Browsing by Author "Oni, Tolu"

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    Analysis of Cameroon’s Sectoral Policies on Physical Activity for Noncommunicable Disease Prevention
    (2021-12-02) Tatah, Lambed; Mapa-Tassou, Clarisse; Shung-King, Maylene; Oni, Tolu; Woodcock, James; Weimann, Amy; McCreedy, Nicole; Muzenda, Trish; Govia, Ishtar; Mbanya, Jean Claude; Assah, Felix
    Physical inactivity is increasing in low- and middle-income countries (LMICs), where noncommunicable diseases (NCDs), urbanisation and sedentary living are rapidly growing in tandem. Increasing active living requires the participation of multiple sectors, yet it is unclear whether physical activity (PA)-relevant sectors in LMICs are prioritising PA. We investigated to what extent sectors that influence PA explicitly integrate it in their policies in an LMIC such as Cameroon. We systematically identified policy documents relevant to PA and NCD prevention in Cameroon; and using the Walt and Gilson policy triangle we described, analysed, and interpreted the policy contexts, contents, processes, and actors. We found 17 PA and NCD policy documents spanning from 1974 to 2019 across seven ministries. Thirteen (13/17) policies targeted infrastructure improvement, and four (4/17) targeted communication for behaviour change, all aiming to enhance leisure domain PA. Only the health sector explicitly acknowledged the role of PA in NCD prevention. Notably, no policy from the transport sector mentioned PA. Our findings highlight the need for intersectoral action to integrate PA into policies in all relevant sectors. These actions will need to encompass the breadth of PA domains, including transport, while emphasising the multiple health benefits of PA for the population.
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    Association of Perceived Neighbourhood Walkability with Self-Reported Physical Activity and Body Mass Index in South African Adolescents
    (Multidisciplinary Digital Publishing Institute, 2023-01-30) Wayas, Feyisayo A.; Smith, Joanne A.; Lambert, Estelle V.; Guthrie-Dixon, Natalie; Wasnyo, Yves; West, Sacha; Oni, Tolu; Foley, Louise
    Adolescence is a life stage critical to the establishment of healthy behaviours, including physical activity (PA). Factors associated with the built environment have been shown to impact PA across the life course. We examined the sociodemographic differences in, and associations between, perceived neighbourhood walkability, PA, and body mass index (BMI) in South African adolescents. We recruited a convenience sample (n = 143; 13–18 years; 65% female) of students from three high schools (middle/high and low-income areas). Participants completed a PA questionnaire and the Neighbourhood Environment Walkability Scale (NEWS)-Africa and anthropometry measurements. Multivariable linear regression was used to examine various relationships. We found that, compared with adolescents living in middle/high income neighbourhoods, those living in low-income neighbourhoods had lower perceived walkability and PA with higher BMI percentiles. The associations between neighbourhood walkability and PA were inconsistent. In the adjusted models, land use diversity and personal safety were associated with club sports participation, street connectivity was positively associated with school sports PA, and more favourable perceived walkability was negatively associated with active transport. Overall, our findings suggest that the perceived walkability of lower income neighbourhoods is worse in comparison with higher income neighbourhoods, though the association with PA and BMI is unclear.
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    Cardio-thoracic ratio is stable, reproducible and has potential as a screening tool for HIV-1 related cardiac disorders in resource poor settings
    (Public Library of Science, 2016) Esmail, Hanif; Oni, Tolu; Thienemann, Friedrich; Omar-Davies, Nashreen; Wilkinson, Robert J; Ntsekhe, Mpiko
    BACKGROUND: Cardiovascular disorders are common in HIV-1 infected persons in Africa and presentation is often insidious. Development of screening algorithms for cardiovascular disorders appropriate to a resource-constrained setting could facilitate timely referral. Cardiothoracic ratio (CTR) on chest radiograph (CXR) has been suggested as a potential screening tool but little is known about its reproducibility and stability. Our primary aim was to evaluate the stability and the inter-observer variability of CTR in HIV-1 infected outpatients. We further evaluated the prevalence of cardiomegaly (CTR≥0.5) and its relationship with other risk factors in this population. METHODOLOGY: HIV-1 infected participants were identified during screening for a tuberculosis vaccine trial in Khayelitsha, South Africa between August 2011 and April 2012. Participants had a digital posterior-anterior CXR performed as well as history, examination and baseline observations. CXRs were viewed using OsiriX software and CTR calculated using digital callipers. RESULTS: 450 HIV-1-infected adults were evaluated, median age 34 years (IQR 30-40) with a CD4 count 566/mm 3 (IQR 443-724), 70% on antiretroviral therapy (ART). The prevalence of cardiomegaly was 12.7% (95% C.I. 9.6%-15.8%). CTR was calculated by a 2 nd reader for 113 participants, measurements were highly correlated r = 0.95 (95% C.I. 0.93-0.97) and agreement of cardiomegaly substantial κ = 0.78 (95% C.I 0.61-0.95). CXR were repeated in 51 participants at 4-12 weeks, CTR measurements between the 2 time points were highly correlated r = 0.77 (95% C.I 0.68-0.88) and agreement of cardiomegaly excellent κ = 0.92 (95% C.I. 0.77-1). Participants with cardiomegaly had a higher median BMI (31.3; IQR 27.4-37.4) versus 26.9; IQR 23.2-32.4); p<0.0001) and median systolic blood pressure (130; IQR 121-141 versus 125; IQR 117-135; p = 0.01). CONCLUSION: CTR is a robust measurement, stable over time with substantial inter-observer agreement. A prospective study evaluating utility of CXR to identify cardiovascular disorder in this population is warranted.
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    Chronic diseases and multi-morbidity - a conceptual modification to the WHO ICCC model for countries in health transition
    (BioMed Central, 2014-06-09) Oni, Tolu; McGrath, Nuala; BeLue, Rhonda; Roderick, Paul; Colagiuri, Stephen; May, Carl R; Levitt, Naomi S
    Background: The burden of non-communicable diseases is rising, particularly in low and middle-income countries undergoing rapid epidemiological transition. In sub-Saharan Africa, this is occurring against a background of infectious chronic disease epidemics, particularly HIV and tuberculosis. Consequently, multi-morbidity, the co-existence of more than one chronic condition in one person, is increasing; in particular multimorbidity due to comorbid non-communicable and infectious chronic diseases (CNCICD). Such complex multimorbidity is a major challenge to existing models of healthcare delivery and there is a need to ensure integrated care across disease pathways and across primary and secondary care. Discussion: The Innovative Care for Chronic Conditions (ICCC) Framework developed by the World Health Organization provides a health systems roadmap to meet the increasing needs of chronic disease care. This framework incorporates community, patient, healthcare and policy environment perspectives, and forms the cornerstone of South Africa’s primary health care re-engineering and strategic plan for chronic disease management integration. However, it does not significantly incorporate complexity associated with multimorbidity and CNCICD. Using South Africa as a case study for a country in transition, we identify gaps in the ICCC framework at the micro-, meso-, and macro-levels. We apply the lens of CNCICD and propose modification of the ICCC and the South African Integrated Chronic Disease Management plan. Our framework incorporates the increased complexity of treating CNCICD patients, and highlights the importance of biomedicine (biological interaction). We highlight the patient perspective using a patient experience model that proposes that treatment adherence, healthcare utilization, and health outcomes are influenced by the relationship between the workload that is delegated to patients by healthcare providers, and patients’ capacity to meet the demands of this workload. We link these issues to provider perspectives that interact with healthcare delivery and utilization. Summary: Our proposed modification to the ICCC Framework makes clear that healthcare systems must work to make sense of the complex collision between biological phenomena, clinical interpretation, beliefs and behaviours that follow from these. We emphasize the integration of these issues with the socio-economic environment to address issues of complexity, access and equity in the integrated management of chronic diseases previously considered in isolation.
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    Completion of isoniazid preventive therapy and factors associated with non-completion in an antiretroviral therapy-naive HIV-infected cohort in Cape Town by Tolu Oni.
    (2012) Oni, Tolu; Coetzee, David
    TB incidence in South Africa remains high, despite high rates of successful treatment suggesting ongoing transmission and a large reservoir of latently infected persons. Isoniazid preventive therapy (IPT) is recommended as preventive therapy in HIV-infected persons. However, implementation has been slow, impeded by barriers and challenges including the fear of non-adherence. A protocol was therefore written to conduct a study to measure IPT completion rates and evaluate predictors of non-completion of a six-month IPT course in Khayelitsha, an informal township in Cape Town. Prior to data analysis, a structured literature review was conducted to assess available evidence particularly from high-burden settings on IPT completion rates and factors associated with loss to follow up.
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    Detectable changes in the blood transcriptome are present after two weeks of antituberculosis therapy
    (Public Library of Science, 2012) Bloom, Chloe I; Graham, Christine M; Berry, Matthew P R; Wilkinson, Katalin A; Oni, Tolu; Rozakeas, Fotini; Xu, Zhaohui; Rossello-Urgell, Jose; Chaussabel, Damien; Banchereau, Jacques
    Rationale: Globally there are approximately 9 million new active tuberculosis cases and 1.4 million deaths annually . Effective antituberculosis treatment monitoring is difficult as there are no existing biomarkers of poor adherence or inadequate treatment earlier than 2 months after treatment initiation. Inadequate treatment leads to worsening disease, disease transmission and drug resistance. Objectives To determine if blood transcriptional signatures change in response to antituberculosis treatment and could act as early biomarkers of a successful response. METHODS: Blood transcriptional profiles of untreated active tuberculosis patients in South Africa were analysed before, during (2 weeks and 2 months), at the end of (6 months) and after (12 months) antituberculosis treatment, and compared to individuals with latent tuberculosis. An active-tuberculosis transcriptional signature and a specific treatment-response transcriptional signature were derived. The specific treatment response transcriptional signature was tested in two independent cohorts. Two quantitative scoring algorithms were applied to measure the changes in the transcriptional response. The most significantly represented pathways were determined using Ingenuity Pathway Analysis. RESULTS: An active tuberculosis 664-transcript signature and a treatment specific 320-transcript signature significantly diminished after 2 weeks of treatment in all cohorts, and continued to diminish until 6 months. The transcriptional response to treatment could be individually measured in each patient. CONCLUSIONS: Significant changes in the transcriptional signatures measured by blood tests were readily detectable just 2 weeks after treatment initiation. These findings suggest that blood transcriptional signatures could be used as early surrogate biomarkers of successful treatment response.
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    Detection of tuberculosis in HIV-infected and-uninfected African adults using whole blood RNA expression signatures: a case-control study
    (Public Library of Science, 2013) Kaforou, Myrsini; Wright, Victoria J; Oni, Tolu; French, Neil; Anderson, Suzanne T; Bangani, Nonzwakazi; Banwell, Claire M; Brent, Andrew J; Crampin, Amelia C; Dockrell, Hazel M
    Background: A major impediment to tuberculosis control in Africa is the difficulty in diagnosing active tuberculosis (TB), particularly in the context of HIV infection. We hypothesized that a unique host blood RNA transcriptional signature would distinguish TB from other diseases (OD) in HIV-infected and -uninfected patients, and that this could be the basis of a simple diagnostic test. Methods and Findings: Adult case-control cohorts were established in South Africa and Malawi of HIV-infected or -uninfected individuals consisting of 584 patients with either TB (confirmed by culture of Mycobacterium tuberculosis [M.TB] from sputum or tissue sample in a patient under investigation for TB), OD (i.e., TB was considered in the differential diagnosis but then excluded), or healthy individuals with latent TB infection (LTBI). Individuals were randomized into training (80%) and test (20%) cohorts. Blood transcriptional profiles were assessed and minimal sets of significantly differentially expressed transcripts distinguishing TB from LTBI and OD were identified in the training cohort. A 27 transcript signature distinguished TB from LTBI and a 44 transcript signature distinguished TB from OD. To evaluate our signatures, we used a novel computational method to calculate a disease risk score (DRS) for each patient. The classification based on this score was first evaluated in the test cohort, and then validated in an independent publically available dataset (GSE19491). In our test cohort, the DRS classified TB from LTBI (sensitivity 95%, 95% CI [87–100]; specificity 90%, 95% CI [80–97]) and TB from OD (sensitivity 93%, 95% CI [83–100]; specificity 88%, 95% CI [74–97]). In the independent validation cohort, TB patients were distinguished both from LTBI individuals (sensitivity 95%, 95% CI [85–100]; specificity 94%, 95% CI [84–100]) and OD patients (sensitivity 100%, 95% CI [100–100]; specificity 96%, 95% CI [93–100]). Limitations of our study include the use of only culture confirmed TB patients, and the potential that TB may have been misdiagnosed in a small proportion of OD patients despite the extensive clinical investigation used to assign each patient to their diagnostic group. Conclusions: In our study, blood transcriptional signatures distinguished TB from other conditions prevalent in HIV-infected and -uninfected African adults. Our DRS, based on these signatures, could be developed as a test for TB suitable for use in HIV endemic countries. Further evaluation of the performance of the signatures and DRS in prospective populations of patients with symptoms consistent with TB will be needed to define their clinical value under operational conditions.
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    Geospatial patterns and determinants of choice of secondary healthcare facilities among National Health Insurance enrolees in Ibadan, Nigeria
    (2021) Adewole, David Ayobami; Reid, Stephen; Oni, Tolu; Adebowale, Ayo Stephen
    Introduction Choice and access to health care are important determinants of health outcomes. Various issues influence choice and determine the degree of, and differences in access to health care. Choice of health care facilities by individuals is often determined by the interplay between patient and provider characteristics. The influence of factors that determine choice of a health care facility or a provider varies depending on individual patient's socio-ecological factors, type and severity of illness (including the presence or absence of co-morbidities), cost of healthcare (including travel costs), and the presence or absence of a third party such as a health insurance plan. On the other hand, provider or facility factors, which include spatial and non-spatial factors such as technical and functional dimensions of quality of care, are the supply–side factors that influence choice of provider and facility. In order to achieve universal health coverage and attain the Sustainable Development Goals, Nigeria adopted a prepayment health care financing method through the National Health Insurance Scheme (NHIS) in 2005. However, population coverage of the scheme remains very low, while it also has a reputation of less than optimal performance. Evidence showed that while some accredited NHIS facilities were burdened with a high volume of enrolees, others had registered low volume (of enrolees). This study explored the influence and magnitude of the various factors responsible for the poor performance of the scheme as well as the lopsided/uneven distribution of enrolees across these health care facilities. Findings will assist in repositioning the scheme for better performance as well as serve as a guide for other countries planning to design and implement similar schemes. This will enable such schemes to learn from and avoid mistakes made under the present scheme. Methods This study was cross-sectional in design, with descriptive and analytical components. Data were collected using a mixed-method approach (geo-spatial, quantitative and qualitative). The geo-spatial component was achieved using three data layers of x and y coordinates: the enrolees' locations, locations of NHIS facilities and locations of health care facilities typically used by enrolees, were used in the spatial analysis to identify the closest NHIS accredited health care facility to each enrolee's residence and also estimate the distance between enrolee's location and NHIS facility being utilised. The Distance to the Nearest Hub (points) function in Quantum GIS 3.10 was used to automatically assign enrolees to the nearest NHIS facility while the Join by lines (Hub Lines) function was used to assign enrolees to the NHIS facility they used. Spider web diagrams that depict geo-spatial relationship between enrolees' residence, patronised health care facilities and health care facilities closest to the residences were constructed. Quantitative data were collected from 432 NHIS enrolees using an adapted questionnaire. A checklist was also used to collect data on structural components of health facilities such as the number and cadre of the health workforce, availability and functionality of medical equipment and facility infrastructure. Quantitative data were analysed using STATA and frequency tables were generated. Qualitative data were collected through in-depth interviews conducted among 29 participants of the NHIS, HMOs, enrolees, head of facilities and an academic. Qualitative data analysis was done using an inductive thematic approach. Audio-taped interviews were transcribed and codes were generated. Themes were thereafter searched for and generated from the codes. Emerging themes were named, documented and analysed accordingly. A conceptual framework that illustrated the Nigeria contextual environment, the health system and the current governance of the NHIS with a highlight on the relationships, factors and patterns of interaction among stakeholders was designed. Results The majority of the enrolees received care across a small proportion of the accredited facilities and bypassed nearby health facilities to receive care. Almost all the study respondents, 405 (93.9%) bypassed, however, only 147 (34.0%) reported to have done so. In this study, predictors of bypass of healthcare facilities were younger age (OR 0.67, CI 0.46 – 0.99, p = 0.046) and employment in the civil service (OR 0.49, CI 0.31-0.79, p = 0.003). Older age (1.66, CI 1.07-2.58, p = 0.024), attainment of tertiary level of education (OR 1.57, CI 1.02-2.44, p = 0.043), high socioeconomic status (OR 1.94, CI 1.24 -3.02, p = 0.003) and presence of multiple morbidities (OR 1.66, CI 0.99-2.78, p = 0.053) were predictors of personal choice of health facility. Physical infrastructure was poor in all the facilities; most of the facilities depended on more than one source of power supply and water supply was mainly from other sources apart from pipe-borne. Identified predictors of satisfaction with care were age, occupation and seeking information about quality of care. Knowledge of the NHIS and patronage of faith-based health facilities were also predictors of satisfaction with care. Respondents who were younger than 35 years of age were more likely to be satisfied with care than those who were older (OR 1.85, CI = 1.05 – 3.25, p< 0.05). Private sector workers under the scheme (OR 1.84, CI 1.03 – 3.28, p< 0.05) were more likely to be satisfied with care than those employed in the civil service. Likewise, compared with those who did not seek information, those who did (OR 1.63, CI = 1.04 – 2. 53, p< 0.05) were more likely to report satisfaction with care. Respondents who claimed not to have a knowledge of the NHIS were more likely to be satisfied with care (OR 1.65, CI = 1.06 – 2.55, p< 0.05). Likewise, patronage of faith–based facilities was identified to be a predictor of satisfaction with care (OR 1.84, CI = 1.09 – 3.08, p< 0.05). Qualitative data revealed that there was a very low level of trust among the stakeholders. The design and operations of the scheme indicated that the NHIS managers lacked the technical and managerial skills required to manage the scheme and other stakeholders. Both the NHIS officials and the health care providers were of the opinion that the HMOs had more political influence than other stakeholders in the scheme, and were using this to take advantage of others. Enrolees and health care providers were reluctant to collaborate with the scheme at inception, because of the low level of trust in government policies generally. In addition, at inception of the scheme, the majority of the enrolees were arbitrarily allocated to the few available health care providers. For some of the enrolees, choice of health care facilities was based on perceived quality of care and occasionally, as a result of proximity to places of residence. Instances of corrupt and unethical practices were reported across the board among the scheme stakeholders. Discussion There was a high level of facility bypassing among study respondents, though only a few of them claimed to be aware of this. This finding is because of the allocation or assignment of majority of the enrolees to the few facilities that were available to participants in the scheme at its inception. The study also revealed that younger age enrolees and civil servants bypassed more than their respective counterparts did. Studies have shown that younger people are more likely to explore and become more adventurous than older individuals. The apparent bypassing among civil servants was largely because of the arbitrary allocation of reluctant enrolees to the available few health care providers at the inception of the scheme. This also explained the skewed distribution of the enrolees in these few facilities under the scheme. Findings also support the observation that most of the facilities with fewer enrolees were those that stayed away from the scheme at inception. However, the observed lopsided/uneven pattern was difficult to reverse despite the complaints of the facilities with fewer enrolees and the efforts of the scheme to address the skewness. It should also be noted that high social economic class is a strong factor of personal choice of healthcare facilities. The only plausible explanation was the fact that this group of enrolees were not civil servants and who had the financial capacity to pay the premiums, which enabled them buy into the scheme voluntarily and personally chose facilities where to receive care. The state of physical infrastructure in all the facilities that were involved in the study is illustrative of the weak health system in Nigeria. Poor facility infrastructure is a known recipe for the failure of social health insurance. Ability to search for healthcare facilities and in the process, the phenomenon of bypass as seen in this study appeared to play a major role in satisfaction with care amongst younger people, and among those from the private sector, the economic ability to search for and receive care in healthcare facilities of choice, and that meets their expectations. Similarly, enrolees who had the opportunity and sought information about the quality of care in the facilities before enrolment were more likely to be satisfied with care than those who did not seek information. Enrolees who claimed they had no knowledge of the scheme were more likely to be satisfied than those who had knowledge of it and may have had a higher expectation of the quality of care than they received. Satisfaction with care that was attributed to patronage of faith-based facilities in this study has similarities with findings in previous studies. Compared with other types of facilities, it has been reported that the likelihood of higher levels of satisfaction with care among those who patronise faith-based facilities, may have been as a result of higher levels of functional quality, (including spiritual care, that is more valued in this setting) in addition to the technical quality of care. The fundamental finding from the qualitative component of the study was a high level of mistrust of government by almost all the stakeholders involved in the scheme. This manifested itself in the reluctance of the majority of the private health facilities to collaborate with the government in providing health care services to enrolees on the scheme at inception. The same explanation goes for the then potential enrolees' outright refusal to take up the opportunity to access health care services through the scheme. Previous failed government policies both in the health and in the non-health sectors were cited as reasons for the low interest in the scheme. Because of this, except for the government health facilities that were instructed to do so, majority of the private facilities stayed away from providing care to enrolees on the scheme until some years later. Thus, the majority of these enrolees at inception were assigned to the few health facilities that were available. This is what was primarily responsible for the lopsided/uneven distribution of enrolees across the NHIS accredited facilities, whereby some had a high volume of enrolees, while the majority, especially those that showed interest in the scheme much later had very low volumes. Unfortunately, this pattern of enrolees' distribution may be irreversible. In addition, mistrust also exists between the NHIS and the HMOs, between the HMOs and providers, and to some extent between the enrolees and providers. It is important to note that the design of the scheme put the HMOs in a powerful position, which they used to influence the political class to their advantage. To compound the situation, NHIS officials had poor technical and managerial skills to administer the scheme. These are indications of an inefficiently managed health intervention. Under these circumstances, it is highly unlikely that universal health coverage could be achieved unless the observed challenges are appropriately addressed. In addressing these issues, a reform should be considered in the design of the scheme and appropriate training given to the NHIS officials saddled with its day-to-day operation. Conclusion This study has elucidated the reasons for the poor uptake and skewed distribution of enrolees across accredited NHIS facilities in the study area. In addition to poor structure and inefficient management, the high level of mistrust among the stakeholders has played a major role in the lopsided/uneven geo-spatial pattern of enrolees' distribution across the NHIS accredited health facilities. As it is presently structured and managed, the NHIS is highly unlikely to achieve its set objectives. It is advocated that a reform that addresses the observed anomalies be instituted to enable the scheme achieve its goals. This is a lesson for other countries planning to design and implement similar schemes.
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    Hypoxia induces an immunodominant target of tuberculosis specific T cells absent from common BCG vaccines
    (Public Library of Science, 2010) Gideon, Hannah Priyadarshini; Wilkinson, Katalin Andrea; Rustad, Tige R; Oni, Tolu; Guio, Heinner; Kozak, Robert Andrew; Sherman, David R; Meintjes, Graeme; Behr, Marcel A; Vordermeier, Hans Martin
    Author Summary Mycobacterium tuberculosis (the cause of tuberculosis) can persist for many years in humans without causing disease but has the potential to reactivate. One of the conditions the bacterium must survive in these circumstances is hypoxia. In order to do so, the bacterium uses a characteristic set of genes that help alter its metabolism. It follows that the products of such genes may encode protein antigens that can be recognized by the immune response. We therefore analyzed gene response patterns of tuberculosis subject to prolonged hypoxia as a guide to the discovery of new antigens that might be useful as vaccines or diagnostic agents. Amongst the genes most strongly increased by low oxygen levels, one was identified (known as Rv1986) that is missing from most strains of the tuberculosis vaccine Mycobacterium bovis BCG. When we analyzed human immune responses to this protein in tuberculosis infected people our experiments showed it was particularly well recognized by cells that produce a chemical messenger (cytokine) called interleukin-2. Interleukin-2 is important for long-term immunological memory. The BCG vaccine is only partially effective and our experiments therefore suggest one of the reasons could be that an important immunological target is missing from many strains. Further evaluation of BCG strains in which Rv1986 is present or absent is therefore warranted in the hope that this might improve the efficacy of existing or new tuberculosis vaccines.
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    Impairment of IFN-gamma response to synthetic peptides of mycobacterium tuberculosis in a 7-day whole blood assay
    (Public Library of Science, 2013) Gideon, Hannah Priyadarshini; Hamilton, Melissa Shea; Wood, Kathryn; Pepper, Dominique; Oni, Tolu; Seldon, Ronnett; Banwell, Claire; Langford, Paul R; Wilkinson, Robert J; Wilkinson, Katalin A
    Studies on Mycobacterium tuberculosis (MTB) antigens are of interest in order to improve vaccine efficacy and to define biomarkers for diagnosis and treatment monitoring. The methodologies used for these investigations differ greatly between laboratories and discordant results are common. The IFN-gamma response to two well characterized MTB antigens ESAT-6 and CFP-10, in the form of recombinant proteins and synthetic peptides, was evaluated in HIV-1 uninfected persons in both long-term (7 day) and 24 hour, commercially available QuantiFERON TB Gold in Tube (QFT-GIT), whole blood assays. Our findings showed differences in the IFN-gamma response between 24 hour and 7 day cultures, with recombinant proteins inducing a significantly higher response than the peptide pools in 7 day whole blood assays. The activity of peptides and recombinant proteins did not differ in 24 hour whole blood or peripheral blood mononuclear cell (PBMC) based assays, nor in the ELISpot assay. Further analysis by SELDI-TOF mass spectrometry showed that the peptides are degraded over the course of 7 days of incubation in whole blood whilst the recombinant proteins remain intact. This study therefore demonstrates that screening antigenic candidates as synthetic peptides in long-term whole blood assays may underestimate immunogenicity.
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    Intersectoral Action for Addressing NCDs through the Food Environment: An Analysis of NCD Framing in Global Policies and Its Relevance for the African Context
    (2021-10-26) Weimann, Amy; Shung-King, Maylene; McCreedy, Nicole; Tatah, Lambed; Mapa-Tassou, Clarisse; Muzenda, Trish; Govia, Ishtar; Were, Vincent; Oni, Tolu
    Noncommunicable diseases contribute the greatest to global mortality. Unhealthy diet—a prominent risk factor—is intricately linked to urban built and food environments and requires intersectoral efforts to address. Framings of the noncommunicable disease problem and proposed solutions within global and African regional diet-related policy documents can reveal how amenable the policy landscape is for supporting intersectoral action for health in low-income to middle-income countries. This study applied a document analysis approach to undertake policy analysis on global and African regional policies related to noncommunicable disease and diet. A total of 62 global and 29 African regional policy documents were analysed. Three problem frames relating to noncommunicable disease and diet were identified at the global and regional level, namely evidence-based, development, and socioeconomic frames. Health promotion, intersectoral and multisectoral action, and evidence-based monitoring and assessment underpinned proposed interventions to improve education and awareness, support structural changes, and improve disease surveillance and monitoring. African policies insufficiently considered associations between food security and noncommunicable disease. In order to effectively address the noncommunicable disease burden, a paradigm shift from ‘health for development’ to ‘development for health’ is required across non-health sectors. Noncommunicable disease considerations should be included within African food security agendas, using malnutrition as a possible intermediary concept to motivate intersectoral action to improve access to nutritious food in African low-income to middle-income countries.
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    Intersectoral policy approaches to healthy cities with a focus on built and food environments
    (2021) Weimann, Amy; Oni, Tolu; London, Leslie
    Rapid urbanisation in many low- and middle-income countries in Africa has led to substantial changes in both built and food environments, with resultant changes to housing and diet, respectively. These changes interact with factors that influence risk of disease and healthcare access, and may contribute to, and exacerbate, inequities in health outcomes. Increasing global attention is given to the link between characteristics of built and food environments and health. In addition, international health agendas are calling for intersectoral action, which may be guided by the World Health Organization's Health-in-All-Policies approach, to address the social determinants of health that largely lie outside the reach of the health sector. The thesis uses two lenses to investigate the intersectoral determinants of health exploring: i) non-communicable diseases through a food environment lens in the African region, and ii) infectious diseases through a human settlement built environment lens in South Africa. Firstly, this research investigates the landscape of global, regional (African) and national (South African) policies to identify opportunities to integrate health considerations into diet-related and human settlements policies. Secondly, focusing on the built environment context of Cape Town, South Africa, this thesis provides a practical demonstration of a transdisciplinary research approach to gathering evidence, integrating data from health and non-health sectors, and building support for a future implementation of a Health-in-All-Policies approach within a sub-national government setting. In addition, an improved transdisciplinary research approach was developed to support future efforts to address health inequities through urban planning interventions.
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    Missed opportunities for NCD multimorbidity prevention in adolescents and youth living with HIV in urban South Africa
    (2020-06-01) Kamkuemah, Monika; Gausi, Blessings; Oni, Tolu
    Abstract Background Epidemiological transition in high HIV-burden settings is resulting in a rise in HIV/NCD multimorbidity. The majority of NCD risk behaviours start during adolescence, making this an important target group for NCD prevention and multimorbidity prevention in adolescents with a chronic condition such as HIV. However, there is data paucity on NCD risk and prevention in adolescents with HIV in high HIV-burden settings. The aim of this study was to investigate the extent to which NCD comorbidity (prevention, diagnosis, and management) is incorporated within existing adolescent HIV primary healthcare services in Cape Town, South Africa. Methods We reviewed medical records of 491 adolescents and youth living with HIV (AYLHIV) aged 10–24 years across nine primary care facilities in Cape Town from November 2018–March 2019. Folders were systematically sampled from a master list of all AYLHIV per facility and information on HIV management and care, NCDs, NCD risk and NCD-related health promotion extracted. Results The median age was 20 years (IQR: 14–23); median age at ART initiation 18 years (IQR: 6–21) and median duration on ART 3 years (IQR: 1.1–8.9). Fifty five percent of participants had a documented comorbidity, of which 11% had an NCD diagnosis with chronic respiratory diseases (60%) and mental disorders (37%) most common. Of those with documented anthropometrics (62%), 48% were overweight or obese. Fifty nine percent of participants had a documented blood pressure, of which 27% were abnormal. Twenty-six percent had a documented health promoting intervention, 42% of which were NCD-related; ranging from alcohol or substance abuse (13%); smoking (9%); healthy weight or diet (9%) and mental health counselling (10%). Conclusions Our study demonstrates limited NCD screening and health promotion in AYLHIV accessing healthcare services. Where documented, our data demonstrates existing NCD comorbidity and NCD risk factors highlighting a missed opportunity for multimorbidity prevention through NCD screening and health promotion. Addressing this missed opportunity requires an integrated health system and intersectoral action on upstream NCD determinants to turn the tide on the rising NCD and multimorbidity epidemic.
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    Patterns of HIV, TB, and non-communicable disease multi-morbidity in an informal peri-urban setting in Cape Town, South Africa
    (2015) Oni, Tolu; Coetzee, David
    BACKGROUND: Many low and middle-income countries are experiencing colliding epidemics of chronic infectious (ID) and non-communicable diseases (NCD). As a result, the prevalence of multiple morbidities (MM) is rising. METHODS: We conducted a retrospective study to describe the epidemiology of MM in a primary care clinic in Khayelitsha, an informal township in Cape Town. Adults with at least one of HIV, tuberculosis (TB), diabetes (T2DM), and hypertension (HPT) were identified between Sept 2012-May 2013 on electronic databases. Using unique patient identifiers, drugs prescribed across all facilities in the province were linked to each patient and each drug class assigned a condition. RESULTS: These 4 diseases accounted for 45% of all prescription visits. Among 14364 chronic disease patients, HPT was the most common morbidity (65%). 22.6% of patients had MM, with an increasing prevalence with age, and a high prevalence among younger antiretroviral therapy (ART) patients (26% in 18-35yr and 30% in 36-45 year age groups). HPT and T2DM prevalence was higher a mong younger ART patients with MM compared to those not on ART. Of note, 37% of TB MM patients were also on treatment for H PT and 12% were on treatment for T2DM respectively, and 86% of T2DM patients were on HPT treatment. CONCLUSION: We highlight the co-existence of multiple ID and NCD. This presents both challenges (increasing complexity and the impact on health services, providers and patients), and opportunities for chronic diseases screening in a population linked to care. It also necessitates re-thinking of models of health care delivery and calls for policy interventions that integrate and coordinate management of co-morbid chronic diseases.
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    Patterns of HIV, TB, and non-communicable disease multi-morbidity in peri-urban South Africa- a cross sectional study
    (BioMed Central, 2015-01-17) Oni, Tolu; Youngblood, Elizabeth; Boulle, Andrew; McGrath, Nuala; Wilkinson, Robert J; Levitt, Naomi S
    Background: Many low and middle-income countries are experiencing colliding epidemics of chronic infectious (ID) and non-communicable diseases (NCD). As a result, the prevalence of multiple morbidities (MM) is rising. Methods: We conducted a study to describe the epidemiology of MM in a primary care clinic in Khayelitsha. Adults with at least one of HIV, tuberculosis (TB), diabetes (DM), and hypertension (HPT) were identified between Sept 2012-May 2013 on electronic databases. Using unique patient identifiers, drugs prescribed across all facilities in the province were linked to each patient and each drug class assigned a condition. Results: These 4 diseases accounted for 45% of all prescription visits. Among 14364 chronic disease patients, HPT was the most common morbidity (65%). 22.6% of patients had MM, with an increasing prevalence with age; and a high prevalence among younger antiretroviral therapy (ART) patients (26% and 30% in 18-35 yr and 36–45 year age groups respectively). Among these younger ART patients with MM, HPT and DM prevalence was higher than in those not on ART. Conclusions: We highlight the co-existence of multiple ID and NCD. This presents both challenges (increasing complexity and the impact on health services, providers and patients), and opportunities for chronic diseases screening in a population linked to care. It also necessitates re-thinking of models of health care delivery and requires policy interventions to integrate and coordinate management of co-morbid chronic diseases.
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    Process evaluation of implementation fidelity of the integrated chronic disease management model in two districts, South Africa
    (2019-12-16) Lebina, Limakatso; Alaba, Olufunke; Ringane, Ashley; Hlongwane, Khuthadzo; Pule, Pogiso; Oni, Tolu; Kawonga, Mary
    Abstract Background The Integrated Chronic Disease Management (ICDM) model has been implemented in South Africa to enhance quality of clinical services in Primary Healthcare (PHC) clinics in a context of a high prevalence of chronic conditions and multi-morbidity. This study aimed to assess the implementation fidelity (adherence to guidelines) of the ICDM model. Methods A cross-sectional study in 16 PHC clinics in two health districts in South Africa: Dr. Kenneth Kaunda (DKK) and West Rand (WR). A fidelity assessment tool with 89 activities and maximum score of 158 was developed from the four interrelated ICDM model components: facility re-organization, clinical supportive management, assisted self-management and strengthening of support systems. Value stream mapping of patient flow was conducted to analyse waiting time and identify operational inefficiencies. ICDM items were scored based on structured observations, facility document reviews and structured questionnaires completed by healthcare workers. Fidelity scores were summarized using medians and proportions and compared by facilities and districts using Chi-Square and Kruskal Wallis test. Results The monthly patient headcount over a six-month period in these 16 PHC clinics was a median of 2430 (IQR: 1685–2942) individuals over 20 years. The DKK district had more newly diagnosed TB patients per month [median 5.5 (IQR: 4.00–9.33) vs 2.0 (IQR: 1.67–2.92)], and fewer medical officers per clinic [median 1 (IQR: 1–1) vs 3.5 (IQR:2–4.5)] compared to WR district. The median fidelity scores in both districts for facility re-organization, clinical supportive management, assisted self-management and strengthening of support systems were 78% [29/37, IQR: 27–31)]; 77% [30/39 (IQR: 27–34)]; 77% [30/39 (IQR: 28–34)]; and 80% [35/44 (IQR: 30–37)], respectively. The overall median implementation fidelity of the ICDM model was 79% (125/158, IQR, 117–132); WR was 80% (126/158, IQR, 123–132) while DKK was 74% (117/158, IQR, 106–130), p = 0.1409. The lowest clinic fidelity score was 66% (104/158), while the highest was 86% (136/158). A patient flow analysis showed long (2–5 h) waiting times and one stream of care for acute and chronic services. Conclusion There was some variability of scores on components of the ICDM model by PHC clinics. More research is needed on contextual adaptations of the model.
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    Protocol for a Multi-Level Policy Analysis of Non-Communicable Disease Determinants of Diet and Physical Activity: Implications for Low- and Middle-Income Countries in Africa and the Caribbean
    (2021-12-10) Shung-King, Maylene; Weimann, Amy; McCreedy, Nicole; Tatah, Lambed; Mapa-Tassou, Clarisse; Muzenda, Trish; Govia, Ishtar; Were, Vincent; Oni, Tolu
    Non-communicable diseases (NCDs) are the leading cause of death globally. Despite significant global policy development for addressing NCDs, the extent to which global policies find expression in low-and-middle income countries’ (LMIC) policies, designed to mitigate against NCDs, is unclear. This protocol is part of a portfolio of projects within the Global Diet and Activity Research (GDAR) Network, which aims to support the prevention of NCDs in LMICs, with a specific focus on Kenya, Cameroon, South Africa and Jamaica. This paper outlines the protocol for a study that seeks to explore the current policy environment in relation to the reduction of key factors influencing the growing epidemic of NCDs. The study proposes to examine policies at the global, regional and country level, related to the reduction of sugar and salt intake, and the promotion of physical activity (as one dimension of healthy placemaking). The overall study will comprise several sub-studies conducted at a global, regional and country level in Cameroon, Kenya and South Africa. In combination with evidence generated from other GDAR workstreams, results from the policy analyses will contribute to identifying opportunities for action in the reduction of NCDs in LMICs.
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    A qualitative study on the experiences and perspectives of public sector patients in Cape Town in managing the workload of demands of HIV and type 2 diabetes co-morbidity
    (2016) Matima, Rangarirai; Oni, Tolu; Murphy, Katherine
    Health systems' strengthening is essential in South Africa in an era of the convergence of communicable and non-communicable diseases. Whilst TB is ranked first in all-cause mortality, non-communicable diseases which include cerebrovascular disease and diabetes mellitus follow; with HIV/AIDS in fourth place. In the Western Cape, diabetes mellitus and HIV are the top two causes of death accounting for 6.8% and 5.8% respectively (StatsSA, 2015b). As the burden of non-communicable disease continues to increase significantly due to more South Africans presenting these co-morbid conditions, the complexity of managing these chronic conditions has increased. The reorganisation of primary health services to better cater for patients with multiple chronic conditions has become an imperative in South Africa but still in its infancy. However, how chronic patients with multi-morbidities experience the current services and what their perceived needs are in order to enhance the management of their conditions both at point of healthcare and in their daily lives is not widely understood. Below, is an outline of the three parts presented in this dissertation. Part A is the study protocol, which gives a background of the intersection of communicable and noncommunicable diseases in South Africa, focusing on HIV and type two diabetes (hereafter HIV/T2D) co-morbidity. A qualitative design was employed. In-depth interviews were conducted with ten patients living with HIV/T2D co-morbidity and six health workers who interacted with these patients. Ethical considerations such as potential risks and benefits; confidentiality, autonomy and informed consent are also highlighted in the protocol. Part B is the structured literature review on chronic care in low and middle-income countries (LMICs). Two sub-sections are presented with the first focusing on LMICs excluding South Africa; and the second for South Africa only. Theoretical frameworks, which were applied to managing chronic conditions and empirical studies on HIV/T2D in these LMICs, are reviewed. Reference to the Cumulative Complexity Model (CCM), will also provide an indepth understanding of the prospects of strengthening the primary healthcare system in South Africa to address chronic conditions more effectively. Part C is the journal-ready manuscript of the data collected in the qualitative study. It consists of the background, methods, results, discussion and conclusions. Findings describe patients' experiences of the primary healthcare services and the daily challenges of living with and managing HIV and T2D among a sample of ten patients attending a clinic in Cape Town. Health worker perspectives on managing HIV/T2D co-morbidity are also presented. Both patients and healthworkers also shared strategies on how health interventions could be more responsive to HIV/T2D co-morbidity. Hence, further contributions are made in the knowledge base of strengthening chronic conditions. However, further research with different subsets of patients living with not only HIV/T2D but also other co-morbid or multi-morbid conditions is important for improvements in health policy-making in South Africa.
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    QuantiFERON conversion following tuberculin administration is common in HIV infection and relates to baseline response
    (BioMed Central, 2016-10-07) Esmail, Hanif; Thienemann, Friedrich; Oni, Tolu; Goliath, Rene; Wilkinson, Katalin A; Wilkinson, Robert J
    Background: HIV-1 infection impairs tuberculosis (TB) specific immune responses affecting the diagnosis of latent TB. We aimed to (1) determine the proportion of HIV-1-infected adults with a negative QuantiFERON®-TB Gold in-tube (QFT-GIT) and Tuberculin skin testing (TST) that convert to QFT-GIT positive following TST, and (2) evaluate the relationship between conversion and baseline QFT-GIT results. Methods: HIV-1 infected adults being screened for a TB vaccine study in South Africa underwent QFT-GIT followed by TST. As per protocol, QFT-GIT was repeated if randomization was delayed allowing for evaluation of TST boosting in a proportion of participants. Results: Of the 22 HIV-1 infected, TST and QFT-GIT negative adults (median CD4 477/mm3 IQR 439–621) who had QFT-GIT repeated after median 62 days (IQR 49–70), 40.9 % (95 % CI 18.6–63.2 %) converted. Converters had a significantly greater increase in the background subtracted TB antigen response (TBAg-Nil – all units IU/mL) following TST, 0.82 (IQR 0.39–1.28) vs 0.03 (IQR −0.05–0.06), p = 0.0001. Those who converted also had a significantly higher baseline TBAg-Nil 0.21(IQR 0.17–0.26) vs 0.02(IQR 0.01–0.07), p = 0.002. Converters did not differ with regard to CD4 count or ART status. ROC analysis showed a baseline cut off of 0.15 correctly classified 86.4 % of converters with 88.9 % sensitivity. Conclusions: Our findings support the possibility that there are 2 distinct groups in an HIV-1 infected population with negative QFT-GIT and TST; a true negative group and a group showing evidence of a weak Mtb specific immune response that boosts significantly following TST resulting in conversion of the test result that may represent false negatives. Further evaluation of whether a lower cut off may improve sensitivity of QFT-GIT in this population is warranted.
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    Randomized placebo-controlled trial of prednisone for paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome
    (Lippincott, Williams & Wilkins, 2010) Meintjes, Graeme; Wilkinson, Robert J; Morroni, Chelsea; Pepper, Dominique J; Rebe, Kevin; Rangaka, Molebogeng X; Oni, Tolu; Maartens, Gary
    Objective: Paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is a frequent complication of antiretroviral therapy in resource-limited countries. We aimed to assess whether a 4 week course of prednisone would reduce morbidity in patients with paradoxical TB-IRIS without excess adverse events. Design: A randomised double blind placebo-controlled trial of prednisone (1.5mg/kg/day for 2 weeks then 0.75mg/kg/day for 2 weeks). Patients with immediately life-threatening TB-IRIS manifestations were excluded. Methods: The primary combined endpoint was days of hospitalization and outpatient therapeutic procedures, which were counted as one hospital day. Results: 110 participants were enrolled (55 to each arm). The primary combined endpoint was more frequent in the placebo than the prednisone arm (median hospital days 3 (IQR 0-9) and 0 (IQR 0-3) respectively; p=0.04). There were significantly greater improvements in symptoms, Karnofsky score, and quality of life (MOS-HIV) in the prednisone versus the placebo arm at 2 and 4 weeks, but not at later timepoints. Chest radiographs improved significantly more in the prednisone arm at weeks 2 (p=0.002) and 4 (p=0.02). Infections on study medication occurred in more participants in prednisone than placebo arm (27 vs 17 respectively; p=0.05), but there was no difference in severe infections (2 vs 4 respectively; p=0.40). Isolates from 10 participants were found to be resistant to rifampicin after enrollment. Conclusions: Prednisone reduced the need for hospitalisation and therapeutic procedures, and hastened improvements in symptoms, performance and quality of life. It is important to investigate for drug-resistant tuberculosis and other causes for deterioration before administering glucocorticoids.