipid profile, maximal oxygen uptake volume, exercise duration, strength and quality of life were assessed pre-exercise and post-exercise training. After 12 weeks, she exhibited reductions in her total subcutaneous fat (18.5%), central subcutaneous fat (21.0%), peripheral subcutaneous fat (10.7%), waist circumference (WC) (4.5%), triglycerides (9.9%), total cholesterol (12.0%) and low-density lipoprotein cholesterol (8.6%). She had increased body mass (4.6%), body mass index (4.37%), humerus and femur diameter (3.0% and 2.3%, respectively), high-density lipoprotein cholesterol (16.7%), maximal oxygen uptake volume (33.3%), exercise duration (37.5%) and strength (65.5%). Quality of life measures improved mainly for psychological and physical measures, independence and social relationships. Conclusions These findings suggest that supervised progressive resistance exercise training is a safe and effective treatment for evolving morphologic and metabolic disorders in adults infected with HIV receiving highly active antiretroviral therapy, and improves their quality of life.

Background: Scale-up of highly active antiretroviral treatment therapy (HAART) programs in Rwanda has been highly successful but data on adherence is limited. We examined HAART adherence in a large cohort of HIV+ Rwandan women. Methods: The Rwanda Women’s Interassociation Study Assessment (RWISA) was a prospective cohort study that assessed effectiveness and toxicity of ART. We analyzed patient data 1263 months after HAART initiation to determine adherence rates in HIV+ women who had initiated HAART. Results: Of the 710 HIV+ women at baseline, 490 (87.2%) initiated HAART. Of these, 6 (1.2%) died within 12 months, 15 others (3.0%) discontinued the study and 80 others (19.0%) remained in RWISA but did not have a post-HAART initiation visit that fell within the 1263 month time points leaving 389 subjects for analysis. Of these 389, 15 women stopped their medications without being advised to do so by their doctors. Of the remaining 374 persons who reported current HAART use 354 completed the adherence assessment. All women, 354/354, reported 100% adherence to HAART at the post-HAART visit. The high self-reported level of adherence is supported by changes in laboratory measures that are influenced by HAART. The median (interquartile range) CD4 cell count measured within 6 months prior to HAART initiation was 185 (128, 253) compared to 264 (182, 380) cells/mm 3 at the post-HAART visit. Similarly, the median (interquartile range) MCV within 6 months prior to HAART initiation was 88 (83, 93) fL compared to 104 (98, 110) fL at the 1263 month visit. Conclusion: Self-reported adherence to antiretroviral treatment 1263 months after initiating therapy was 100% in this cohort of HIV-infected Rwandan women. Future studies should explore country-specific factors that may be contributing to high levels of adherence to HAART in this population.

Background Body mass index (BMI) independently predicts mortality in studies of HIV infected patients initiating antiretroviral therapy (ART). We hypothesized that poorer nutritional status would be associated with smaller gains in CD4 count in Rwandan women initiating ART. Methods and Findings The Rwandan Women's Interassociation Study and Assessment, enrolled 710 ART-naive HIV-positive and 226 HIV-negative women in 2005 with follow-up every 6 months. The outcome assessed in this study was change in CD4 count at 6, 12, and 24 months after ART initiation. Nutritional status measures taken prior to ART initiation were BMI; height adjusted fat free mass (FFMI); height adjusted fat mass (FMI), and sum of skinfold measurements. 475 women initiated ART. Mean (within 6 months) pre-ART CD4 count was 216 cells/µL. Prior to ART initiation, the mean (±SD) BMI was 21.6 (±3.78) kg/m2 (18.3% malnourished with BMI

Background: Although cervical cancer is an AIDS-defining condition, infection with human immunodeficiency virus (HIV) may only modestly increase the risk of cervical cancer. There is a paucity of information regarding factors that influence the natural history of human papillomavirus (HPV) in HIV-infected women. We examined factors associated with cervical intraepithelial neoplasia grade 3 or cancer (CIN3+) in Rwandan women infected with both HIV and HPV (HIV+/HPV+). Methods: In 2005, 710 HIV+ Rwandan women $25 years enrolled in an observational cohort study; 476 (67%) tested HPV+. Each woman provided sociodemographic data, CD4 count, a cervical cytology specimen and cervicovaginal lavage (CVL), which was tested for .40 HPV genotypes by MY09/MY11 PCR assay. Logistic regression models calculated odds ratios (OR) and 95% confidence intervals (CI) of associations of potential risk factors for CIN3+ among HIV+/HPV+ women. Results: Of the 476 HIV+/HPV+ women 42 (8.8%) were diagnosed with CIN3+. Factors associated with CIN3+ included $7 (vs. 0-2) pregnancies, malarial infection in the previous six months (vs. never), and $7 (vs. 0-2) lifetime sexual partners. Compared to women infected by non-HPV16 carcinogenic HPV genotypes, HPV16 infection was positively associated and non-carcinogenic HPV infection was inversely associated with CIN3+. CD4 count was significantly associated with CIN3+ only in analyses of women with non-HPV16 carcinogenic HPV (OR=0.62 per 100 cells/mm 3 , CI=0.40-0.97). Conclusions: In this HIV+/HPV+ population, lower CD4 was significantly associated with CIN3+ only in women infected with carcinogenic non-HPV16. We found a trend for higher risk of CIN3+ in HIV+ women reporting recent malarial infection; this association should be investigated in a larger group of HIV+/HPV+ women.

Infections by 15–20 cancer-associated (“carcinogenic”) human papillomavirus (HPV) types cause virtually all cervical cancers and their immediate precursor lesions [1]. HPV-16 and HPV-18 are the most important HPV types, causing ~70% of cancers and 50%– 60% of cervical precancerous lesions. Recently developed prophylactic HPV vaccines targeting HPV-16 and HPV-18 have demonstrated >90% efficacy against these types in unexposed women; the next generation of vaccines may target a broader array of HPV types [2– 6]. Because the vaccine does not provide complete protection and is not currently affordable in many regions, and because a substantial number of women have already been exposed to HPV, screening for HPV infection and/or cervical neoplasia continues to be necessary to reduce the risk of cervical cancer. Worldwide, >80% of cervical cancer incidence and mortality occur in resource-limited regions, where women are medically underserved and have little or no access to preventive health services [7]. Data from developing countries on the overall prevalence of HPV and carcinogenic HPV infection, age-specific prevalence, and the most important HPV types are thus needed to inform rational implementation of HPV vaccination and screening strategies in these areas. Knowledge of the median age of sexual debut in the population and of the peak of age-specific prevalence is useful for the timing of HPV vaccination, which is highly effective in preventing infection but does not treat preexisting infections [2– 6, 8 –10]. The prevalence of HPV infection among older women will help determine which screening method should be considered, because excessive prevalence of HPV infection will render HPV testing too nonspecific for cervical precancer and cancer detection to be clinically useful. Africa, along with Latin America, bears the greatest burden of cervical cancer globally [11]. Regional and, preferably, local data on HPV infection are thus needed to guide these decisions in politically, religiously, and economically diverse continents. Most data on HPV infection prevalence among human immunodeficiency virus (HIV)–infected women from Africa come from a few countries, including Uganda, Senegal, and South Africa. It is unclear how representative these sites are in relation to regional HPV infection patterns in other African countries. The prevalence of HPV infection can vary significantly between adjacent regions with similar ethnic and cultural identities, owing to recent social and political upheaval, as observed in North and South Vietnam [12]. In 1994, Rwanda was dramatically affected by rape, violence, and social upheaval, and cytology-based cervical cancer prevention screening is not currently available for most Rwandan women. There are few data on HIV infection, HPV infection, and cervical cancer in Rwanda, owing to limited research and public health infrastructure, including the loss of many expert health care workers during the 1994 genocide. During 1991–1993, cervical cancer was the most common malignancy among Rwandan women, accounting for 22% of all cancer cases among women in the Butare prefecture [13]. Cervical cancer precursors were also common, especially among HIV-infected women, with squamous intraepithelial lesions (SILs) of the cervix found in 24% and high-grade SILs (HSILs) in 10% of HIV-infected pregnant women in a 1992–1993 Rwandan survey [14]. A more recent retrospective study conducted in 2005 found that cervical cancer represented 27% of diagnosed cancer cases among women [15]. We report here an epidemiologic study performed to characterize the spectrum of HPV types in HIV-positive and HIV-negative Rwandan women and to identify risk factors for HPV infection among these women. These data are essential for developing cost-effective cervical cancer prevention programs in Rwanda.

Our objective was to examine the effects of exercise training (EXS) on quality of life (QoL) in highly active antiretroviral therapy (HAART)-treated HIV-positive (HIV+) subjects with body fat redistribution (BFR) in Rwanda.The effects of a randomised controlled trial of EXS on QoL were measured using World Health Organisation Quality of Life (WHOQOL)-BREF in HIV+ subjects with BFR randomised to EXS (n = 50; BFR + EXS) or no exercise training (n = 50; BFR + noEXS).At 6 months, scores on the psychological [1.3 (0.3) vs. 0.5 (0.1); P0.0001], independence [0.6 (0.1) vs. 0.0 (0.0); P0.0001], social relationships [0.6 (0.2) vs. 0.0 (0.0); P0.0001] and HIV HAART-specific QoL domains [1.4 (0.2) vs. -0.1 (0.2); P0.0001] improved more in BFR + EXS than BFR + noEXS group, respectively. Self-esteem [1.3 (0.8) vs. 0.1 (0.6); P0.001], body image [1.5 (0.6) vs. 0.0 (0.5); P0.001] and emotional stress [1.6 (0.7) vs. 0.2 (0.5); P0.001] improved more in the BFR + EXS group than BFR + noEXS group, respectively. Psychological [1.5 (0.2) vs. 1.1 (0.3); P0.0001], social relationship [0.8 (0.2) vs. 0.4 (0.2); P0.0001], and HIV HAART-specific well-being [1.8 (0.2) vs. 1.0 (0.0); P0.0001] improved more in BFR + EXS female than male subjects.Exercise training improved several components of QoL in HAART-treated HIV+ African subjects with BFR. Exercise training is an inexpensive and efficacious strategy for improving QoL in HIV+ African subjects, which may improve HAART adherence and treatment initiatives in resource-limited areas of sub-Saharan Africa.

As HAART becomes more accessible in sub-Saharan Africa, metabolic syndromes, body fat redistribution (BFR), and cardiovascular disease may become more prevalent. We conducted a 6-month, randomized controlled trial to test whether cardiorespiratory exercise training (CET), improves metabolic, body composition and cardiorespiratory fitness parameters in HAART-treated HIV(+) African subjects with BFR. Six months of CET reduced waist circumference (-7.13 +/- 4.4 cm, p < 0.0001), WHR (-0.10 +/- 0.1, p < 0.0001), sum skinfold thickness (-6.15 +/- 8.2 mm, p < 0.0001) and % body fat mass (-1.5 +/- 3.3, p < 0.0001) in HIV(+)BFR(+)EXS. Hip circumference was unchanged in non-exercise control groups. CET reduced fasting total cholesterol (-0.03 +/- 1.11 mM, p < 0.05), triglycerides (-0.22 +/-0.48 mM, p < 0.05) and glucose levels (-0.21 +/- 0.71 mM, p < 0.05) (p < 0.0001). HDL-, LDL-cholesterol and HOMA values were unchanged after CET. Interestingly, HIV(+) subjects randomized to non-exercising groups experienced increases in fasting plasma glucose levels, whereas HIV seronegative controls did not (p < 0.001). Predicted VO(2) peak increased more in the HIV(+)BFR(+)EXS than in all other groups (4.7 +/- 3.9 ml/kg/min, p < 0.0001). Exercise training positively modulated body composition and metabolic profiles, and improved cardiorespiratory fitness in HAART-treated HIV(+) Africans. These beneficial adaptations imply that exercise training is a safe, inexpensive, practical, and effective treatment for evolving metabolic and cardiovascular syndromes associated with HIV and HAART exposure in resource-limited sub-Saharan countries, where treatment is improving, morbidity and mortality rates are declining, but where minimal resources are available to manage HIVand HAART-associated cardiovascular and metabolic syndromes.

The advent of highly active antiretroviral therapy (HAART) has transformed human immunodeficiency virus (HIV)/AIDS into a manageable chronic disorder. Clinical care, however, needs to address the metabolic, anthropometric, and cardiovascular changes associated with HIV infection and HAART. Studies in developing countries suggest an increasing incidence of HIV-associated cardiometabolic syndrome (CMS), especially in urban settings. Predictions indicate that the greatest increase in the prevalence of diabetes will occur in Africa over the next 2 decades due to lifestyle changes. This, coupled with increased access to HAART, may exponentially increase the prevalence of CMS in developing countries, where HIV infection is prevalent. Appropriate evaluation and intervention programs need to be implemented in the developing world, especially sub-Saharan Africa, to curtail HIV-related CMS. This should include routine cardiovascular risk assessments, management of HIV infection with more "metabolically friendly" HAART, and encouragement of lifestyle modifications, particularly smoking cessation, weight management, regular exercise, and adherence to a healthy diet.

This study measured the prevalence of lipodystrophy and the metabolic effects of highly active antiretroviral therapy (HAART) in HIV-infected African subjects. Prevalence was measured in 571 Rwandans receiving HAART for $6 months. Metabolic variables were measured in 100 HIV-positive adults with lipodystrophy 50 HIV-positive nonlipodystrophic adults and 50 HIV-negative controls. A HAART regimen of stavudine lamivudine and nevirapine was used by 81.6% of subjects; none received protease inhibitors. Lipodystrophy was observed in 34% (48.5% in urban groups and 17.3% in rural groups) of subjects with a prevalence of 69.6% in those receiving HAART for .72 weeks. Peripheral lipoatrophy combined with abdominal lipohypertrophy was observed in 72% of lipodystrophic subjects. HIV-positive adults with lipodystrophy had a significantly higher waist-to-hip ratio (WHR; 0.99 +or- 0.05 vs. 0.84 +or- 0.03: P < 0.0005) than HIV-positive nonlipodystrophic adults. Total cholesterol concentrations (median [interquartile range] mmol/L) were significantly higher in the HIV-positive adults with lipodystrophy (3.60 [1.38]) than in HIV-positive nonlipodystrophic adults (3.19 [0.65]; P < 0.005) and control (3.13 [0.70]; P < 0.0005) groups. Impaired fasting glucose was observed in 18% of HIV-positive adults with lipodystrophy 16% of HIV-positive nonlipodystrophic adults and 2% of controls but insulin levels did not differ. African subjects with lipodystrophy have increased WHR glucose and cholesterol levels. Glucose concentrations are also elevated in nonlipodystrophic HIV-positive subjects. Therefore factors other than body fat redistribution contribute to the glucose intolerance. (authors)