title: Observational research on NCDs in HIV-positive populations: conceptual and methodological considerations.
abstract: Noncommunicable diseases (NCDs) account for a growing burden of morbidity and mortality among people living with HIV in low- and middle-income countries (LMICs). HIV infection and antiretroviral therapy interact with NCD risk factors in complex ways, and research into this "web of causation" has so far been largely based on data from high-income countries. However, improving the understanding, treatment, and prevention of NCDs in LMICs requires region-specific evidence. Priority research areas include: (1) defining the burden of NCDs among people living with HIV, (2) understanding the impact of modifiable risk factors, (3) evaluating effective and efficient care strategies at individual and health systems levels, and (4) evaluating cost-effective prevention strategies. Meeting these needs will require observational data, both to inform the design of randomized trials and to replace trials that would be unethical or infeasible. Focusing on Sub-Saharan Africa, we discuss data resources currently available to inform this effort and consider key limitations and methodological challenges. Existing data resources often lack population-based samples; HIV-negative, HIV-positive, and antiretroviral therapy-naive comparison groups; and measurements of key NCD risk factors and outcomes. Other challenges include loss to follow-up, competing risk of death, incomplete outcome ascertainment and measurement of factors affecting clinical decision making, and the need to control for (time-dependent) confounding. We review these challenges and discuss strategies for overcoming them through augmented data collection and appropriate analysis. We conclude with recommendations to improve the quality of data and analyses available to inform the response to HIV and NCD comorbidity in LMICs.
authors.affiliation: *Division of Biostatistics, Berkeley School of Public Health, Berkeley, CA; †Department of Biostatistics, Indiana University R. M. Fairbanks School of Public Health, Indianapolis, IN; ‡Section of General Internal Medicine, Yale University Schools of Medicine and Public Health and Veterans Affairs (VA) Connecticut Healthcare System, West Haven, CT; §Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; and ‖HIV/AIDS Research Group Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.
authors.forename: Maya
authors.initials: M
authors.lastname: Petersen
authors.forename: Constantin T
authors.initials: CT
authors.lastname: Yiannoutsos
authors.forename: Amy
authors.initials: A
authors.lastname: Justice
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D044966:Anti-Retroviral Agents / Q000009:adverse effects / Q000627:therapeutic use; D035843:Biomedical Research / Q000379:methods* / Q000639:trends; D015897:Comorbidity / Q000639:trends*; D019033:Delivery of Health Care, Integrated; D003906:Developing Countries; D003955:Diagnostic Tests, Routine / Q000379:methods; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology*; D006801:Humans; D015995:Prevalence; D011314:Preventive Health Services; D012307:Risk Factors
chemical_list: D044966:Anti-Retroviral Agents