Background: In the light of the increasing burden of non-communicable diseases (NCDs) on health systems in low-and middle-income countries, particularly in Sub-Saharan Africa, context-adapted, cost-effective service delivery models are now required as a matter of urgency. We describe the experience of setting up and organising a nurseled Diabetes Mellitus (DM) and Hypertension (HTN) model of care in rural Zimbabwe, a low-income country with unique socioeconomic challenges and a dual disease burden of HIV and NCDs. Methods: Mirroring the HIV experience, we designed a conceptual framework with 9 key enablers: decentralization of services, integration of care, simplification of management guidelines, mentoring and task-sharing, provision of affordable medicines, quality assured laboratory support, patient empowerment, a dedicated monitoring and evaluation system, and a robust referral system. We selected 9 primary health care clinics (PHC) and two hospitals in Chipinge district and integrated DM and HTN either into the general outpatient department, pre-existing HIV clinics, or an integrated chronic care clinic (ICCC). We provided structured intensive mentoring for staff, using simplified protocols, and disease-specific education for patients. Free medication with differentiated periodic refills and regular monitoring with point of care (POC) glycosylated haemoglobin (HbA1c) were provided. Results: Nurses in 7 PHC facilities and one hospital developed sufficient knowledge and skills to diagnose, initiate treatment and monitor DM and HTN patients, and 3094 patients were registered in the programme (188 with DM only, 2473 with HTN only, 433 with both DM and HTN). Major lessons learned from our experience include: the value of POC devices in the management of diabetes; the pressure on services of the added caseload, exacerbated by the availability of free medications in supported health facilities; and the importance of leadership in the successful implementation of care in health facilities. Conclusion: Our experience demonstrates a model for nurse-led decentralized integrated DM and HTN care in a high HIV prevalence rural, low-income context. Developing a context-adapted efficient model of care is a dynamic process. We present our lessons learned with the intention of sharing experience which may be of value to other public health programme managers.

Background In light of the increasing burden of non-communicable diseases on health systems in low- and middle-income countries, particularly in Sub-Saharan Africa, context adapted cost effective service delivery models are now required as a matter of urgency. Multiple models have thus been trialled across Africa with varying degrees of success. Zimbabwe is a low-income country with unique socio-economic challenges but similar dual disease burden of infectious chronic diseases such as HIV and non-communicable diseases. We aim to describe the experience of setting up and organising a nurse-led Diabetes Mellitus (DM) and Hypertension (HTN) model of care in a rural context of a low-income country from July 2016 to June 2019.Methods A descriptive study based on a conceptual framework successfully applied in the roll-out of antiretroviral therapy in Manicaland Province, Zimbabwe. Attempting to mirror the HIV experience, we describe the key enablers in the design and implementation of the model: decentralization of services, integration of care, simplification of management guidelines, mentoring and task-sharing, provision of affordable medicines, quality assured laboratory support, patient empowerment, a dedicated monitoring and evaluation system, and a robust referral system.Results 11 out of 51 health facilities were selected in Chipinge district, of which nine were primary health care (PHC) clinics and two were hospitals. DM/HTN services were set up and integrated into the general out-patient department or pre-existing HIV clinics. In one hospital, an integrated chronic care clinic was established. Through structured intensive mentoring, including simplified protocols, nurses in seven PHC facilities and one hospital developed sufficient knowledge and skills to diagnose, initiate treatment and monitor DM/HTN patients. Overall, more than 3000 patients were registered in a dedicated recording system and offered education. Free medication with differentiated periodic refills and regular monitoring of blood pressure and/or blood glucose with the use of glycosylated haemoglobin were provided.Conclusion Our experience shows that it is feasible to implement nurse-led decentralized integrated DM/HTN care in a high HIV prevalence rural, low-income context. Developing a context-adapted efficient model of care is a dynamic process.

Introduction: Dengue virus (DENV) is the arbovirus with the widest impact on human health. In Africa in general, and in Angola in particular, the epidemiology and public health impact of DENV is far from clear. However, rapid population growth, unplanned urbanization, increased international travel, and the presence of virus major vector (Aedes aegypti) in the country suggest that DENV transmission may occur. Methodology: In parallel to the occurrence of a dengue outbreak affecting the capital of Angola, between March and July 2013 four Portuguese institutions diagnosed dengue infection in 146 individuals returning to Portugal. Clinical presentation, laboratory findings, and molecular analyses of partial viral genomic segments were performed. Results: The mean age of the individuals included in this study was 42 years old, the majority being men of Portuguese nationality, reporting various lengths of stay in Angola. Fever was the most reported clinical sign, being frequently associated (61.0%) with myalgia and headache. Hematological values, including hematocrit, white-blood cell and platelets counts, correlated with the absence of severe or complicated cases, or coagulation disorders. No deaths were observed. Viral NS1 was detected in 56.2% of the samples, and all NS1 negative cases had antidengue IgM antibodies. RT-PCR indicated the presence of DENV1, which was confirmed by phylogenetic analysis of 25 partial NS5 viral sequences. Conclusion: The DENV cases analyzed conformed to classical and uncomplicated dengue, caused by the suggested exclusive circulation of a genetically homogeneous DENV1 of genotype III, apparently with a single origin.

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IntroductionLate HIV diagnosis is common and associated with an increased risk of clinical progression, blunted immune response on antiretroviral (ARV) therapy and higher risk of drug toxicity. Across Europe, more than a third of patients are diagnosed late and consequently delay medical care. European Consensus definition group identify as late presentation (LP) persons, presenting for care, with a CD4 count below 350 cell/mm3 or presenting with AIDS-defining event, regardless of CD4 cell count. Additionally, advanced HIV disease (AD) is defined by a CD4 count below 200 cell/mm3 or an AIDS defining condition in persons presenting to care.Materials and MethodsRetrospective observational study of a cohort of 705 HIV-infected patients diagnosed between 1986 and 2014 and medically followed at an Infectious Diseases Service in Lisbon.ObjectivesEvaluate LP rate evolution in the last three decades (10-year time intervals considered: 1986–1995; 1996–2005; 2006–2014); compare clinic, immunologic, virologic and therapeutic response over time. Identify main reasons responsible for late HIV diagnosis in order to promote optimized intervention strategies. SPSS version 20.0 was used for statistical analysis.ResultsStudy included 705 patients HIV diagnosed during 3 time intervals: group A n=82 [1986–1995]; group B n=332 [1996–2005]; group C n=291 [2006–2014]. Demographic and epidemiological characterization revealed (A vs B vs C): male predominance of 79% vs 66% vs 66%; mean age at diagnosis 30 vs 36 vs 42 years; Portugal (82% vs 70% vs 58%) and Africa (13% vs 23% vs 29%) as the main places of birth; transmission by heterosexual contact in 21% vs 47% vs 62%, MSM in 21% vs 15% vs 23% and IVDU in 57% vs 35% vs 13%. Mean CD4 at diagnosis was 362 vs 344 vs 377 cell/mm3. Considering the time intervals, LP was found in 52% vs 56% vs 52% of patients and AD in 31% vs 38% vs 35%, respectively. At first health care encounter, 46% vs 43% vs 39% of individuals presented with AIDS. Over follow up, the vast majority initiated ARV (95% vs 98% vs 84%) and mean CD4 at that time was 254 vs 282 vs 250 cell/mm3. The last immunologic and virologic determination available registered mean CD4 of 657 vs 644 vs 584 cell/mm3 and undetectable HIV plasma RNA in 92% vs 84% vs 82% of treated patients.ConclusionsThis study evidenced a maintained LP rate, slightly above 50% in each of the three analyzed last decades, and one-third of patients presented AD at HIV diagnosis. At initial health care contact, nearly 40% of individuals met AIDS clinical or immunological criteria.