Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases

Forecasting the effect of HIV-targeted interventions on the age distribution of people with HIV in Kenya

OBJECTIVES

To provide accurate forecasts of the age distribution of people with HIV (PWH) in Kenya from 2025 to 2040.

DESIGN

Development of a compartmental model of HIV in Kenya, calibrated to historical estimates of HIV epidemiology.

METHODS

We forecasted changes in population size and age distribution of new HIV infections and PWH under the status quo and under scale-up of HIV services.

RESULTS

Without scale-up, new HIV infections were forecasted to fall from 34 000 (28 000-41 000) in 2,025 to 29 000 (15 000-57 000) in 2,040; the percentage of new infections occurring among persons over 30 increased from 33% (20-50%) to 40% (24-62%). The median age of PWH increased from 39 years (38-40) in 2025 to 43 years (39-46) in 2040, and the percentage of PWH over age 50 increased from 26% (23-29%) to 34% (26-43%). Under the full intervention scenario, new infections were forecasted to fall to 6,000 (3,000-12 000) in 2,040. The percentage of new infections occurring in people over age 30 increased to 52% (34-71%) in 2,040, and there was an additional shift in the age structure of PWH [forecasted median age of 46 (43-48) and 40% (33-47%) over age 50].

CONCLUSION

PWH in Kenya are forecasted to age over the next 15 years; improvements to the HIV care continuum are expected to contribute to the growing proportion of older PWH.

Prevalence of Mental Health Disorders and Their Associated Risk Factors Among People Living with HIV in Rwanda: A Cross-Sectional Study

While life expectancy of people living with HIV is increasing, their burden of non-communicable diseases, including mental health disorders, is growing as well. The aim of this study is to investigate the prevalence and identify the risk factors associated with mental health disorders among this population in Rwanda. This cross-sectional study enrolled people living with HIV from 12 HIV clinics across Rwanda using random sampling. Trained HIV nurses conducted the Mini International Neuropsychiatric Interview to estimate the prevalence of major depressive episode, post-traumatic stress disorder, and generalized anxiety disorder. Sociodemographic, psychosocial, and HIV-related data were also collected. Associated risk factors for being diagnosed with one of the mental health disorders were assessed using modified Poisson regression with robust error variance. Of 428 participants, 70 (16.4%) had at least one mental health disorder with major depressive episode being most prevalent (n = 60, 14.0%). Almost all participants were adherent to antiretroviral therapy (n = 424, 99.1%) and virally suppressed (n = 412, 96.9%). Of those diagnosed with a mental health disorder, only few were aware of (n = 4, 5.7%) or under treatment for this mental health disorder (n = 5, 7.2%). Mental health disorders were associated with experiences of HIV-related stigma and discrimination (aRR = 2.14, 95%CI 1.30-3.53, p = 0.003). The results demonstrate underdiagnosis and undertreatment of mental health disorders among Rwandan People Living with HIV. Using HIV nurses to diagnose mental health disorders could serve as a low-cost strategy for integrating mental health care with existing HIV services and could inspire the implementation in other low-resource settings.

Why is there a gap in self-rated health among people with hypertension in Zambia? A decomposition of determinants and rural‒urban differences

BACKGROUND

Hypertension affects over one billion people globally and is one of the leading causes of premature death. Low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from more affluent and urban populations towards poorer and rural communities. Our study examined inequalities in self-rated health (SRH) among people with hypertension and whether there is a rural‒urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa.

METHODS

We utilized the Zambia Household Health Expenditure and Utilization Survey for data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from the Zambia Population-Based HIV Impact Assessment (ZAMPHIA) survey. We applied the Linear Probability Model to assess the association between self-rated health and independent variables as a preliminary step. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups.

RESULTS

Advanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (73.6%), district HIV prevalence (30.8%) and household expenditure (4.8%) being the most important determinants that explain the health gap.

CONCLUSIONS

Urban hypertension patients have better SRH than rural patients in Zambia. Education, district HIV prevalence and household expenditure were the most important determinants of the health gap between rural and urban hypertension patients. Policies aimed at promoting educational interventions, improving access to financial resources and strengthening hypertension health services, especially in rural areas, can significantly improve the health of rural patients, and potentially reduce health inequalities between the two regions.

"I only seek treatment when I am ill": experiences of hypertension and diabetes care among adults living with HIV in urban Tanzania

BACKGROUND

For adults living with HIV (ALHIV) and comorbidities, access to comprehensive healthcare services is crucial to achieving optimal health outcomes. This study aims to describe lived experiences, challenges, and coping strategies for accessing care for hypertension and/or diabetes (HTN/DM) in HIV care and treatment clinics (CTCs) and other healthcare settings.

METHODOLOGY

We conducted a qualitative study that employed a phenomenological approach between January and April 2022 using a semi-structured interview guide in six HIV CTCs in Dar es Salaam, Tanzania. We purposively recruited 33 ALHIV with HTN (n = 16), DM (n = 10), and both (n = 7). Thematic content analysis was guided by the 5As framework of access to care.

FINDINGS

The majority of the participants were females, between the ages of 54-73, and were recruited from regional referral hospitals. HIV CTCs at regional referral hospitals had more consistent provision of HTN screening services compared to those from district hospitals and health centers. Participants sought HTN/DM care at non-CTC health facilities due to the limited availability of such services at HIV CTCs. However, healthcare delivery for these conditions was perceived as unaccommodating and poorly coordinated. The need to attend multiple clinic appointments for the management of HTN/DM in addition to HIV care was perceived as frustrating, time-consuming, and financially burdensome. High costs of care and transportation, limited understanding of comorbidities, and the perceived complexity of HTN/DM care contributed to HTN/DM treatment discontinuity. As a means of coping, participants frequently monitored their own HTN/DM symptoms at home and utilized community pharmacies and dispensaries near their residences to check blood pressure and sugar levels and obtain medications. Participants expressed a preference for non-pharmaceutical approaches to comorbidity management such as lifestyle modification (preferred by young participants) and herbal therapies (preferred by older participants) because of concerns about side effects and perceived ineffectiveness of HTN/DM medications. Participants also preferred integrated care and focused patient education on multimorbidity management at HIV CTCs.

CONCLUSION

Our findings highlight significant barriers to accessing HTN/DM care among ALHIV, mostly related to affordability, availability, and accessibility. Integration of NCD care into HIV CTCs, could greatly improve ALHIV health access and outcomes and align with patient preference.

Conceptualising engagement with HIV care for people on treatment: the Indicators of HIV Care and AntiRetroviral Engagement (InCARE) Framework

BACKGROUND

As the crisis-based approach to HIV care evolves to chronic disease management, supporting ongoing engagement with HIV care is increasingly important to achieve long-term treatment success. However, 'engagement' is a complex concept and ambiguous definitions limit its evaluation. To guide engagement evaluation and development of interventions to improve HIV outcomes, we sought to identify critical, measurable dimensions of engagement with HIV care for people on treatment from a health service-delivery perspective.

METHODS

We used a pragmatic, iterative approach to develop a framework, combining insights from researcher experience, a narrative literature review, framework mapping, expert stakeholder input and a formal scoping review of engagement measures. These inputs helped to refine the inclusion and definition of important elements of engagement behaviour that could be evaluated by the health system.

RESULTS

The final framework presents engagement with HIV care as a dynamic behaviour that people practice rather than an individual characteristic or permanent state, so that people can be variably engaged at different points in their treatment journey. Engagement with HIV care for those on treatment is represented by three measurable dimensions: 'retention' (interaction with health services), 'adherence' (pill-taking behaviour), and 'active self-management' (ownership and self-management of care). Engagement is the product of wider contextual, health system and personal factors, and engagement in all dimensions facilitates successful treatment outcomes, such as virologic suppression and good health. While retention and adherence together may lead to treatment success at a particular point, this framework hypothesises that active self-management sustains treatment success over time. Thus, evaluation of all three core dimensions is crucial to realise the individual, societal and public health benefits of antiretroviral treatment programmes.

CONCLUSIONS

This framework distils a complex concept into three core, measurable dimensions critical for the maintenance of engagement. It characterises elements that the system might assess to evaluate engagement more comprehensively at individual and programmatic levels, and suggests that active self-management is an important consideration to support lifelong optimal engagement. This framework could be helpful in practice to guide the development of more nuanced interventions that improve long-term treatment success and help maintain momentum in controlling a changing epidemic.

Artificial intelligence-based computer aided detection (AI-CAD) in the fight against tuberculosis: Effects of moving health technologies in global health

Computer Aided Detection software based on Artificial Intelligence (AI-CAD), combined with chest X-rays have recently been promoted as an easy fix for a complex problem: ending TB by 2030. WHO has recommended the use of such imaging devices in 2021 and many partnerships have helped propose benchmark analysis and technology comparisons to facilitate their "market access". Our aim is to examine the socio-political and health issues that stem from using AI-CAD technology in a global health context conceptualized as a set of practice and ideas organizing global intervention "in the life of others". We also question how this technology, which is not yet fully implemented in routine use, may limit or amplify some inequalities in the care of tuberculosis. We describe AI-CAD through Actor-Network-Theory framework to understand the global assemblage and composite activities associated with detection through AI-CAD, and interrogate how the technology itself may consolidate a specific configuration of "global health". We explore the various dimensions of AI-CAD "health effects model": technology design, development, regulation, institutional competition, social interaction and health cultures. On a broader level, AI-CAD represents a new version of global health's accelerationist model centered on "moving and autonomous-presumed technologies". We finally present key aspects in our research which help discuss the theories mobilized: AI-CAD ambivalent insertion in global health, the social lives of its data: from efficacy to markets and AI-CAD human care and maintenance it requires. We reflect on the conditions that will affect AI-CAD use and its promises. In the end, the risk of new detection technologies such as AI-CAD is indeed that the fight against TB could be reduced to one that is purely technical and technological, with neglect to its social determinants and effects.

Cardiometabolic syndrome in HIV-positive and HIV-negative patients at Zewditu Memorial Hospital, Addis Ababa, Ethiopia: a comparative cohort study

Cardiometabolic syndrome (CMetS) has recently emerged as a serious public health concern, particularly for individuals living with chronic conditions. This study aimed to determine the incidence and prevalence of CMetS, as well as the risk factors linked with it, in HIV-positive and HIV-negative adult patients.

Methods

A comparative cohort study was designed. The National Cholesterol Education Program (NCEP) and the International Diabetes Federation (IDF) tools were used to determine the outcome variables. Association studies were done using logistic regression.

Result

CMetS was found to have a greater point and period prevalence, and incidence estimation in HIV-negative than HIV+ patients using both the NCEP and the IDF tools. Using the NCEP tool, the risk of obesity was 44.1% [odds ratio (OR) = 0.559, 95% confidence interval (CI), (0.380-0.824); P = 0.003] lower in HIV+ than in HIV-negative participants. By contrast, no apparent difference was noted using the IDF tool. Similarly, hyperglycemia [OR = 0.651, 95% CI (0.457-0.926); P = 0.017], and hypertension [OR = 0.391, 95% CI (0.271-0.563); P < 0.001] were shown to be lower in HIV+ patients than HIV-negative patients by 34.9% and 60.9%, respectively. The study revealed significant variation in all biomarkers across the follow-up period in both HIV+ and HIV-negative participants, except for SBP.

Conclusions

CMetS caused more overall disruption in HIV-negative people with chronic diseases than in HIV-positive people. All of the indicators used to assess the increased risk of CMetS were equally meaningful in HIV+ and HIV-negative subjects.

Economic evaluation of integrated services for non-communicable diseases and HIV: costs and client outcomes in rural Malawi

OBJECTIVE

To evaluate the costs and client outcomes associated with integrating screening and treatment for non-communicable diseases (NCDs) into HIV services in a rural and remote part in southeastern Africa.

DESIGN

Prospective cohort study.

SETTING

Primary and secondary level health facilities in Neno District, Malawi.

PARTICIPANTS

New adult enrollees in Integrated Chronic Care Clinics (IC3) between July 2016 and June 2017.

MAIN OUTCOME MEASURES

We quantified the annualised total and per capita economic cost (US$2017) of integrated chronic care, using activity-based costing from a health system perspective. We also measured enrolment, retention and mortality over the same period. Furthermore, we measured clinical outcomes for HIV (viral load), hypertension (controlled blood pressure), diabetes (average blood glucose), asthma (asthma severity) and epilepsy (seizure frequency).

RESULTS

The annualised total cost of providing integrated HIV and NCD care was $2 461 901 to provide care to 9471 enrollees, or $260 per capita. This compared with $2 138 907 for standalone HIV services received by 6541 individuals, or $327 per capita. Over the 12-month period, 1970 new clients were enrolled in IC3, with a retention rate of 80%. Among clients with HIV, 81% achieved an undetectable viral load within their first year of enrolment. Significant improvements were observed among clinical outcomes for clients enrolled with hypertension, asthma and epilepsy (p<0.05, in all instances), but not for diabetes (p>0.05).

CONCLUSIONS

IC3 is one of the largest examples of fully integrated HIV and NCD care. Integrating screening and treatment for chronic health conditions into Malawi's HIV platform appears to be a financially feasible approach associated with several positive clinical outcomes.

Chronic disease care integration into primary care services in sub-Saharan Africa: a 'best fit' framework synthesis and new conceptual model

OBJECTIVE

To examine the relevance of existing chronic care models to the integration of chronic disease care into primary care services in sub-Saharan Africa and determine whether additional context-specific model elements should be considered.

DESIGN

'Best fit' framework synthesis comprising two systematic reviews. First systematic review of existing chronic care conceptual models with construction of a priori framework. Second systematic review of literature on integrated HIV and diabetes care at a primary care level in sub-Saharan Africa, with thematic analysis carried out against the a priori framework. New conceptual model constructed from a priori themes and new themes. Risk of bias of included studies was assessed using CASP and MMAT.

ELIGIBILITY CRITERIA

Conceptual models eligible for inclusion in construction of a priori framework if developed for a primary care context and described a framework for long-term management of chronic disease care. Articles eligible for inclusion in second systematic review described implementation and evaluation of an intervention or programme to integrate HIV and diabetes care into primary care services in SSA.

INFORMATION SOURCES

PubMed, Embase, CINAHL Plus, Global Health and Global Index Medicus databases searched in April 2020 and September 2022.

RESULTS

Two conceptual models of chronic disease care, comprising six themes, were used to develop the a priori framework. The systematic review of primary research identified 16 articles, within which all 6 of the a priori framework themes, along with 5 new themes: Improving patient access, stigma and confidentiality, patient-provider partnerships, task-shifting, and clinical mentoring. A new conceptual model was constructed from the a priori and new themes.

CONCLUSION

The a priori framework themes confirm a need for co-ordinated, longitudinal chronic disease care integration into primary care services in sub-Saharan Africa. Analysis of the primary research suggests integrated care for HIV and diabetes at a primary care level is feasible and new themes identified a need for a contextualised chronic disease care model for sub-Saharan Africa.

What are the barriers to the diagnosis and management of chronic respiratory disease in sub-Saharan Africa? A qualitative study with healthcare workers, national and regional policy stakeholders in five countries

OBJECTIVES

Chronic respiratory diseases (CRD) are among the top four non-communicable diseases globally. They are associated with poor health and approximately 4 million deaths every year. The rising burden of CRD in low/middle-income countries will strain already weak health systems. This study aimed to explore the perspectives of healthcare workers and other health policy stakeholders on the barriers to effective diagnosis and management of CRD in Kenya, Malawi, Sudan, Tanzania and Uganda.

STUDY DESIGN

Qualitative descriptive study.

SETTINGS

Primary, secondary and tertiary health facilities, government agencies and civil society organisations in five sub-Saharan African countries.

PARTICIPANTS

We purposively selected 60 national and district-level policy stakeholders, and 49 healthcare workers, based on their roles in policy decision-making or health provision, and conducted key informant interviews and in-depth interviews, respectively, between 2018 and 2019. Data were analysed through framework approach.

RESULTS

We identified intersecting vicious cycles of neglect of CRD at strategic policy and healthcare facility levels. Lack of reliable data on burden of disease, due to weak information systems and diagnostic capacity, negatively affected inclusion in policy; this, in turn, was reflected by low budgetary allocations for diagnostic equipment, training and medicines. At the healthcare facility level, inadequate budgetary allocations constrained diagnostic capacity, quality of service delivery and collection of appropriate data, compounding the lack of routine data on burden of disease.

CONCLUSION

Health systems in the five countries are ill-equipped to respond to CRD, an issue that has been brought into sharp focus as countries plan for post-COVID-19 lung diseases. CRD are underdiagnosed, under-reported and underfunded, leading to a vicious cycle of invisibility and neglect. Appropriate diagnosis and management require health systems strengthening, particularly at the primary healthcare level.

Factors influencing the integration of evidence-based task-strengthening strategies for hypertension control within HIV clinics in Nigeria

Background

Evidence-based task-strengthening strategies for hypertension (HTN) control (TASSH) are not readily available for patients living with HIV in sub-Saharan Africa where the dual burden of HTN and HIV remains high. We are conducting a cluster randomized controlled trial comparing the effectiveness of practice facilitation versus a self-directed control (i.e., receipt of TASSH with no practice facilitation) in reducing blood pressure and increasing the adoption of task-strengthening strategies for HTN control within HIV clinics in Nigeria. Prior to implementing the trial, we conducted formative research to identify factors that may influence the integration of TASSH within HIV clinics in Nigeria.

Methods

This mixed-methods study was conducted with purposively selected healthcare providers at 29 HIV clinics, followed by a 1-day stakeholder meeting with 19 representatives of HIV clinics. We collected quantitative practice assessment data using two instruments: (a) an adapted Service Availability and Readiness Assessment (SARA) tool to assess the capacity of the clinic to manage NCDs and (b) Implementation Climate Scale to assess the degree to which there is a strategic organizational climate supportive of the evidence-based practice implementation. The quantitative data were analyzed using descriptive statistics and measures of scale reliability. We also used the Consolidated Framework for Implementation Research (CFIR), to thematically analyze qualitative data generated and relevant to the aims of this study.

Results

Across the 29 clinics surveyed, the focus on TASSH (mean=1.77 (SD=0.59)) and educational support (mean=1.32 (SD=0.68)) subscales demonstrated the highest mean score, with good–excellent internal consistency reliability (Cronbach’s alphas ranging from 0.84 to 0.96). Within the five CFIR domains explored, the major facilitators of the intervention included relative advantage of TASSH compared to current practice, compatibility with clinic organizational structures, support of patients’ needs, and intervention alignment with national guidelines. Barriers included the perceived complexity of TASSH, weak referral network and patient tracking mechanism within the clinics, and limited resources and diagnostic equipment for HTN.

Conclusion

Optimizing healthcare workers’ implementation of evidence-based TASSH within HIV clinics requires attention to both the implementation climate and contextual factors likely to influence adoption and long-term sustainability. These findings have implications for the development of effective practice facilitation strategies to further improve the delivery and integration of TASSH within HIV clinics in Nigeria.

Trial registration

ClinicalTrials.gov, NCT04704336

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00289-z.

A sub-group evaluation of the multi-month dispensing strategy for differentiated HIV care: is personalization of care guidelines warranted in Haiti?

Background

Differentiated care strategies are rapidly becoming the norm for HIV care delivery globally. Building upon an interest in tailoring antiretroviral therapy (ART) delivery for client-centered needs, the Ministry of Health and Population in Haiti formally endorsed multiple-month dispenses (MMD) in the 2016 national ART guidelines This study explores heterogeneity in retention in care with MMD for specific Haitian populations living with HIV and evaluates if a targeted algorithm for optimal ART prescription intervals is warranted in Haiti.

Methods

This study included ART-naïve individuals who started ART on or after January 1st, 2017 in Haiti. To identify subgroups in which to explore heterogeneity of retention, we implemented a double-lasso regression method to determine which individual characteristics would define the subgroups. Characteristics evaluated for potential subgroup definition included: sex, age category, WHO clinical stage, and body mass index category. We employed instrumental variable models to estimate the causal effect of increasing ART dispensing length on ART retention, by client subgroup. The outcome of interest was retention in care after one year in treatment. We then estimated the marginal effect of a 30-day increase to ART dispensing length to retention in care for each of these subgroups.

Results

There was evidence for heterogeneity in the effect of extending ART dispensing intervals on retention by WHO clinical stage. We observed significant improvements to retention in care at one year with a 30-day increase in ART dispense length for all subgroups defined by WHO clinical stages 1-4. The effects ranged from a 14.7% increase (95% CI: 12.4-17.0) to the likelihood of retention for people with HIV in WHO stage 1 to a 21.6% increase (95% CI: 18.7-24.5) to the likelihood of retention for those in WHO stage 3.

Conclusions

All the subgroups defined by WHO clinical stage experienced a benefit of extending ART intervals to retention in care at one year. Though the effect did differ slightly by WHO stage, the effects went in the same direction and were of similar magnitude. Therefore, a standardized recommendation for MMD among those living with HIV and new on ART is appropriate for Haiti treatment guidelines.

Linkage to HIV care and hypertension and diabetes control in rural South Africa: Results from the population-based Vukuzazi Study

Non-communicable diseases (NCDs) account for half of all deaths in South Africa, partly reflecting unmet NCDs healthcare needs. Leveraging existing HIV infrastructure is touted as a strategy to alleviate this chronic care gap. We evaluated whether HIV care platforms are associated with improved NCDs care. We conducted a community-based screening of adults in rural KwaZulu-Natal, collecting BP, HbA1c, and health services utilization data. Care cascade indicators for hypertension and diabetes mellitus were defined as: 1) aware, if previously diagnosed, 2) in care, if seeing a provider within last 6 months; 3) treated, if reporting medication use within preceding 2 weeks; and 4) controlled, if BP<140/90mmHg or HbA1c<6.5%. We fit multivariable adjusted logistic regression models to compare successful completion of each step of the care cascade for hypertension and diabetes between people with virally suppressed HIV and HIV-negative comparators. Inverse probability sampling weights were applied to derive population-level estimates. The analytic sample included 4,933 individuals [mean age 58.4 years; 77% female]. Compared to being HIV-negative, having suppressed HIV was associated with lower adjusted prevalence of being aware (-6.0% [95% CI: -11.0, -1.1%]), in care (-5.7% [-10.6, -0.8%]), and in treatment (-4.8% [-9.7, 0.1%]) for diabetes; but higher adjusted prevalence of controlled diabetes (3.2% [0.2-6.2%]). In contrast, having suppressed HIV was associated with higher adjusted prevalence of being aware (7.4% [5.3-9.6%]), in care (8.0% [5.9-10.2%]), in treatment (8.4% [6.1-10.6%]) and controlled (9.0% [6.2-11.8%]), for hypertension. Overall, disease control was achieved for 40.0% (38.6-40.8%) and 6.8% (5.9-7.8%) of individuals with hypertension and diabetes, respectively. Engagement in HIV care in rural KwaZulu-Natal was generally associated with worse diabetes care and improved hypertension care. While further work should explore how success of HIV programs can be translated to NCD care, strengthening of primary healthcare will also be needed to respond to the growing NCDs epidemic.

How Home Delivery of Antiretroviral Drugs Ensured Uninterrupted HIV Treatment During COVID-19: Experiences From Indonesia, Laos, Nepal, and Nigeria

INTRODUCTION

Faced with the coronavirus disease (COVID-19) pandemic, governments worldwide instituted lockdowns to curtail virus spread. Health facility closures and travel restrictions disrupted access to antiretroviral (ARV) therapy for people living with HIV. This report describes how HIV programs in Indonesia, Laos, Nepal, and Nigeria supported treatment continuation by introducing home delivery of ARVs.

METHODS

Staff supporting the programs provided accounts of when and how decisions were taken to support ARV home delivery. They captured programmatic information about home delivery implementation using an intervention documentation tool. The 4 country experiences revealed lessons learned about factors favoring successful expansion of ARV home delivery.

RESULTS

Three of the countries relied on existing networks of community health workers for ARV delivery; the fourth country, Indonesia, relied on a private sector courier service. Across the 4 countries, between 19% and 51% of eligible clients were served by home delivery. The experiences showed that ARV home delivery is feasible and acceptable to health service providers, clients, and other stakeholders. Essential to success was rapid mobilization of stakeholders who led the design of the home delivery mechanisms and provided leadership support of the service innovations. Timely service adaptation was made possible by pre-existing differentiated models of care supportive of community-based ARV provision by outreach workers. Home delivery models prioritized protection of client confidentiality and prevention measures for COVID-19. Sustainability of the innovation depends on reinforcement of the commodity management infrastructure and investment in financing mechanisms.

CONCLUSION

Home delivery of ARVs is a feasible client-centered approach to be included among the options for decentralized drug distribution. It serves as a measure for expanding access to care both when access to health services is disrupted and under routine circumstances.

Cervical Visual Inspection with Acetic Acid (VIA) and Oncogenic Human Papillomavirus Screening in Rural Indigenous Guatemalan Women: Time to Rethink VIA

Single-visit “screen-and-treat” strategies using visual inspection with acetic acid (VIA) and cryotherapy (liquid nitrous oxide ablation) in low-resource settings are commonly used to detect and treat precancerous lesions for cervical cancer prevention. This study compared VIA sensitivity and specificity in rural indigenous Guatemalan communities, to that of oncogenic human papillomavirus (HPV) testing for detection of precancerous changes, using cytology as the reference standard. Between 3–8 September 2017, trained nurses examined 222 women aged 23–58 years with VIA. Specimens for liquid-based cytology and HPV testing were obtained prior to VIA with a cytobrush and transported in PreservCyt to a US clinical laboratory. VIA and HPV test sensitivities were assessed as proportions of women with abnormal cytology that had abnormal VIA or HPV results, respectively, and specificities, as proportions with normal cytology with normal VIA or negative HPV tests. Of 222 women, 18 (8.1%) had abnormal cytology (1 carcinoma in a participant who received VIA-based cryotherapy in 2015, 4 high- and 5 low-grade squamous intraepithelial lesions, and 8 atypical squamous cells of undetermined significance (ASCUS)). Excluding ASCUS, sensitivities of VIA and HPV were 20.0% and 100%, respectively. VIA-based screening may not be acceptable for detecting precancerous lesions, and field cryotherapy for preventing malignancy. The World Health Organization recommended in 2021 “…using HPV DNA detection as the primary screening test rather than VIA or cytology”.

Patient-Centered, Sustainable Hypertension Care: The Case for Adopting a Differentiated Service Delivery Model for Hypertension Services in Low- and Middle-Income Countries

Expanding hypertension services in low- and middle-income countries requires efficient and effective service delivery approaches that meet the needs and expectations of people living with hypertension within the resource constraints of existing national health systems. Ideally, a hypertension program will extend treatment coverage while maintaining service quality, maximizing efficient resource utilization and improving clinical outcomes. In this article, we discuss lessons learned from HIV differentiated service delivery initiatives, and make the case that the same approach should be adopted for hypertension programs.

Translating Implementation Experiences and Lessons Learned From Polio Eradication Into a Global Health Course: Insights From an International Consortium

Using international collaborations to develop educational materials presents several challenges but offers enormous benefits in gleaning a wealth of information, perspectives, and context. The global course that resulted from this collaboration mirrors the goals of implementation science more broadly—to bring the findings of research into routine practice to improve health services.

Lessons learned from one global health program can inform responses to challenges faced by other programs. One way to disseminate these lessons is through courses. However, such courses are often delivered by and taught to people based in high-income countries and thus may not present a truly global perspective. The Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) is a consortium of 8 institutions in Afghanistan, Bangladesh, the Democratic Republic of the Congo, Ethiopia, India, Indonesia, Nigeria, and the United States that seeks to carry out such a transfer of the lessons learned in polio eradication. This short report describes the collaborative process of developing content and curriculum for an international course, the learnings that emerged, the barriers we faced, and recommendations for future similar efforts. Various parts of our course were developed by teams of researchers from countries across South Asia and sub-Saharan Africa. We held a series of regional in-person team meetings hosted in different countries to improve rapport and provide a chance to work together in person. The course content reflects the diversity of team members’ knowledge in a variety of contexts. Challenges to this effort included team coordination (e.g., scheduling across time zones); hierarchies across and between countries; and the coronavirus disease (COVID-19) pandemic. We recommend planning for these hierarchies ahead of time and ensuring significant in-person meeting time to make the most of international collaboration.

Factors associated with adherence to guideline-recommended cardiovascular disease prevention among HIV clinicians

Integrating cardiovascular disease (CVD) prevention in routine HIV care remains a challenge. This study aimed to identify factors associated with adherence to guideline-recommended CVD preventive practices among HIV clinicians. Clinicians from eight HIV clinics in Atlanta were invited to complete an online survey. The survey was informed by the Consolidated Framework for Implementation Research and assessed the following: clinician CVD risk screening and advice frequency (never to always), individual characteristics (clinician beliefs, self-efficacy, and motivation), inner setting factors (clinic culture, learning climate, leadership engagement, and resources available), and outer setting factors (peer pressure and patient needs). Bivariate correlations examined associations between these factors and guideline adherence. Thirty-eight clinicians completed the survey (82% women, mean age 42 years, 50% infectious disease physicians). For risk screening, clinicians always check patient blood pressure (median score 7.0/7), while they usually ask about smoking or check their blood glucose (median score 6.0/7). For advice provision, clinicians usually recommend quitting smoking, controlling cholesterol or controlling blood pressure (median score 6.0/7), while they often recommend controlling blood glucose, losing weight, or improving diet/physical activity (median score 5.5/7). Clinician beliefs, motivation and self-efficacy were positively correlated with screening and advice practices (r = .55−.84), while inner setting factors negatively correlated with lifestyle-related screening and advice practices (r = −.51 to −.76). Peer pressure was positively correlated with screening and advice practices (r = .57–.89). Clinician psychosocial characteristics and perceived peer pressure positively influence adherence to guideline-recommended CVD preventive practices. These correlates along with leadership engagement could be targeted with proven implementation strategies.

Using social networks to scale up and sustain community-based programmes to improve physical activity and diet in low-income and middle-income countries: a scoping review protocol

INTRODUCTION

The World Health Organisation endorses community-based programmes as a cost-effective, feasible and a 'best buy' in the prevention and management of non-communicable diseases (NCDs). These programmes are particularly successful when the community actively participates in its design, implementation and evaluation. However, they may be only useful insofar as they can be scaled up and sustained in some meaningful way. Social network research may serve as an important tool for determining the underlying mechanisms that contribute to this process. The aim of this planned scoping review is to map and collate literature on the role of social networks in scaling-up and sustaining community-based physical activity and diet programmes in low-income and middle-income countries.

METHODS AND ANALYSIS

This scoping review protocol has been planned around the Arksey and O'Malley framework and its enhancement. Inclusion criteria are peer-reviewed articles and grey literature exploring the role of social networks in the scale-up and/or sustainability of NCD prevention community-based programmes in adult populations. Studies must have been published since 2000, in English, and be based in a low-income or middle-income country. The following databases will be used for this review: PubMed, Cochrane, Scopus, Web of Science, CINAHL, SocIndex, the International Bibliography of the Social Sciences, Google and Google Scholar. Books, conference abstracts and research focused only on children will be excluded. Two reviewers will independently select and extract eligible studies. Included publications will be thematically analysed using the Framework Approach.

ETHICS AND DISSEMINATION

Ethical approval will not be sought for this review as no individual-level data or human participants will be involved. This protocol is registered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/KG7TX). The findings from the review will be published in an accredited journal. The Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews checklist will be used to support transparency and guide translation of the review.

The Looming Threat: Cancer in Sub-Saharan Africa

Recent trends in cancer epidemiology in low‐ and middle‐income countries show the need for urgent action. This article focuses on sub‐Saharan Africa, where populations are showing an increased risk for diseases associated with the Western lifestyle, including cancer.

Management of chronic lung diseases in Sudan and Tanzania: how ready are the country health systems?

Background

Chronic lung diseases (CLDs), responsible for 4 million deaths globally every year, are increasingly important in low- and middle-income countries where most of the global mortality due to CLDs currently occurs. As existing health systems in resource-poor contexts, especially sub-Saharan Africa (SSA), are not generally oriented to provide quality care for chronic diseases, a first step in re-imagining them is to critically consider readiness for service delivery across all aspects of the existing system.

Methods

We conducted a mixed-methods assessment of CLD service readiness in 18 purposively selected health facilities in two differing SSA health system contexts, Tanzania and Sudan. We used the World Health Organization’s (WHO) Service Availability and Readiness Assessment checklist, qualitative interviews of key health system stakeholders, health facility registers review and assessed clinicians’ capacity to manage CLD using patient vignettes. CLD service readiness was scored as a composite of availability of service-specific tracer items from the WHO service availability checklist in three domains: staff training and guidelines, diagnostics and equipment, and basic medicines. Qualitative data were analysed using the same domains.

Results

One health facility in Tanzania and five in Sudan, attained a CLD readiness score of ≥ 50 % for CLD care. Scores ranged from 14.9 % in a dispensary to 53.3 % in a health center in Tanzania, and from 36.4 to 86.4 % in Sudan. The least available tracer items across both countries were trained human resources and guidelines, and peak flow meters. Only two facilities had COPD guidelines. Patient vignette analysis revealed significant gaps in clinicians’ capacity to manage CLD. Key informants identified low prioritization as key barrier to CLD care.

Conclusions

Gaps in service availability and readiness for CLD care in Tanzania and Sudan threaten attainment of universal health coverage in these settings. Detailed assessments by health systems researchers in discussion with stakeholders at all levels of the health system can identify critical blockages to reimagining CLD service provision with people-centered, integrated approaches at its heart.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06759-9.

Nutrition related non-communicable diseases and sugar sweetened beverage policies: a landscape analysis in Zambia

Background: Taxation on unhealthy products is recommended as a cost-effective intervention to address the global burden of non-communicable diseases. Taxation of sugar-sweetened beverages dis-incentivize consumption of unhealthy products. Implementation of such policies is difficult in Sub-Saharan African countries, which are targets for global corporate expansion by the sugar-sweetened beverages industry.Objective: To identify opportunities to strengthen policies relating to sugar-sweetened beverage taxation in Zambia, through: (1) understanding the policy landscape and political context in which policies for nutrition-related non-communicable diseases are being developed, particularly sugar-sweetened beverage taxation, and exploring the potential use of revenue arising from sugar-sweetened beverage taxation to support improved nutrition.Methods: We conducted a retrospective qualitative policy analysis with a review of nutrition-related non-communicable diseases policies and key informant interviews (n = 10) with policy actors. Data were coded and analyzed data using pre-constructed matrices based on the Kingdon's Policy Agenda Framework.Results: Government responses to nutrition-related non-communicable diseases were developed in an incoherent policy environment. The health sector's commitment to regulate sugar-sweetened beverages conflicted with the manufacturing sector's priorities for economic growth. Increased regulation of sugar-sweetened beverages was a priority for the health sector. Economic interests sought to grow the manufacturing sector, including the food and beverage industries. Consequently, incoherent policy objectives might have contributed to the adoption of a weakened excise tax. The general public were poorly informed about nutrition-related non-communicable diseases.Conclusions: The tension between the Government's economic and public health priorities is a barrier for strengthening fiscal measures to address nutrition-related non-communicable diseases. However, this did not prevent the introduction of a differential sugar tax on sugar-sweetened beverages. Opportunities exist to strengthen the existing taxation of sugar-sweetened beverages in Zambia. These include a more inclusive consultation process for policy formulation and comprehensive monitoring of risk factors.

Community Group-Based Models of Medication Delivery: Applicability to Cardiovascular Diseases

The rising global burden of chronic non-communicable diseases (NCDs) has put a strain on healthcare systems globally, especially in low- and middle-income countries, which have seen disproportionate mortality rates due to non-communicable diseases. These deaths are in part due to challenges with medication adherence, which are compounded by lack of access to medication and weak community support systems. This paper aims to propose a potential solution using models of service delivery in HIV/AIDS, given the many similarities between NCD and HIV/AIDS. Models that have been particularly effective in HIV/AIDS are the community-based peer-support medication delivery groups: medication adherence clubs and community antiretroviral therapy (ART) groups. The positive outcomes from these models, including improved medication adherence and patient satisfaction, provide evidence for their potential success when applied to non-communicable diseases, particularly hypertension and cardiovascular disease.

An evaluation of self-management outcomes among chronic care patients in community home-based care programmes in rural Malawi: A 12-month follow-up study

This paper investigates the impact of community home-based care (CHBC) on self-management outcomes for chronically ill patients in rural Malawi. A pre- and post-evaluation survey was administered among 140 chronically ill patients with HIV and non-communicable diseases, newly enrolled in four CHBC programmes. We translated, adapted and administered scales from the Stanford Chronic Disease Self-Management Programme to evaluate patient's self-management outcomes (health status and self-efficacy), at four time points over a 12-month period, between April 2016 and May 2017. The patient's drop-out rate was approximately 8%. Data analysis included descriptive statistics, tests of associations, correlations and pairwise comparison of outcome variables between time points, and multivariate regression analysis to explore factors associated with changes in self-efficacy following CHBC interventions. The results indicate a reduction in patient-reported pain, fatigue and illness intrusiveness, while improvements in general health status and quality of life were not statistically significant. At baseline, the self-efficacy mean was 5.91, which dropped to 5.1 after 12 months. Factors associated with this change included marital status, education, employment and were condition-related; whereby self-efficacy for non-HIV and multimorbid patients was much lower. The odds for self-efficacy improvement were lower for patients with diagnosed conditions of longer duration. CHBC programme support, regularity of contact and proximal location to other services influenced self-efficacy. Programmes maintaining regular home visits had higher patient satisfaction levels. Our findings suggest that there were differential changes in self-management outcomes following CHBC interventions. While self-management support through CHBC programmes was evident, CHBC providers require continuous training, supervision and sustainable funding to strengthen their contribution. Furthermore, sociodemographic and condition-related factors should inform the design of future interventions to optimise outcomes. This study provides a systematic evaluation of self-management outcomes for a heterogeneous chronically ill patient population and highlights the potential and relevant contribution of CHBC programmes in improving chronic care within sub-Saharan Africa.

Expanding the Vision for Differentiated Service Delivery: A Call for More Inclusive and Truly Patient-Centered Care for People Living With HIV

BACKGROUND

Simplifying antiretroviral therapy for clinically stable people living with HIV (PLHIV) is important but insufficient to meet their health care needs, including prevention and treatment of tuberculosis and noncommunicable diseases, routine primary care, and family planning. Integrating these services into differentiated service delivery (DSD) platforms is a promising avenue to achieve such coverage. We propose a transition from an HIV-focused "DSD 1.0" to a patient-centered "DSD 2.0" that is inclusive of additional chronic care services for PLHIV.

DISCUSSION

The lack of coordination between HIV programs and these critical services puts a burden on both PLHIV and health systems. For individual patients, fractionated services increase cost and time, diminish the actual and perceived quality of care, and increase the risk that they will disengage from health care altogether. The burden on the health system is one of inefficiency and suboptimal outcomes resulting from the parallel systems required to manage multiple vertical programs.

CONCLUSIONS

DSD 2.0 provides an opportunity for the HIV and Universal Health Coverage agendas-which can seem to be at odds-to achieve greater collective impact for patients and health systems by integrating strong vertical HIV, tuberculosis and family planning programs, and relatively weaker noncommunicable disease programs. Increasing coordination of care for PLHIV will increase the likelihood of achieving and sustaining UNAIDS' goals of retention on antiretroviral therapy and viral suppression. Eventually, this shift to DSD 2.0 for PLHIV could evolve to a more person-centered vision of chronic care services that would also serve the general population.

Barriers and facilitators for scaling up mental health and psychosocial support interventions in low- and middle-income countries for populations affected by humanitarian crises: a systematic review

BACKGROUND

Humanitarian crises increase the burden of mental disorders due to exposure to traumatic events and ongoing daily stressors. Effective mental health and psychosocial support (MHPSS) interventions exist, but barriers and facilitators for scaling up those interventions are less understood. The study aim was to identify barriers and facilitators for scaling up MHPSS interventions for populations affected by humanitarian crises in low- and middle-income countries.

METHODS

A systematic review following PRISMA guidelines was conducted. Types of scale up were summarised, and barriers and facilitators analysed using the World Health Organization's Expandnet framework of scaling up. Evidence quality was appraised using the Mixed Methods Appraisal Tool.

RESULTS

Fourteen eligible studies were identified. Most described horizontal types of scale up, integrating services into primary and community care through staff training, task-sharing, and establishing referral and supervision mechanisms. Barriers were reported in a range of framework elements, but primarily related to those in the health system. The overall quality of studies were limited.

CONCLUSION

Few MHPSS interventions in humanitarian crises appear to have been scaled up, and scaling up efforts were largely horizontal which challenges long-term sustainability. Greater focus should be on both horizontal and vertical scaling up, which should be accompanied by higher quality research.

Implementation of a non-communicable disease clinic in rural Sierra Leone: early experiences and lessons learned

This study is an evaluation of the first cohort of patients enrolled in an outpatient non-communicable disease clinic in Kono, Sierra Leone. In the first year, the clinic enrolled 916 patients. Eight months after the enrollment of the last patient, 53% were still active in care, 43% had been lost to follow-up (LTFU) and 4% had defaulted. Of the LTFU patients, 47% only came for the initial enrollment visit and never returned. Treatment outcomes of three patient groups [HTN only (n = 720), DM only (n = 51), and HTN/DM (n = 96)] were analyzed through a retrospective chart review. On average, all groups experienced reductions in blood pressure and/or blood glucose of approximately 10% and 20%, respectively. The proportions of patients with their condition controlled also increased. As NCDs remain underfunded and under-prioritized in low-income countries, the integrated program in Kono demonstrates the possibility of improving outpatient NCD care in Sierra Leone and similar settings.

Expanding access to non-communicable disease care in rural Malawi: outcomes from a retrospective cohort in an integrated NCD-HIV model

OBJECTIVES

Non-communicable diseases (NCDs) account for one-third of disability-adjusted life years in Malawi, and access to care is exceptionally limited. Integrated services with HIV are widely recommended, but few examples exist globally. We report descriptive outcomes from an Integrated Chronic Care Clinic (IC3).

DESIGN

This is a retrospective cohort study.

SETTING

The study includes an HIV-NCD clinic across 14 primary care facilities in the rural district of Neno, Malawi.

PARTICIPANTS

All new patients, including 6233 HIV-NCD diagnoses, enrolled between January 2015 and December 2017 were included. This included 3334 patients with HIV (59.7% women) and 2990 patients with NCD (67.3% women), 10% overall under age 15 years.

INTERVENTIONS

Patients were seen at their nearest health centre, with a hospital team visiting routinely to reinforce staffing. Data were collected on paper forms and entered into an electronic medical record.

PRIMARY AND SECONDARY OUTCOME MEASURES

Routine clinical measurements are reported at 1-year post-enrolment for patients with more than one visit. One-year retention is reported by diagnosis.

RESULTS

NCD diagnoses were 1693 hypertension, 668 asthma, 486 epilepsy, 149 diabetes and 109 severe mental illness. By December 2018, 8.3% of patients with NCD over 15 years were also on HIV treatment. One-year retention was 85% for HIV and 72% for NCDs, with default in 8.4% and 25.5% and deaths in 4.0% and 1.4%, respectively. Clinical outcomes showed statistically significant improvement for hypertension, diabetes, asthma and epilepsy. Of the 1807 (80%) of patients with HIV with viral load results, 85% had undetectable viral load.

CONCLUSIONS

The IC3 model, built on an HIV platform, facilitated rapid decentralisation and access to NCD services in rural Malawi. Clinical outcomes and retention in care are favourable, suggesting that integration of chronic disease care at the primary care level poses a way forward for the large dual burden of HIV and chronic NCDs.

Planning the scale up of brief psychological interventions using theory of change

BACKGROUND

A large mental health treatment gap exists among conflict-affected populations, and Syrian refugees specifically. Promising brief psychological interventions for conflict-affected populations exist such as the World Health Organization's Problem Management Plus (PM+) and the Early Adolescent Skills for Emotions (EASE) intervention, however, there is limited practical guidance for countries of how these interventions can be taken to scale. The aim of this study was to unpack pathways for scaling up PM+ and EASE for Syrian refugees.

METHODS

We conducted three separate Theory of Change (ToC) workshops in Turkey, the Netherlands, and Lebanon in which PM+ and EASE are implemented for Syrian refugees. ToC is a participatory planning process involving key stakeholders, and aims to understand a process of change by mapping out intermediate and long-term outcomes on a causal pathway. 15-24 stakeholders were invited per country, and they participated in a one-day interactive ToC workshop on scaling up.

RESULTS

A cross-country ToC map for scale up brief psychological interventions was developed which was based on three country-specific ToC maps. Two distinct causal pathways for scale up were identified (a policy and financing pathway, and a health services pathway) which are interdependent on each other. A list of key assumptions and interventions which may hamper or facilitate the scaling up process were established.

CONCLUSION

ToC is a useful tool to help unpack the complexity of scaling up. Our approach highlights that scaling up brief psychological interventions for refugees builds on structural changes and reforms in policy and in health systems. Both horizontal and vertical scale up approaches are required to achieve sustainability. This paper provides the first theory-driven map of causal pathways to help support the scaling-up of evidence-based brief psychological interventions for refugees and populations in global mental health more broadly.

Global Health Perspectives Among Radiation Oncology Residency Program Directors: A Knowledge, Attitudes, and Practices Survey

PURPOSE

Interest in global health has risen among medical students applying to and residents training in radiation oncology, often outpacing available educational offerings. The Association of Residents in Radiation Oncology Global Health Subcommittee sought to determine the perceptions of program directors (PDs) in radiation oncology and their current or planned global health curricular opportunities.

METHODS AND MATERIALS

A standardized, Knowledge-Attitudes-Practices survey composed of 32 binary items was sent to PDs for all Accreditation Council for Graduate Medical Education-accredited radiation oncology programs.

RESULTS

The program response rate was 60% (55 of 91). Responding programs were distributed evenly geographically and included a range of training program sizes. Most PDs (77%) knew that most nations did not meet standard minimum benchmarks for radiation therapy access. Although 89% would support residents in pursuing global health rotations, only 22% would support departmental funding of such rotations. Furthermore, 94% believed that global health was a field worthy of an academic career, but only 39% believed that it had appropriate rigor. Only 8% of programs had dedicated global health rotations.

CONCLUSIONS

Radiation oncology PDs largely expressed favorable views of global health as a pursuit and affirmed a high degree of resident and medical student interest. However, faculty commitment and program offerings currently lag behind the interest level. In particular, a substantial number of PDs do not perceive global health to be a rigorous academic endeavor. Future progress in academic global health in radiation oncology will require strategies to systematically support pathways for the development of experience and scholarship both within and beyond residency.

Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district

BACKGROUND

With the increasing double burden of communicable and non-communicable diseases (NCDs) in sub-Saharan Africa, health systems require new approaches to organise and deliver services for patients requiring long-term care. There is increasing recognition of the need to integrate health services, with evidence supporting integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This study investigates current practices of delivering and implementing integrated care for chronically-ill patients in rural Malawi, focusing on the primary level.

METHODS

A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017, with a sub-analysis performed on the data following a document analysis to understand the policy context and how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities, selected purposively to represent different levels of care (primary and secondary), and ownership (private and public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities. Meetings with five non-governmental organisations to study their projects and support towards chronic care in Phalombe. Data were analysed using a thematic approach and managed in NVivo.

RESULTS

Our study found that, while policies supported integration of various disease-specific programmes at point of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g. inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems.

CONCLUSION

In rural Malawi, major impediments to integrated care provision for chronically-ill patients include the frail state of primary healthcare services and sub-optimal NCD care at the lowest healthcare level. In pursuit of integrative strategies, opportunities lie in utilising and expanding community-based outreach strategies offering multi-disease screening and care with strong referral linkages; careful task delegation and role realignment among care teams supported with proper training and incentive mechanisms; and collaborative partnership between public and private sector actors to expand the resource-base and promoting cross-programme initiatives.

Recommendations for the use of mathematical modelling to support decision-making on integration of non-communicable diseases into HIV care

INTRODUCTION

Integrating services for non-communicable diseases (NCDs) into existing primary care platforms such as HIV programmes has been recommended as a way of strengthening health systems, reducing redundancies and leveraging existing systems to rapidly scale-up underdeveloped programmes. Mathematical modelling provides a powerful tool to address questions around priorities, optimization and implementation of such programmes. In this study, we examine the case for NCD-HIV integration, use Kenya as a case-study to highlight how modelling has supported wider policy formulation and decision-making in healthcare and to collate stakeholders' recommendations on use of models for NCD-HIV integration decision-making.

DISCUSSION

Across Africa, NCDs are increasingly posing challenges for health systems, which historically focused on the care of acute and infectious conditions. Pilot programmes using integrated care services have generated advantages for both provider and user, been cost-effective, practical and achieve rapid coverage scale-up. The shared chronic nature of NCDs and HIV means that many operational approaches and infrastructure developed for HIV programmes apply to NCDs, suggesting this to be a cost-effective and sustainable policy option for countries with large HIV programmes and small, un-resourced NCD programmes. However, the vertical nature of current disease programmes, policy financing and operations operate as barriers to NCD-HIV integration. Modelling has successfully been used to inform health decision-making across a number of disease areas and in a number of ways. Examples from Kenya include (i) estimating current and future disease burden to set priorities for public health interventions, (ii) forecasting the requisite investments by government, (iii) comparing the impact of different integration approaches, (iv) performing cost-benefit analysis for integration and (v) evaluating health system capacity needs.

CONCLUSIONS

Modelling can and should play an integral part in the decision-making processes for health in general and NCD-HIV integration specifically. It is especially useful where little data is available. The successful use of modelling to inform decision-making will depend on several factors including policy makers' comfort with and understanding of models and their uncertainties, modellers understanding of national priorities, funding opportunities and building local modelling capacity to ensure sustainability.

Setting up a nurse-led model of care for management of hypertension and diabetes mellitus in a high HIV prevalence context in rural Zimbabwe: a descriptive study

Background

In the light of the increasing burden of non-communicable diseases (NCDs) on health systems in low- and middle-income countries, particularly in Sub-Saharan Africa, context-adapted, cost-effective service delivery models are now required as a matter of urgency. We describe the experience of setting up and organising a nurse-led Diabetes Mellitus (DM) and Hypertension (HTN) model of care in rural Zimbabwe, a low-income country with unique socio-economic challenges and a dual disease burden of HIV and NCDs.

Methods

Mirroring the HIV experience, we designed a conceptual framework with 9 key enablers: decentralization of services, integration of care, simplification of management guidelines, mentoring and task-sharing, provision of affordable medicines, quality assured laboratory support, patient empowerment, a dedicated monitoring and evaluation system, and a robust referral system. We selected 9 primary health care clinics (PHC) and two hospitals in Chipinge district and integrated DM and HTN either into the general out-patient department, pre-existing HIV clinics, or an integrated chronic care clinic (ICCC). We provided structured intensive mentoring for staff, using simplified protocols, and disease-specific education for patients. Free medication with differentiated periodic refills and regular monitoring with point of care (POC) glycosylated haemoglobin (HbA1c) were provided.

Results

Nurses in 7 PHC facilities and one hospital developed sufficient knowledge and skills to diagnose, initiate treatment and monitor DM and HTN patients, and 3094 patients were registered in the programme (188 with DM only, 2473 with HTN only, 433 with both DM and HTN). Major lessons learned from our experience include: the value of POC devices in the management of diabetes; the pressure on services of the added caseload, exacerbated by the availability of free medications in supported health facilities; and the importance of leadership in the successful implementation of care in health facilities.

Conclusion

Our experience demonstrates a model for nurse-led decentralized integrated DM and HTN care in a high HIV prevalence rural, low-income context. Developing a context-adapted efficient model of care is a dynamic process. We present our lessons learned with the intention of sharing experience which may be of value to other public health programme managers.

Reimagining the role of the nursing workforce in Uganda after more than a decade of ART scale-up

BACKGROUND

The expanding roles and increasing importance of the nursing workforce in health services delivery in resource-limited settings is not adequately documented and sufficiently recognized in the current literature. Drawing upon the theme of 2020 as the International Year of the Nurse and the Midwife, we set out to describe how the role of nurses expanded tremendously in health facilities in Uganda during the era of anti-retroviral therapy (ART) scale-up that commenced in June 2004.

METHODS

We employed a mixed-methods sequential explanatory research design. Phase I entailed a cross-sectional health facility survey (n = 195) to assess the extent to which human resource management strategies (such as task shifting) were common. Phase II entailed a qualitative multiple case study of 16 (of the 195) health facilities for an in-depth understanding of the strategies adopted (e.g. nurse-centred HIV care). Descriptive analyses were performed in STATA (v 13) while qualitative data were analysed by thematic approach.

RESULTS

We found that nurses were the most represented cadre of health workers involved in the overall leadership of HIV clinics across Uganda. Most nurse-led HIV clinics were based in rural settings; however, this trend was fairly even across setting (rural/urban/peri-urban). While 181 (93%) health facilities allowed non-physician cadre to prescribe ART, a number of health facilities (n = 36) or 18% deliberately adopted nurse-led HIV care models. Nurses were empowered to be multi-skilled with a wide range of competencies across the HIV care continuum right from HIV testing to mainstream clinical HIV disease management. In several facilities, nursing cadre were the backbone of ART service delivery. A select number of facilities devised differentiated models of task shifting from physicians to nurses in which the latter handled patients who were stable on ART.

CONCLUSION

Overall, our study reveals a wide expansion in the scope-of-practice of nurses during ART scale-up in Uganda. Nurses were thrust in roles of HIV disease management that were traditionally the preserve of physicians. Our study underscores the importance of reforming regulatory frameworks governing nursing workforce scope of practice such as the need for developing a policy on task shifting which is currently lacking in Uganda.

Global Health - emergence, hegemonic trends and biomedical reductionism

Background

Global Health has increasingly gained international visibility and prominence. First and foremost, the spread of cross-border infectious disease arouses a great deal of media and public interest, just as it drives research priorities of faculty and academic programmes. At the same time, Global Health has become a major area of philanthropic action. Despite the importance it has acquired over the last two decades, the complex collective term “Global Health” still lacks a uniform use today.

Objectives

The objective of this paper is to present the existing definitions of Global Health, and analyse their meaning and implications. The paper emphasises that the term “Global Health” goes beyond the territorial meaning of “global”, connects local and global, and refers to an explicitly political concept. Global Health regards health as a rights-based, universal good; it takes into account social inequalities, power asymmetries, the uneven distribution of resources and governance challenges. Thus, it represents the necessary continuance of Public Health in the face of diverse and ubiquitous global challenges. A growing number of international players, however, focus on public-private partnerships and privatisation and tend to promote biomedical reductionism through predominantly technological solutions. Moreover, the predominant Global Health concept reflects the inherited hegemony of the Global North. It takes insufficient account of the global burden of disease, which is mainly characterised by non-communicable conditions, and the underlying social determinants of health.

Conclusions

Beyond resilience and epidemiological preparedness for preventing cross-border disease threats, Global Health must focus on the social, economic and political determinants of health. Biomedical and technocratic reductionism might be justified in times of acute health crises but entails the risk of selective access to health care. Consistent health-in-all policies are required for ensuring Health for All and sustainably reducing health inequalities within and among countries. Global Health must first and foremost pursue the enforcement of the universal right to health and contribute to overcoming global hegemony.

Outcomes of decentralizing hypertension care from district hospitals to health centers in Rwanda, 2013-2014

Setting

Three district hospitals (DHs) and seven health centers (HCs) in rural Rwanda.

Objective

To describe follow-up and treatment outcomes in stage 1 and 2 hypertension patients receiving care at HCs closer to home in comparison to patients receiving care at DHs further from home.

Design

A retrospective descriptive cohort study using routinely collected data involving adult patients aged ⩾18 years in care at chronic non-communicable disease clinics and receiving treatment for hypertension at DH and HC between 1 January 2013 and 30 June 2014.

Results

Of 162 patients included in the analysis, 36.4% were from HCs. Patients at DHs travelled significantly further to receive care (10.4 km vs. 2.9 km for HCs, P < 0.01). Odds of being retained were significantly lower among DH patients when not adjusting for distance (OR 0.11, P = 0.01). The retention effect was consistent but no longer significant when adjusting for distance (OR 0.18, P = 0.10). For those retained, there was no significant difference in achieving blood pressure targets between the DHs and HCs.

Conclusion

By removing the distance barrier, decentralizing hypertension management to HCs may improve long-term patient retention and could provide similar hypertension outcomes as DHs.

Leveraging the lessons learned from financing HIV programs to advance the universal health coverage (UHC) agenda in the East African Community

Background

Although there is broad consensus around the need to accelerate progress towards universal health coverage (UHC) in Sub-Saharan Africa, the financing strategies for achieving it are still unclear. We sought to leverage the lessons learned in financing HIV programs over the past two decades to inform efforts to advance the universal health coverage agenda in the East African Community.

Methods

We conducted a literature review of studies reporting financing mechanisms for HIV programs between 2004 and 2014. This review is further underpinned by evidence from a mixed-methods study entailing a survey of 195 health facilities across Uganda supplemented with 18 semi-structured interviews with HIV service managers.

Results

Our data shows that there are six broad HIV financing strategies with potential for application to the universal health coverage agenda in the East African Community (EAC); i) Bi-lateral and multi-lateral funding vehicles: The establishment of HIV-specific global financing vehicles such as PEPFAR and The Global Fund heralded an era of unprecedented levels of international funding of up to $ 500 billion over the past two decades ii) Eliciting private sector contribution to HIV funding: The private sector's financial contribution to HIV services was leveraged through innovative engagement and collaborative interventions iii) Private sector-led alternative HIV financing mechanisms: The introduction of 'VIP' HIV clinics, special 'HIV insurance' schemes and the rise of private philanthropic aid were important alternatives to the traditional sources of funding iv) Commodity social marketing: Commodity social marketing campaigns led to an increase in condom use among low-income earners v) The use of vouchers: Issuing of HIV-test vouchers to the poor was an important demand-side financing approach vi) Earmark HIV taxes: Several countries in Africa have introduced 'special HIV' taxes to boost domestic HIV funding.

Conclusions

The lessons learned from financing HIV programs suggest that a hybrid of funding strategies are advisable in the quest to achieve UHC in EAC partner states. The contribution of the private sector is indispensable and can be enhanced through targeted interventions towards UHC goals.

Community Health Workers Improve Linkage to Hypertension Care in Western Kenya

BACKGROUND

Elevated blood pressure (BP) is the leading global risk factor for mortality. Delay in seeking hypertension care is associated with increased mortality.

OBJECTIVES

This study investigated whether community health workers, equipped with behavioral communication strategies and smartphone technology, can increase linkage of individuals with elevated BP to a hypertension care program in western Kenya and significantly reduce BP.

METHODS

The study was a cluster randomized trial with 3 arms: 1) usual care (standard training); 2) "paper-based" (tailored behavioral communication, using paper-based tools); and 3) "smartphone" (tailored behavioral communication, using smartphone technology). The co-primary outcomes were: 1) linkage to care; and 2) change in systolic BP (SBP). A covariate-adjusted mixed-effects model was used, adjusting for differential time to follow-up. Bootstrap and multiple imputation were used to handle missing data.

RESULTS

A total of 1,460 individuals (58% women) were enrolled (491 usual care, 500 paper-based, 469 smartphone). Average baseline SBP was 159.4 mm Hg. Follow-up measures of linkage were available for 1,128 (77%) and BP for 1,106 (76%). Linkage to care was 49% overall, with significantly greater linkage in the usual care and smartphone arms of the trial. Average overall follow-up SBP was 149.9 mm Hg. Participants in the smartphone arm experienced a modestly greater reduction in SBP versus usual care (-13.1 mm Hg vs. -9.7 mm Hg), but this difference was not statistically significant. Mediation analysis revealed that linkage to care contributed to SBP change.

CONCLUSIONS

A strategy combining tailored behavioral communication and mobile health (mHealth) for community health workers led to improved linkage to care, but not statistically significant improvement in SBP reduction. Further innovations to improve hypertension control are needed. (Optimizing Linkage and Retention to Hypertension Care in Rural Kenya [LARK]; NCT01844596).

Patient-provider perspectives on self-management support and patient empowerment in chronic care: A mixed-methods study in a rural sub-Saharan setting

AIM

To explore how provision of self-management support to chronically-ill patients in resource-limited settings contributes to patient empowerment in chronic care.

DESIGN

Concurrent descriptive mixed methods research.

METHODS

A survey of 140 patients with chronic conditions administered at four time-points in 12 months. We conducted 14 interviews and four focus-group discussions with patients (N = 31); 13 healthcare provider interviews; and observations of four patient-support group meetings. Data were collected between April 2016 - May 2017 in rural Malawi. Qualitative data were analysed using a thematic approach and descriptive statistical analysis performed on survey data.

RESULTS

Healthcare professionals facilitated patient empowerment through health education, although literacy levels and environmental factors affected self-management guidance. Information exchanged during patient-provider interactions varied and discussions centred around medical aspects and health promoting behaviour. Less than 40% of survey patients prepared questions prior to clinic consultations. Health education was often unstructured and delegated to non-physician providers, mostly untrained in chronic care. Patients accessed psychosocial support from volunteer-led community home-based care programmes. HIV support-groups regularly interacted with peers and practical skills exchanged in a supportive environment, reinforcing patient's self-mangement competence and proactiveness in health care.

CONCLUSION

For optimal self-management, reforms at inter-personal and organizational level are needed including; mutual patient-provider collaboration, diversifying access to self-management support resources and restructuring patient support-groups to cater to diverse chronic conditions.

IMPACT

Our study provides insights and framing of self-management support and empowerment for patients in long-term care in sub-Saharan Africa. Lessons drawn could feed into designing and delivering responsive chronic care interventions.

How have researchers defined and used the concept of 'continuity of care' for chronic conditions in the context of resource-constrained settings? A scoping review of existing literature and a proposed conceptual framework

Background

Within the context of the growing burden of non-communicable diseases (NCDs) globally, there is limited evidence on how researchers have explored the response to chronic health needs in the context of health policy and systems in low- and middle-income countries. Continuity of care (CoC) is one concept that represents several elements of a long-term model of care. This scoping review aims to map and describe the state of knowledge regarding how researchers in resource-constrained settings have defined and used the concept of CoC for chronic conditions in primary healthcare.

Methods

This scoping review adopted the modified framework for interpretive scoping literature reviews. A systematic literature search in PubMed was performed, followed by a study selection process and data extraction, analysis and synthesis. Extracted data regarding the context of using CoC and the definition of CoC were analysed inductively to identify similar patterns; based on this, articles were divided into groups. MaxQDA was then used to re-code each article with themes according to the CoC definition to perform a cross-case synthesis under each identified group.

Results

A total of 55 peer-reviewed articles, comprising reviews or commentaries and qualitative or quantitative studies, were included. The number of articles has increased over the years. Five groups were identified as those (1) reflecting a change across stages or systems of care, (2) mentioning continuity or lack of continuity without a detailed definition, (3) researching CoC in HIV/AIDS programmes and its scaling up to support management of NCDs, (4) researching CoC in NCD management, and (5) measuring CoC with validated questionnaires.

Conclusion

Research or policy documents need to provide an explicit definition of CoC when this terminology is used. A framework for CoC is suggested, acknowledging three components for CoC (i.e. longitudinal care, the nature of the patient–provider relationship and coordinated care) while considering relevant contextual factors, particularly access and quality.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0426-1) contains supplementary material, which is available to authorized users.

Global palliative radiotherapy: a framework to improve access in resource-constrained settings

Radiotherapy is an essential component of cancer therapy. Lack of access to radiotherapy in less-developed countries prevents its use for both cure and symptom relief, resulting in a significant disparity in patient suffering. Several recent initiatives have highlighted the need for expanded access to both palliative medicine and radiotherapy globally. Yet, these efforts have remained largely independent, without attention to overlap and integration. This review provides an update on the progress toward global palliative radiotherapy access and proposes a strategic framework to address further scale-up. Synergies between radiotherapy, palliative medicine, and other global health initiatives will be essential in bringing palliative radiotherapy to patients around the globe.

Earth Observation: Investigating Noncommunicable Diseases from Space

The United Nations has called on all nations to take immediate actions to fight noncommunicable diseases (NCDs), which have become an increasingly significant burden to public health systems around the world. NCDs tend to be more common in developed countries but are also becoming of growing concern in low- and middle-income countries. Earth observation (EO) technologies have been used in many infectious disease studies but have been less commonly employed in NCD studies. This review discusses the roles that EO data and technologies can play in NCD research, including ( a) integrating natural and built environment factors into NCD research, ( b) explaining individual-environment interactions, ( c) scaling up local studies and interventions, ( d) providing repeated measurements for longitudinal studies including cohorts, and ( e) advancing methodologies in NCD research. Such extensions hold great potential for overcoming the challenges of inaccurate and infrequent measurements of environmental exposure at the level of both the individual and the population, which is of great importance to NCD research, practice, and policy.

Access to hypertension care and services in primary health-care settings in Vietnam: a systematic narrative review of existing literature

Background: Health care in Vietnam is challenged by a high burden of hypertension (HTN). Since 2000, several interventions were implemented to manage HTN; it is not clear what is the status of patient access to HTN care. Objective: This article aims to perform a systematic narrative review of the available evidence on access to HTN care and services in primary health-care settings in Vietnam. Methods: Search engines were used to identify relevant records of scientific and grey literature. Data from selected articles were analysed using standardised spreadsheets and MaxQDA and following a framework synthesis methodology. Results: There has been increasing interest in research and policy concerning the burden of HTN in Vietnam, covering many aspects of access to treatment at the primary health-care level. Vietnam's National HTN Programme is managed as a vertical programme and its services integrated into the network of primary health-care facilities across the public sector in selected provinces. The Programme financed population-wide screening campaigns for the early detection of HTN among people above 40 years of age. There was no information on the acceptability of HTN health services, especially regarding the interaction between patients and health professionals. In general, articles reported good availability of medication, but problems in accessing them included: fragmentation and lack of consistency in prescribing medication between different levels and short timespans for dispensing medication at primary health-care facilities. There was limited information related to the cost and economic impact of HTN treatment. Treatment adherence among hypertensive patients based on four studies did not exceed 70%. Conclusions: Although the Vietnamese health-care system has taken steps to accommodate some of the needs of HTN patients, it is crucial to scale-up interventions that allow for regular, systematic, and integrated care, especially at the lowest levels of care.

Patients experiences of self-management and strategies for dealing with chronic conditions in rural Malawi

BACKGROUND

The high burden of chronic communicable diseases such as HIV/AIDS, and an escalating rise of non-communicable diseases (NCDs) in Malawi and other sub-Saharan African countries, calls for a shift in how health care services are designed and delivered. Patient-centred care and patient self-management are critical elements in chronic care, and are advocated as universal strategies. In sub-Saharan Africa, there is need for more evidence around the practice of patient self-management, and how to best support patients with chronic conditions in the African context. Our study explored self-management practices of patients with different chronic conditions, and their strategies to overcome care challenges in a resource-constrained setting in Malawi.

METHODS

This is primarily a qualitative study, involving patients with different chronic conditions from one rural district in Malawi. Data are drawn from semi-structured questions of a survey with 129 patients (from the third of four-part data collection series), 14 in-depth interviews, and four focus-group discussions with patients (n = 31 respondents). A framework approach was used for qualitative analysis, and descriptive statistical analysis was performed on survey data.

RESULTS

Patients demonstrated ability to self-manage their conditions, though this varied between conditions, and was influenced by individual and external factors. Factors included: 1) ability to acquire appropriate disease knowledge; 2) poverty level; 3) the presence of support from family caregivers and community-based support initiatives; 4) the nature of one's social relations; and 5) the ability to deal with stressors and stigma. NCD and HIV comorbid patients were more disadvantaged in their access to care, as they experienced frequent drug stock-outs and incurred additional costs when referred. These barriers contributed to delayed care, poorer treatment adherence, and likelihood of poorer treatment outcomes. Patients proved resourceful and made adjustments in the face of (multiple) care challenges.

CONCLUSION

Our findings complement other research on self-management experiences in chronically ill patients with its analysis on factors and barriers that influence patient self-management capacity in a resource-constrained setting. We recommend expanding current peer-patient and support group initiatives to patients with NCDs, and further investments in the decentralisation of integrated health services to primary care level in Malawi.

Building on the HIV platform: tackling the challenge of noncommunicable diseases among persons living with HIV

: The global HIV response has enabled access to prevention and treatment interventions for millions of people around the world. This investment has enabled the strengthening of health systems, which offers a remarkable opportunity to integrate care for noncommunicable diseases for persons living with HIV who are at risk for or have a noncommunicable disease.