Key message 2: diabetes and its consequences are costly to patients and economies We estimate that, in 2015, the overall cost of diabetes in sub-Saharan Africa was US$19•45 billion or 1•2% of cumulative gross domestic product (GDP). Around $10•81 billion (55•6%) of this cost arose from direct costs, which included expenditure on diabetes treatment (eg, medication, hospital stays, and treatment of complications), with out-of-pocket expenditure likely to exceed 50% of the overall health expenditure in many countries. We estimate that the total cost will increase to between $35•33 billion (1•1% of GDP) and $59•32 billion (1•8% of GDP) by 2030. Putting in place systems to prevent, detect, and manage hyperglycaemia and its consequences is therefore warranted from a health economics perspective. Key message 3: health systems in countries in sub-Saharan Africa are unable to cope with the current burden of diabetes and its complications By use of information from WHO Service Availability Readiness Assessment surveys and World Bank Service Delivery Indicator surveys and the local knowledge of Commissioners, we found inadequacies at all levels of the health system required to provide adequate management for diabetes and its associated risk factors and sequelae. We found inadequate availability of simple equipment for diagnosis and monitoring, a lack of sufficiently knowledgable health-care providers, insufficient availability of treatments, a dearth of locally appropriate guidelines, and few disease registries. These inadequacies result in a substantial dropoff of patients along the diabetes care cascade, with many patients going undiagnosed and with those who are diagnosed not receiving the advice and drugs they need. We also noted scarce facilities to manage the microvascular and macro vascular complications of diabetes. Additionally, despite calls for adding the care of diabetes and other cardiovascular risk factors onto existing infectious disease programmes (such as those for HIV), we found little evidence that such combined programmes are successful at improving outcomes.

The global prevalence and impact of diabetes has increased dramatically, particularly in sub-Saharan Africa. This region faces unique challenges in combating the disease including lack of funding for noncommunicable diseases, lack of availability of studies and guidelines specific to the population, lack of availability of medications, differences in urban and rural patients, and inequity between public and private sector health care. Because of these challenges, diabetes has a greater impact on morbidity and mortality related to the disease in sub-Saharan Africa than any other region in the world. In order to address these unacceptably poor trends, contextualized strategies for the prevention, identification, management, and financing of diabetes care within this population must be developed. This narrative review provides insights into the policy landscape, epidemiology, pathophysiology, care protocols, medication availability, and health care systems to give readers a comprehensive summary of many factors in these domains as they pertain to diabetes in sub-Saharan Africa. In addition to providing a review of the current evidence available in these domains, potential solutions to address the major gaps in care will be proposed to reverse the negative trends seen with diabetes in sub-Saharan Africa.

Improved data collection and surveillance of NCDs among PLHIV in LMICs are necessary to inform integrated HIV/NCD care models. Although efforts to integrate care exist, further research is needed to optimize the efficacy of these programs.

Leveraging existing HIV infrastructure for NCD care is feasible with various approaches possible depending on available program capacity. Process and clinical outcomes for existing models of care integration are not yet described but are urgently required to further advise policy decisions on HIV/NCD care integration.

The implementation of a contextualized care delivery model built around the unique needs of rural SSA participants led to statistically significant improvements in linkage to care and blood pressure reduction.

BackgroundThe burdens of hypertension and diabetes are increasing in low- and middle-income countries (LMICs). It is important to identify patients with these conditions early in the disease process. The goal of this study, therefore, is to compare community- versus home-based screening for hypertension and diabetes in Kenya.MethodsThis was a feasibility study conducted by the Academic Model Providing Access to Healthcare (AMPATH) program in Webuye, a town in western Kenya. Home-based (door-to-door) screening occurred in March 2010 and community-based screening in November 2011. HIV counselors were trained to screen for diabetes and hypertension in the home-based screening with local district hospital based staff conducting the community-based screening. Participants >18 years old qualified for screening in both groups. Counselors referred all participants with a systolic blood pressure (SBP) ≥160 mmHg and/or a random blood glucose ≥7 mmol/L (126 mg/dL) to a local clinic for follow-up. Differences in likelihood of screening positive between the two strategies were compared using Fischer’s Exact Test. Logistic regression models were used to identify factors associated with the likelihood of following-up after a positive screening.ResultsThere were 236 participants in home-based screening: 13 (6%) had a SBP ≥160 mmHg, and 54 (23%) had a random glucose ≥ 7 mmol/L. There were 346 participants in community-based screening: 35 (10%) had a SBP ≥160 mmHg, and 27 (8%) had a random glucose ≥ 7 mmol/L. Participants in community-based screening were twice as likely to screen positive for hypertension compared to home-based screening (OR=1.93, P=0.06). In contrast, participants were 3.5 times more likely to screen positive for a random blood glucose ≥7 mmol/L with home-based screening (OR=3.51, P<0.01). Rates for following-up at the clinic after a positive screen were low for both groups with 31% of patients with an elevated SBP returning for confirmation in both the community-based and home-based group (P=1.0). Follow-up after a random glucose was also low with 23% returning in the home-based group and 22% in the community-based group (P=1.0).ConclusionCommunity- or home-based screening for diabetes and hypertension in LMICs is feasible. Due to low rates of follow-up, screening efforts in rural settings should focus on linking cases to care.

Aim The Diabetes in Pregnancy Study Group of India (DIPSI) guidelines recommend the non-fasting 75-g oral glucose tolerance test (OGTT) as a single-step screening and diagnostic test for gestational diabetes mellitus (GDM). The aim of this study was to compare the DIPSI criteria with the World Health Organization (WHO) 1999 and the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria for GDM.MethodsA total of 1,031 pregnant women attending antenatal clinics in urban and rural Tamil Nadu, India, underwent a 75-g OGTT in both non-fasting and fasting states, 2–3 days apart. Venous plasma glucose was measured using an autoanalyser, and GDM was diagnosed by DIPSI, WHO 1999 and IADPSG criteria.ResultsOf the 83 women identified to have GDM by WHO 1999 criteria, only 23 were diagnosed by DIPSI criteria. Of the 106 women diagnosed to have GDM by the IADPSG criteria, only 24 were diagnosed by DIPSI. The DIPSI non-fasting OGTT 2-h VPG cut point of 140 mg/dl (7.8 mmol/l) had a very low sensitivity when compared to the WHO 1999 criteria (sensitivity 27.7 %, specificity 97.7 %) and IADPSG criteria (sensitivity 22.6 %, specificity 97.8 %).ConclusionsThe DIPSI non-fasting OGTT criteria cannot be recommended for diagnosis of GDM due to its low sensitivity. Thus, as a single-step diagnostic test for GDM, the fasting OGTT needs to be done. When this is not possible, the well-established two-step procedure using the 50-g glucose challenge test as an initial screening test, followed by the diagnostic fasting OGTT, can be continued.

The alarmingly high frequency of potentially harmful errors uncovered in this study necessitates further investigation using larger sample sizes. Interventions to reduce and prevent these errors must be sought to eliminate the unintended harm associated with hospitalization.