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Advanced Neurology Stroke care in sub-Sahara Africa

100 cardiomyopathy, HIV-associated opportunistic infections
91 of the central nervous system, effects of aging as PLWH
90 83 87
80 live longer, and potentially immune reconstitution
51-53
68 inflammatory syndrome.
70
Percentages (%) 50 36 52 39 4. Organized stroke care in SSA
60
4.1. Levels of care
40
30 24 SSA is a region marked by vast geographical, cultural,
22
20 18 and economic diversity, impacting the availability and
11 12
10 organization of resources for acute stroke care. Countries
classified as upper-middle and lower-middle income
0
Nig/Ghana Abuja, Nig Tanzania Uganda countries by the World Bank, particularly in South and
HTN Dyslipid DM West Africa, have a higher number of hospitals with
Figure 2. Selected modifiable stroke risk factors in selected sub-Saharan organized stroke care services. In contrast, low-income
African countries. Notes: Nig/Ghana: Nigeria/Ghana; Abuja, Nig: Abuja, countries typically have fewer such facilities. Despite these
Nigeria; Tanzania: Dar es Salaam, Tanzania; Uganda: Kampala, Uganda. disparities, the framework for acute stroke care remains
Abbreviations: DM: Diabetes mellitus; Dyslipid: Dyslipidemia; HTN: consistent across SSA, categorized by the level of resources
Hypertension.
and expertise available at health-care centers, as illustrated
in Table 2 and detailed in the following subsections.

diet) comorbidities act in concert with hypertension to 4.2. Lower-level health-care centers (LLHCCs)
drive the overall stroke burden in the region. 45-47 Adding LLHCCs encompass community health units, district
to the complexity of hypertension is poorly recognized hospitals, and private clinics. They are often the
and treated. Indeed, a cross-sectional study using first point of contact for patients exhibiting acute
nationally representative individual-level data from 16 stroke symptoms. LLHCCs are equipped to provide
SSA countries, conducted between 2018 and 2019, found patient stabilization, triage, and referral. Basic clinical
that <50% of individuals with hypertension are aware that assessments and vital sign monitoring, particularly
they have this condition or have received a diagnosis. blood pressure measurements, are standard practices.
Among those who were diagnosed, up to 50% were not These centers can provide minimal health-care services,
receiving treatment. 48 as per the World Stroke Organization’s categorization,
HIV infection is an established stroke risk factor that which includes offering basic swallow screens, dysphagia
54
is uniquely prevalent in SSA. The largest global burden of management, and temperature management (Table 2).
HIV infection is in Africa, with an estimated 70% of the Empirical treatment for hypotension or hypertension is
36.8 million people living with HIV infection (PLWH) provided, often before the determination of the exact
residing in SSA. HIV infection is common among stroke intracranial pathology. Blood glucose examinations are
49
patients presenting to hospitals in SSA. For example, a routinely performed, and dysglycemia is addressed as
hospital-based retrospective study in South Africa reported needed. Following stabilization, patients are typically
an HIV infection frequency of 9.3% in a cohort of stroke referred to higher-level hospital facilities for further
patients. Studies in the region have established that HIV management.
50
infection is a significant stroke risk factor. A community-
based prospective case–control study in Tanzania 4.3. Higher-level health-care centers (HHCCs)
identified HIV infection as an independent risk factor for HHCCs encompass regional and national referral hospitals,
stroke, with an OR of 5.61 (95% CI: 2.41 – 13.09). PLWH as well as privately owned hospitals in major cities. Patients
45
with stroke, particularly in the pre-antiretroviral therapy with acute stroke symptoms may either present directly to
(ART) era, are younger, have more severe strokes, and face an HHCC or be referred from a LLHCC. Regardless of
increased mortality. This profile may be changing in the the initial point of contact, patients are typically assessed
28
post-ART era, although studies on stroke epidemiology in the emergency room at HHCCs by medical doctors,
in PLWH in the ART era are lacking. Several mechanisms often under the supervision or staffing of an internist
of HIV-associated stroke have been postulated, including or a neurologist. Patients undergo appropriate clinical
HIV-associated vasculopathy (arterial stenosis, aneurysm evaluations and investigative tests, including basic blood
formation, vasculitis, and accelerated atherosclerosis), tests such as complete blood count and serum chemistry,
metabolic effects of antiretroviral therapy, HIV-associated which are available, although sometimes for a small fee.

Volume 3 Issue 2 (2024) 6 doi: 10.36922/an.2804