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Namakoola I, Moyo F, Birungi J, Kivuyo S, Karoli P, Mfinanga S, Nyirenda M, Jaffar S, Garrib A. Long-term impact of an integrated HIV/non-communicable disease care intervention on patient retention in care and clinical outcomes in East Africa. Trop Med Int Health 2024; 29:723-730. [PMID: 38973259 DOI: 10.1111/tmi.14026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
OBJECTIVE To describe rates of retention in care and control of hypertension, diabetes and HIV among participants receiving integrated care services for a period of up to 24 months in East Africa. METHODS Between 5 October 2018 and 23 June 2019 participants enrolled into a prospective cohort study evaluating the feasibility of integrated care delivery for HIV, diabetes and hypertension from a single point of care in Tanzania and Uganda (MOCCA study). Integrated care clinics were established in 10 primary healthcare facilities and care was provided routinely according to national guidelines. Initial follow-up was 12 months. Outcomes were rates of retention in care, proportions of participants with controlled hypertension (blood pressure <140/90 mmHg), diabetes (fasting blood glucose <7.0 mmol/L) and HIV (plasma viral load <1000 copies/ml). The study coincided with the COVID-19 pandemic response. Afterwards, all participants were approached for extended follow-up by a further 12 months in the same clinics. We evaluated outcomes of the cohort at the end of long-term follow-up. RESULTS The MOCCA study enrolled 2273 participants of whom 1911 (84.5%) were retained in care after a median follow-up of 8 months (Interquartile range: 6.8-10.7). Among these, 1283/1911 (67.1%) enrolled for a further year of follow-up, 458 (24.0%) were unreachable, 71 (3.7%) reverted to vertical clinics (clinics providing services dedicated to study conditions), 31 (1.6%) died and 68 (3.6%) refused participation. Among participants who enrolled for longer follow-up, mean age was 51.4 ± 11.7 years, 930 (72.5%) were female and 509 (39.7%) had multiple chronic conditions. Overall, 1236 (96.3%) [95% confidence interval 95.2%-97.3%] participants were retained in care, representing 1236/2273 (54.3%) [52.3%-56.4%] of participants ever enrolled in the study. Controlled hypertension, diabetes and HIV at the end of follow-up was, 331/618 (53.6%) [49.5%-57.5%], 112/354 (31.6%) [26.8%-36.8%] and 332/343 (96.7%) [94.3%-98.4%] respectively. CONCLUSION Integrated care can achieve high rates of retention in care long term, but control of blood pressure and blood sugar remains low.
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Affiliation(s)
- Ivan Namakoola
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Faith Moyo
- Institute for Global Health, University College London, London, UK
| | - Josephine Birungi
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
- The AIDS Support Organization, Kampala, Uganda
| | - Sokoine Kivuyo
- Muhimbili Medical Research Centre, National Institute for Medical Research-Muhimbili Centre, Dar Es Salaam, Tanzania
- Barcelona Institute for Global Health Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Peter Karoli
- Muhimbili Medical Research Centre, National Institute for Medical Research-Muhimbili Centre, Dar Es Salaam, Tanzania
| | - Sayoki Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research-Muhimbili Centre, Dar Es Salaam, Tanzania
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Moffat Nyirenda
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Shabbar Jaffar
- Institute for Global Health, University College London, London, UK
| | - Anupam Garrib
- Institute for Global Health, University College London, London, UK
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Gala P, Ponatshego P, Bogart LM, Youssouf N, Ramotsababa M, Van Pelt AE, Moshomo T, Dintwa E, Seipone K, Ilias M, Tonwe V, Gaolathe T, Hirschhorn LR, Mosepele M. A mixed methods approach identifying facilitators and barriers to guide adaptations to InterCARE strategies: an integrated HIV and hypertension care model in Botswana. Implement Sci Commun 2024; 5:67. [PMID: 38902846 PMCID: PMC11188218 DOI: 10.1186/s43058-024-00603-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 06/09/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Botswana serves as a model of success for HIV with 95% of people living with HIV (PLWH) virally suppressed. Yet, only 19% of PLWH and hypertension have controlled blood pressure. To address this gap, InterCARE, a care model that integrates HIV and hypertension care through a) provider training; b) adapted electronic health record; and c) treatment partners (peer support), was designed. This study presents results from our baseline assessment of the determinants and factors used to guide adaptations to InterCARE implementation strategies prior to a hybrid type 2 effectiveness-implementation study. METHODS This study employed a convergent mixed methods design across two clinics (one rural, one urban) to collect quantitative and qualitative data through facility assessments, 100 stakeholder surveys (20 each PLWH and hypertension, existing HIV treatment partners, clinical healthcare providers (HCPs), and 40 community leaders) and ten stakeholder key informative interviews (KIIs). Data were analyzed using descriptive statistics and deductive qualitative analysis organized by the Consolidated Framework for Implementation Research (CFIR) and compared to identify areas of convergence and divergence. RESULTS Although 90.3% of 290 PLWH and hypertension at the clinics were taking antihypertensive medications, 52.8% had uncontrolled blood pressure. Results from facility assessments, surveys, and KIIs identified key determinants in the CFIR innovation and inner setting domains. Most stakeholders (> 85%) agreed that InterCARE was adaptable, compatible and would be successful at improving blood pressure control in PLWH and hypertension. HCPs agreed that there were insufficient resources (40%), consistent with facility assessments and KIIs which identified limited staffing, inconsistent electricity, and a lack of supplies as key barriers. Adaptations to InterCARE included a task-sharing strategy and expanded treatment partner training and support. CONCLUSIONS Integrating hypertension services into HIV clinics was perceived as more advantageous for PLWH than the current model of hypertension care delivered outside of HIV clinics. Identified barriers were used to adapt InterCARE implementation strategies for more effective intervention delivery. TRIAL REGISTRATION ClinicalTrials.gov, ClinicalTrials.gov Identifier: NCT05414526 . Registered 18 May 2022 - Retrospectively registered.
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Affiliation(s)
- Pooja Gala
- Department of Medicine, NYU Langone Grossman School of Medicine, New York, NY, USA.
| | - Ponego Ponatshego
- Department of Internal Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Nabila Youssouf
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Mareko Ramotsababa
- Government of Botswana, Ministry of Health and Wellness, Gaborone, Botswana
| | - Amelia E Van Pelt
- Department of Medical Social Sciences, Northwestern University, Chicago, IL, USA
| | - Thato Moshomo
- Department of Internal Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Evelyn Dintwa
- Government of Botswana, Ministry of Health and Wellness, Gaborone, Botswana
| | - Khumo Seipone
- Government of Botswana, Ministry of Health and Wellness, Gaborone, Botswana
| | - Maliha Ilias
- Center for Translation Research and Implementation Science, Department of Health and Human Services, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Veronica Tonwe
- Center for Translation Research and Implementation Science, Department of Health and Human Services, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Tendani Gaolathe
- Department of Internal Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Government of Botswana, Ministry of Health and Wellness, Gaborone, Botswana
| | - Lisa R Hirschhorn
- Department of Medical Social Sciences, Northwestern University, Chicago, IL, USA
| | - Mosepele Mosepele
- Department of Internal Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Government of Botswana, Ministry of Health and Wellness, Gaborone, Botswana
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Amutuhaire W, Semitala FC, Kimera ID, Namugenyi C, Mulindwa F, Ssenyonjo R, Katwesigye R, Mugabe F, Mutungi G, Ssinabulya I, Schwartz JI, Katahoire AR, Musoke LS, Yendewa GA, Longenecker CT, Muddu M. Time to blood pressure control and predictors among patients receiving integrated treatment for hypertension and HIV based on an adapted WHO HEARTS implementation strategy at a large urban HIV clinic in Uganda. J Hum Hypertens 2024; 38:452-459. [PMID: 38302611 PMCID: PMC11076202 DOI: 10.1038/s41371-024-00897-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 10/01/2023] [Accepted: 01/18/2024] [Indexed: 02/03/2024]
Abstract
In this cohort study, we determined time to blood pressure (BP) control and its predictors among hypertensive PLHIV enrolled in integrated hypertension-HIV care based on the World Health Organization (WHO) HEARTS strategy at Mulago Immunosuppression Clinic in Uganda. From August 2019 to March 2020, we enrolled hypertensive PLHIV aged ≥ 18 years and initiated Amlodipine 5 mg mono-therapy for BP (140-159)/(90-99) mmHg or Amlodipine 5 mg/Valsartan 80 mg duo-therapy for BP ≥ 160/90 mmHg. Patients were followed with a treatment escalation plan until BP control, defined as BP < 140/90 mmHg. We used Cox proportional hazards models to identify predictors of time to BP control. Of 877 PLHIV enrolled (mean age 50.4 years, 62.1% female), 30% received mono-therapy and 70% received duo-therapy. In the monotherapy group, 66%, 88% and 96% attained BP control in the first, second and third months, respectively. For patients on duo-therapy, 56%, 83%, 88% and 90% achieved BP control in the first, second, third, and fourth months, respectively. In adjusted Cox proportional hazard analysis, higher systolic BP (aHR 0.995, 95% CI 0.989-0.999) and baseline ART tenofovir/lamivudine/efavirenz (aHR 0.764, 95% CI 0.637-0.917) were associated with longer time to BP control, while being on ART for >10 years was associated with a shorter time to BP control (aHR 1.456, 95% CI 1.126-1.883). The WHO HEARTS strategy was effective at achieving timely BP control among PLHIV. Additionally, monotherapy anti-hypertensive treatment for stage I hypertension is a viable option to achieve BP control and limit pill burden in resource limited HIV care settings.
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Affiliation(s)
- Willington Amutuhaire
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | | | | | | | - Frank Mulindwa
- Makerere University Infectious Diseases Institute, Kampala, Uganda
| | | | | | - Frank Mugabe
- Department of non-communicable diseases, Uganda Ministry of Health, Kampala, Uganda
| | - Gerald Mutungi
- Department of non-communicable diseases, Uganda Ministry of Health, Kampala, Uganda
| | | | - Jeremy I Schwartz
- Yale School of Medicine, Section of General Internal Medicine, Connecticut, CT, USA
| | - Anne R Katahoire
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lewis S Musoke
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - George A Yendewa
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Chris T Longenecker
- Department of Global Health and Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Martin Muddu
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
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Oboho IK, Esber AL, Dear N, Paulin HN, Iroezindu M, Bahemana E, Kibuuka H, Owuoth J, Maswai J, Shah N, Crowell TA, Ake JA, Polyak CS. Advanced HIV disease in East Africa and Nigeria, in The African Cohort Study. J Acquir Immune Defic Syndr 2024; 96:51-60. [PMID: 38427929 PMCID: PMC11008437 DOI: 10.1097/qai.0000000000003392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/18/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Earlier antiretroviral therapy (ART) may decrease progression to advanced HIV disease (AHD) with CD4 count of <200 cells per cubic millimeter or clinical sequelae. We assessed factors associated with AHD among people living with HIV before and during the "test and treat" era. SETTING The African Cohort Study prospectively enrolls adults with and without HIV from 12 clinics in Uganda, Kenya, Tanzania, and Nigeria. METHODS Enrollment evaluations included clinical history, physical examination, and laboratory testing. Generalized estimating equations were used to estimate adjusted odds ratios and 95% confidence intervals for factors associated with CD4 count of <200 cells per cubic millimeter at study visits. RESULTS From 2013 to 2021, 3059 people living with HIV with available CD4 at enrollment were included; median age was 38 years [interquartile range: 30-46 years], and 41.3% were men. From 2013 to 2021, the prevalence of CD4 count of <200 cells per cubic millimeter decreased from 10.5% to 3.1%, whereas the percentage on ART increased from 76.6% to 100% ( P <0.001). Factors associated with higher odds of CD4 count of <200 cells per cubic millimeter were male sex (adjusted odds ratio 1.56 [confidence interval: 1.29 to 1.89]), being 30-39 years (1.42 [1.11-1.82]) or older (compared with <30), have World Health Organization stage 2 disease (1.91 [1.48-2.49]) or higher (compared with stage 1), and HIV diagnosis eras 2013-2015 (2.19 [1.42-3.37]) or later (compared with <2006). Compared with ART-naive, unsuppressed participants, being viral load suppressed on ART, regardless of ART duration, was associated with lower odds of CD4 count of <200 cells per cubic millimeter (<6 months on ART: 0.45 [0.34-0.58]). CONCLUSION With ART scale-up, AHD has declined. Efforts targeting timely initiation of suppressive ART may further reduce AHD risk.
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Affiliation(s)
- Ikwo K. Oboho
- HIV Care and Treatment Branch, Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Atlanta, GA
| | - Allahna L. Esber
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD
- Henry M. Jackson Foundation (HJF) for the Advancement of Military Medicine, Inc., Bethesda, MD
| | - Nicole Dear
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD
- Henry M. Jackson Foundation (HJF) for the Advancement of Military Medicine, Inc., Bethesda, MD
| | - Heather N. Paulin
- HIV Care and Treatment Branch, Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Atlanta, GA
| | - Michael Iroezindu
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD
- HJF Medical Research International, Abuja, Nigeria
| | - Emmanuel Bahemana
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD
- HJF Medical Research International, Mbeya, Tanzania
| | - Hannah Kibuuka
- Makerere University Walter Reed Project, Kampala, Uganda
| | - John Owuoth
- U.S. Army Medical Research Directorate–Africa, Kisumu, Kenya
- HJF Medical Research International, Kisumu, Kenya; and
| | - Jonah Maswai
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD
- U.S. Army Medical Research Directorate–Africa, Kericho, Kenya
| | - Neha Shah
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD
| | - Trevor A. Crowell
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD
- Henry M. Jackson Foundation (HJF) for the Advancement of Military Medicine, Inc., Bethesda, MD
| | - Julie A. Ake
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD
| | - Christina S. Polyak
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD
- Henry M. Jackson Foundation (HJF) for the Advancement of Military Medicine, Inc., Bethesda, MD
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Ogugu EG, Bidwell JT, Ruark A, Butterfield RM, Weiser SD, Neilands TB, Mulauzi N, Rambiki E, Mkandawire J, Conroy AA. Barriers to accessing care for cardiometabolic disorders in Malawi: partners as a source of resilience for people living with HIV. Int J Equity Health 2024; 23:83. [PMID: 38678232 PMCID: PMC11055364 DOI: 10.1186/s12939-024-02181-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND People living with HIV (PLWH) are at increased risk of cardiometabolic disorders (CMD). Adequate access to care for both HIV and CMD is crucial to improving health outcomes; however, there is limited research that have examined couples' experiences accessing such care in resource-constrained settings. We aimed to identify barriers to accessing CMD care among PLWH in Malawi and the role of partners in mitigating these barriers. METHODS We conducted a qualitative investigation of barriers to CMD care among 25 couples in Malawi. Couples were eligible if at least one partner was living with HIV and had hypertension or diabetes (i.e., the index patient). Index patients were recruited from HIV care clinics in the Zomba district, and their partners were enrolled thereafter. Interviews were conducted separately with both partners to determine barriers to CMD care access and how partners were involved in care. RESULTS Participants framed their experiences with CMD care by making comparisons to HIV treatment, which was free and consistently available. The main barriers to accessing CMD care included shortage of medications, cost of tests and treatments, high cost of transportation to health facilities, lengthy wait times at health facilities, faulty or unavailable medical equipment and supplies, inadequate monitoring of patients' health conditions, some cultural beliefs about causes of illness, use of herbal therapies as an alternative to prescribed medicine, and inadequate knowledge about CMD treatments. Partners provided support through decision-making on accessing medical care, assisting partners in navigating the healthcare system, and providing financial assistance with transportation and treatment expenses. Partners also helped manage care for CMD, including communicating health information to their partners, providing appointment reminders, supporting medication adherence, and supporting recommended lifestyle behaviors. CONCLUSIONS Couples identified many barriers to CMD care access, which were perceived as greater challenges than HIV care. Partners provided critical forms of support in navigating these barriers. With the rise of CMD among PLWH, improving access to CMD care should be prioritized, using lessons learned from HIV and integrated care approaches. Partner involvement in CMD care may help mitigate most barriers to CMD care.
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Affiliation(s)
- Everlyne G Ogugu
- Betty Irene Moore School of Nursing, University of California Davis, Davis, CA, USA.
- Betty Irene Moore School of Nursing, University of California Davis, 2570 48th Street, Sacramento, CA, 95817, USA.
| | - Julie T Bidwell
- Betty Irene Moore School of Nursing, University of California Davis, Davis, CA, USA
| | - Allison Ruark
- Wheaton College, Biological and Health Sciences, Wheaton, IL, USA
| | - Rita M Butterfield
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sheri D Weiser
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Torsten B Neilands
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Amy A Conroy
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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Mugo R, Pliakas T, Kamano J, Sanga LA, Nolte E, Gasparrini A, Barasa E, Etyang A, Perel P. Evaluating the implementation of the Primary Health Integrated Care Project for Chronic Conditions: a cohort study from Kenya. BMJ PUBLIC HEALTH 2024; 2:e000146. [PMID: 38939473 PMCID: PMC7616119 DOI: 10.1136/bmjph-2023-000146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Introduction In Kenya, non-communicable diseases (NCDs) are estimated to account for almost one-third of all deaths and this is likely to rise by over 50% in the next 10 years. The Primary Health Integrated Care for Chronic Conditions (PIC4C) project aims to strengthen primary care by integrating comprehensive NCD care into existing HIV primary care platform. This paper evaluates the association of PIC4C implementation on clinical outcomes. Methods Outcomes included proportion of new patients, systolic blood pressure (SBP), fasting plasma glucose (FPG), diastolic blood pressure, hypertension control, random plasma glucose, diabetes control, viral load and HIV viral suppression. We used interrupted time series and binomial regression with random effects for facility-level data and generalised mixed-effects regression for visit-level data to examine the association between PIC4C and outcomes between January 2017 and December 2021. We conducted sensitivity analysis with restrictions on sites and the number of visits. Results Data from 66 641 visits of 13 046 patients with hypertension, 24 005 visits of 7267 patients with diabetes and 84 855 visits of 21 186 people with HIV were analysed. We found evidence of association between PIC4C and increase in proportion of new patients per month with hypertension (adjusted OR (aOR) 1.57, 95% CI 1.39 to 1.78) and diabetes (aOR 1.31, 95% CI 1.19 to 1.45), small increase in SBP (adjusted beta (aB) 1.7, 95% CI 0.8 to 2.7) and FPG (aB 0.6, 95% CI 0.0 to 1.1). There was no strong evidence of association between PIC4C and viral suppression (aOR 1.20, 95% CI 0.98 to 1.47). In sensitivity analysis, there was no strong evidence of association between PIC4C and SBP (aB 1.74, 95% CI -0.70 to 4.17) or FPG (aB 0.52, 95% CI -0.64 to 1.67). Conclusions PIC4C implementation was associated with increase in proportion of new patients attending clinics and a slight increase in SBP and FPG. The immediate post-PIC4C implementation period coincided with the COVID-19 pandemic, which is likely to explain some of our findings.
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Affiliation(s)
| | - Triantafyllos Pliakas
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
- GSK Vaccines, Wavre, Belgium
| | - Jemima Kamano
- School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | | | - Ellen Nolte
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Antonio Gasparrini
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Anthony Etyang
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Pablo Perel
- London School of Hygiene & Tropical Medicine, London, UK
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Van Hout MC, Akugizibwe M, Shayo EH, Namulundu M, Kasujja FX, Namakoola I, Birungi J, Okebe J, Murdoch J, Mfinanga SG, Jaffar S. Decentralising chronic disease management in sub-Saharan Africa: a protocol for the qualitative process evaluation of community-based integrated management of HIV, diabetes and hypertension in Tanzania and Uganda. BMJ Open 2024; 14:e078044. [PMID: 38508649 PMCID: PMC10961519 DOI: 10.1136/bmjopen-2023-078044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION Sub-Saharan Africa continues to experience a syndemic of HIV and non-communicable diseases (NCDs). Vertical (stand-alone) HIV programming has provided high-quality care in the region, with almost 80% of people living with HIV in regular care and 90% virally suppressed. While integrated health education and concurrent management of HIV, hypertension and diabetes are being scaled up in clinics, innovative, more efficient and cost-effective interventions that include decentralisation into the community are required to respond to the increased burden of comorbid HIV/NCD disease. METHODS AND ANALYSIS This protocol describes procedures for a process evaluation running concurrently with a pragmatic cluster-randomised trial (INTE-COMM) in Tanzania and Uganda that will compare community-based integrated care (HIV, diabetes and hypertension) with standard facility-based integrated care. The INTE-COMM intervention will manage multiple conditions (HIV, hypertension and diabetes) in the community via health monitoring and adherence/lifestyle advice (medicine, diet and exercise) provided by community nurses and trained lay workers, as well as the devolvement of NCD drug dispensing to the community level. Based on Bronfenbrenner's ecological systems theory, the process evaluation will use qualitative methods to investigate sociostructural factors shaping care delivery and outcomes in up to 10 standard care facilities and/or intervention community sites with linked healthcare facilities. Multistakeholder interviews (patients, community health workers and volunteers, healthcare providers, policymakers, clinical researchers and international and non-governmental organisations), focus group discussions (community leaders and members) and non-participant observations (community meetings and drug dispensing) will explore implementation from diverse perspectives at three timepoints in the trial implementation. Iterative sampling and analysis, moving between data collection points and data analysis to test emerging theories, will continue until saturation is reached. This process of analytic reflexivity and triangulation across methods and sources will provide findings to explain the main trial findings and offer clear directions for future efforts to sustain and scale up community-integrated care for HIV, diabetes and hypertension. ETHICS AND DISSEMINATION The protocol has been approved by the University College of London (UK), the London School of Hygiene and Tropical Medicine Ethics Committee (UK), the Uganda National Council for Science and Technology and the Uganda Virus Research Institute Research and Ethics Committee (Uganda) and the Medical Research Coordinating Committee of the National Institute for Medical Research (Tanzania). The University College of London is the trial sponsor. Dissemination of findings will be done through journal publications and stakeholder meetings (with study participants, healthcare providers, policymakers and other stakeholders), local and international conferences, policy briefs, peer-reviewed journal articles and publications. TRIAL REGISTRATION NUMBER ISRCTN15319595.
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Affiliation(s)
| | | | - Elizabeth Henry Shayo
- Health Systems, Policy and Translational Reseach Section, National Institute for Medical Research, Dar es Salaam, Tanzania, United Republic
| | - Moreen Namulundu
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
| | | | - Ivan Namakoola
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
| | | | - Joseph Okebe
- Institute for Global Health, University College London, London, UK
| | - Jamie Murdoch
- School of Life Course and Population Sciences, King's College London, London, London, UK
| | - Sayoki Godfrey Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research Tanzania, Dar es Salaam, Tanzania, United Republic of
| | - Shabbar Jaffar
- Institute for Global Health, University College London, London, UK
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Badacho AS, Mahomed OH. Lived experiences of people living with HIV and hypertension or diabetes access to care in Ethiopia: a phenomenological study. BMJ Open 2024; 14:e078036. [PMID: 38417958 PMCID: PMC10900422 DOI: 10.1136/bmjopen-2023-078036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND People living with HIV (PLWH) are more likely to develop hypertension and diabetes than people without HIV. Previous studies have shown that HIV stigma, discrimination and exclusion make it difficult for PLWH to access care for hypertension and diabetes. OBJECTIVES This study aimed to explore the lived experiences of PLWH with comorbid hypertension or diabetes to access hypertension and diabetes care in southern Ethiopia. DESIGN We conducted a qualitative study using a semistructured interview guide for an in-depth, in-person interview. SETTINGS From 5 August to 25 September 2022, PLWH with comorbid hypertension or diabetes were purposefully selected from five primary healthcare (PHC) facilities in the Wolaita zone of southern Ethiopia. PARTICIPANTS A total of 14 PLWH with comorbid hypertension or diabetes who were receiving antiretroviral therapy from PHC were interviewed. Among them, 10 were women, and 4 were men. METHODS In-person, in-depth interviews were conducted. Qualitative data analysis software (NVivo V.12) was used to assist with the data organisation, and Colaizzi's (1978) inductive thematic analyses were conducted to explore key concepts. RESULT This study yielded two main themes: Theme 1: barriers to accessing care as individual barriers to access (low awareness of non-communicable diseases, misperceptions, lack of health insurance and cost of treatment); healthcare system barriers (shortage of supplies, drugs and equipment; long wait times; lack of integrated services; absence of routine screening and lack of respect from providers); community barriers (lack of support from families, friends and the community) and stigma and discrimination access to hypertension and diabetes. Theme 2: accessibility facilitators (support from family, friends and organisations; health insurance coverage). CONCLUSION PLWH recommended that access to services can be improved by service integration, awareness-raising activities, no user fee charges for hypertension and diabetes care and routine screening.
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Affiliation(s)
- Abebe Sorsa Badacho
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- School of Public Health, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Ozayr Haroon Mahomed
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Dasman Diabetes Institute, Kuwait City, Kuwait
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Ottaru TA, Wood CV, Butt Z, Hawkins C, Hirschhorn LR, Karoli P, Shayo EH, Metta E, Chillo P, Siril H, Kwesigabo GP. "I only seek treatment when I am ill": experiences of hypertension and diabetes care among adults living with HIV in urban Tanzania. BMC Health Serv Res 2024; 24:186. [PMID: 38336716 PMCID: PMC10858457 DOI: 10.1186/s12913-024-10688-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 02/06/2024] [Indexed: 02/12/2024] Open
Abstract
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.
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Affiliation(s)
- Theresia A Ottaru
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Christine V Wood
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Zeeshan Butt
- Phreesia, Inc, New York, NY, USA
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Claudia Hawkins
- Feinberg School of Medicine, Robert J Havey Institute of Global Health, Northwestern University, Chicago, IL, USA
| | - Lisa R Hirschhorn
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Feinberg School of Medicine, Robert J Havey Institute of Global Health, Northwestern University, Chicago, IL, USA
| | - Peter Karoli
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | | | - Emmy Metta
- Department of Behavioral Sciences, Muhimbli University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Pilly Chillo
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Hellen Siril
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Gideon P Kwesigabo
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Dawood H, Yende-Zuma N, Singh U, Moodley MC, Ramruthan J, Naidoo K. Incidence and prevalence of hypertension among HIV-TB co-infected participants accessing treatment: A five-year prospective cohort analysis. PLoS One 2024; 19:e0297224. [PMID: 38285691 PMCID: PMC10824407 DOI: 10.1371/journal.pone.0297224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 01/01/2024] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Hypertension is a leading risk factor for cardiovascular disease among people living with human immunodeficiency virus (PLWH). This study determined incidence and prevalence of hypertension among PLWH receiving antiretroviral therapy (ART). METHOD We prospectively followed-up 642 HIV and tuberculosis (TB) co-infected study participants from 2005-2013. We defined hypertension as two consecutive elevated systolic and/or diastolic blood pressure measurements above 139/89 mmHg or current use of antihypertensive therapy. RESULTS Of 507 participants analyzed, 53% were women. Median [interquartile range (IQR)] age, body mass index (BMI), and CD4 count was 34 (28.0-40.0) years, 22.7 (20.5-25.4) kg/m2, and 145 (69.0-252.0) cells/mm3, respectively. Incidence [95% confidence interval (CI)] of both systolic and diastolic hypertension overall, in men, and in women over 40 years was 1.9 (1.4-2.6), 5.9 (3.6-9.6), and 5.0 (2.7-9.3) per 100 person-years (PY), respectively. Risk of developing hypertension was higher in men [(adjusted hazard ratio (aHR) 12.04, 95% CI: 4.35-33.32)] and women over 40 years (aHR 8.19, 95% CI 2.96-22.64), and in men below 40 years (aHR 2.79, 95% CI 0.95-8.23). CONCLUSION Higher incidence rates of hypertension among older men and women accessing ART highlight opportunities to expand current integrated HIV-TB care models, to include cardiovascular disease risk screening and care to prevent premature death.
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Affiliation(s)
- Halima Dawood
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- Department of Internal Medicine, Infectious Diseases, Greys Hospital, Pietermaritzburg, South Africa
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Upasna Singh
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Mikaila C. Moodley
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Jenine Ramruthan
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
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Prattipati S, Tarimo TG, Kweka GL, Mlangi JJ, Samuel D, Sakita FM, Tupetz A, Bettger JP, Thielman NM, Temu G, Hertz JT. Patient and provider perspectives on barriers to myocardial infarction care among persons with human immunodeficiency virus in Tanzania: A qualitative study. Int J STD AIDS 2024; 35:18-24. [PMID: 37703080 PMCID: PMC11139408 DOI: 10.1177/09564624231199507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
INTRODUCTION People with HIV (PLWH) have an increased risk myocardial infarction (MI), and evidence suggests that MI is under-diagnosed in Tanzania. However, little is known about barriers to MI care among PLWH in the region. METHODS In this qualitative study grounded in phenomenology, semi-structured interviews were conducted in northern Tanzania. Purposive sampling was used to recruit a diverse group of providers who care for PLWH and patients with HIV and electrocardiographic evidence of prior MI. Emergent themes were identified via inductive thematic analysis. RESULTS 24 physician and patient participants were interviewed. Most participants explained MI as caused by emotional shock and were unaware of the association between HIV and increased MI risk. Providers described poor provider training regarding MI, high out-of-pocket costs, and lack of diagnostic equipment and medications. Patients reported little engagement with and limited knowledge of cardiovascular care, despite high engagement with HIV care. Most provider and patient participants indicated that they would prefer to integrate cardiovascular care with routine HIV care. CONCLUSIONS PLWH face many barriers to MI care in Tanzania. There is a need for multifaceted interventions to educate providers and patients, improve access to MI diagnosis, and increase engagement with cardiovascular care among this population.
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Affiliation(s)
| | | | | | | | | | - Francis M Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre University College, Moshi, Tanzania
| | - Anna Tupetz
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Janet P Bettger
- Department of Health and Rehabilitation Sciences, Temple University College of Public Health, Philadelphia, PA, USA
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Gloria Temu
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical Centre University College, Moshi, Tanzania
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC, USA
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12
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Sakita FM, O’Leary P, Prattipati S, Kessy MS, Kilonzo KG, Mmbaga BT, Rugakingira AA, Manavalan P, Thielman NM, Samuel D, Hertz JT. Six-month incidence of hypertension and diabetes among adults with HIV in Tanzania: A prospective cohort study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001929. [PMID: 37603550 PMCID: PMC10441788 DOI: 10.1371/journal.pgph.0001929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/28/2023] [Indexed: 08/23/2023]
Abstract
Data describing the incidence of hypertension and diabetes among people with HIV in sub-Saharan Africa remain sparse. In this study, adults with HIV were enrolled from a public clinic in Moshi, Tanzania (September 2020-March 2021). At enrollment, a survey was administered to collect information on comorbidities and medication use. Each participant's blood pressure and point-of-care glucose were measured. Baseline hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension at enrollment. Baseline diabetes was defined by self-reported diabetes or hyperglycemia (fasting glucose ≥126 mg/dl or random glucose ≥200 mg/dl) at enrollment. At 6-month follow-up, participants' blood pressure and point-of-care glucose were again measured. Incident hypertension was defined by self-report of new hypertension diagnosis or blood pressure ≥140/90 mmHg at follow-up in a participant without baseline hypertension. Incident diabetes was defined as self-report of new diabetes diagnosis or measured hyperglycemia at follow-up in a participant without baseline diabetes. During the study period, 477 participants were enrolled, of whom 310 did not have baseline hypertension and 457 did not have baseline diabetes. At six-month follow-up, 51 participants (95% CI: 38, 67) had new-onset hypertension, corresponding to an incidence of 33 new cases of hypertension per 100 person-years. Participants with incident hypertension at 6-month follow-up were more likely to have a history of alcohol use (90.2% vs. 73.7%, OR = 3.18, 95% CI:1.32-9.62, p = 0.008) and were older (mean age = 46.5 vs. 42.3, p = 0.027). At six-month follow-up, 8 participants (95% CI: 3, 16) had new-onset diabetes, corresponding to an incidence of 3 new cases of diabetes per 100 person-years. In conclusion, the incidence of elevated blood pressure and diabetes among Tanzanians with HIV is higher than what has been reported in high-income settings.
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Affiliation(s)
| | - Paige O’Leary
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sainikitha Prattipati
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | | | | | | | - Preeti Manavalan
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, United States of America
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Dorothy Samuel
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Julian T. Hertz
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
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13
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Goldstein D, Salvatore M, Ferris R, Phelps BR, Minior T. Integrating global HIV services with primary health care: a key step in sustainable HIV epidemic control. Lancet Glob Health 2023; 11:e1120-e1124. [PMID: 37349037 DOI: 10.1016/s2214-109x(23)00156-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/27/2023] [Accepted: 03/06/2023] [Indexed: 06/24/2023]
Abstract
Ending the HIV epidemic relies in part on integrating stand-alone HIV programming with primary health-care platforms to improve population-level health and ensure sustainability. Integration of HIV and primary health care services in sub-Saharan Africa improves both outcomes. Existing models support both integrating primary health care services into existing HIV services, and incorporating HIV services into primary health care platforms, with optimal programming based on local contexts and local epidemic factors. Person-centred differentiated service delivery, community-based interventions, and a well supported health workforce form the backbone of successful integration. Strategic financing to optimise HIV and primary health care integration requires well-coordinated partnerships with host governments, private sector companies, multilateral stakeholders, development banks, and non-government organisations. Programme success will require increased flexibility of international donors' implementation guidance as well as involvement of local communities and civil society organisations. As we seek to end the HIV epidemic by 2030 amidst a constrained global economic climate, integration of HIV programming with primary health care offers an avenue of opportunity and hope.
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Affiliation(s)
- Deborah Goldstein
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA.
| | | | - Robert Ferris
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Benjamin Ryan Phelps
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Thomas Minior
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
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Goldstein D, Ford N, Kisyeri N, Munsamy M, Nishimoto L, Osi K, Kambale H, Minior T, Bateganya M. Person-centred, integrated non-communicable disease and HIV decentralized drug distribution in Eswatini and South Africa: outcomes and challenges. J Int AIDS Soc 2023; 26 Suppl 1:e26113. [PMID: 37408477 PMCID: PMC10323318 DOI: 10.1002/jia2.26113] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 05/09/2023] [Indexed: 07/07/2023] Open
Abstract
INTRODUCTION Non-communicable diseases (NCDs) are highly prevalent in people living with HIV above 50 years of age and account for increasing mortality. There is little published evidence supporting person-centred, integrated models of HIV care, hypertension and diabetes treatment in southern Africa, and no data demonstrating mortality reduction. Where clinical visits for NCDs and HIV cannot be combined, integrated medication delivery presents an opportunity to streamline care and reduce patient costs. We present experiences of integrated HIV and NCD medication delivery in Eswatini and South Africa, focusing on programme successes and implementation challenges. Programmatic data from Eswatini's Community Health Commodities Distribution (CHCD) from April 2020 to December 2021 and South Africa's Central Chronic Medicines Dispensing and Distribution (CCMDD) from January 2016 to December 2021 were provided by programme managers and are summarized here. DISCUSSION Launched in 2020, Eswatini's CHCD provides over 28,000 people with and without HIV with integrated services, including HIV testing, CD4 cell count testing, antiretroviral therapy refills, viral load monitoring and pre-exposure prophylaxis alongside NCD services, including blood pressure and glucose monitoring and hypertension and diabetes medication refills. Communities designate neighbourhood care points and central gathering places for person-centred medication dispensing. This programme reported fewer missed medication refill appointments among clients in community settings compared to facility-based settings. South Africa's CCMDD utilizes decentralized drug distribution to provide medications for over 2.9 million people, including those living with HIV, hypertension and diabetes. CCMDD incorporates community-based pickup points, facility "fast lanes" and adherence clubs with public sector health facilities and private sector medication collection units. There are no out-of-pocket payments for medications or testing commodities. Wait-times for medication refills are lower at CCMDD sites than facility-based sites. Innovations to reduce stigma include uniformly labelled medication packages for NCD and HIV medications. CONCLUSIONS Eswatini and South Africa demonstrate person-centred models for HIV and NCD integration through decentralized drug distribution. This approach adapts medication delivery to serve individual needs and decongest centralized health facilities while efficiently delivering NCD care. To bolster programme uptake, additional reporting of integrated decentralized drug distribution models should include HIV and NCD outcomes and mortality trends.
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Affiliation(s)
| | - Nathan Ford
- Global HIVHepatitis and Sexually Transmitted Infections ProgrammesWorld Health OrganizationGenevaSwitzerland
| | - Nicholas Kisyeri
- Eswatini National AIDS ProgramMbabaneEswatini
- ICAPColumbia UniversityMbabaneEswatini
| | | | | | | | - Herve Kambale
- ICAPColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
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Van Hout MC, Zalwango F, Akugizibwe M, Chaka MN, Birungi J, Okebe J, Jaffar S, Bachmann M, Murdoch J. Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial. BMC Health Serv Res 2023; 23:570. [PMID: 37268916 DOI: 10.1186/s12913-023-09534-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/10/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Sub-Saharan Africa is experiencing a dual burden of chronic human immunodeficiency virus and non-communicable diseases. A pragmatic parallel arm cluster randomised trial (INTE-AFRICA) scaled up 'one-stop' integrated care clinics for HIV-infection, diabetes and hypertension at selected facilities in Uganda. These clinics operated integrated health education and concurrent management of HIV, hypertension and diabetes. A process evaluation (PE) aimed to explore the experiences, attitudes and practices of a wide variety of stakeholders during implementation and to develop an understanding of the impact of broader structural and contextual factors on the process of service integration. METHODS The PE was conducted in one integrated care clinic, and consisted of 48 in-depth interviews with stakeholders (patients, healthcare providers, policy-makers, international organisation, and clinical researchers); three focus group discussions with community leaders and members (n = 15); and 8 h of clinic-based observation. An inductive analytical approach collected and analysed the data using the Empirical Phenomenological Psychological five-step method. Bronfenbrenner's ecological framework was subsequently used to conceptualise integrated care across multiple contextual levels (macro, meso, micro). RESULTS Four main themes emerged; Implementing the integrated care model within healthcare facilities enhances detection of NCDs and comprehensive co-morbid care; Challenges of NCD drug supply chains; HIV stigma reduction over time, and Health education talks as a mechanism for change. Positive aspects of integrated care centred on the avoidance of duplication of care processes; increased capacity for screening, diagnosis and treatment of previously undiagnosed comorbid conditions; and broadening of skills of health workers to manage multiple conditions. Patients were motivated to continue receiving integrated care, despite frequent NCD drug stock-outs; and development of peer initiatives to purchase NCD drugs. Initial concerns about potential disruption of HIV care were overcome, leading to staff motivation to continue delivering integrated care. CONCLUSIONS Implementing integrated care has the potential to sustainably reduce duplication of services, improve retention in care and treatment adherence for co/multi-morbid patients, encourage knowledge-sharing between patients and providers, and reduce HIV stigma. TRIAL REGISTRATION NUMBER ISRCTN43896688.
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Affiliation(s)
| | - Flavia Zalwango
- MRC/UVRI & LSHTM Research Unit, MRC/UVRI & LSHTM, Entebbe, Uganda
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Okpechi IG, Chukwuonye II, Ekrikpo U, Noubiap JJ, Raji YR, Adeshina Y, Ajayi S, Barday Z, Chetty M, Davidson B, Effa E, Fagbemi S, George C, Kengne AP, Jones ESW, Liman H, Makusidi M, Muhammad H, Mbah I, Ndlovu K, Ngaruiya G, Okwuonu C, Samuel-Okpechi U, Tannor EK, Ulasi I, Umar Z, Wearne N, Bello AK. Task shifting roles, interventions and outcomes for kidney and cardiovascular health service delivery among African populations: a scoping review. BMC Health Serv Res 2023; 23:446. [PMID: 37147670 PMCID: PMC10163711 DOI: 10.1186/s12913-023-09416-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 04/18/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Human resources for health (HRH) shortages are a major limitation to equitable access to healthcare. African countries have the most severe shortage of HRH in the world despite rising communicable and non-communicable disease (NCD) burden. Task shifting provides an opportunity to fill the gaps in HRH shortage in Africa. The aim of this scoping review is to evaluate task shifting roles, interventions and outcomes for addressing kidney and cardiovascular (CV) health problems in African populations. METHODS We conducted this scoping review to answer the question: "what are the roles, interventions and outcomes of task shifting strategies for CV and kidney health in Africa?" Eligible studies were selected after searching MEDLINE (Ovid), Embase (Ovid), CINAHL, ISI Web of Science, and Africa journal online (AJOL). We analyzed the data descriptively. RESULTS Thirty-three studies, conducted in 10 African countries (South Africa, Nigeria, Ghana, Kenya, Cameroon, Democratic Republic of Congo, Ethiopia, Malawi, Rwanda, and Uganda) were eligible for inclusion. There were few randomized controlled trials (n = 6; 18.2%), and tasks were mostly shifted for hypertension (n = 27; 81.8%) than for diabetes (n = 16; 48.5%). More tasks were shifted to nurses (n = 19; 57.6%) than pharmacists (n = 6; 18.2%) or community health workers (n = 5; 15.2%). Across all studies, the most common role played by HRH in task shifting was for treatment and adherence (n = 28; 84.9%) followed by screening and detection (n = 24; 72.7%), education and counselling (n = 24; 72.7%), and triage (n = 13; 39.4%). Improved blood pressure levels were reported in 78.6%, 66.7%, and 80.0% for hypertension-related task shifting roles to nurses, pharmacists, and CHWs, respectively. Improved glycaemic indices were reported as 66.7%, 50.0%, and 66.7% for diabetes-related task shifting roles to nurses, pharmacists, and CHWs, respectively. CONCLUSION Despite the numerus HRH challenges that are present in Africa for CV and kidney health, this study suggests that task shifting initiatives can improve process of care measures (access and efficiency) as well as identification, awareness and treatment of CV and kidney disease in the region. The impact of task shifting on long-term outcomes of kidney and CV diseases and the sustainability of NCD programs based on task shifting remains to be determined.
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Affiliation(s)
- Ikechi G Okpechi
- Department of Medicine, University of Alberta, Edmonton, Canada.
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa.
| | - Ijezie I Chukwuonye
- Department of Internal Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria
| | - Udeme Ekrikpo
- Division of Nephrology, University of Uyo, Akwa Ibo State, Uyo, Nigeria
| | - Jean Jacques Noubiap
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Yemi R Raji
- Department of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Yusuf Adeshina
- Division of Nephrology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
| | - Samuel Ajayi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Zunaid Barday
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Malini Chetty
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Bianca Davidson
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Emmanuel Effa
- Department of Medicine, University of Calabar, Calabar, Nigeria
- Department of Internal Medicine, Edward Francis Small Teaching Hospital, Banjul, The Gambia
| | - Stephen Fagbemi
- Department of Epidemiology, Ondo State Ministry of Health, Ondo, Nigeria
| | - Cindy George
- Non-Communicable Disease Research Unit, South Africa Medical Research Council, Cape Town, South Africa
| | - Andre P Kengne
- Non-Communicable Disease Research Unit, South Africa Medical Research Council, Cape Town, South Africa
| | - Erika S W Jones
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Hamidu Liman
- Division of Nephrology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
| | - Mohammad Makusidi
- Division of Nephrology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
| | - Hadiza Muhammad
- Division of Nephrology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
| | - Ikechukwu Mbah
- Dept of Medicine College of Med and Health Sciences, Bingham University, Jos, Nigeria
| | - Kwazi Ndlovu
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | | | - Chimezie Okwuonu
- Department of Internal Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria
| | | | - Elliot K Tannor
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Ifeoma Ulasi
- Department of Medicine, University of Nigeria, Ituku Ozalla, Enugu State, Nigeria
| | - Zulkifilu Umar
- Department of Epidemiology, Ondo State Ministry of Health, Ondo, Nigeria
| | - Nicola Wearne
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Edmonton, Canada
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Beichler H, Grabovac I, Dorner TE. Integrated Care as a Model for Interprofessional Disease Management and the Benefits for People Living with HIV/AIDS. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3374. [PMID: 36834069 PMCID: PMC9965658 DOI: 10.3390/ijerph20043374] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Today, antiretroviral therapy (ART) is effectively used as a lifelong therapy to treat people living with HIV (PLWH) to suppress viral replication. Moreover, PLWH need an adequate care strategy in an interprofessional, networked setting of health care professionals from different disciplines. HIV/AIDS poses challenges to both patients and health care professionals within the framework of care due to frequent visits to physicians, avoidable hospitalizations, comorbidities, complications, and the resulting polypharmacy. The concepts of integrated care (IC) represent sustainable approaches to solving the complex care situation of PLWH. AIMS This study aimed to describe the national and international models of integrated care and their benefits regarding PLWH as complex, chronically ill patients in the health care system. METHODS We conducted a narrative review of the current national and international innovative models and approaches to integrated care for people with HIV/AIDS. The literature search covered the period between March and November 2022 and was conducted in the databases Cinahl, Cochrane, and Pubmed. Quantitative and qualitative studies, meta-analyses, and reviews were included. RESULTS The main findings are the benefits of integrated care (IC) as an interconnected, guideline- and pathway-based multiprofessional, multidisciplinary, patient-centered treatment for PLWH with complex chronic HIV/AIDS. This includes the evidence-based continuity of care with decreased hospitalization, reductions in costly and burdensome duplicate testing, and the saving of overall health care costs. Furthermore, it includes motivation for adherence, the prevention of HIV transmission through unrestricted access to ART, the reduction and timely treatment of comorbidities, the reduction of multimorbidity and polypharmacy, palliative care, and the treatment of chronic pain. IC is initiated, implemented, and financed by health policy in the form of integrated health care, managed care, case and care management, primary care, and general practitioner-centered concepts for the care of PLWH. Integrated care was originally founded in the United States of America. The complexity of HIV/AIDS intensifies as the disease progresses. CONCLUSIONS Integrated care focuses on the holistic view of PLWH, considering medical, nursing, psychosocial, and psychiatric needs, as well as the various interactions among them. A comprehensive expansion of integrated care in primary health care settings will not only relieve the burden on hospitals but also significantly improve the patient situation and the outcome of treatment.
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Affiliation(s)
- Helmut Beichler
- Nursing School, Vienna General Hospital, Medical University of Vienna, 1090 Vienna, Austria
| | - Igor Grabovac
- Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Thomas E. Dorner
- Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, 1090 Vienna, Austria
- Academy for Ageing Research, Haus der Barmherzigkeit, 1090 Vienna, Austria
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Akugizibwe M, Zalwango F, Namulundu CM, Namakoola I, Birungi J, Okebe J, Bachmann M, Jamie M, Jaffar S, Van Hout MC. "After all, we are all sick": multi-stakeholder understanding of stigma associated with integrated management of HIV, diabetes and hypertension at selected government clinics in Uganda. BMC Health Serv Res 2023; 23:20. [PMID: 36624438 PMCID: PMC9827009 DOI: 10.1186/s12913-022-08959-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 12/12/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Integrated care is increasingly used to manage chronic conditions. In Uganda, the integration of HIV, diabetes and hypertension care has been piloted, to leverage the advantages of well facilitated and established HIV health care provision structures. This qualitative study aimed to explore HIV stigma dynamics whilst investigating multi-stakeholder perceptions and experiences of providing and receiving integrated management of HIV, diabetes and hypertension at selected government clinics in Central Uganda. METHODS: We adopted a qualitative-observational design. Participants were purposively selected. In-depth interviews were conducted with patients and with health care providers, clinical researchers, policy makers, and representatives from international nongovernmental organizations (NGOs). Focus group discussions were conducted with community members and leaders. Clinical procedures in the integrated care clinic were observed. Data were managed using Nvivo 12 and analyzed thematically. RESULTS Triangulated findings revealed diverse multi-stakeholder perceptions around HIV related stigma. Integrated care reduced the frequency with which patients with combinations of HIV, diabetes, hypertension visited health facilities, reduced the associated treatment costs, increased interpersonal relationships among patients and healthcare providers, and increased the capacity of health care providers to manage multiple chronic conditions. Integration reduced stigma through creating opportunities for health education, which allayed patient fears and increased their resolve to enroll for and adhere to treatment. Patients also had an opportunity to offer and receive psycho-social support and coupled with the support they received from healthcare worker. This strengthened patient-patient and provider-patient relationships, which are building blocks of service integration and of HIV stigma reduction. Although the model significantly reduced stigma, it did not eradicate service level challenges and societal discrimination among HIV patients. CONCLUSION The study reveals that, in a low resource setting like Uganda, integration of HIV, diabetes and hypertension care can improve patient experiences of care for multiple chronic conditions, and that integrated clinics may reduce HIV related stigma.
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Affiliation(s)
| | | | | | - Ivan Namakoola
- MRC/UVRI and LSHTM, Uganda Research Unit, Entebbe, Uganda
| | | | - Joseph Okebe
- Liverpool School of Tropical Medicine, Liverpool, UK, England
| | | | | | - Shabbar Jaffar
- Liverpool School of Tropical Medicine, Liverpool, UK, England
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Sakita FM, Prattipati S, Chick J, Samu LP, Maro AV, Coaxum L, Galson SW, Samuel D, Limkakeng AT, O'Leary PR, Kilonzo KG, Thielman NM, Temu G, Hertz JT. Six-month blood pressure and glucose control among HIV-infected adults with elevated blood pressure and hyperglycemia in northern Tanzania: A prospective observational study. PLoS One 2023; 18:e0285472. [PMID: 37155672 PMCID: PMC10166506 DOI: 10.1371/journal.pone.0285472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 04/25/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND People with HIV in sub-Saharan Africa are increasingly developing age-related comorbidities. The purpose of this prospective observational study was to describe 6-month outcomes among Tanzanians with HIV and elevated blood pressure or hyperglycemia under current care pathways. METHODS Adults presenting for routine HIV care were enrolled and underwent blood pressure and blood glucose measurements. Participants with abnormal blood pressure or glucose were referred for further care, as per current guidelines. Participants' blood pressure and point-of-care glucose were re-evaluated during their 6-month follow-up visit. Elevated blood pressure was defined as systolic ≥140 mmHg or diastolic ≥90 mmHg. Hyperglycemia was defined as fasting glucose ≥126 mg/dl or random glucose ≥200 mg/dl. An electrocardiogram was obtained at enrollment and at follow-up. Interim myocardial infarction and interim myocardial ischemia were defined as new pathologic Q waves and new T-wave inversions, respectively. RESULTS Of 500 participants, 155 had elevated blood pressure and 17 had hyperglycemia at enrolment. At 6-month follow-up, 7 (4.6%) of 155 participants with elevated blood pressure reported current use of an anti-hypertensive medication, 100 (66.2%) had persistent elevated blood pressure, 12 (7.9%) developed interim myocardial infarction, and 13 (8.6%) developed interim myocardial ischemia. Among 17 participants with hyperglycemia, 9 (56%) had persistent hyperglycemia at 6 months and 2 (12.5%) reported current use of an anti-hyperglycemic medication. CONCLUSIONS Interventions are needed to improve non-communicable disease care pathways among Tanzanians with HIV.
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Affiliation(s)
- Francis M Sakita
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Sainikitha Prattipati
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Jordan Chick
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Linda P Samu
- Health Department, Moshi Municipal Council, Moshi, Tanzania
| | | | - Lauren Coaxum
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sophie W Galson
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | | | - Alexander T Limkakeng
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Paige R O'Leary
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Kajiru G Kilonzo
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Nathan M Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Gloria Temu
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
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Van Hout MCA, Zalwango F, Akugizibwe M, Namulundu Chaka M, Bigland C, Birungi J, Jaffar S, Bachmann M, Murdoch J. Women living with HIV, diabetes and/or hypertension multi-morbidity in Uganda: a qualitative exploration of experiences accessing an integrated care service. JOURNAL OF INTEGRATED CARE 2022. [DOI: 10.1108/jica-06-2022-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
PurposeWomen experience a triple burden of ill-health spanning non-communicable diseases (NCDs), reproductive and maternal health conditions and human immunodeficiency virus (HIV) in sub-Saharan Africa. Whilst there is research on integrated service experiences of women living with HIV (WLHIV) and cancer, little is known regarding those of WLHIV, diabetes and/or hypertension when accessing integrated care. Our research responds to this gap.Design/methodology/approachThe INTE-AFRICA project conducted a pragmatic parallel arm cluster randomised trial to scale up and evaluate “one-stop” integrated care clinics for HIV-infection, diabetes and hypertension at selected primary care centres in Uganda. A qualitative process evaluation explored and documented patient experiences of integrated care for HIV, diabetes and/or hypertension. In-depth interviews were conducted using a phenomenological approach with six WLHIV with diabetes and/or hypertension accessing a “one stop” clinic. Thematic analysis of narratives revealed five themes: lay health knowledge and alternative medicine, community stigma, experiences of integrated care, navigating personal challenges and health service constraints.FindingsWLHIV described patient pathways navigating HIV and diabetes/hypertension, with caregiving responsibilities, poverty, travel time and cost and personal ill health impacting on their ability to adhere to multi-morbid integrated treatment. Health service barriers to optimal integrated care included unreliable drug supply for diabetes/hypertension and HIV linked stigma. Comprehensive integrated care is recommended to further consider gender sensitive aspects of care.Originality/valueThis study whilst small scale, provides a unique insight into the lived experience of WLHIV navigating care for HIV and diabetes and/or hypertension, and how a “one stop” integrated care clinic can support them (and their children) in their treatment journeys.
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