The Evolving Landscape of Multimorbidity: An Analysis of Disease Clustering Across 13 HDSS Sites in Africa and Asia (2018-2021)
1
School of public health, University of the Witswatersrand, johanesburg, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A488
ABSTRACT
BACKGROUND:
Low- and middle-income countries (LMICs) face a dual burden of chronic infectious diseases (HIV/TB) and accelerating non-communicable diseases (NCDs) [1,2]. The COVID-19 pandemic caused profound health system disruptions, potentially reconfiguring multimorbidity clusters. This study aimed to model geographic and temporal variation in multimorbidity clustering across 13 Health and Demographic Surveillance System (HDSS) sites in Africa and Asia: (Southern Africa: Agincourt, DIMAMO, AHRI, Karonga; East Africa: Siaya, Manyatta, Harar, Haramaya, Kersa; West Africa: Dakar, Nanoro; South Asia: Matlab, Chakaria), comparing cluster configuration pre-COVID (2018-19) and during COVID-19 (2020-21).
METHODS:
We analysed 38,672 de-identified adult verbal autopsies (VA) from 13 sites, coding conditions, hypertension, diabetes, HIV, and TB. Multimorbidity was defined as ≥2 conditions. We employed dual analytical approaches: Latent Class Analysis (LCA) and Partitioning Around Medoids (PAM) to identify disease clusters for each site-period. This combination separated underlying structure from membership weighting. Models were selected using majority rule on the relevant indices. Within each site and region, we compared class profiles and prevalence across periods. For concordance between LCA and PAM, we examined overlap of top diseases per class and computed adjusted Rand indices on hard assignments to gauge agreement
RESULTS:
Analyses revealed distinct regional patterns. In Southern Africa, a TB/HIV-anchored LCA class expanded to ~60% during COVID-19, while PAM showed growth in hybrid TB/HIV-NCD combinations. DIMAMO remained HPT/DM-dominant but introduced a new HIV+cancer+stroke class. South Asian sites were NCD-saturated, with the proportion of decedents with ≥3 conditions rising sharply. East/West African sites exhibited an intermediate profile. Both methods confirmed stable cluster architectures, but membership shares proved elastic to pandemic shocks.
CONCLUSIONS:
The pandemic reweighted membership in pre-existing multimorbidity scaffolds rather than creating new clusters. The findings review the need for integrated care models that bundle HIV/TB and cardiometabolic management, prioritise hypertension control, and anticipate the aging of HIV cohorts.
Low- and middle-income countries (LMICs) face a dual burden of chronic infectious diseases (HIV/TB) and accelerating non-communicable diseases (NCDs) [1,2]. The COVID-19 pandemic caused profound health system disruptions, potentially reconfiguring multimorbidity clusters. This study aimed to model geographic and temporal variation in multimorbidity clustering across 13 Health and Demographic Surveillance System (HDSS) sites in Africa and Asia: (Southern Africa: Agincourt, DIMAMO, AHRI, Karonga; East Africa: Siaya, Manyatta, Harar, Haramaya, Kersa; West Africa: Dakar, Nanoro; South Asia: Matlab, Chakaria), comparing cluster configuration pre-COVID (2018-19) and during COVID-19 (2020-21).
METHODS:
We analysed 38,672 de-identified adult verbal autopsies (VA) from 13 sites, coding conditions, hypertension, diabetes, HIV, and TB. Multimorbidity was defined as ≥2 conditions. We employed dual analytical approaches: Latent Class Analysis (LCA) and Partitioning Around Medoids (PAM) to identify disease clusters for each site-period. This combination separated underlying structure from membership weighting. Models were selected using majority rule on the relevant indices. Within each site and region, we compared class profiles and prevalence across periods. For concordance between LCA and PAM, we examined overlap of top diseases per class and computed adjusted Rand indices on hard assignments to gauge agreement
RESULTS:
Analyses revealed distinct regional patterns. In Southern Africa, a TB/HIV-anchored LCA class expanded to ~60% during COVID-19, while PAM showed growth in hybrid TB/HIV-NCD combinations. DIMAMO remained HPT/DM-dominant but introduced a new HIV+cancer+stroke class. South Asian sites were NCD-saturated, with the proportion of decedents with ≥3 conditions rising sharply. East/West African sites exhibited an intermediate profile. Both methods confirmed stable cluster architectures, but membership shares proved elastic to pandemic shocks.
CONCLUSIONS:
The pandemic reweighted membership in pre-existing multimorbidity scaffolds rather than creating new clusters. The findings review the need for integrated care models that bundle HIV/TB and cardiometabolic management, prioritise hypertension control, and anticipate the aging of HIV cohorts.
| eISSN: | 2654-1459 |
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