Abstract
BACKGROUND
Non-communicable diseases (NCDs) account for the majority of adult deaths worldwide, and 80% of these deaths occur in
low and middle-income countries (LMICs). The burden of NCDs in LMICs is predicted to grow with improvements in sanitation and infectious disease control, and will be altered by local diet, smoking rates, and HIV co-infection. There is a critical need to identify and implement low-cost, well-validated diagnostic tests to elucidate the epidemiology of NCDs, and enable diagnostic monitoring and ther- apeutic interventions. Moreover, tests that enable non-healthcare professionals to lead care provision will augment the scalability of this strategy. We recently completed implementation and evaluation of a bundle of point-of-care, low-cost diagnostics for NCD measurement in rural Uganda.
METHODS
We performed a cross-sectional cohort study in rural, southwestern Uganda of HIV-infected persons on antiretroviral therapy at the Mbarara Regional Referral Hospital and a control group of HIV-uninfected persons from the clinic catchment area. Three non-healthcare professional Ugandan staff completed a two- week intensive course to perform a series of point-of-care cardiovas- cular assessments, including portable electrocardiogram (EKG), ankle-brachial index (ABI), hemoglobin A1c testing (HbA1c), auto- mated blood pressure, and anthropometric measurements. An American medical student was trained through the University of Wisconsin Atherosclerosis Imaging Research Program to perform measurement of carotid intima-media thickness (CIMT). We assessed the quality and feasibility of each measurement by: 1) proportion of valid hemoglobin A1c results; 2) proportion of interpretable carotid ultrasound images as graded by a board-certified vascular cardiologist using the University of Wisconsin CIMT image quality assessment scale; and 3) correlation between brachial blood pressure measure- ments and automated systolic blood pressure measurements. The study received ethics approval from the Mbarara University of Science & Technology and Partners Healthcare. All participants provided written informed consent.
FINDINGS
105 HIV-infected and 90 HIV-uninfected individuals were enrolled in the study. None of the HbA1c tests were invalid (0/ 195). Of the 96 CIMT images reviewed, 86 (90%) were found to be of adequate quality, and 10 (10.4%) were not suitable for measure- ment. The right and left brachial blood pressure measurements had coefficients of determination of 0.79 and 0.72, respectively, with the automated systolic blood pressure measurements. Based on an esti- mate patient volume of 1,000 patients per year and measurement for 3 years, the cost for this array of tests, including capital equipment, would be approximately $28 per patient.
INTERPRETATION
Low-cost, portable, and well-validated point-of-care tests can be implemented by non-medical professionals in LMICs. Implementation evaluations should be pursued to assess the large- scale feasibility, scalability, and impact of this strategy.
