HIV, aging and continuity care: strengthening health systems to support services for noncommunicable diseases in low-income countries

Mapping evidence on barriers to and facilitators of diagnosing noncommunicable diseases among people living with human immunodeficiency virus in low- and middle-income countries in Africa: A scoping review

Objectives

To map the evidence on the barriers to and facilitators of diagnosing noncommunicable diseases among people living with HIV in low- and middle-income countries in Africa.

Introduction

Noncommunicable diseases are increasing among people living with HIV. Thus, strengthened and sustained diagnosis of noncommunicable diseases through integrated noncommunicable diseases and HIV care is needed to improve patient outcomes. However, there is paucity of evidence on the barriers and facilitators diagnosing noncommunicable diseases among people living with HIV in low- and middle-income countries.

Methods

The Arksey and O'Malley methodological framework was used. A comprehensive systematic search of academic databases (MEDLINE, Academic Search Complete, APA PsycInfo, CAB, and Health Source/Nursing) was performed via EBSCO search and PubMed. The articles were reviewed independently by three reviewers. The results were structured using Capability-Opportunity-Motivation-Behavior model and Theoretical Domains Framework.

Results

A total of 152 articles were retrieved for full-text review. Forty-one articles met the inclusion criteria. The identified barriers were relevant to all the Capability-Opportunity-Motivation-Behavior constructs and 14 Theoretical Domains Framework domains. A lack of knowledge and awareness of noncommunicable diseases, fear of stigma, financial problems and out-of-pocket payments were the most cited patient-level barriers. Healthcare providers (knowledge and awareness gaps, skill and competence deficiencies, unwillingness, burnout, low motivation, and apathy) were frequently cited. Lack of equipment, noncommunicable disease medications and supply chain challenges, lack of integrated noncommunicable disease and HIV care, and shortage of trained healthcare providers were identified as health-system-level barriers.

Conclusion

This scoping review is the first to identify barriers and facilitators using a theoretical framework. The most cited barriers include a lack of integrated HIV and noncommunicable disease care, equipment and logistics chain challenges for noncommunicable diseases, patients' and healthcare providers' lack of knowledge and awareness of noncommunicable diseases, and healthcare provider's skill and competency deficiencies. Addressing these issues is crucial for improving patient outcomes and reducing the burden on healthcare providers and health systems.

Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and care cascade for HIV infected individuals (SCALE SAIA-HTN): a stepped-wedge cluster randomized trial

BACKGROUND

Undiagnosed and untreated hypertension is a main driver of cardiovascular disease and disproportionately affects persons living with HIV (PLHIV) in low- and middle-income countries. Across sub-Saharan Africa, guideline application to screen and manage hypertension among PLHIV is inconsistent due to poor service readiness, low health worker motivation, and limited integration of hypertension screening and management within HIV care services. In Mozambique, where the adult HIV prevalence is over 13%, an estimated 39% of adults have hypertension. As the only scaled chronic care service in the county, the HIV treatment platform presents an opportunity to standardize and scale hypertension care services. Low-cost, multi-component systems-level strategies such as the Systems Analysis and Improvement Approach (SAIA) have been found effective at integrating hypertension and HIV services to improve the effectiveness of hypertension care delivery for PLHIV, reduce drop-offs in care, and improve service quality. To build off lessons learned from a recently completed cluster randomized trial (SAIA-HTN) and establish a robust evidence base on the effectiveness of SAIA at scale, we evaluated a scaled-delivery model of SAIA (SCALE SAIA-HTN) using existing district health management structures to facilitate SAIA across six districts of Maputo Province, Mozambique.

METHODS

This study employs a stepped-wedge design with randomization at the district level. The SAIA strategy will be "scaled up" with delivery by district health supervisors (rather than research staff) and will be "scaled out" via expansion to Southern Mozambique, to 18 facilities across six districts in Maputo Province. SCALE SAIA-HTN will be introduced over three, 9-month waves of intensive intervention, where technical support will be provided to facilities and district managers by study team members from the Mozambican National Institute of Health. Our evaluation of SCALE SAIA-HTN will be guided by the RE-AIM framework and will seek to estimate the budget impact from the payer's perspective.

DISCUSSION

SAIA packages user-friendly systems engineering tools to support decision-making by frontline health workers and to identify low-cost, contextually relevant improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial will determine an effective strategy for national scale-up and inform program planning.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05002322 (registered 02/15/2023).

Continuity and care coordination of primary health care: a scoping review

BACKGROUND

Healthcare coordination and continuity of care conceptualize all care providers and organizations involved in health care to ensure the right care at the right time. However, systematic evidence synthesis is lacking in the care coordination of health services. This scoping review synthesizes evidence on different levels of care coordination of primary health care (PHC) and primary care.

METHODS

We conducted a scoping review of published evidence on healthcare coordination. PubMed, Scopus, Embase, CINAHL, Cochrane, PsycINFO, Web of Science and Google Scholar were searched until 30 November 2022 for studies that describe care coordination/continuity of care in PHC and primary care. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines to select studies. We analysed data using a thematic analysis approach and explained themes adopting a multilevel (individual, organizational, and system) analytical framework.

RESULTS

A total of 56 studies were included in the review. Most studies were from upper-middle-income or high-income countries, primarily focusing on continuity/care coordination in primary care. Ten themes were identified in care coordination in PHC/primary care. Four themes under care coordination at the individual level were the continuity of services, linkage at different stages of health conditions (from health promotion to rehabilitation), health care from a life-course (conception to elderly), and care coordination of health services at places (family to hospitals). Five themes under organizational level care coordination included interprofessional, multidisciplinary services, community collaboration, integrated care, and information in care coordination. Finally, a theme under system-level care coordination was related to service management involving multisectoral coordination within and beyond health systems.

CONCLUSIONS

Continuity and coordination of care involve healthcare provisions from family to health facility throughout the life-course to provide a range of services. Several issues could influence multilevel care coordination, including at the individual (services or users), organizational (providers), and system (departments and sectors) levels. Health systems should focus on care coordination, ensuring types of care per the healthcare needs at different stages of health conditions by a multidisciplinary team. Coordinating multiple technical and supporting stakeholders and sectors within and beyond health sector is also vital for the continuity of care especially in resource-limited health systems and settings.

Preventing cardiovascular disease in midlife women with HIV: An examination of facilitators and barriers to heart health behaviors

Midlife women with HIV (WWH) are disproportionately impacted by cardiovascular disease (CVD), yet little is known about perceptions of CVD risk and the factors that influence engagement in heart health behaviors in this population. Few (if any) studies have used a qualitative approach to examine these perceptions, which has important implications for minimizing the negative impact of HIV-related noncommunicable diseases, the risk for which increases after midlife. Eighteen midlife WWH (aged 40-59) in Boston, MA, completed semistructured interviews to explore perceptions of CVD, HIV, and barriers and facilitators to healthy lifestyle behaviors. Interviews were analyzed via thematic analysis. Participants viewed heart health as important but were unaware of HIV-associated CVD risk. Facilitators included family and generational influences, social support, and access to resources. Physical symptoms, menopause, mental health challenges, and limited financial resources were barriers. Midlife WWH may benefit from tailored CVD prevention interventions that target their unique motivations and barriers to healthy behaviors.

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.

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.

ffects of integrated models of care for diabetes and hypertension in low-income and middle-income countries: a systematic review and meta-analysis

OBJECTIVES

To assess the effects of integrated models of care for people with multimorbidity including at least diabetes or hypertension in low-income and middle-income countries (LMICs) on health and process outcomes.

DESIGN

Systematic review.

DATA SOURCES

We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Africa-Wide, CINAHL and Web of Science up to 12 December 2019.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs), non-RCTs, controlled before-and-after studies and interrupted time series (ITS) studies of people with diabetes and/or hypertension plus any other disease, in LMICs; assessing the effects of integrated care.

DATA EXTRACTION AND SYNTHESIS

Two authors independently screened retrieved records; extracted data and assessed risk of bias. We conducted meta-analysis where possible and assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Of 7568 records, we included five studies-two ITS studies and three cluster RCTs. Studies were conducted in South Africa (n=3), Uganda/Kenya (n=1) and India (n=1). Integrated models of care compared with usual care may make little or no difference to mortality (very low certainty), the number of people achieving blood pressure (BP) or diabetes control (very low certainty) and access to care (very low certainty); may increase the number of people who achieve both HIV and BP/diabetes control (very low certainty); and may have a very small effect on achieving HIV control (very low certainty). Interventions to promote integrated delivery of care compared with usual care may make little or no difference to mortality (very low certainty), depression (very low certainty) and quality of life (very low certainty); and may have little or no effect on glycated haemoglobin (low certainty), systolic BP (low certainty) and total cholesterol levels (low certainty).

CONCLUSIONS

Current evidence on the effects of integrated care on health outcomes is very uncertain. Programmes and policies on integrated care must consider context-specific factors related to health systems and populations.

PROSPERO REGISTRATION NUMBER

CRD42018099314.

The Rising Burden of Diabetes-Related Blindness: A Case for Integration of Primary Eye Care into Primary Health Care in Eswatini

There is a rampant increase in diabetes prevalence globally. Sub-Saharan Africa (SSA) is projected to carry the largest burden of diabetes (34.2 million) by 2030. This will inevitably cause a parallel increase in diabetes-associated complications; with the predominant complications being blindness due to diabetic retinopathy and diabetic cataracts. Eye programs in developing countries remain inadequate, existing as stand-alone programs, focused on the provision of acute symptomatic care at secondary and tertiary health levels. Over 60% of people with undiagnosed diabetes report to eye care facilities with already advanced retinopathy. While vision loss due to cataracts is reversible, loss of vision from diabetic retinopathy is irreversible. Developing countries have in the last two decades been significantly impacted by infectious pandemics; with SSA countries committing over 80% of their health budgets towards infectious diseases. Consequently, non-communicable diseases and eye health have been neglected. This paper aimed to highlight the importance of strengthening primary health care services to prevent diabetes-related blindness. In SSA, where economies are strained by infectious disease, the projected rise in diabetes prevalence calls for an urgent need to reorganize health systems to focus on life-long preventative and integrated measures. However, research is critical in determining how best to integrate these without further weakening health systems.

Reorienting Primary Health Care Services for Non-Communicable Diseases: A Comparative Preparedness Assessment of Two Healthcare Networks in Malawi and Zambia

Despite positive NCD policies in recent years, majority of Sub-Saharan African (SSA) health systems are inadequately prepared to deliver comprehensive first-line care for NCDs. Primary health care (PHC) settings in countries like Malawi and Zambia could be a doorway to effectively manage NCDs by moving away from delivering only episodic care to providing an integrated approach over time. As part of a collaborative health system strengthening project, we assessed and compared the preparedness and operational capacity of two target networks of public PHC settings in Lilongwe (Malawi) and Lusaka (Zambia) to integrate NCD services within routine service delivery. Data was collected and analyzed using validated health facility survey tools. These baseline assessments conducted between August 2018 and March 2019, also included interviews with 20 on-site health personnel and focal persons, who described existing barriers in delivering NCD services. In both countries, policy directives to decentralize disease-specific NCD services to the primary care level were initiated to meet increased demand but lacked operational guidance. In general, the assessed PHC sites were inadequately prepared to integrate NCDs into various service delivery domains, thus requiring further support. In spite of existing multi-faceted limitations, there was motivation among healthcare staff to provide NCD services.

The Role of Noncommunicable Diseases in the Pursuit of Global Health Security

Noncommunicable diseases and their risk factors are important for all aspects of outbreak preparedness and response, affecting a range of factors including host susceptibility, pathogen virulence, and health system capacity. This conceptual analysis has 2 objectives. First, we use the Haddon matrix paradigm to formulate a framework for assessing the relevance of noncommunicable diseases to health security efforts throughout all phases of the disaster life cycle: before, during, and after an event. Second, we build upon this framework to identify 6 technical action areas in global health security programs that are opportune integration points for global health security and noncommunicable disease objectives: surveillance, workforce development, laboratory systems, immunization, risk communication, and sustainable financing. We discuss approaches to integration with the goal of maximizing the reach of global health security where infectious disease threats and chronic disease burdens overlap.

A Multi-Dimensional Characterization of Aging and Wellbeing Among HIV-Positive Adults in Malawi

There is relatively little research on aging with HIV and wellbeing in sub-Saharan Africa. A cross-sectional survey was implemented in Malawi; eligible respondents were ≥ 30 years old and on ART for ≥ 2 years. Univariate and multiple regression analyses were stratified by age (younger adults: aged 30-49; older adults: aged ≥ 50) and gender. The median age was 51 years (total sample n = 134). Viral suppression was less common among older respondents (83.7% versus 93.0% among younger respondents) although not significant in adjusted models. Despite exhibiting worse physical and cognitive functioning (any physical functioning challenge: aOR 5.35, p = 0.02; cognitive functioning score difference: - 0.89 points, p = 0.04), older adults reported less interpersonal violence and fewer depressive symptoms (mild depression: aOR 0.23 p = 0.002; major depression: aOR 0.16, p = 0.004); in gender-stratified models, these relationships were significant only for females. More research is needed to disentangle the interplay between aging, gender and HIV in high-burden contexts and develop interventions to support comprehensive wellbeing in this population.

Social Capital in Old People Living with HIV Is Associated with Quality of Life: A Cross-Sectional Study in China

Objective

Old people living with HIV (PLWH) are experiencing a lower quality of life (QoL) than their younger counterparts and have received insufficient attention in China. Given that social capital has been proven to be effective in improving QoL in other countries, we aimed to examine the association between social capital and QoL among old PLWH in China.

Methods

The data presented in this study was based on the baseline sample of an ongoing observational prospective cohort study, which was carried out from November 2018 to February 2019. Participants were old PLWH aged ≥50 in Sichuan, China, and were recruited by stratified multistage cluster sampling from 30 communities/towns. A total of 529 eligible participants finished the face-to-face investigation to measure their social capital (i.e., individual and family- (IF-) based social capital and community and society- (CS-) based social capital) and QoL. The QoL's dimensions of physical health summary (PCS) and mental health summary (MCS) were taken as dependent variables. Stepwise linear regression models were used to examine the association between social capital and QoL.

Results

After considering all significant covariates, the PCS was nonsignificantly correlated with IF-based social capital (β = −0.08, 95% CI [-0.28-0.11]) and CS-based social capital (β = 0.28, 95% CI [-0.03-0.59]), and MCS was significantly correlated with IF-based social capital (β = 0.77, 95% CI [0.54-0.99], p < 0.001) and CS-based social capital (β = 0.40, 95% CI [0.08-0.72], p < 0.05).

Conclusion

Targeted interventions related to building up social capital should be applied to improve the QoL of old PLWH. Providing extra relief funds and allowances might be helpful to improve PCS; improving community networking and engagement and improving family care might be helpful to improve MCS among this vulnerable population.

Strengthening human and physical infrastructure of primary healthcare settings to deliver hypertension care in Vietnam: a mixed-methods comparison of two provinces

In Vietnam, the overall prevalence of hypertension (HTN) was 21%, with lower estimates for the prevalence of HTN awareness and treatment. The health systems, like other low- and middle-income countries, were designed to provide acute care for episodic conditions, rather than a chronic condition where patients need long-term care across time and disciplines. This article describes the delivery and organization of HTN care at primary healthcare (PHC) settings in both urban and rural areas at Hue Province of Central Vietnam in comparison with Thai Nguyen province in Northern Vietnam based on the infrastructure capacity and patients’ and providers’ perspectives and experiences We used mixed-methods design that included in-depth semi-structured interviews with patients and healthcare providers at purposively selected PHC facilities in two districts of each province and a modified version of the service availability and readiness assessment inventory at all PHC facilities. We found that HTN patients in both provinces can access healthcare services to diagnose, treat and control their HTN condition at the PHC level with a focus on district facilities. Health services in Hue have allowed commune health stations (CHSs) to provide routine monitoring and prescription refills for HTN patients while maintaining periodical visits to a higher level of care to monitor the stability of the disease. Such provision of care at CHSs remained restricted in Thai Nguyen. Further improvements are necessary for referral procedures, information system to allow for longitudinal follow-up across levels of care and defining a basic health insurance or benefits package, which meets patients’ preferences with a monthly timespan for prescription refills.

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.

Level of adult client satisfaction with clinic flow time and services of an integrated non-communicable disease-HIV testing services clinic in Soweto, South Africa: a cross-sectional study

BACKGROUND

While HIV Testing Services (HTS) have increased, many South Africans have not been tested. Non-communicable diseases (NCDs) are the top cause of death worldwide. Integrated NCD-HTS could be a strategy to control both epidemics. Healthcare service strategies depends partially on positive user experience. We investigated client satisfaction of services and clinic flow time of an integrated NCD-HTS clinic.

METHODS

This prospective, cross-sectional study evaluated HTS client satisfaction with an HTS clinic at two phases. Phase 1 (February-June 2018) utilised standard HTS services: counsellor-led height/weight/blood pressure measurements, HIV rapid testing, and symptoms screening for sexually transmitted infections/Tuberculosis. Phase 2 (June 2018-March 2019) further integrated counsellor-led obesity screening (body mass index/abdominal circumference measurements), rapid cholesterol/glucose testing; and nurse-led Chlamydia and human papilloma virus (HPV)/cervical cancer screening. Socio-demographics, proportion of repeat clients, clinic flow time, and client survey data (open/closed-ended questions using five-point Likert scale) are reported. Fisher's exact test, chi-square analysis, and Kruskal Wallis test conducted comparisons. Multiple linear regression determined predictors associated with clinic time. Content thematic analysis was conducted for free response data.

RESULTS

Two hundred eighty-four and three hundred thirty-three participants were from Phase 1 and 2, respectively (N = 617). Phase 1 participants were significantly older (median age 36.5 (28.0-43.0) years vs. 31.0 (25.0-40.0) years; p = 0.0003), divorced/widowed (6.7%, [n = 19/282] vs. 2.4%, [n = 8/332]; p = 0.0091); had tertiary education (27.9%, [n = 79/283] vs. 20.1%, [n = 67/333]; p = 0.0234); and less female (53.9%, [n = 153/284] vs 67.6%, [n = 225/333]; p = 0.0005), compared to Phase 2. Phase 2 had 10.2% repeat clients (n = 34/333), and 97.9% (n = 320/327) were 'very satisfied' with integrated NCD-HTS, despite standard HTS having significantly shorter median time for counsellor-led HTS (36.5, interquartile range [IQR]: 31.0-45.0 vs. 41.5, IQR: 35.0-51.0; p < 0.0001). Phase 2 associations with longer clinic time were clients living together/married (est = 6.548; p = 0.0467), more tests conducted (est = 3.922; p < 0.0001), higher overall satisfaction score (est = 1.210; p = 0.0201). Those who matriculated experienced less clinic time (est = - 7.250; p = 0.0253).

CONCLUSIONS

It is possible to integrate counsellor-led NCD rapid testing into standard HTS within historical HTS timeframes, yielding client satisfaction. Rapid cholesterol/glucose testing should be integrated into standard HTS. Research is required on the impact of cervical cancer/HPV screenings to HTS clinic flow to determine if it could be scaled up within the public sector.

Systems analysis and improvement approach to optimize the hypertension diagnosis and care cascade for PLHIV individuals (SAIA-HTN): a hybrid type III cluster randomized trial

BACKGROUND

Across sub-Saharan Africa, evidence-based clinical guidelines to screen and manage hypertension exist; however, country level application is low due to lack of service readiness, uneven health worker motivation, weak accountability of health worker performance, and poor integration of hypertension screening and management with chronic care services. The systems analysis and improvement approach (SAIA) is an evidence-based implementation strategy that combines systems engineering tools into a five-step, facility-level package to improve understanding of gaps (cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and iteratively test and redesign these modifications (continuous quality improvement). As hypertension screening and management are integrated into chronic care services in sub-Saharan Africa, an opportunity exists to test whether SAIA interventions shown to be effective in improving efficiency and coverage of HIV services can be effective when applied to the non-communicable disease services that leverage the same platform. We hypothesize that SAIA-hypertension (SAIA-HTN) will be effective as an adaptable, scalable model for broad implementation.

METHODS

We will deploy a hybrid type III cluster randomized trial to evaluate the impact of SAIA-HTN on hypertension management in eight intervention and eight control facilities in central Mozambique. Effectiveness outcomes include hypertension cascade flow measures (screening, diagnosis, management, control), as well as hypertension and HIV clinical outcomes among people living with HIV. Cost-effectiveness will be estimated as the incremental costs per additional patient passing through the hypertension cascade steps and the cost per additional disability-adjusted life year averted, from the payer perspective (Ministry of Health). SAIA-HTN implementation fidelity will be measured, and the Consolidated Framework for Implementation Research will guide qualitative evaluation of the implementation process in high- and low-performing facilities to identify determinants of intervention success and failure, and define core and adaptable components of the SAIA-HTN intervention. The Organizational Readiness for Implementing Change scale will measure facility-level readiness for adopting SAIA-HTN.

DISCUSSION

SAIA packages user-friendly systems engineering tools to guide decision-making by front-line health workers to identify low-cost, contextually appropriate chronic care improvement strategies. By integrating SAIA into routine hypertension screening and management structures, this pragmatic trial is designed to test a model for national scale-up.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04088656 (registered 09/13/2019; https://clinicaltrials.gov/ct2/show/NCT04088656).

Integrated care experiences and out-of-pocket expenditures: a cross-sectional survey of adults receiving treatment for HIV and hypertension in Malawi

OBJECTIVES

As HIV-positive individuals' life expectancy extends, there is an urgent need to manage other chronic conditions during HIV care. We assessed the care-seeking experiences and costs of adults receiving treatment for both HIV and hypertension in Malawi.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey was conducted with HIV-positive adults with hypertension at a health facility in Lilongwe that offers free HIV care and free hypertension screening, with antihypertensives available for purchase (n=199). Questions included locations and costs of all medication refills and preferences for these refill locations. Respondents were classified as using 'integrated care' if they refilled HIV and antihypertensive medications simultaneously. Data were collected between June and December 2017.

RESULTS

Only half of respondents reported using the integrated care offered at the study site. Among individuals using different locations for antihypertensive medication refills, the most frequent locations were drug stores and public sector health facilities which were commonly selected due to greater convenience and lower medication costs. Although the number of antihypertensive medications was equivalent between the integrated and non-integrated care groups, the annual total cost of care differed substantially (approximately US$21 in integrated care vs US$90 for non-integrated care)-mainly attributable to differences in other visit costs for non-integrated care (transportation, lost wages, childcare). One-third of those in the non-integrated care group reported no expenditure for antihypertensive medication, and six people in each group reported no annual hypertension care-seeking costs at all.

CONCLUSIONS

Individuals using integrated care saw efficiencies because, although they were more likely to pay for antihypertensive medications, they did not incur additional costs. These results suggest that preferences and experiences must be better understood to design effective policies and programmes for integrated care among adults on antiretroviral therapy.

Tailored HIV programmes and universal health coverage

Improvements in geospatial health data and tailored human immunodeficiency virus (HIV) testing, prevention and treatment have led to greater microtargeting of the HIV response, based on location, risk, clinical status and disease burden. These approaches show promise for achieving control of the HIV epidemic. At the same time, United Nations Member States have committed to achieving broader health and development goals by 2030, including universal health coverage (UHC). HIV epidemic control will facilitate UHC by averting the need to commit ever-increasing resources to HIV services. Yet an overly targeted HIV response could also distort health systems, impede integration and potentially threaten broader health goals. We discuss current approaches to achieving both UHC and HIV epidemic control, noting potential areas of friction between disease-specific microtargeting and integrated health systems, and highlighting opportunities for convergence that could enhance both initiatives. Examples of these programmatic elements that could be better aligned include: improved information systems with unique identifiers to track and monitor individuals across health services and the life course; strengthened subnational data use; more accountable supply chains that supply a broad range of services; and strengthened community-based services and workforces. We argue that the response both to HIV and to broader health threats should use these areas of convergence to increase health systems efficiency and mitigate the harm of any potential decrease in health funding. Further investments in implementation and monitoring of these programme elements will be needed to make progress towards both UHC and HIV epidemic control.

HIV and the growing health burden from noncommunicable diseases in Botswana: modelling study

Background

The “greying of AIDS” – the aging of the population living with HIV who benefit from antiretroviral treatment (ART) and the emergence of age-related non-communicable diseases (NCDs) – has been well documented. The emerging health systems challenges – eg, the implications of HIV on the disease burden from NCDs on the population level, and the evolving role of HIV as a co-morbidity or co-existing disease of various NCDs – are less well understood. The paper elucidates these challenges by providing a quantitative analysis of HIV-NCD interactions for Botswana.

Methods

We projected the prevalence of HIV and of selected NCDs in Botswana using demographic and HIV-specific estimates building on data on the state and the dynamics of the HIV epidemic, using the Spectrum modelling software, and extrapolating on estimates of the prevalence of NCDs from the 2015 global burden of disease (GBD).

Results

HIV has slowed down overall population aging and thus has attenuated the growing burden of many NCDs so far, because cohorts reaching old age have been decimated by AIDS-related mortality in the 1990s and early 2000s. Aging and the rise in the prevalence of NCDs, however, will accelerate rapidly from about 2030 because of reduced attrition of cohorts living with HIV since the start of the ART scale-up in Botswana. While HIV prevalence will decline over time, the health needs of people living with HIV will become more complex. HIV prevalence among the growing populations affected by various important NCDs will not decline for decades, because of the aging of the population living with HIV and interactions between HIV, ART and NCDs.

Conclusions

Even though HIV prevalence is projected to decline steeply to 2030 because of reduced HIV incidence, the prevalence of HIV among people affected by many of the most important NCDs will increase or barely change. While the health care needs of people living with HIV will increase and become more complex, HIV will also emerge as a key factor complicating the management of the growing burden of NCDs. Health systems will need to prepare for the challenge of large numbers of patients living with both HIV and NCDs.

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.

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.

"I attend at Vanguard and I attend here as well": barriers to accessing healthcare services among older South Africans with HIV and non-communicable diseases

Background

HIV and non-communicable disease (NCD) are syndemic within sub-Saharan Africa especially among older persons. The two epidemics interact with one another within a context of poverty, inequality and inequitable access to healthcare resulting in an increase in those aged 50 and older living with HIV and experiencing an NCD co-morbidity. We explore the challenges of navigating healthcare for older persons living with HIV and NCD co-morbidity.

Methods

In-depth semi-structured interviews were conducted with a small sample of older persons living with HIV (OPLWH). The perspectives of key informants were also sought to triangulate the evidence of OPLWH. The research took place in two communities on the outskirts of Cape Town, South Africa. All interviews were conducted by a trained interviewer and transcribed and translated for analysis. Thematic content analysis guided data analysis.

Results

OPLWH experienced an HIV-NCD syndemic. Our respondents sought care and accessed treatment for both HIV and other chronic (and acute) conditions, though these services were provided at different health facilities or by different health providers. Through the syndemic theory, it is possible to observe that OPLWH and NCDs face a number of physical and structural barriers to accessing the healthcare system. These barriers are compounded by separate appointments and spaces for each condition. These difficulties can exacerbate the impact of their ill-health and perpetuate structural vulnerabilities. Despite policy changes towards integrated care, this is not the experience of OPLWH in these communities.

Conclusions

The population living with HIV is aging increasing the likelihood that those living with HIV will also be living with other chronic conditions including NCDs. Thus, it is essential that health policy address this basic need to integrate HIV and NCD care.

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.

Strengthening the health workforce to support integration of HIV and noncommunicable disease services in sub-Saharan Africa

OBJECTIVE

The successful expansion of HIV services in sub-Saharan Africa has been a signature achievement of global public health. This article explores health workforce-related lessons from HIV scale-up, their implications for integrating noncommunicable disease (NCD) services into HIV programs, ways to ensure that healthcare workers have the knowledge, skills, resources, and enabling environment they need to provide comprehensive integrated HIV/NCD services, and discussion of a priority research agenda.

DESIGN AND METHODS

We conducted a scoping review of the published and 'gray' literature and drew upon our cumulative experience designing, implementing and evaluating HIV and NCD programs in low-resource settings.

RESULTS AND CONCLUSION

Lessons learned from HIV programs include the role of task shifting and the optimal use of multidisciplinary teams. A responsible and adaptable policy environment is also imperative; norms and regulations must keep pace with the growing evidence base for task sharing, and early engagement of regulatory authorities will be needed for successful HIV/NCD integration. Ex-ante consideration of work culture will also be vital, given its impact on the quality of service delivery. Finally, capacity building of a robust interdisciplinary workforce is essential to foster integrated patient-centered care. To succeed, close collaboration between the health and higher education sectors is needed and comprehensive competency-based capacity building plans for various health worker cadres along the education and training continuum are required. We also outline research priorities for HIV/NCD integration in three key domains: governance and policy; education, training, and management; and service delivery.

Psychiatric disorders among people living with HIV/AIDS in IRAN: Prevalence, severity, service utilization and unmet mental health needs

BACKGROUND

HIV and psychiatric disorders are closely correlated and are accompanied by some similar risk factors.

OBJECTIVE

The aim of this study was to assess psychiatric comorbidity and health service utilization for mental problems among people living with HIV/AIDS in Iran.

METHODS

A total of 250 cases were randomly selected from a large referral center for HIV treatment and care in Tehran, Iran. Psychiatric disorders in the past 12 months including mood, anxiety, and substance use disorders were assessed through face-to-face interview, using a validated Persian translation of the Composite International Diagnostic Interview (CIDI v2.1). Severity of psychiatric disorders, social support, socio-economic status, service utilization and HIV-related indicators were assessed.

RESULTS

Participants consisted of 147 men and 103 women. Psychiatric disorders were found in 50.2% (95% confidence interval: 43.8-56.6) of the participants. Major depressive disorder was the most prevalent diagnosis (32.1%), followed by substance use disorders (17.1%). In bivariate analysis, psychiatric disorders were significantly higher among male gender, single and unemployed individuals and those with lower social support. In multivariate regression analysis, only social support was independently associated with psychiatric disorders. Among those with a psychiatric diagnosis, 41.1% had used a health service for mental problems and 53% had received minimally adequate treatment.

CONCLUSION

The findings of the study highlight the importance of mental health services in the treatment of people living with HIV/AIDS.

Integrating cardiovascular disease risk factor screening into HIV services in Swaziland: lessons from an implementation science study

OBJECTIVE

To study the feasibility of cardiovascular disease risk factor (CVDRF) screening at an HIV clinic in Swaziland.

METHODS

A sample of HIV-positive patients at least 40 years on antiretroviral treatment was screened for hypertension, diabetes, hyperlipidemia, and tobacco smoking.

RESULTS

A total of 1826 patients were screened; 684 (39%) had at least one CVDRF. Screening volume varied markedly, and was limited by staffing, space, and supplies.

DISCUSSION

CVDRF screening was feasible and prevalence of risk factors in people living with HIV at least 40 years was high.

A scoping review of the role of HIV-related stigma and discrimination in noncommunicable disease care

Background

People living with HIV are increasingly burdened by noncommunicable diseases (NCDs) as a result of the NCD susceptibility that accompanies increased life expectancy and the rising global prevalence of NCDs. Health systems are being strengthened and programs are being developed to address this burden, often building on HIV care strategies and infrastructure or through integrated care models. HIV remains a stigmatized condition and the role of HIV stigma in the provision of NCD care is not well understood.

Methods

We conducted a scoping literature review of both peer reviewed and grey literature to identify evidence of the role of HIV stigma in the NCD-care continuum (prevention, diagnosis, care seeking, retention in care, and adherence to treatment of NCDs). We searched PsychInfo and Pubmed and conducted additional searches of programmatic reports and conference abstracts. Included studies were published in English within the past decade and examined HIV-related stigma as it relates to NCD-care or to integrated NCD-and HIV-care programs.

Results

Sixteen articles met the inclusion criteria. Findings suggest: fear of disclosure, internalized shame and embarrassment, and negative past experiences with or negative perceptions of health care providers negatively influence engagement with NCD care; HIV stigma can adversely affect not only people living with HIV in need of NCD care, but all NCD patients; some NCDs are stigmatized in their own right or because of their association with HIV; integrating NCD and HIV care can both reduce stigma for people living with HIV and a present a barrier to access for NCD care.

Conclusion

Due to the dearth of available research and the variability in initial findings, further research on the role of HIV stigma in the NCD-care continuum for people living with HIV is necessary. Lessons from the field of HIV-stigma research can serve as a guide for these efforts.

Improving pathology and laboratory medicine in low-income and middle-income countries: roadmap to solutions

Insufficient awareness of the centrality of pathology and laboratory medicine (PALM) to a functioning health-care system at policy and governmental level, with the resultant inadequate investment, has meant that efforts to enhance PALM in low-income and middle-income countries have been local, fragmented, and mostly unsustainable. Responding to the four major barriers in PALM service delivery that were identified in the first paper of this Series (workforce, infrastructure, education and training, and quality assurance), this second paper identifies potential solutions that can be applied in low-income and middle-income countries (LMICs). Increasing and retaining a quality PALM workforce requires access to mentorship and continuing professional development, task sharing, and the development of short-term visitor programmes. Opportunities to enhance the training of pathologists and allied PALM personnel by increasing and improving education provision must be explored and implemented. PALM infrastructure must be strengthened by addressing supply chain barriers, and ensuring laboratory information systems are in place. New technologies, including telepathology and point-of-care testing, can have a substantial role in PALM service delivery, if used appropriately. We emphasise the crucial importance of maintaining PALM quality and posit that all laboratories in LMICs should participate in quality assurance and accreditation programmes. A potential role for public-private partnerships in filling PALM services gaps should also be investigated. Finally, to deliver these solutions and ensure equitable access to essential services in LMICs, we propose a PALM package focused on these countries, integrated within a nationally tiered laboratory system, as part of an overarching national laboratory strategic plan.

A Human-Centered Approach to CV Care: Infrastructure Development in Uganda

In this case study, we describe an ongoing approach to develop sustainable acute and chronic cardiovascular care infrastructure in Uganda that involves patient and provider participation. Leveraging strong infrastructure for HIV/AIDS care delivery, University Hospitals Harrington Heart and Vascular Institute and Case Western Reserve University have partnered with U.S. and Ugandan collaborators to improve cardiovascular capabilities. The collaboration has solicited innovative solutions from patients and providers focusing on education and advanced training, penicillin supply, diagnostic strategy (e.g., hand-held ultrasound), maternal health, and community awareness. Key outcomes of this approach have been the completion of formal training of the first interventional cardiologists and heart failure specialists in the country, establishment of 4 integrated regional centers of excellence in rheumatic heart disease care with a national rheumatic heart disease registry, a penicillin distribution and adherence support program focused on retention in care, access to imaging technology, and in-country capabilities to treat advanced rheumatic heart valve disease.

The growing burden of noncommunicable disease among persons living with HIV in Zimbabwe

Supplemental Digital Content is available in the text

Objectives:

We aim to characterize the future noncommunicable disease (NCD) burden in Zimbabwe to identify future health system priorities.

Methods:

We developed an individual-based multidisease model for Zimbabwe, simulating births, deaths, infection with HIV and progression and key NCD [asthma, chronic kidney disease (CKD), depression, diabetes, hypertension, stroke, breast, cervical, colorectal, liver, oesophageal, prostate and all other cancers]. The model was parameterized using national and regional surveillance and epidemiological data. Demographic and NCD burden projections were generated for 2015 to 2035.

Results:

The model predicts that mean age of PLHIV will increase from 31 to 45 years between 2015 and 2035 (compared with 20–26 in uninfected individuals). Consequently, the proportion suffering from at least one key NCD in 2035 will increase by 26% in PLHIV and 6% in uninfected. Adult PLHIV will be twice as likely to suffer from at least one key NCD in 2035 compared with uninfected adults; with 15.2% of all key NCDs diagnosed in adult PLHIV, whereas contributing only 5% of the Zimbabwean population. The most prevalent NCDs will be hypertension, CKD, depression and cancers. This demographic and disease shift in PLHIV is mainly because of reductions in incidence and the success of ART scale-up leading to longer life expectancy, and to a lesser extent, the cumulative exposure to HIV and ART.

Conclusion:

NCD services will need to be expanded in Zimbabwe. They will need to be integrated into HIV care programmes, although the growing NCD burden amongst uninfected individuals presenting opportunities for additional services developed within HIV care to benefit HIV-negative persons.

Chronicity, crisis, and the 'end of AIDS'

In biomedical, public health, and popular discourses, the 'end of AIDS' has emerged as a predominant way to understand the future of HIV research and prevention. This approach is predicated on structuring and responding to HIV in ways that underscore its presumed lifelong nature. In this article, I examine the phenomenon of HIV chronicity that undergirds the 'end of AIDS' discourse. In particular, I explore how the logic of HIV chronicity, induced by technological advances in treatment and global financial and political investments, intensifies long-term uncertainty and prolonged crisis. Focusing on over 10 years of anthropological and public health research in the United States, I argue that HIV chronicity, and subsequently, the 'end of AIDS' discourse, obscure the on-going HIV crisis in particular global communities, especially among marginalised and ageing populations who live in under-resourced areas. By tracing the 'end of AIDS' discourse in my field sites and in other global locations, I describe how HIV chronicity signals a continuing global crisis and persistent social precarity rather than a 'break' with a hopeless past or a promising future free from AIDS.

The association between HIV and atherosclerotic cardiovascular disease in sub-Saharan Africa: a systematic review

Background

Sub-Saharan Africa (SSA) has confronted decades of the HIV epidemic with substantial improvements in access to life-saving antiretroviral therapy (ART). Now, with improved survival, people living with HIV (PLWH) are at increased risk for non-communicable diseases (NCDs), including atherosclerotic cardiovascular disease (CVD). We assessed the existing literature regarding the association of CVD outcomes and HIV in SSA.

Methods

We used the PRISMA guidelines to perform a systematic review of the published literature regarding the association of CVD and HIV in SSA with a focus on CVD surrogate and clinical outcomes in PLWH.

Results

From January 2000 until March 2017, 31 articles were published regarding CVD outcomes among PLWH in SSA. Data from surrogate CVD outcomes (n = 13) suggest an increased risk of CVD events among PLWH in SSA. Although acute coronary syndrome is reported infrequently in SSA among PLWH, limited data from five studies suggest extensive thrombus and hypercoagulability as contributing factors. Additional studies suggest an increased risk of stroke among PLWH (n = 13); however, most data are from immunosuppressed ART-naïve PLWH and thus are potentially confounded by the possibility of central nervous system infections.

Conclusions

Given ongoing gaps in our current understanding of CVD and other NCDs in PLWH in SSA, it is imperative to ascertain the burden of CVD outcomes, and to examine strategies for intervention and best practices to enhance the health of this vulnerable population.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4940-1) contains supplementary material, which is available to authorized users.

Aids in the elderly: reasons that lead to late diagnosis

Objective:

to investigate elderly living with HIV/Aids and health professionals, what are the reasons that lead to late diagnosis of HIV infection in the elderly.

Method:

prospective, qualitative study, conducted at a specialized outpatient clinic with elderly living with HIV/Aids, diagnosed age over 60 years and in the Family Health Strategy units with nurses and physicians. Data were collected through interviews and verified by content analysis, using the theoretical framework of vulnerability.

Results:

a total of 11 elderly, 11 nurses and 12 physicians participated in the study. Three empirical categories emerged: the late diagnosis of HIV happens against the health service; invisibility of the sexuality of the elderly; and weaknesses in the anti-HIV serology request for the elderly.

Conclusion:

there are health professionals who see the elderly as asexual, causing the diagnosis of HIV to happen in the secondary and tertiary service instead of primary care.

Prevalência de violência por parceiro íntimo em idosos e fatores associados: revisão sistemática

Resumo Este artigo tem por objetivo identificar a prevalência de violência por parceiro íntimo (VPI) em idosos e seus fatores associados. Realizou-se revisão sistemática de estudos transversais de base populacional nas bases de dados PubMed, Lilacs e PsycInfo, sem restrições quanto ao período e idioma de publicação. Dois revisores independentes conduziram a seleção, extração dos dados e análise de qualidade metodológica. Dezenove artigos foram selecionados para análise. Houve variação do tipo de violência, sexo dos entrevistados e instrumentos utilizados. A maioria dos estudos apresentou qualidade metodológica moderada ou alta. A VPI ocorreu em homens e mulheres idosos, sendo mais prevalentes a violência psicológica e o abuso econômico. Os fatores associados mais frequentes foram o consumo de álcool, depressão, baixa renda, comprometimento funcional e exposição pregressa à violência.

They ‘don't cure old age’: older Ugandans’ delays to health-care access

Uganda's population is ageing, which comes with increased and varied burdens of disease and health-care needs. At the same time, gerontological care in Uganda remains neglected. This paper examines the factors that cause older Ugandans to delay health-care access. We conduct a thematic analysis of data drawn from nine focus groups held with rural Ugandans aged 60-plus. Our analysis highlights the factors that delay older persons’ access to health care and how these align with the Three-Delay Model, which was originally developed to assess and improve obstetric care in low-resource settings. Our participants report delays in deciding to seek care related to mobility and financial limitations, disease aetiology, severity and stigma (Delay I); reaching care because of poor roads and limited transportation options (Delay II); and receiving appropriate care because of ageism among health-care workers, and poorly staffed and under-supplied facilities (Delay III). We find these delays to care are interrelated and impacted by factors at the individual, community and health-system levels. We conclude by arguing for multi-pronged interventions that will address these delays, improve access to care and ultimately enhance older Ugandans’ health and wellbeing.

Metabolic Syndrome After HIV Acquisition in South African Women

BACKGROUND

Noncommunicable diseases are common among chronically infected patients with HIV in the developed world, but little is known about these conditions in African cohorts. We assessed the epidemiology of metabolic syndrome among young South African women during the first 3 years after HIV acquisition.

METHODS

A total of 160 women were followed prospectively in the CAPRISA 002 Acute Infection study. Metabolic syndrome was defined as a constellation of hyperlipidemia, hypertension, hyperglycemia/diabetes, and abdominal obesity. Time trends were assessed using generalized estimation equation models.

RESULTS

Median age was 24 years and body mass index 27 kg/m. Prevalence of metabolic syndrome at infection was 8.7% increasing to 19.2% over 36 months (P = 0.001). The proportion of women with body mass index >30 kg/m increased from 34.4% to 47.7% (P = 0.004), those with abnormal waist circumference and elevated blood pressure increased from 33.5% to 44.3% (P = 0.060) and 23.8% to 43.9% (P < 0.001), respectively. Incidence of metabolic syndrome was 9.13/100 person-years (95% CI: 6.02 to 13.28). Predictors of metabolic syndrome were age (per year increase odds ratio (OR) = 1.12; 95% CI: 1.07 to 1.16), time postinfection (per year OR = 1.47; 95% CI: 1.12 to 1.92), family history of diabetes (OR = 3.13; 95% CI: 1.71 to 5.72), and the human leukocyte antigen (HLA)-B*81:01 allele (OR = 2.95; 95% CI: 1.21 to 7.17), whereas any HLA-B*57 or B*58:01 alleles were protective (OR = 0.34; 95% CI: 0.15 to 0.77). HIV-1 RNA (OR = 0.89; 95% CI: 0.62 to 1.27) and CD4 count (OR = 1.03; 95% CI: 0.95 to 1.11) did not predict metabolic syndrome.

CONCLUSIONS

The high burden of metabolic conditions in young South African HIV-infected women highlights the need to integrate noncommunicable disease and HIV care programs. Interventions to prevent cardiovascular disease must start at HIV diagnosis, rather than later during the disease course.

A systematic review of primary care models for non-communicable disease interventions in Sub-Saharan Africa

Background

Chronic diseases, primarily cardiovascular disease, respiratory disease, diabetes and cancer, are the leading cause of death and disability worldwide. In sub-Saharan Africa (SSA), where communicable disease prevalence still outweighs that of non-communicable disease (NCDs), rates of NCDs are rapidly rising and evidence for primary healthcare approaches for these emerging NCDs is needed.

Methods

A systematic review and evidence synthesis of primary care approaches for chronic disease in SSA. Quantitative and qualitative primary research studies were included that focused on priority NCDs interventions. The method used was best-fit framework synthesis.

Results

Three conceptual models of care for NCDs in low- and middle-income countries were identified and used to develop an a priori framework for the synthesis. The literature search for relevant primary research studies generated 3759 unique citations of which 12 satisfied the inclusion criteria. Eleven studies were quantitative and one used mixed methods. Three higher-level themes of screening, prevention and management of disease were derived. This synthesis permitted the development of a new evidence-based conceptual model of care for priority NCDs in SSA.

Conclusions

For this review there was a near-consensus that passive rather than active case-finding approaches are suitable in resource-poor settings. Modifying risk factors among existing patients through advice on diet and lifestyle was a common element of healthcare approaches. The priorities for disease management in primary care were identified as: availability of essential diagnostic tools and medications at local primary healthcare clinics and the use of standardized protocols for diagnosis, treatment, monitoring and referral to specialist care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0613-5) contains supplementary material, which is available to authorized users.

Can the Success of HIV Scale-Up Advance the Global Chronic NCD Agenda?

Noncommunicable diseases (NCD) are the leading causes of death and disability worldwide but have received suboptimal attention and funding from the global health community. Although the first United Nations General Assembly Special Session (UNGASS) for NCD in 2011 aimed to stimulate donor funding and political action, only 1.3% of official development assistance for health was allocated to NCD in 2015, even less than in 2011. In stark contrast, the UNGASS on human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) in 2001 sparked billions of dollars in funding for HIV and enabled millions of HIV-infected individuals to access antiretroviral treatment. Using an existing analytic framework, we compare the global responses to the HIV and NCD epidemics and distill lessons from the HIV response that might be utilized to enhance the global NCD response. These include: 1) further educating and empowering communities and patients to increase demand for NCD services and to hold national governments accountable for establishing and achieving NCD targets; and 2) evidence to support the feasibility and effectiveness of large-scale NCD screening and treatment programs in low-resource settings. We conclude with a case study from Swaziland, a country that is making progress in confronting both HIV and NCD.

Alcohol use and depression: link with adherence and viral suppression in adult patients on antiretroviral therapy in rural Lesotho, Southern Africa: a cross-sectional study

Background

Depression and alcohol use disorder have been shown to be associated with poor adherence to antiretroviral therapy (ART). Studies examining their association with viral suppression in rural Africa are, however, scarce.

Methods

This study reports prevalence of depressive symptoms and alcohol use disorder, and their potential association with adherence and viral suppression in adult patients on ART in ten clinics in rural Lesotho, Southern Africa.

Results

Among 1,388 adult patients (69 % women), 80.7 % were alcohol abstinent, 6.3 % were hazardous drinkers (men: 10.7 %, women: 4.4 %, p < 0.001). The prevalence of depressive symptoms was 28.8 % (men 20.2 %, women 32.7 %, p < 0.001). Both alcohol consumption (adjusted odds-ratio: 2.09, 95 % CI: 1.58-2.77) and alcohol use disorder (2.73, 95 % CI: 1.68-4.42) were significantly associated with poor adherence. There was, however, no significant association with viral suppression.

Conclusions

Whereas the results of this study confirm previously reported association of alcohol use disorder with adherence to ART, there was no association with viral suppression.

Trial registration

April 28th 2014; NCT02126696.

From end of life to chronic care: the provision of community home-based care for HIV and the adaptation to new health care demands in Zambia

Aim We present the evolution of primary-level HIV and AIDS services, shifting from end of life to chronic care, and draw attention to the opportunities and threats for the future of Zambia's nascent chronic care system.

BACKGROUND

Although African governments struggled to provide primary health care services in the context of a global economic crisis, civil society organisations (CSO) started mobilising settlement residents to respond to another crisis: the HIV and AIDS pandemic. These initiatives actively engaged patients, families and settlement residents to provide home-based care to HIV-infected patients. After 30 years, CHBC programmes continue to be appropriate in the context of changing health care needs in the population.

METHODS

The study took place in 2011 and 2012 and was part of a multi-country study. It used a mixed method approach involving semi-structured interviews, focus group discussions, structured interviews, service observations and a questionnaire survey. Findings Our research revealed long-standing presence of extensive mutual support amongst residents in many settlements, the invocation of cultural values that emphasise social relationships and organisation of people by CSO in care and support programmes. This laid the foundation for a locally conceived model of chronic care capable of addressing the new care demands arising from the country's changing burden of disease. However, this capacity has come under threat as the reduction in donor funding to community home-based care programmes and donor and government interventions, which have changed the nature of these programmes in the country. Zambia's health system risks losing valuable capacity for fulfilling its vision 'to bring health care as close to the family as possible' if government strategies do not acknowledge the need for transformational approaches to community participation and continuation of the brokering role by CSO in primary health care.

Quality Improvement for Cardiovascular Disease Care in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

The majority of global cardiovascular disease (CVD) burden falls on people living in low- and middle-income countries (LMICs). In order to reduce preventable CVD mortality and morbidity, LMIC health systems and health care providers need to improve the delivery and quality of CVD care.

OBJECTIVES

As part of the Disease Control Priorities Three (DCP3) Study efforts addressing quality improvement, we reviewed and summarized currently available evidence on interventions to improve quality of clinic-based CVD prevention and management in LMICs.

METHODS

We conducted a narrative review of published comparative clinical trials that evaluated efficacy or effectiveness of clinic-based CVD prevention and management quality improvement interventions in LMICs. Conditions selected a priori included hypertension, diabetes, hyperlipidemia, coronary artery disease, stroke, rheumatic heart disease, and congestive heart failure. MEDLINE and EMBASE electronic databases were systematically searched. Studies were categorized as occurring at the system or patient/provider level and as treating the acute or chronic phase of CVD.

RESULTS

From 847 articles identified in the electronic search, 49 met full inclusion criteria and were selected for review. Selected studies were performed in 19 different LMICs. There were 10 studies of system level quality improvement interventions, 38 studies of patient/provider interventions, and one study that fit both criteria. At the patient/provider level, regardless of the specific intervention, intensified, team-based care generally led to improved medication adherence and hypertension control. At the system level, studies provided evidence that introduction of universal health insurance coverage improved hypertension and diabetes control. Studies of system and patient/provider level acute coronary syndrome quality improvement interventions yielded inconclusive results. The duration of most studies was less than 12 months.

CONCLUSIONS

The results of this review suggest that CVD care quality improvement can be successfully implemented in LMICs. Most studies focused on chronic CVD conditions; more acute CVD care quality improvement studies are needed. Longer term interventions and follow-up will be needed in order to assess the sustainability of quality improvement efforts in LMICs.

Delivery of health care for cardiovascular and metabolic diseases among people living with HIV/AIDS in African countries: a systematic review protocol

BACKGROUND

People living with HIV (PLHIV) in African countries are living longer due to the rollout of antiretroviral drug therapy programs, but they are at increasing risk of non-communicable diseases (NCDs). However, there remain many gaps in detecting and treating NCDs in African health systems, and little is known about how NCDs are being managed among PLHIV. Developing integrated chronic care models that effectively prevent and treat NCDs among PLHIV requires an understanding of the current patterns of care delivery and the major barriers and facilitators to health care. We present a systematic review protocol to synthesize studies of healthcare delivery for an important subset of NCDs, cardiovascular and metabolic diseases (CMDs), among African PLHIV.

METHODS/DESIGN

We plan to search electronic databases and reference lists of relevant studies published in African settings from January 2003 to the present. Studies will be considered if they address one or both of our major objectives and focus on health care for one or more of six interrelated CMDs (ischemic heart disease, stroke, heart failure, hypertension, diabetes, and hyperlipidemia) in PLHIV. Our first objective will be to estimate proportions of CMD patients along the "cascade of care"-i.e., screened, diagnosed, aware of the diagnosis, initiated on treatment, adherent to treatment, and with controlled disease. Our second objective will be to identify unique barriers and facilitators to health care faced by PLHIV in African countries. For studies deemed eligible for inclusion, we will assess study quality and risk of bias using previously published criteria. We will extract study data using standardized instruments. We will meta-analyze quantitative data at each level of the cascade of care for each CMD (first objective). We will use meta-synthesis techniques to understand and integrate qualitative data on health-related behaviors (second objective).

DISCUSSION

CMDs and other NCDs are becoming major health concerns for African PLHIV. The results of our review will inform the development of research into chronic care models that integrate care for HIV/AIDS and CMDs among PLHIV. Our findings will be highly relevant to health policymakers, administrators, and practitioners in African settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015029375.

Coronary artery disease risk reduction in HIV-infected persons: a comparative analysis

Despite an increased risk of coronary artery disease (CAD) in persons infected with human immunodeficiency virus (HIV), few data are available on primary prevention of CAD in this population. In this retrospective cohort study, HIV-infected patients treated in an academic medical center HIV Specialty Clinic between 1996 and 2010 were matched by age, gender, and ethnicity to a cohort of presumed uninfected persons followed in an academic medical center Internal Medicine primary care clinic. We compared CAD primary prevention care practices between the two clinics, including use of aspirin, HMG-CoA reductase inhibitors ("statins"), and anti-hypertensive drugs. CAD risk between the two groups was assessed with 10-year Framingham CAD risk scores. In the comparative analysis, 890 HIV-infected persons were compared to 807 controls. Ten-year Framingham CAD Risk Scores were similar in the two groups (median, 3; interquartile range [IQR], 0-5). After adjusting for relevant risk factors, HIV-infected persons were less likely to be prescribed aspirin (odds ratio [OR] 0.53; 95% confidence interval [CI], 0.40-0.71), statins (OR, 0.70; 95% CI, 0.53-0.92), and anti-hypertensive drugs (OR, 0.63; 95% CI, 0.50-0.79) than persons in the control group. In summary, when compared to demographically similar uninfected persons, HIV-infected persons treated in an HIV specialty clinic were less likely to be prescribed medications appropriate for CAD risk reduction. Improving primary preventative CAD care in HIV specialty clinic populations is an important step toward diminishing risk of heart disease in HIV-infected persons.

The U.S. prevention of cardiovascular disease guidelines and implications for implementation in LMIC

The 2013 guidelines for the Prevention of Cardiovascular Disease released by the American College of Cardiology and the American Heart Association included guidelines of assessment of cardiovascular disease (CVD) risk, lifestyle management, management of overweight and obesity, and treatment of blood cholesterol. In addition, there were also 2014 guidelines on hypertension management released by members appointed to the Eighth Joint National Committee. Taken together, these guidelines, though extensively discussed and disseminated in the United States, have not been widely recognized beyond the United States, nor have their implications been considered for lower- and middle-income developing countries. With an estimated 80% of the global burden in CVD occurring in developing countries, it is important to develop strategies to adequately detect those at increased CVD risk and to manage their risk through lifestyle and where appropriate, pharmacologic means. Though certain aspects of each guideline may be suitable for implementation globally, including in developing countries, other recommendations would be unrealistic for many countries based on local epidemiology and resources. CVD prevention priorities can be set using guidance from recently published CVD prevention guidelines if appropriately modified to the context of lower- and middle-income developing countries. Establishment of global CVD prevention standards and rapid adaptation and dissemination of clinical guidelines are of paramount importance if we are to make significant progress into achieving World Health Organization 2025 goals to reduce the burden from CVD and other noncommunicable diseases.

Enhancing cancer care in areas of limited resources: our next steps

In-depth knowledge of local conditions is necessary in order to enhance care in low- and middle-income countries. In this review we discuss: improving cancer diagnosis, optimizing patient management, increasing health awareness, prevention, early detection, eradication of causative infectious diseases and agents, tobacco control, healthy diets and lifestyles, availability of diagnostic methods, easy access to care, affordable costs, improving infrastructures, quality care measures, implementing and adapting guidelines, multidisciplinary management, supportive and survivorship care, research and optimization of medical school curriculum and training in oncology. Establishment of national cancer control plans by policy makers, physician societies, medical schools, and patient advocates is recommended. We will review evidence and controversies, and outline the next steps needed to prevent cancer and enhance care of cancer patients in LMICs.

Future challenges for clinical care of an ageing population infected with HIV: a modelling study

BACKGROUND

The population infected with HIV is getting older and these people will increasingly develop age-related non-communicable diseases (NCDs). We aimed to quantify the scale of the change and the implications for HIV care in the Netherlands in the future.

METHODS

We constructed an individual-based model of the ageing HIV-infected population, which followed patients on HIV treatment as they age, develop NCDs-including cardiovascular disease (hypertension, hypercholesterolaemia, myocardial infarctions, and strokes), diabetes, chronic kidney disease, osteoporosis, and non-AIDS malignancies-and start co-medication for these diseases. The model was parameterised by use of data for 10 278 patients from the national Dutch ATHENA cohort between 1996 and 2010. We made projections up to 2030.

FINDINGS

Our model suggests that the median age of HIV-infected patients on combination antiretroviral therapy (ART) will increase from 43·9 years in 2010 to 56·6 in 2030, with the proportion of HIV-infected patients aged 50 years or older increasing from 28% in 2010 to 73% in 2030. In 2030, we predict that 84% of HIV-infected patients will have at least one NCD, up from 29% in 2010, with 28% of HIV-infected patients in 2030 having three or more NCDs. 54% of HIV-infected patients will be prescribed co-medications in 2030, compared with 13% in 2010, with 20% taking three or more co-medications. Most of this change will be driven by increasing prevalence of cardiovascular disease and associated drugs. Because of contraindications and drug-drug interactions, in 2030, 40% of patients could have complications with the currently recommended first-line HIV regimens.

INTERPRETATION

The profile of patients in the Netherlands infected with HIV is changing, with increasing numbers of older patients with multiple morbidities. These changes mean that, in the near future, HIV care will increasingly need to draw on a wide range of medical disciplines, in addition to evidence-based screening and monitoring protocols to ensure continued high-quality care. These findings are based on a large dataset of HIV-infected patients in the Netherlands, but we believe that the overall patterns will be repeated elsewhere in Europe and North America. The implications of such a trend for care of HIV-infected patients in high-burden countries in Africa could present a particular challenge.

FUNDING

Medical Research Council, Bill & Melinda Gates Foundation, Rush Foundation, and Netherlands Ministry of Health, Welfare and Sport.

Future challenges for clinical care of an ageing population infected with HIV: a modelling study

BACKGROUND

The population infected with HIV is getting older and these people will increasingly develop age-related non-communicable diseases (NCDs). We aimed to quantify the scale of the change and the implications for HIV care in the Netherlands in the future.

METHODS

We constructed an individual-based model of the ageing HIV-infected population, which followed patients on HIV treatment as they age, develop NCDs-including cardiovascular disease (hypertension, hypercholesterolaemia, myocardial infarctions, and strokes), diabetes, chronic kidney disease, osteoporosis, and non-AIDS malignancies-and start co-medication for these diseases. The model was parameterised by use of data for 10 278 patients from the national Dutch ATHENA cohort between 1996 and 2010. We made projections up to 2030.

FINDINGS

Our model suggests that the median age of HIV-infected patients on combination antiretroviral therapy (ART) will increase from 43·9 years in 2010 to 56·6 in 2030, with the proportion of HIV-infected patients aged 50 years or older increasing from 28% in 2010 to 73% in 2030. In 2030, we predict that 84% of HIV-infected patients will have at least one NCD, up from 29% in 2010, with 28% of HIV-infected patients in 2030 having three or more NCDs. 54% of HIV-infected patients will be prescribed co-medications in 2030, compared with 13% in 2010, with 20% taking three or more co-medications. Most of this change will be driven by increasing prevalence of cardiovascular disease and associated drugs. Because of contraindications and drug-drug interactions, in 2030, 40% of patients could have complications with the currently recommended first-line HIV regimens.

INTERPRETATION

The profile of patients in the Netherlands infected with HIV is changing, with increasing numbers of older patients with multiple morbidities. These changes mean that, in the near future, HIV care will increasingly need to draw on a wide range of medical disciplines, in addition to evidence-based screening and monitoring protocols to ensure continued high-quality care. These findings are based on a large dataset of HIV-infected patients in the Netherlands, but we believe that the overall patterns will be repeated elsewhere in Europe and North America. The implications of such a trend for care of HIV-infected patients in high-burden countries in Africa could present a particular challenge.

FUNDING

Medical Research Council, Bill & Melinda Gates Foundation, Rush Foundation, and Netherlands Ministry of Health, Welfare and Sport.