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

非洲目前感染了世界上绝大多数(69%)的艾滋病毒，有2600万艾滋病毒携带者 (PLHIV)。在非洲，获得抗逆转录病毒治疗(ART)的机会增加，显著延长了PLHIV的生命 并正在将艾滋病毒感染者的发病率和死亡率转向非传染性疾病，包括 高负荷心肺非传染性疾病(CP-NCDs)，如充血性心力衰竭、高血压、哮喘和 慢性阻塞性肺病。此外，非洲正在经历快速的城市化，与之相关的 空气污染增加，生活方式以及社会、结构和卫生服务环境发生变化。 艾滋病毒、CP-NCDs和城市化的这种显著融合对 全球健康。不幸的是，关于城市化和空气污染对CP的影响的数据很少- 非传染性疾病和艾滋病毒作为效应修饰物的潜在作用，例如艾滋病毒可能更容易受到城市疾病的影响 尽管艾滋病毒病毒血症已被抑制，但仍存在慢性炎症，或来自既往结核病或其他疾病的后遗症 肺部感染。此外，人们对艾滋病毒和CP-NCDs卫生服务利用模式知之甚少，如 人们迁移到城市环境，以及艾滋病毒和慢性非传染性疾病护理可能如何更好地整合。最后，艾滋病毒和 非洲的CP-NCDs研究主要是横断面研究，往往没有艾滋病毒阴性对照。 在理解因果因素和准确计算以下因素的归属分数方面存在主要限制 传统风险因素和非传统风险因素。需要纵向的、人口层面的方法来更好地指导 未来的研究、计划和政策。Rakai社区队列研究(RCCS)成立于1994年，是 在乌干达中南部40个社区进行了一次公开的、以人口为基础的队列调查 超过18个月的间隔(RCCS普查人口约33,000成年人，艾滋病毒流行率约18%)。农村信用社 社区是非城市的；然而，队列经历了每一轮约950名参与者的迁出 到两个大型城市中心(坎帕拉和Masaka)，农村信用社在这两个城市设有卫星办事处。有了这项独特的研究 基础设施，RCCS提供了一个新的机会来对艾滋病毒进行纵向的、以人群为基础的研究， 在一个全面的健康决定因素框架内，慢性疾病--非传染性疾病和城市化并存。本研究 建议(1)确定与艾滋病毒相关和无关的心肺非传染性疾病的危险因素 一种新的从农村到城市(R2U)的非洲队列中的疾病；(2)表征空气污染和 艾滋病毒对R2U移民心肺结局的缓和作用；以及，(Iii)评估艾滋病毒和CP- R2U流动人口非传染性疾病卫生服务利用状况。据我们所知，这将是第一次 以人口为基础的纵向队列研究，对非洲艾滋病毒、CP-NCDs和城市化的共同影响。我们的 利用从农村到城市的队列的独特能力、卓越的研究基础设施和新颖的目标将 生成抗击不断演变的艾滋病毒的新研究、干预措施和政策所需的重要数据 和CP-NCDs流行。

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.