Warfarin anticoagulation in patients with cardiovascular disease in sub-Saharan Africa

The War-PATH NIHR Global Research Group is between the University of Liverpool and two low and middle income countries (LMICs), Uganda and South Africa. It will focus on a clinically important noncommunicable disease area which requires the use of anticoagulation. Anticoagulants, in particular warfarin, are used in these countries for the treatment of venous thromboembolism, rheumatic heart disease and prevention of strokes in patients with irregular heart rhythms (atrial fibrillation). Anticoagulation represents an unmet clinical need in Sub-Saharan Africa as patients either do not receive anticoagulation (because of difficulties in monitoring) or are poorly anticoagulated because of poor dosing guidelines. This results in potentially preventable morbidity and mortality which affects the poorer sectors of the population in particular. We have extensive expertise in the UK and EU of improving the use of warfarin through the development of novel dosing algorithms, which have now began incorporating genetic factors. By contrast, in our two collaborating partner countries, no good dosing algorithms exist, even those which only take into account clinical factors. The situation in these 2 countries is further complicated by the fact that there is a high prevalence of HIV and TB, which make anticoagulation harder because (a) they increase the risk of thrombosis, and (b) the drugs used for treatment interact with warfarin. Our research will focus on: (a) evaluating the quality of anticoagulant services in Cape Town and Kampala taking into account the indications, anticoagulant clinic set-up and quality of anticoagulation control; (b) recruiting patients currently on warfarin to identify clinical factors determining anticoagulation quality to develop a dosing algorithm; (c) a study to implement the clinical algorithm in the two sites; and (d) evaluating genes specific to the African population that can impact on anticoagulation control, and the development of novel genetic dosing algorithms. The work will be accompanied by education and training of the local workforce to improve local capability and capacity. We will also train 4 students to Masters level, and 2 post-doctoral researchers will be seconded to Liverpool to gain training in high-end genomics. We will also engage with regional health policy makers in both countries to develop the best pathways for implementing the research findings to improve anticoagulation care, for the benefit of patients, the local society and ultimately the economy. We will also work with technology companies to develop long-term cost-effective strategies to implement novel technologies that will allow for point-of-care testing of anticoagulation, and also of genetic markers.