Integration of HIV and noncommunicable diseases in health care delivery in low- and middle-income countries

A need to integrate healthcare services for HIV and non-communicable diseases: An Indian perspective

With the decline in HIV mortality, a concomitant increase in morbidity and death not directly related to HIV has been witnessed. Consequently, many countries especially low- and middle-income countries (LMICs) are now facing the dual burden of HIV and non-communicable diseases (NCDs). 2.3 million people living with HIV in India are at a higher risk of developing NCDs due to ageing, which can be attributed to the additional impact of long-standing HIV infection and the side-effects of antiretroviral therapy. This has led to a rise in demand for a combined health system response for managing HIV infection and co-existing NCDs, especially in LMICs such as India. The health and wellness centres (HWCs) envisioned to provide an expanded range of preventive and curative services including that for chronic conditions may act as a window of opportunity for providing egalitarian and accessible primary care services to these individuals. The reasons for integrating HIV and NCD care are epidemiological overlap between these conditions and the similar strategies required for provision of healthcare services.

Prevalence of hypertension and diabetes and associated risk factors among people living with human immunodeficiency virus in Southern Ethiopia

Background

Access to antiretroviral therapy (ART) allows people living with HIV (PLWH) to live longer. Consequently, non communicable diseases (NCD) have emerged as the main drivers of ill health, disability, and premature death. This study assessed the magnitude of hypertension and diabetes and risk factors among PLWH receiving ART in Ethiopia.

Methods

A cross-sectional study was conducted using an analytical component. Data were collected through face-to-face interviews, physical measurements, and chart reviews of the 520 adults. Associations between the demographic and clinical attributes of hypertension and diabetes were assessed using logistic regression models.

Results

Prevalence of hypertension was (18.5%) (95% CI: 15.2%-21.7%), and diabetes was (6.9%) (95% CI: 4.8%-9.2%). More than two-thirds (70.8%) and 61% were newly diagnosed with hypertension and diabetes, respectively. Age > = 45 years [adjusted odds ratio (AOR) = 2.47], alcohol consumption (AOR = 4.51), Insufficient physical activity (AOR = 3.7), BMI ≥25 (AOR = 3.95), family history of hypertension (AOR = 7.1), and diabetes (AOR = 4.95) were associated with hypertension. Age ≥45 years [adjusted odds ratio (AOR) = 2.47], BMI ≥25 (AOR = 1.91), Central obesity (AOR = 3.27), detectable viral load (AOR = 4.2), hypertension (AOR = 4.95) and duration of ART >10 years (AOR = 3.12) were associated with diabetes.

Conclusions

A combination of modifiable and nonmodifiable factors increased the risk of hypertension and diabetes. Primary prevention strategies, regular screening for hypertension and diabetes and integration with HIV care in primary health care are the recommended intervention measures.

Barriers to early diagnosis of cervical cancer: a mixed-method study in Côte d'Ivoire, West Africa

BACKGROUND

Cervical cancer, a major public health problem in many developing countries, is usually associated with a poor survival related to an advanced disease at diagnosis. In Côte d'Ivoire and other developing countries with high cervical cancer prevalence, little is known about factors associated with advanced cervical cancer stages in a context of limited access to screening services.

METHODS

From May to July 2019, we conducted a cross-sectional study using a mixed, quantitative and qualitative method. Information on socio-demographic and history of the disease was extracted from a rapid case ascertainement study performed by the cancer registry of Côte d'Ivoire that enrolled all women diagnosed with cervical cancer between July 2018 and June 2019. In-depth semi-structured interviews were conducted among a subset of these women (12 women) and six healthcare providers to further capture barriers to early cervical cancer diagnosis. Factors associated with an advanced stage III, IV (according to FIGO classification) were estimated by a logistic regression model. Qualitative data were analyzed using a thematic analysis technique guided by the treatment pathway model and triangulated with quantitative data.

RESULTS

In total, 95 women with cervical cancer [median age = 51 (IQR 42-59)] years, were included. Among them, 18.9% were living with HIV and only 9.5% were covered by a health insurance. The majority (71.5%) were diagnosed with advanced cervical cancer. Being HIV-uninfected (aOR = 5.4; [1.6-17.8], p = 0.006) and being uninsured (aOR = 13.1; [2.0-85.5], p = 0.007) were independently associated with advanced cervical cancer in multivariable analysis. Qualitative data raised additional factors potentially related to advanced cervical cancer stages at diagnosis, including the lack of patient information on cervical cancer by healthcare providers and inadequate national awareness and screening campaigns.

CONCLUSION

In a context of challenges in access to systematic cervical cancer screening in Côte d'Ivoire, access to health insurance or integrated healthcare program appear to be key determinants of early diagnosis of cervical cancer.

Implementing screening for hypertension in archetypal HIV primary care: a mixed-methods assessment

BACKGROUND

High prevalence of HIV and hypertension in sub-Saharan Africa puts adults living with HIV (ALWH) at high risk of end-organ complications. Both World Health Organization (WHO) and national guidelines recommend screening and treatment of hypertension among ALWH on antiretroviral therapy (ART). We evaluated the implementation of hypertension screening among adults on ART at three Uganda Cares Primary care facilities.

METHODS

Using a sequential explanatory mixed-methods approach, we reviewed patient records, and interviewed both patients and providers during 2018 and 2019. We obtained demographics, clinical and blood pressure (BP) measurements via records review. We estimate the period prevalence of screening and use adjusted modified Poisson regression models to evaluate predictors of screening. In-depth interviews were analysed using a thematic approach to explain the observed prevalence and predictors of BP screening.

RESULTS

Records for 1426 ALWH were reviewed. Patients had a median age of 35 years and 65% of them were female. Most were on ART (89% on first-line) with a median duration of 4 years. Only 262 (18%) were overweight or obese with a body mass index (BMI) > 25 Kg/M². In 2017 or 2018 patients made a median of 3 visits and 783 patients had a BP recorded, hence a period prevalence 55%. Older age, male sex, more clinic visits, and clinic site were associated with screening in the adjusted analyses. Erratic BP screening was corroborated by patients' and providers' interviews. Challenges included; high patient numbers, low staffing, provider apathy, no access to treatment, and lack of functioning of BP equipment.

CONCLUSION

Almost half of regular HIV clinic attendees at these prototypical primary care HIV clinics were not screened for hypertension for a whole year. Improving BP screening requires attention to address modifiable challenges and ensure local buy-in beyond just providing equipment.

Prevalence of diabetes mellitus and hypertension amongst the HIV-positive population at a district hospital in eThekwini, South Africa

Background

Life expectancies of HIV-positive patients have been increasing with the rapid implementation of antiretroviral therapy (ART). This has led to an increase in comorbidities such as diabetes mellitus (DM) and hypertension (HT) amongst the HIV population. The burden of the non-communicable diseases (NCDs) such as DM and HT need to be quantified in order to ensure that patients receive optimal integrated care as patients often access care at different clinics compromising holistic care.

Aim

The aim of the study was to determine the prevalence of DM and HT amongst the HIV-positive population.

Setting

The study was conducted at Wentworth Hospital, a district facility in South Durban, KwaZulu-Natal.

Methods

This cross-sectional study was undertaken to determine the prevalence of two NCDs, namely DM and HT in HIV-positive patients attending the ART clinic at a district hospital in the eThekwini district. We compared the socio-demographic and clinical profiles of those with and without comorbidities. A sample of 301 HIV-positive patients were administered a structured questionnaire.

Results

Of the 301 patients, 230 (76.41%) had HIV only (95% confidence interval [CI]: 71.25–80.89) and 71 (23.59%) had HIV and at least one comorbidity, namely DM and/or HT (95% CI: 19.11-28.75). Hypertension was the most prevalent comorbidity. This study revealed that there was no association between the duration of ART and comorbidities. Older age and body mass index (BMI) were associated with comorbidities, whilst gender and ethnicity were not associated.

Conclusion

Non-communicable diseases such as DM and HT do pose a burden for HIV-positive patients attending the ARV clinic at this district facility. This study highlights the definite need to plan for the increased burden of NCDs as HIV-positive patients live longer and gain weight.

Scale-up integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium (SCUBY): a study design for a quasi-experimental multiple case study

Health systems worldwide struggle to manage the growing burden of type 2 diabetes and hypertension. Many patients receive suboptimal care, especially those most vulnerable. An evidence-based Integrated Care Package (ICP) with primary care-based diagnosis, treatment, education and self-management support and collaboration, leads to better health outcomes, but there is little knowledge of how to scale-up. The Scale-up integrated care for diabetes and hypertension project (SCUBY) aims to address this problem by roadmaps for scaling-up ICP in different types of health systems: a developing health system in a lower middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly funded highly privatised health-care health system in a high-income country (Belgium). In a quasi-experimental multi-case design, country-specific scale-up strategies are developed, implemented and evaluated. A three-dimensional framework assesses scale-up along three axes: (1) increase in population coverage; (2) expansion of the ICP package; and (3) integration into the health system. The study includes a formative, intervention and evaluation phase. The intervention entails the development and implementation of an improved scale-up strategy through a roadmap with a minimum dataset to monitor proximal and distal outcomes. The SCUBY project is expected to result in three different roadmaps, tailored to the specific health system and country context, to progress scale-up of the ICP along three dimensions. These roadmaps can be adapted to other health systems with similar typology. Implementation is expected to increase the number of well-controlled patients with type 2 diabetes and hypertension in Cambodia, to reduce inequities in care and increase patient empowerment in Belgium and Slovenia.

HIV-related cardiovascular diseases: the search for a unifying hypothesis

Although the extensive rollout of antiretroviral (ARV) therapy resulted in a longer life expectancy for people living with human immunodeficiency virus (PLHIV), such individuals display a relatively increased occurrence of cardiovascular diseases (CVD). This health challenge stimulated significant research interests in the field, leading to an improved understanding of both lifestyle-related risk factors and the underlying mechanisms of CVD onset in PLHIV. However, despite such progress, the precise role of various risk factors and mechanisms underlying the development of HIV-mediated CVD still remains relatively poorly understood. Therefore, we review CVD onset in PLHIV and focus on 1) the spectrum of cardiovascular complications that typically manifest in such persons and 2) underlying mechanisms that are implicated in this process. Here, the contributions of such factors and modulators and underlying mechanisms are considered in a holistic and integrative manner to generate a unifying hypothesis that includes identification of the core pathways mediating CVD onset. The review focuses on the sub-Saharan African context, as there are relatively high numbers of PLHIV residing within this region, indicating that the greater CVD risk will increasingly threaten the well-being and health of its citizens. It is our opinion that such an approach helps point the way for future research efforts to improve treatment strategies and/or lifestyle-related modifications for PLHIV.

The prevalence of selected non-communicable disease risk factors among HIV patients on anti-retroviral therapy in Bushbuckridge sub-district, Mpumalanga province

Background

The rates of non-communicable diseases (NCD’s) appear to be increasing in human immunodeficiency virus (HIV) infected people as compared to non-HIV infected people and this will have major implications for clinical care. The aim of the current study was to profile selected cardiovascular disease risk factors among HIV patients on anti-retroviral therapy (ART) in Bushbuckridge sub-district.

Methods

The current study followed a quantitative cross-sectional study design using a questionnaire which was adapted from World Health Organization STEPwise approach to Surveillance (WHO STEPS). Participants were HIV infected people on ART and data was entered into a computer software Microsoft excel, then imported to Stata 12 for analysis.

Discussion

The overall prevalence of overweight at the initiation of ART amongst the participants was 18.1% and obesity was 11.5% as compared to the time of the study which was 21.4% overweight and 19.6% obese. The average time of ART initiation to study period was 3.6 years. The study findings revealed a significant difference (p-value 0.006) between the baseline and current body mass index at time of study for females. Hypertension was found to be having a significant difference (p-value 0.026 and 0.038) between the baseline and current body mass index at time of study for males and females respectively. The overall prevalence of hypertension was found to be 34.6%, overweight was 21.4% obesity was 19.6%.

The overall prevalence of abnormal waist circumference was 31.9% and females had a higher prevalence of 42.5% as compared to 4.4% of males. The overall prevalence of smoking 10.8% and alcohol consumption was 21.7%. Males were 22.5 times more likely to be smokers than females (p < 0.001) and older people were found to be 0.3 times less likely to consume alcohol as compared to young people.

Conclusions

The high levels of selected risk factors for NCDs among adults on ART in the current study area suggest an urgent need for health interventions to control risk factors in an era of HIV with an aim of reducing multiple morbidity of chronic diseases. Occurrence of NCDs and their risk factors with an aim to achieve positive effects of the long-term ART.

Chronic Diseases Multimorbidity among Adult People Living with HIV at Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia

Background

Due to the wide implementation of antiretroviral therapy (ART), people living with HIV (PLWHIV) are now living longer. This increased the risk of developing noncommunicable chronic diseases (NCCDs) among them.

Objective

We aimed to describe prevalence of NCCDs multimorbidity among PLWHIV at Hawassa University Comprehensive Specialized Hospital (HUCSH).

Method

In April 2016, institution-based cross-sectional study was conducted among PLWHIV, aged ≥ 18 years at the ART unit of HUCSH. A nurse working in the ART unit interviewed patients and reviewed medical records. Data on the NCCDs and its risk factors were obtained. List of diseases considered in this study were arthritis, diabetes mellitus, hypertension, congestive heart failure (CHF), rheumatic heart diseases (RHD), chronic bronchitis, asthma, and cancer.

Results

More than half of the respondents (196) had at least one of the NCCDs and 34 (8.9%) had multimorbidity. The main system of the body affected were the musculoskeletal system, 146 (38.2%) and respiratory system, 46 (12.0%). There was no significant difference in the prevalence of individual NCCDs by gender. Patients aged above 44 years, patients with ART duration of at least 6 years, and patients with higher CD4 counts had increased odds of having any one of the NCCDs. Multimorbidity patients with a longer ART duration had an increased risk.

Conclusion

The prevalence of NCCD multimorbidity among PLWHIV was high. Monitoring the occurrence of NCCDs among PLWHIV and noncommunicable disease care is recommended.

Diabetes mellitus and its associated risk factors in patients with human immunodeficiency virus on anti-retroviral therapy at referral hospitals of Northwest Ethiopia

BACKGROUND

The use of highly active anti- retroviral therapy (HAART) as well as human immunodeficiency virus (HIV) per se have been shown to be related with diabetes among patients living with HIV. There is limited evidence on the prevalence of diabetes among HIV-infected patients in developing countries like Ethiopia. Therefore, the aim of this study is to determine the prevalence of diabetes among patients living with HIV/AIDS at referral hospitals of Northwest Ethiopia.

MATERIALS AND METHODS

a hospital based cross-sectional study was conducted at referral hospitals of Northwest Ethiopia between February 2019 and April 2019. Using WHO stepwise approach, sociodemographic, behavioral and clinical data were collected from 407 included adult patients. Simple random sampling methods was used to select the study participants. Lipid profiles, fasting blood sugar as well as anthropometric indicators were also measured. SPSS version 25 was used for analysis of data; bivariate and multivariate binary logistic regression analysis was performed.

RESULT

From a total of 415 patients living with HIV deemed eligible for inclusion, 407 with complete data were included in the final analysis giving a response rate of 98%. From 407 study subjects included in the analysis, 161 (39.6%) were men. The prevalence of diabetes mellitus was found to be 8.8% (95% CI 6.05, 11.55). Multivariate logistic regression analysis revealed that age [AOR (95% CI) 1.04 (1.001,1.084), p < 0.05], educational status [AOR (95% CI) 6.27 (1.72, 22.85), p < 0.05, diploma; AOR (95% CI) 9.64 (2.57, 36.12), p < 0.05, degree and above], triglyceride level [AOR (95% CI) 1.007 (1.003, 1.010), p < 0.01] have shown statistically significant association with odds of diabetes mellitus.

CONCLUSION

The prevalence of diabetes was notably high in patients living with HIV/AIDS. Factors such as increased age, educational status and higher level of serum triglyceride were found to contribute to this high prevalence of diabetes.

HIV, antiretroviral therapy and non-communicable diseases in sub-Saharan Africa: empirical evidence from 44 countries over the period 2000 to 2016

INTRODUCTION

The HIV-infected population is growing due to the increased accessibility of antiretroviral therapy (ART) that extends the lifespan of people living with HIV (PLHIV). We aimed to assess whether national HIV prevalence and ART use are associated with an increased prevalence of cardiovascular risk factors.

METHODS

Using country-level data, we analysed the effect of HIV prevalence and use of ART on cardiovascular risk factors in 44 countries in sub-Saharan Africa between 2000 and 2016. We used fixed-effects estimation to quantify the effect of HIV and ART on the prevalence of diabetes, mean body mass index, the prevalence of overweight, obesity and hypertension, and mean systolic blood pressure. The models were adjusted for calendar time, the age structure of the population, income and education.

RESULTS

Diabetes prevalence among PLHIV was 5.8 percentage points higher (95% confidence interval (CI) 1.8 pp to 9.8 pp) compared to individuals without HIV. People receiving ART had a 4.6 percentage point higher prevalence (95% CI 2.6 pp to 6.6 pp). The prevalence of obesity was increased by 14.7 percentage points (95% CI 2.5 pp to 26.9 pp) for PLHIV. Receiving ART was associated with an increased obesity prevalence by 14.0 percentage points (95% CI 4.8 pp to 23.2 pp), whereas it had no significant association with the prevalence of overweight. The population aged 40 to 59 had a significantly higher prevalence of diabetes, overweight and obesity. HIV prevalence and ART use had no significant association with the prevalence of hypertension.

CONCLUSIONS

An ageing HIV-infected population on ART is associated with a significant increase in the prevalence of diabetes and obesity in sub-Saharan Africa. The increasing prevalence of these cardiovascular risk factors emphasizes the need for comprehensive healthcare programmes that screen and treat both HIV and non-communicable diseases to decrease the associated morbidity and mortality rates.

Operationalization of bi-directional screening for tuberculosis and diabetes in private sector healthcare clinics in Karachi, Pakistan

BACKGROUND

Many countries are facing overlapping epidemics of tuberculosis (TB) and diabetes mellitus (DM). Diabetes increases the overall risk of developing Tuberculosis (TB) and contributes to adverse treatment outcomes. Active screening for both diseases can reduce TB transmission and prevent the development of complications of DM. We investigated bi-directional TB-DM screening in Karachi, Pakistan, a country that ranks fifth among high TB burden countries, and has the seventh highest country burden for DM.

METHODS

Between February to November 2014, community-based screeners identified presumptive TB and DM through verbal screening at private health clinics. Individuals with presumptive TB were referred for a chest X-ray and Xpert MTB/RIF. Presumptive DM cases had random blood glucose (RBS) tested. All individuals with bacteriologically positive TB were referred for diabetes testing (RBS). All pre-diabetics and diabetics were referred for a chest X-ray and Xpert MTB/RIF test. The primary outcomes of this study were uptake of TB and DM testing.

RESULTS

A total of 450,385 individuals were screened, of whom 18,109 had presumptive DM and 90,137 had presumptive TB. 14,550 of these individuals were presumptive for both DM and TB. The uptake of DM testing among those with presumptive diabetes was 26.1% while the uptake of TB testing among presumptive TB cases was 5.9%. Despite efforts to promote bi-directional screening of TB and DM, the uptake of TB testing among pre-diabetes and diabetes cases was only 4.7%, while the uptake of DM testing among MTB positive cases was 21.8%.

CONCLUSION

While a high yield for TB was identified among pre-diabetics and diabetics along with a high yield of DM among individuals diagnosed with TB, there was a low uptake of TB testing amongst presumptive TB patients who were recorded as pre-diabetic or diabetic. Bi-directional screening for TB and DM which includes the integration of TB diagnostics, DM screening and TB-DM treatment within existing health care programs will need to address the operational challenges identified before implementing this as a strategy in public health programs.

Integrating hypertension screening at the time of voluntary HIV testing among adults in South Africa

BACKGROUND

Guidelines recommend integrating hypertension screening for HIV-infected adults, but blood pressure measurements may be dynamic around the time of HIV testing.

METHODS

We measured a seated resting blood pressure in adults (≥18 years) prior to HIV testing, and again after receiving HIV test results, in an ambulatory HIV clinic in KwaZulu-Natal, South Africa. We assessed sociodemographics, smoking, body mass index, diabetes, substance abuse, and anxiety/depression. We used blood pressure categories defined by the Seventh Joint National Committee (JNC 7) classifications, which includes normal, pre-hypertension, stage 1 hypertension, and stage 2 hypertension.

RESULTS

Among 5,428 adults, mean age was 31 years, 51% were male, and 35% tested HIV-positive. Before HIV testing, 47% (2,634) had a normal blood pressure, 40% (2,225) had prehypertension, and 10% (569) had stage 1 or 2 hypertension. HIV-infected adults had significantly lower blood pressure measurements and less hypertension, as compared to HIV-negative adults before HIV testing; while also having significantly elevated blood pressures after HIV testing. In a multivariable model, HIV-infected adults had a 30% lower odds of hypertension, compared to HIV-uninfected adults (aOR = 0.70, 95% CI: 0.57-0.85). In a separate multivariable model, HIV-infected adults with CD4 ≤200 cells/mm3 had a 44% lower odds of hypertension (aOR = 0.56, 95% CI: 0.38-0.83), as compared to adults with CD4 >200 cells/mm3. The mean arterial blood pressure was 6.5 mmHg higher among HIV-infected adults after HIV testing (p <0.001).

CONCLUSIONS

HIV-infected adults experienced a transient blood pressure increase after receiving HIV results. Blood pressure measurements may be more accurate before HIV testing and repeated blood pressure measurements are recommended after ART initiation before formally diagnosing hypertension in HIV-infected adults.

The use of home-based HIV testing and counseling in low-and-middle income countries: a scoping review

BACKGROUND

Knowledge of HIV status is crucial for both prevention and treatment of HIV infection. However, according to the Joint United Nations Programme on HIV/AIDS in low-and-middle-income countries (LMICs), only 10% of the population has access to HIV testing services. Home-based HIV testing and counseling (HTC) is one of the approaches which have been shown to be effective in improving access to HIV testing in LMICs. The objective of this review was to map evidence on the use of home-based HTC in LMICs.

METHODS

We searched PubMed, EBSCOhost, Google Scholar, Science Direct, World Health Organization library database and UNAIDS databases from January 2013 to October 2017. Eligibility criteria included articles pertaining to the use of home-based HTC in LMICs. Two reviewers independently reviewed the articles for eligibility. The following themes were extracted from the included studies: use, feasibility and effectiveness of home-based HTC on patient-centered outcomes in LMICs. The risk of bias for the included studies was assessed using mixed methods appraisal tool -version 2011.

RESULTS

A total of 855,117 articles were identified from all the databases searched. Of this, only 17 studies met the inclusion criteria after full article screening and were included for data extraction. All included studies presented evidence on the use of Home-based HTC by most age groups (18 months to 70 years) comprising of both males and females. The included studies were conducted in the following countries: Zambia, Uganda, South Africa, Kenya, Ethiopia, Malawi, Swaziland, Pakistan, and Botswana. This study demonstrated that home-based HTC was used in LMICs alongside supervised HTC intervention using different types of HTC tests kits produced by different manufacturers. This study also showed that home-based HTC was feasible, highly effective, and increased uptake of HIV testing and counseling. This study further demonstrated a highly successful usage of supervised home-based HTC by most age groups in LMICs, with majority of users being females (89.1%).

CONCLUSION

We therefore recommend primary studies in other LMICs to determine the feasibility and use of HTC to help achieve the UNAIDS 90:90:90 targets. Interventions to improve the use of home-based HTC by males are also recommended.

TRIAL REGISTRATION

PROSPERO registration number: CRD42017056478.

Comparative Assessment of the Magnitude of Hyperlipidemia in HIV-Infected Patients Receiving Lopinavir/r- and Atazanavir/r-Based Antiretroviral Drugs

OBJECTIVE

To assess prevalence of hyperlipidemia in patients receiving lopinavir boosted with ritonavir (LPV/r) and atazanavir boosted with ritonavir (ATV/r) antiretroviral drugs.

METHODS

HIV-infected patients (300) were recruited in the study between December 2015 and April 2016. Lipid profile including triglycerides (TG), high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol (LDL-C) were assessed.

RESULTS

Prevalence of derangement in TG was 71.0% in patients using LPV/r compared to 44% in those using ATV/r ( P = .01). Use of LPV/r was independently associated with increased total cholesterol (TC; P = .001) and TG ( P = .0003). Females had raised levels of TC compared to males ( P = .00008). Body mass index of ≥ 25 kg/m2 was also associated with raised TC ( P = .002) and LDL-C ( P = .006).

CONCLUSION

LPV/r was significantly associated with lipid derangements, indicating the need to regularly monitor lipid profile in patients using LPV/r.

Approaches to Improve the Surveillance, Monitoring, and Management of Noncommunicable Diseases in HIV-Infected Persons: Viewpoint

Low-income and middle-income countries (LMICs) are undergoing an epidemiological transition, in which the burden of noncommunicable diseases (NCDs) is rising and mortality will shift from infectious diseases to NCDs. Specifically, cardiovascular disease, diabetes, renal diseases, chronic respiratory diseases, and cancer are becoming more prevalent. In some regions, particularly sub-Saharan Africa, the dual HIV and NCD epidemics will pose challenges because their joint burden will have adverse effects on the quality of life and will likely increase global inequities. Given the austere clinical infrastructure in many LMICs, innovative models of care delivery are needed to provide comprehensive care in resource-limited settings. Improved data collection and surveillance of NCDs among HIV-infected persons in LMICs are necessary to inform integrated NCD-HIV prevention, care, and treatment models that are effective across a range of geographic settings. These efforts will preserve the considerable investments that have been made to prevent the number of lives lost to HIV, promote healthy aging of persons living with HIV, and contribute to meeting United Nations Sustainable Development Goals.

Integrated models of care for diabetes and hypertension in low- and middle-income countries (LMICs) : Protocol for a systematic review

BACKGROUND

In low- and middle-income countries (LMICs), the burden of non-communicable diseases (NCDs) is growing against an existing burden of other diseases such as HIV/AIDS. Integrated models of care can help address the rising burden of multi-morbidity. Although integration of care can occur at various levels and has been defined in numerous ways, our aim is to assess the effects of integration of service delivery at primary healthcare level in LMICs.

METHODS

We will consider randomised controlled trials (RCTs), cluster RCTs, non-randomised trials, controlled before-after studies and interrupted time series that examine integrated models of care among people with multi-morbidities, of which diabetes or hypertension is one, living in LMICs. We will compare fully integrated models of care to stand-alone care, partially integrated models of care to stand-alone care and fully integrated models to partially integrated models of care. Primary outcomes include all-cause mortality, disease-specific morbidity, HbA1c, systolic blood pressure and cholesterol levels. Secondary outcomes include access to care, retention in care, adherence, continuity of care, quality of care and cost of care. We will conduct a comprehensive search in the following databases: MEDLINE, EMBASE, the Cochrane Central Register of Control Trials, LILACS, Africa-Wide Information, CINAHL and Web of Science. In addition, we will search trial registries, relevant conference abstracts and check references lists of included studies. Selection of studies, data extraction and assessment of risk of bias will be performed independently by two review authors. We will resolve discrepancies through discussion with a third author. We will contact study authors in case of missing data. If included studies are sufficiently homogenous, we will pool results in a meta-analysis. Clinical heterogeneity related to the population, intervention, outcomes and context will be documented in table format and explored through subgroup analysis. We will assess χ 2 and I 2 tests for statistical heterogeneity. We will use GRADE to make judgements about the certainty of evidence and present findings in a summary of findings table.

DISCUSSION

In light of limited evidence on the provision of comprehensive care for diabetes and hypertension, and its comorbidity in LMCIs, we believe that the findings of this systematic review will provide a synthesis of evidence on effective models of integrated care for diabetes and hypertension and their comorbidities at primary healthcare level. This will enable policy-makers to device policies and programs that are evidence informed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018099314 .

Magnitude and associated factors of diabetes mellitus and hypertension among adult HIV-positive individuals receiving highly active antiretroviral therapy at Jugal Hospital, Harar, Ethiopia

BACKGROUND

People with HIV infection are at increased risk of noncommunicable diseases (NCDs). Diabetes mellitus (DM) and hypertension are recognized as the major NCDs. Except few findings in general population, there is no well-documented evidence on the magnitude of NCDs and associated factors among HIV-positive patients.

PURPOSE

The aim of this study was to determine the magnitude and associated factors of DM and hypertension among adult HIV-positive subjects receiving highly active antiretroviral therapy (HAART).

METHODS

A hospital-based cross-sectional study was conducted from February to April at Jugal Hospital, Harar, Eastern Ethiopia. Sociodemographic and anthropometric data and blood pressure (BP) were collected by senior clinical nurses. A total of 5 mL of venous blood was collected. Serum glucose and lipid profile were measured using the Autolab 18 clinical chemistry analyzer. Data were analyzed using STATA version 13.

RESULTS

A total of 425 HIV-infected individuals taking HAART of age ranging from 18 to 68 years were included. The prevalence of DM and hypertension were 7.1% (95% CI: 4.9-9.9) and 12.7% (95% CI: 9.8-16.2), respectively. Increased blood triglyceride (adjusted odds ratio [AOR] =4.7, 95% CI: 1.7-13.1), high BP (AOR =3.3, 95% CI: 1.1-9.5), and high baseline body mass index (BMI) (AOR =8.7, 95% CI: 2.4-31.8) were significantly associated with DM. In contrast, raised waist-hip ratio (AOR =4.6, 95% CI: 1.6-13.3), raised blood glucose (AOR =3.5, 95% CI: 1.1-11.4), increased total cholesterol (AOR =3.9, 95% CI: 1.3-11.9), high current BMI (AOR =3.8, 95% CI: 1.5-9.6), drinking alcohol (AOR =3.4, 95% CI: 1.5-8.1), CD4 count <500 cell/mL (AOR =2.7, 95% CI: 1.3-5.6), and longer duration of HAART (AOR =2.3, 95% CI: 1.1-5.1) were significantly associated with hypertension.

CONCLUSION

DM and hypertension were frequent among HIV patients on HAART, and they were linked to the well-known risk factors. Therefore, regular screening and monitoring of DM and hypertension before and after the initiation of HAART is of paramount importance.

Satisfaction about Patient-centeredness and Healthcare System among Patients with Chronic Multimorbidity

The aim of the present study was to measure the prevalence of multimorbidity in Bangladesh, India and China, and to assess the relationship between multimorbidity and patient's opinion regarding their involvement in healthcare decision-making and overall satisfaction of healthcare system. Cross-sectional data on 18 696 men and women aged 18 and above were collected from the World Health Survey of World Health Organization (WHO). Outcome variables were subjective rating of (1) healthcare system's ability to involve patients in decision-making, and (2) satisfaction with the way healthcare system runs in the country. Self-reported chronic conditions were used to measure the prevalence of multimorbidity. Out of 9 chronic conditions, back pain, arthritis, and chronic cough appeared to be the most prevalent ones among majority of the participants. About one-third of the participants in China (30.7%) and two-thirds in Bangladesh (66.1%) and India (66.6%) reported having at least one chronic illness. Prevalence of multimorbidity was highest in India (34.3%) followed by Bangladesh (28.8%) and China (14.3%). In Bangladesh, India and China, respectively 70.5%, 41.7%, 61.3% women and 54.5%, 42.8% and 58.8 % men expressed dissatisfaction regarding the way healthcare system runs in their country. In Bangladesh and India, men who were living with multimorbidity were more likely to rate the patient-centeredness as "bad" than those who had no disease illness. This study suggests that the prevalence of multimorbidity was remarkably high especially in Bangladesh and India. Higher likelihood of dissatisfaction about healthcare system among multimorbid patients might be indicative of inadequacy in the provision of care in qualitative and quantitative terms.

Health systems facilitators and barriers to the integration of HIV and chronic disease services: a systematic review

Integration of services for patients with more than one diagnosed condition has intuitive appeal but it has been argued that the empirical evidence to support it is limited. We report the findings of a systematic review that sought to identify health system factors, extrinsic to the integration process, which either facilitated or hindered the integration of services for two common disorders, HIV and chronic non-communicable diseases. Findings were initially extracted and organized around a health system framework, followed by a thematic cross-cutting analysis and validation steps. Of the 150 articles included, 67% (n = 102) were from high-income countries. The articles explored integration with services for one or several chronic disorders, the most studied being alcohol or substance use disorders (47.7%), and mental health issues (29.5%). Four cross-cutting themes related to the health system were identified. The first and most common theme was the requirement for effective collaboration and coordination: formal and informal productive relationships throughout the system between providers and within teams, and between staff and patients. The second was the need for adequate and appropriately skilled and incentivized health workers-with the right expertise, training and operational support for the programme. The third was the need for supportive institutional structures and dedicated resources. The fourth was leadership in terms of political will, effective managerial oversight and organizational culture, indicating that actual implementation is as important as programme design. A fifth theme, outside the health system, but underpinning all aspects of the system operation, was that placing the patient at the centre of service delivery and responding holistically to their diverse needs. This was an important facilitator of integration. These findings confirm that integration processes in service delivery depend substantially for their success on characteristics of the health systems in which they are embedded.

Diabetes in sub-Saharan Africa - from policy to practice to progress: targeting the existing gaps for future care for diabetes

The global prevalence and impact of diabetes has increased dramatically, particularly in sub-Saharan Africa. This region faces unique challenges in combating the disease including lack of funding for noncommunicable diseases, lack of availability of studies and guidelines specific to the population, lack of availability of medications, differences in urban and rural patients, and inequity between public and private sector health care. Because of these challenges, diabetes has a greater impact on morbidity and mortality related to the disease in sub-Saharan Africa than any other region in the world. In order to address these unacceptably poor trends, contextualized strategies for the prevention, identification, management, and financing of diabetes care within this population must be developed. This narrative review provides insights into the policy landscape, epidemiology, pathophysiology, care protocols, medication availability, and health care systems to give readers a comprehensive summary of many factors in these domains as they pertain to diabetes in sub-Saharan Africa. In addition to providing a review of the current evidence available in these domains, potential solutions to address the major gaps in care will be proposed to reverse the negative trends seen with diabetes in sub-Saharan Africa.

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.

Clearing the smoke around the TB-HIV syndemic: smoking as a critical issue for TB and HIV treatment and care

The collision of the tuberculosis (TB) and human immunodeficiency virus (HIV) epidemics has been described as a 'syndemic' due to the synergistic impact on the burden of both diseases. This paper explains the urgent need for practitioners and policy makers to address a third epidemic that exacerbates TB, HIV and TB-HIV. Tobacco use is the leading cause of preventable death worldwide. Smoking is more prevalent among persons diagnosed with TB or HIV. Smoking is associated with tuberculous infection, TB disease and poorer anti-tuberculosis treatment outcomes. It is also associated with an increased risk of smoking-related diseases among people living with HIV, and smoking may also inhibit the effectiveness of life-saving ART. In this paper, we propose integrating into TB and HIV programmes evidence-based strategies from the 'MPOWER' package recommended by the World Health Organization's Framework Convention on Tobacco Control. Specific actions that can be readily incorporated into current practice are recommended to improve TB and HIV outcomes and care, and reduce the unnecessary burden of death and disease due to smoking.

Temporal trends in death causes in adults attending an urban HIV clinic in Uganda: a retrospective chart review

OBJECTIVE

To study temporal trends of mortality in HIV-infected adults who attended an HIV clinic in Kampala, Uganda, between 2002 and 2012.

DESIGN

Descriptive retrospective study.

METHODS

Two doctors independently reviewed the clinic database that contained information derived from the clinic files and assigned one or more causes of death to each patient >18 years of age with a known date of death. Four cause-of-death categories were defined: 'communicable conditions and AIDS-defining malignancies', 'chronic non-communicable conditions', 'other non-communicable conditions' and 'unknown'. Trends in cause-of-death categories over time were evaluated using multinomial logistic regression with year of death as an independent continuous variable.

RESULTS

1028 deaths were included; 38% of these individuals were on antiretroviral therapy (ART). The estimated mortality rate dropped from 21.86 deaths/100 person years of follow-up (PYFU) in 2002 to 1.75/100 PYFU in 2012. There was a significant change in causes of death over time (p<0.01). Between 2002 and 2012, the proportion of deaths due to 'communicable conditions and AIDS-defining malignancies' decreased from 84% (95% CI 74% to 90%) to 64% (95% CI 53% to 74%) and the proportion of deaths due to 'chronic non-communicable conditions', 'other non-communicable conditions' and a combination of 'communicable and non-communicable conditions' increased. Tuberculosis (TB) was the main cause of death (34%). Death from TB decreased over time, from 43% (95% CI 32% to 53%) in 2002 to a steady proportion of approximately 25% from 2006 onwards (p<0.01).

CONCLUSIONS

Mortality rate decreased over time. The proportion of deaths from communicable conditions and AIDS-defining malignancies decreased and from non-communicable diseases, both chronic and non-chronic, increased. Nevertheless, communicable conditions and AIDS-defining malignancies continued to cause the majority of deaths, with TB as the main cause. Ongoing monitoring of cause of death is warranted and strategies to decrease mortality from TB and other common opportunistic infections are essential.

Mobile phone text messaging interventions for HIV and other chronic diseases: an overview of systematic reviews and framework for evidence transfer

BACKGROUND

Strong international commitment and the widespread use of antiretroviral therapy have led to higher longevity for people living with human immune deficiency virus (HIV). Text messaging interventions have been shown to improve health outcomes in people living with HIV. The objectives of this overview were to: map the state of the evidence of text messaging interventions, identify knowledge gaps, and develop a framework for the transfer of evidence to other chronic diseases.

METHODS

We conducted a systematic review of systematic reviews on text messaging interventions to improve health or health related outcomes. We conducted a comprehensive search of PubMed, EMBASE (Exerpta Medica Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, Web of Science (WoS) and the Cochrane Library on the 17th April 2014. Screening, data extraction and assessment of methodological quality were done in duplicate. Our findings were used to develop a conceptual framework for transfer.

RESULTS

Our search identified 135 potential systematic reviews of which nine were included, reporting on 37 source studies, conducted in 19 different countries. Seven of nine (77.7%) of these reviews were high quality. There was some evidence for text messaging as a tool to improve adherence to antiretroviral therapy. Text messages also improved attendance at appointments and behaviour change outcomes. The findings were inconclusive for self-management of illness, treatment of tuberculosis and communicating results of medical investigations. The geographical distribution of text messaging research was limited to specific regions of the world. Prominent knowledge gaps included the absence of data on long term outcomes, patient satisfaction, and economic evaluations. The included reviews also identified methodological limitations in many of the primary studies.

CONCLUSIONS

Global evidence supports the use of text messaging as a tool to improve adherence to medication and attendance at scheduled appointments. Given the similarities between HIV and other chronic diseases (long-term medications, life-long care, strong link to behaviour and the need for home-based support) evidence from HIV may be transferred to these diseases using our proposed framework by integration of HIV and chronic disease services or direct transfer.

Magnitude and risk factors of non-communicable diseases among people living with HIV in Tanzania: a cross sectional study from Mbeya and Dar es Salaam regions

Background

HIV and Non communicable diseases (NCDs) are major problem of public health importance in developing countries. This study was conducted to explore and establish information on the magnitude, distribution of NCDs risk factors among people living with HIV (PLWHIV) which is scarce in Tanzania.

Method

A cross sectional study was conducted to PLWHIV from 12 care and treatment clinics in Dar es Salaam and Mbeya regions from October 2011 to February 2012. Data on demographic characteristics, NCD risk factors including behavioral, biochemical tests and physical measurements was collected from PLWHIV.

Results

Of 754 PLWHIV recruited, 671(89.0%) consented to participate in the study and 354/671(52.8%) were on antiretroviral therapy (ART). The following NCD risk factors: raised blood levels of low density lipoprotein (61.3% vs 38.7%, p < 0.001) total cholesterol (TC) (71.6% vs 28.4%, p < 0.001) and triglyceride (67.0% vs 33.0%, p = 0.001) as well as overweight/obesity (61.1% vs 38.9%, p = 0.010), abnormal waist circumference (61.7% vs 38.3%, p < 0.001) and being aged >40 years (63.3% vs 36.7%, p < 0.001) were more prevalent among PLWHIV on ART than ART naïve. The prevalence of Diabetes mellitus among PLWHIV was 4.2% and was slightly high among those ART naïve (4.7% vs 3.7%). The prevalence of hypertension was 26.2% and was high among those on ART (30.0% vs 21.9%, p = 0.010). Being aged >40 years (AOR = 2.52, 95% CI 1.37-4.63), abnormal waist circumference (AOR = 2.37 95% CI 1.13-5.00), overweight/obesity (AOR = 2.71, 95% CI 1.26-5.84) and male sex (AOR = 1.17, 1.02-4.20) were the predictors of hypertension among patients on ART while raised TC (AOR = 1.47 (1.01-2.21) and being aged >40 years (AOR = 3.42, 95% CI 2.06-5.70) were predictors for hypertension among ART naïve patients.

Conclusion

This study has revealed that the magnitude of NCD risk factors is significantly higher among PLWHIV on ART than those not on ART. Initiating and strengthening of interventions for minimizing preventable NCD risks should be considered when initiating ART among PLWHIV. Regular monitoring of NCD risk factors is of paramount importance among ART patients.

HIV, tuberculosis, and noncommunicable diseases: what is known about the costs, effects, and cost-effectiveness of integrated care?

Unprecedented investments in health systems in low- and middle-income countries (LMICs) have resulted in more than 8 million individuals on antiretroviral therapy. Such individuals experience dramatically increased survival but are increasingly at risk of developing common noncommunicable diseases (NCDs). Integrating clinical care for HIV, other infectious diseases, and NCDs could make health services more effective and provide greater value. Cost-effectiveness analysis is a method to evaluate the clinical benefits and costs associated with different health care interventions and offers guidance for prioritization of investments and scale-up, especially as resources are increasingly constrained. We first examine tuberculosis and HIV as 1 example of integrated care already successfully implemented in several LMICs; we then review the published literature regarding cervical cancer and depression as 2 examples of NCDs for which integrating care with HIV services could offer excellent value. Direct evidence of the benefits of integrated services generally remains scarce; however, data suggest that improved effectiveness and reduced costs may be attained by integrating additional services with existing HIV clinical care. Further investigation into clinical outcomes and costs of care for NCDs among people living with HIV in LMICs will help to prioritize specific health care services by contributing to an understanding of the affordability and implementation of an integrated approach.

Integration of non-communicable diseases in health care: tackling the double burden of disease in African settings

Sub-Saharan African countries now face the double burden of Non Communicable and Communicable Diseases. This situation represents a major threat to fragile health systems and emphasises the need for innovative integrative approaches to health care delivery. Health services need to be reorganised to address populations' needs holistically and effectively leverage resources in already resource-limited settings. Access and delivery of quality health care should be reinforced and implemented at primary health care level within the framework of health system strengthening. Competencies need to be developed around services provided rather than specific diseases. New models of integration within the health sector and other sectors should be explored and further evidence generated to inform policy and practice to combat the double burden.

Public policy, health system, and community actions against illness as platforms for response to NCDs in Tanzania: a narrative review

BACKGROUND

Most low- and middle- income countries are facing a rise of the burden of non-communicable diseases (NCDs) alongside the persistent burden of infectious diseases. This narrative review aims to provide an inventory of how the existing policy environment, health system, and communities are addressing the NCDs situation in Tanzania and identify gaps for advancing the NCD research and policy agenda.

METHODOLOGY

A literature search was performed on PubMed and Google scholar with full text retrieval from HINARI of English language articles published between 2000 and 2012. Documents were read to extract information on what Tanzanian actors were doing that contributed to NCDs prevention, treatment, and control, and a narration was written out of these. Reference lists of all retrieved articles were searched for additional relevant articles. Websites of organizations active in the field of NCDs including the Government of Tanzania and WHO were searched for reports and grey literature.

RESULTS

Lack of a specific and overarching NCD policy has slowed and fragmented the implementation of existing strategies to prevent and control NCDs and their determinants. The health system is not prepared to deal with the rising NCD burden although there are random initiatives to improve this situation. How the community is responding to these emerging conditions is still unknown, and the current health-seeking behavior and perceptions on the risk factors may not favor control of NCDs and their risk factors.

CONCLUSION AND RECOMMENDATION

There is limited information on the burden and determinants of NCDs to inform the design of an integrative and multisectorial policy. Evidence on effective interventions for NCD services in primary care levels and on community perceptions on NCDs and their care seeking is virtually absent. Research and public health interventions must be anchored in the policy, health system, and community platforms for a holistic response.

[Increasing participation of primary care in the management of people with human immunodeficiency virus: hospital care professionals express their views]

AIM

To determine the opinions of infectious diseases professionals on the possibilities of monitoring patients with HIV in Primary Care.

DESIGN

Qualitative study using in-depth interviews.

LOCATION

Infectious Diseases Unit in the University Hospital "Virgen de la Victoria" in Málaga.

PARTICIPANTS

Health professionals with more than one year experience working in infectious diseases. A total of 25 respondents: 5 doctors, 15 nurses and 5 nursing assistants.

METHOD

Convenience sample. Semi-structured interviews were used that were later transcribed verbatim. Content analysis was performed according to the Taylor and Bogdan approach with computer support. Validation of information was made through additional analysis, expert participation, and feedback of part of the results to the participants.

RESULTS

Hospital care professionals considered the disease-related complexity of HIV, treatment and social aspects that may have an effect on the organizational level of care. Professionals highlighted the benefits of specialized care, although opinions differed between doctors and nurses as regards follow up in Primary Care. Some concerns emerged about the level of training, confidentiality and workload in Primary Care, although they mentioned potential advantages related to accessibility of patients.

CONCLUSIONS

Physicians perceive difficulties in following up HIV patients in Primary Care, even for those patients with a good control of their disease. Nurses and nursing assistants are more open to this possibility due to the proximity to home and health promotion in Primary Care.

Developing an action model for integration of health system response to HIV/AIDS and noncommunicable diseases (NCDs) in developing countries

INTRODUCTION

Although there are several models of integrated architecture, we still lack models and theories about the integration process of health system responses to HIV/AIDS and NCDs.

OBJECTIVE

The overall purpose of this study is to design an action model, a systematic approach, for the integration of health system responses to HIV/AIDS and NCDs in developing countries.

METHODS

An iterative and progressive approach of model development using inductive qualitative evidence synthesis techniques was applied. As evidence about integration is spread across different fields, synthesis of evidence from a broad range of disciplines was conducted.

RESULTS

An action model of integration having 5 underlying principles, 4 action fields, and a 9-step action cycle is developed. The INTEGRATE model is an acronym of the 9 steps of the integration process: 1) Interrelate the magnitude and distribution of the problems, 2) Navigate the linkage between the problems, 3) Testify individual level co-occurrence of the problems, 4) Examine the similarities and understand the differences between the response functions, 5) Glance over the health system's environment for integration, 6) Repackage and share evidence in a useable form, 7) Ascertain the plan for integration, 8) Translate the plan in to action, 9) Evaluate and Monitor the integration.

CONCLUSION

Our model provides a basis for integration of health system responses to HIV/AIDS and NCDs in the context of developing countries. We propose that future empirical work is needed to refine the validity and applicability of the model.