Over the last decades, the burden of non-communicable diseases (NCDs) has dramatically increased throughout sub-Saharan Africa, and this trend is expected to continue in the future. Diabetes is one of the most prevalent NCDs affecting people in Africa. The age-adjusted prevalence of diabetes in sub-Saharan Africa increased from 3.8% in 2010 to 4.7% in 2019 and is expected to reach 5.1% by 2030. Concretely in Tanzania, the number of people suffering from diabetes is growing rapidly. The prevalence in the Dar es Salaam region increased from 1% in 1980 to 9% in 2012.
Many people living with diabetes are currently not diagnosed and, therefore, are not receiving treatment and proper long-term management. In 2019, there were 60% of people with undiagnosed diabetes in sub-Saharan Africa, and the proportion of diabetes-related deaths under the age of 60 years was 73%. In the same period, the number of children and adolescents diagnosed with type 1 diabetes was 9.4% for those under 14 years of age, and 25.8% for those aged under 19.
In the Shree Hindu Mandal Hospital, located in Dar es Salaam, we estimate that for every person diagnosed with diabetes there are at least two people who remain undiagnosed. Among the patients that get a correct diagnosis, it is estimated that only 15% reach the hospital. This means that from every 10 persons with diabetes only two receive treatment, and only one reaches controlled sugar levels. Often this can be due to the difficulty in accessing hospitals, as 70-80% of the Tanzanian population lives in rural areas and making the trip to a hospital equipped to diagnose diabetes is timely and costly for many.
A lack of awareness of diabetes is a major barrier to its proper diagnosis, both in the general population and among healthcare professionals, especially concerning diabetes type 1 among children. To combat this, the national Tanzanian NCD programme is working on increasing diabetes awareness among healthcare professionals. In addition, many people do not have health insurance to cover the cost of treatment and care, creating another barrier to accessing care.
Efforts to Improve Access to Care and Prevention
In the last few years, different projects and alliances have been formed to improve care for people in Tanzania living with diabetes. Steps have been taken to improve diabetes care. Diabetes clinics are now included in zonal hospitals across all 26 regions and 184 districts of Tanzania. Additionally, the Tanzania NCD Alliance has been established, as well as the Tanzanian Diabetes Association, which is receiving funds from the World Diabetes Foundation to provide training for healthcare professionals, in addition to receiving equipment needed for diabetes care, and to run health programmes in schools.
In this video, I express my concerns that most of these efforts only focus on secondary prevention: providing better care for people that already have diabetes and preventing the disease to progress to further possible complications. I want to emphasize that additional attention and interventions are needed at the primary prevention level to ensure the incidence of diabetes decreases, with a focus on healthy lifestyle choices like diet and exercise.
Preventing Diabetes in People with HIV
One form of primary prevention is stopping prediabetes from progressing to diabetes. Prediabetes is defined as having elevated levels of blood sugar that fall just below the threshold for getting a diabetes type 2 diagnosis. It is a strong predictor for diabetes, since 10-20% of people with pre-diabetes will develop clinical diabetes within a year, and 70% will do so over their lifetime. The META phase III trial (META-TRIAL), which is part of the larger RESPOND-AFRICA collaboration, aims to define whether Metformin administration can be an effective low-cost intervention for preventing and delaying the onset of diabetes among people with pre-diabetes and HIV infection that are taking antiretroviral therapy (ART) in Africa. Metformin is recommended for people with diabetes and HIV infection, and has also been tested on people living with HIV on ART, but not in people living with HIV and pre-diabetes.
We are proud to announce that this October 2021, recruitment for the META-TRIAL began in Tanzania. This study is a collaboration between a large interdisciplinary group including researchers, policymakers, healthcare professionals and patient representatives. 2,000 people living with HIV and with pre-diabetes that have been on ART for at least 6 months will be given Metformin or placebo treatment and followed up for 36 months. The primary endpoint will be diabetes incidence, in addition to cost-effectiveness, and health-related quality of life data.
At the Shree Hindu Mandal Hospital, we are proud to be part of this study and contribute to improving care for people in Africa living with Diabetes.