Epidemiology and Impact of the HIV, NCD, and Urbanization Syndemic in Africa

Africa bears the vast majority (69%) of the world’s current HIV infections with 26 million persons living with HIV
(PLHIV). Increased access to antiretroviral therapy (ART) in Africa has markedly extended the lives of PLHIV
and is shifting morbidity and mortality among PLHIV toward non-communicable diseases (NCDs), including
high burden cardiopulmonary NCDs (CP-NCDs) such as congestive heart failure, hypertension, asthma, and
chronic obstructive pulmonary disease. In addition, Africa is experiencing rapid urbanization with its associated
increases in air pollution and changes in lifestyle and the social, structural, and health service environment.
This remarkable convergence of HIV, CP-NCDs, and urbanization has profound implications for the future of
global health. Unfortunately, there is a paucity of data on the impact of urbanization and air pollution on CP-
NCDs and the potential role of HIV as an effect modifier, e.g. PLHIV may be more susceptible to urban ills due
to existing chronic inflammation despite suppressed HIV viremia or from sequelae of past tuberculosis or other
pulmonary infections. In addition, little is known about HIV and CP-NCDs health service utilization patterns as
people migrate to urban settings and how HIV and CP-NCD care might be better integrated. Finally, HIV and
CP-NCDs research in Africa has primarily been cross-sectional and often without HIV-negative comparison
groups, major limitations in understanding causal factors and accurately calculating attributable fractions for
traditional and non-traditional risk factors. Longitudinal, population-level approaches are needed to better guide
future research, programs, and policies. The Rakai Community Cohort Study (RCCS), established in 1994, is
an open, population-based cohort in 40 communities in south-central Uganda with survey rounds conducted
over ~18 month intervals (RCCS census population ~33,000 adults, HIV prevalence ~18%). RCCS
communities are non-urban; however, the cohort experiences an out-migration of ~950 participants per round
to two large urban centers (Kampala and Masaka) where RCCS has satellite offices. With this unique research
infrastructure, RCCS offers a novel opportunity to conduct longitudinal, population-based research on the HIV,
CP-NCDs, and urbanization syndemic within a comprehensive health determinants framework. This study
proposes to (i) Characterize HIV-related and -unrelated risk factors for cardiopulmonary non-communicable
diseases in a novel Rural-to-Urban (R2U) African cohort; (ii) Characterize the impact of air pollution and
moderating effects of HIV on cardiopulmonary outcomes among R2U migrants; and, (iii) Assess HIV and CP-
NCDs health services utilization patterns among R2U migrants. To our knowledge, this would be the first
population-based, longitudinal cohort study of the HIV, CP-NCDs, and urbanization syndemic in Africa. Our
unique ability to leverage a rural-to-urban cohort, the excellent research infrastructure, and novel Aims will
generate vital data needed for designing new research, interventions, and policies to combat the evolving HIV
and CP-NCDs epidemic.

Grant Number: 5R01HL152813-05
NIH Institute/Center: NIH
Principal Investigator: Larry Chang