@LancetGH examines the "collision" of #HIV and chronic disease (among other things)

Friday, January 26, 2018

The first thing that caught my eye in the February edition of Lancet Global Health was an article on the prevalence of COPD among persons living with HIV. The issue of care and treatment of non-communicable diseases among PLWH has become increasingly important as HIV itself has transitioned from a life-threatening condition to a chronic disease to be managed. However, what I found interesting about this particular meta-analysis was that its aim was to assess the hypothesis that HIV infection itself makes people more likely to develop COPD, even when controlling for tobacco use:
Results from several original observational studies and narrative reviews have suggested that the prevalence of chronic obstructive pulmonary disease (COPD) would be increased in people with HIV and even higher than in the general population. Findings from studies with similar designs also suggested an association between HIV infection and COPD.
Using strong and robust statistical methods, we found an association between HIV and COPD, even after adjustment for tobacco consumption, the leading risk factor for COPD. We have also shown a high prevalence of COPD in HIV-positive individuals. We identified three factors favouring an increase in the prevalence of COPD among HIV-positive people: tobacco consumption (a common factor between people with HIV and the general population), the presence of a detectable HIV viral load (in HIV-positive people only), and country level of income. We found that the prevalence of COPD in HIV-positive people increased with the level of income of the country.
Interestingly, the accompanying commentary also pointed out that, while the highest HIV burden is borne by LMICs, there were very few studies based on such countries that were robust enough to be included:
Although most of the included studies were done in high-income countries in Europe and North America, most of the people with COPD and HIV live in LMICs. Only four of the included studies were done in Africa, the WHO region with the most people living with HIV. This finding is similar to what we found in 2013, when we did a systematic review of COPD studies in sub-Saharan Africa and found only one high quality prevalence study. This Burden of Obstructive Lung Disease (BOLD) study was done in South Africa and found a high prevalence of COPD: 22% of men and 17% of women. Taken together, these observations highlight an important imbalance between where this kind of research is done and where the need is greatest.
The journal issue contains a number of other tasty morsels as well. I thought this piece on indigenous languages as a factor in access to care was particularly interesting, as well as this one on "equitable access" to (unpaid) WHO internships (and boy, do I have a soapbox about that). One contributor from Stanford even held up a mirror to the journal, analyzing the geographic focus and authorship of all of its articles to assess its progress toward its stated aim to represent “disadvantaged populations” in health-related scenarios around the world:
From all 236 articles, only about 35% (SD=0·31) of the authors were affiliated with or came from LMICs. Articles on Africa had 44% (SD=0·28) LMIC authorship, south Asia had 52% (SD=0·29), southeast Asia had 56% (SD=0·35), and the Middle East and north Africa had 28% (SD=0·33). The Americas had 33% (SD=0·41). Multiregional articles had 17% (0·24) LMIC authorship.

The apparent under-representation of authors from LMICs contributing to articles focusing on LMICs highlights several issues. These include so-called safari research that recruits LMIC specialists, with minimum involvement, into studies driven by high-income-country authors for perceived credibility, the scarcity of grants in LMICs, low awareness of fee waivers within open access journals, insufficient infrastructure for large-scale studies of high impact, and not enough funding directly to academic institutions in LMICs.
It is worth pointing out that even awareness of open access fee waivers does not make them easy to get. In my efforts to get a paper on the IH Section's global health jobs analysis published in BMC Public Health, I engaged in a snarky exchange with the waivers department to explain (repeatedly) that we were volunteers and not part of an academic institution - and didn't get the waiver until I publicly called them out on Twitter. I can't imagine being in a situation like that and trying to make my case in a language that is not my own.

However, my favorite bit by far came from a commentary piece on an outcomes assessment of a healthcare "social franchise" (whatever the heck that is) in Uttar Pradesh. The author throws some not-so-subtle shade toward aid-funded projects and their reticence to rigorously evaluate their own effectiveness:
More importantly, and perhaps inadvertently, the study has shed light on more fundamental questions: why has social franchising as a model expanded at an exponential rate when there was little rigorous evidence of the model's impact on population health? Why have millions of dollars, often taxpayer money, been poured into an unproven idea? Why is there a paucity of rigorous research in documenting effectiveness of this heavily invested idea?

Perhaps the last question might be the easiest to answer. [...] The remit of major bilateral donors is to provide services that will directly improve the health of recipient populations. They are not in the business of research. Consequently, most donors limit their data collection activities to before and after surveys under the rubric of evaluation. They tend to be averse to funding data collection from control sites where their programme was not implemented.

Additionally, bilateral donors, as custodians of taxpayer money, operate in environments characterised by structural disincentives to acknowledge when programme efforts are not achieving their intended results.

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