Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic cluster-randomised, controlled trial

Priorities for Research on Hypertension Care Delivery: A WHO Report Executive Summary

In 2024, the World Health Organization released a report on Priorities for Research on Hypertension Care Delivery; this article provides its executive summary. The World Health Organization and its technical experts formed a leadership team, developed a scope and objectives, created a thematic framework, developed a survey for each theme, and identified research priorities. The 5 themes included (1) Health care workforce for hypertension care delivery, (2) Service delivery system/models, (3) Patient retention/adherence, (4) Financing the care delivery system, and (5) Research gaps identified in the World Health Organization 2021 Hypertension Guideline. The leadership team received feedback from diverse experts through webinars and online surveys. The final report was peer-reviewed by external experts. According to postwebinar surveys, we identified 5 to 7 research priorities within each theme, totaling 29 research priorities. The 10 highest priorities were (1) Cost-effectiveness of combination therapy in low/middle-income countries, (2) A system allowing hypertension care closer to home, (3) Health system reform allowing trained community health workers to refill/initiate/titrate antihypertensive medications, (4) Health system reform allowing nurses to diagnose and treat hypertension, (5) Gaps in the medication supply chain, (6) New approaches integrating the management of hypertension and other diseases, (7) Digital approaches for improving medication adherence, (8) Optimal approaches to train health care workers, (9) Approaches to finance hypertension control programs, and (10) Implementation research on task-sharing approaches. These research priorities provide guidance to researchers, with immediate implications for substantially improve hypertension care and prevent its sequelae. We urge governments, funding agencies, and organizations to consider supporting these research topics.

Gaps in hypertension and diabetes treatment among people living with and without HIV: Findings from a prospective cohort study in Kenya, Nigeria, Tanzania, and Uganda, 2013-2023

Hypertension and diabetes are increasingly important contributors to morbidity and mortality in African countries, including among people living with HIV (PLWH) who are on lifelong antiretroviral therapy. However, local HIV care programs have historically not included management of noncommunicable diseases. The African Cohort Study enrolls PLWH and people living without HIV (PLWoH) aged 15 years and older who are receiving clinical care at 12 PEPFAR-supported health facilities in Kenya, Nigeria, Tanzania, and Uganda. Participants undergo clinical assessments and medical record review every six months. We defined hypertension as a persistently elevated systolic and/or diastolic blood pressure ≥140/90 mmHg at two consecutive 6-monthly visits or receipt of hypertension medication. We defined diabetes as a single study visit with a fasting plasma glucose ≥7.0 mmol/L and/or non-fasting plasma glucose ≥11.1 mmol/L or receipt of diabetes medication. We computed descriptive statistics for hypertension/diabetes prevalence and treatment and used random intercept models adjusted for demographic and clinical characteristics to examine predictors of untreated hypertension and diabetes. From 2013 through 2023, among 3617 participants, 692 (19.1%) met our definition of hypertension, with a prevalence of 19.5% among PLWH and 17.3% among PLWoH; 276 (39.9%) received hypertension treatment. No significant difference in untreated hypertension was found comparing PLWH with PLWoH (adjusted risk ratio [aRR] 0.93, 95% confidence interval [CI]: 0.84-1.04). Among 3995 participants, 253 (6.3%) met our definition of diabetes, with a prevalence of 6.6% among PLWH and 4.7% among PLWoH; 51 (20.2%) received diabetes treatment. No significant difference in untreated diabetes was found comparing PLWH with PLWoH (aRR 1.01, 95% CI: 0.91-1.12). The high burden of untreated hypertension and diabetes among PLWH and PLWoH highlight the need for integrated non-communicable disease management within existing HIV services and strengthening of primary healthcare systems.

Multimorbidity and health system priorities in Zimbabwe: A participatory ethnographic study

Multimorbidity, increasingly recognised as a global health challenge, has recently emerged on the health agendas of many countries experiencing rapid epidemiological change, including in Africa. Yet with its conceptual origins in the global North, its meaning and possible utility in African contexts remains abstract. This study drew together policymakers, public health practitioners, academics, health informaticians, health professionals, and people living with multimorbidity (PLWMM) in Zimbabwe to understand: What is the transformative potential and possible limitations of elevating multimorbidity as a priority in this setting? To bring these different perspectives into conversation, we used a participatory ethnographic design that involved a health facility survey, participant-observation, in-depth interviews, audio-visual diaries, and participatory workshops. We found that multimorbidity was new to many respondents but generally viewed as a meaningful and useful concept. It captured the increasingly complex health profile of Zimbabwe's ageing population, foregrounded a range of challenges related to the 'vertical' organisation and uneven funding of different conditions, and revealed opportunities for integration across entrenched silos of knowledge and practice. However, with capacity and momentum to address multimorbidity concentrated within the HIV programme, there was concern that multimorbidity could itself become verticalized, undercutting its transformative potential. Participants agreed that responding to multimorbidity requires a decisive shift from vertical, disease-centred programming to restore the comprehensive primary care that undergirded Zimbabwe's once-renowned health system. It also means building a policy-enabling environment that values generalist (as well as specialist) knowledge, ground-level experience, and inclusive stakeholder engagement. We conclude that the 'learning' health system represents a promising conceptual lens for unifying these imperatives, providing a tangible framework for how knowledge, policy, and practice synergise within more self-reliant, person-centred health systems able to respond to complex health challenges like multimorbidity.

Implementation of hospital-initiated complex interventions for adult people with multiple long-term conditions: a scoping review

BACKGROUND

The increasing prevalence of multiple long-term conditions (MLTC) presents significant challenges to healthcare delivery globally. Although interventions for long-term conditions have predominantly been designed and evaluated in primary care settings, there is a growing recognition of the need to address the management of MLTC within secondary care. This scoping review aims to comprehensively evaluate hospital-initiated complex interventions for people with MLTC.

METHODS

We searched MEDLINE, Embase, PsycINFO, CINAHL Plus and Cochrane Library to identify published studies from Jan 1, 2010, evaluating hospital-initiated interventions initiated for adults (aged ≥ 18 years) with MLTC (PROSPERO: CRD42024498448). Studies reporting patients with frailty only, one long-term condition or orthogeriatric studies that did not focus solely on people with MLTC were excluded. The primary outcome measures were the characteristics of these complex interventions measured as: (i) intervention components, (ii) stakeholders involved; and (iii) implementation strategies, reported according to a theoretical framework (Expert Recommendations for Implementing Change). Secondary outcome measures were clinical and cost implications of these complex interventions, feasibility and sustainability, defined according to the World Health Organisation implementation framework.

FINDINGS

This scoping review identified 70 studies (56,111 participants). Twelve intervention components were identified in 52 combinations; the most common were medication review and optimisation (n = 39), chronic disease management (n = 34) and providing detailed care plans (n = 23). Majority of studies included two or more interventions components (n = 49) delivered by multiple stakeholders (n = 38). Of eleven implementation strategies reported, training and educating stakeholders, establishing integrated wards or clinics and regular multidisciplinary team meetings were the most common. Majority of combinations of intervention groups were associated with improved clinical outcomes for patients with MLTC (n = 43/70, 61.4%), yet eight studies reported on costs. However, embedding training and education or integrated clinics in delivering these intervention groups were associated with improved clinical outcomes, irrespective of the number of healthcare professionals involved. Majority of studies were evaluated in single centre settings, with limited evaluation of broader implementation measures.

INTERPRETATION

Hospital-initiated complex interventions that involve multiple stakeholders may be feasible and appear to be clinically useful for people with MLTC. To strengthen impact and support wider scale-up across health systems, closing knowledge gaps around cost-implications and strategies to improve implementation of these complex interventions through training and education or integrated clinics will be crucial.

Integration of healthcare services for HIV and non-communicable diseases in sub-Saharan Africa: protocol for a scoping review of randomised controlled trials

INTRODUCTION

Stand-alone HIV clinics in sub-Saharan Africa (SSA) have effectively expanded antiretroviral therapy since the 2000s, transforming HIV from a deadly infection into a chronic condition. However, over the past decade, there has been a significant rise in the prevalence of non-communicable diseases (NCDs) globally and in SSA. People living with HIV are at higher risk for some NCDs, including hypertension, diabetes and different cancers. The region's current healthcare infrastructure is not equipped to address this growing burden. Integrating health services for HIV and NCDs (ie, combining services for HIV with services for hypertension, diabetes, depression and mental health, substance use disorder or cancer) could be one strategy for responding to these challenges. In this scoping review, we aim to identify randomised controlled trials on HIV-NCD integration, assess implemented integration models and measured outcomes and highlight evidence gaps.

METHODS AND ANALYSIS

This scoping review will follow the Arksey and O'Malley (2005) methodological framework. Reporting will be guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist. We will conduct a systematic search of the databases OVID Medline, Embase, Web of Science, Global, Africa Index Medicus, including terms related to HIV, NCDs and healthcare integration. Included trials must have been conducted within SSA and have been published in English or French after 1 January 2010. We will not select based on sample size or number of clusters. Both the title and abstract screening and full-text screening will be done in Covidence by at least two reviewers working independently. Data extraction will focus on key variables, including study design, geographical location, integration intervention, measured outcomes and reported findings.

ETHICS AND DISSEMINATION

This scoping review aims to generate new insights from publicly available research. Therefore, ethical approval is not required. Study findings will be shared through discussion with policymakers, implementation science researchers and healthcare providers. The results of this study are intended to be published in a peer-reviewed journal.

TRIAL REGISTRATION

This protocol has been registered with Center for Open Science OSF Registry (DOI: 10.17605/OSF.IO/RGQSN). The search was conducted on 25 March 2024 and updated on 21 October 2024. The review is expected to be completed by March 2025.

Protocol for the economic evaluation of integrated community-based care compared with integrated facility-based care for HIV, hypertension and diabetes in Tanzania and Uganda (INTE-COMM trial)

Background

The number of people living with multiple chronic conditions in sub-Saharan Africa is increasing, but health facilities are unable to meet demand. To improve health system capacity and access to care, community models of HIV care have been trialled in countries such as Tanzania and Uganda. However, no evidence exists to inform policymakers on the effectiveness and cost-effectiveness of integrated community-based models of care for HIV and chronic non-communicable conditions. This protocol outlines a within-trial economic evaluation to address this gap.

Methods & analysis

We will estimate the costs and cost-effectiveness of integrated community-based care for HIV, hypertension and diabetes compared with facility-based care within the INTE-COMM pragmatic cluster-randomised trial in Tanzania and Uganda. Analyses will adopt a 52-week time horizon, the duration of trial follow-up. The full enrolled trial sample will be analysed from a societal perspective, comprising provider and patient perspectives. Economic costs will be estimated, which includes valuing inputs such as donated goods or time foregone by participants because of receiving care. For provider costs, participant case report forms will inform resource use along with data from facilities and community sites. Resources will be valued using project accounts, facility spending, and locally available cost data. Patient costs will be estimated based on a care-seeking and cost questionnaire administered to participants. Estimated costs will be analysed with co-primary trial outcomes on plasma viral load suppression, glycaemia and blood pressure control to calculate incremental cost-effectiveness ratios (ICER). We will also calculate ICERs for secondary trial outcomes related to health-related quality of life and wellbeing. Cost drivers and outcomes will be varied within confidence bounds in a two-way sensitivity analysis. We will investigate equity impact by estimating the mean difference in outcomes between integrated community-based and facility-based care across household socio-economic quintiles and by measuring whether participants incurred catastrophic health expenditures.

Trial registration number

The ISRCTN Registry: ISRCTN15319595. Registered on 07 June 2022: https://doi.org/10.1186/ISRCTN15319595.

HIV clinical outcomes among people with HIV and diabetes mellitus in Kampala, Uganda; A matched retrospective cohort study

Suppressive antiretroviral treatment (ART) has resulted into prolonged survival of people with HIV (PWH) in Sub-Saharan Africa (SSA) with resultant increase in the incidence of non-communicable diseases (NCD), such as diabetes mellitus (DM). However, there is a lack of data on the effect of DM on HIV-related outcomes among PWH in this setting. The study aimed to compare HIV clinical outcomes (viral load suppression, retention in care, hospitalization, tuberculosis, and mortality) between PWH with DM and those without at two large HIV clinics in Kampala, Uganda. We conducted a matched retrospective cohort study using secondary data of PWH with DM and PWH without DM from January 2020 to June 2022. We used descriptive statistics to compare baseline characteristics and a chi-square test to compare the outcomes between the HIV/DM and HIV/no DM groups. The cohort consisted of 243 PWH diagnosed with DM matched with 1221 PWH without DM. We analysed 1,469 participant records: 1,009 (68.7%) from Mulago ISS clinic and 460 (31.3%) from Kisenyi HC IV. Most study participants (63.6%) were female, and the mean age was 43 years (standard deviation [SD] 11) and 38 years (SD 10) for those with DM and without DM, respectively. PWH with DM had significantly higher odds of hospitalization (adjusted odds ratio [AOR] 4.94; 95% CI: 1.93-12.66; p = 0.001) and were less likely to be retained in care (AOR 0.12, 95% CI: 0.07-0.20 p = <0.001). There were no differences in viral load suppression, TB diagnosis, and mortality between the PWH with DM and those without DM. These findings underscore the need for integrated management approaches that address both HIV and DM to improve health outcomes for this population. Future research could also explore the causes of hospitalization and non-retention among PWH and DM.

HIV and CKD in the Tenofovir Era: A Prospective Parallel-Group Cohort Study From Tanzania

Rationale & Objective

Longitudinal research on chronic kidney disease (CKD) in sub-Saharan Africa is sparse, especially among people living with HIV (PLWH). We evaluated the incidence of CKD among PLWH compared with HIV-uninfected controls in Tanzania.

Study Design

Prospective cohort study.

Setting & Participants

A total of 495 newly diagnosed PLWH who initiated antiretroviral therapy (ART) and 505 HIV-uninfected adults enrolled from public HIV clinics and followed from 2016-2021. The control group was recruited from HIV treatment partners from the same HIV clinics.

Exposures

Untreated HIV (at baseline), ART, sociodemographic information, health behaviors, hypertension, and diabetes.

Outcomes

Incident CKD, defined as a follow-up estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2 with ≥25% reduction from baseline; annual eGFR change; incident albuminuria; 3-year all-cause mortality.

Analytical Approach

Multivariable Poisson and linear regression determined the association between HIV and other factors with a baseline prevalent reduced eGFR and albuminuria, incident CKD and albuminuria, and annual eGFR change. Cox hazard regression assessed the association between baseline CKD and mortality.

Results

Median age was 35 years and 67.5% were women. There were 101 incident CKD cases, 71 among PLWH and 30 among HIV-uninfected participants, equivalent to a CKD incidence of 57.9 per 1,000 person-years (95% CI, 44.4-71.4) and 26.2 per 1,000 person-years (95% CI, 16.8-35.5), respectively. PLWH had a more rapid eGFR decline (-6.65 vs -2.61 mL/min/1.73 m2 per year). Female sex and older age were positively associated with incident CKD. Albuminuria incidence did not differ by HIV status. PLWH with albuminuria at baseline had higher mortality (HR, 2.13; 95% CI, 1.08-4.21).

Limitations

As an observational cohort study, there was no comparison group of HIV-positive participants on a nontenofovir disoproxil fumarate-based ART regimen.

Conclusions

PLWH receiving tenofovir disoproxil fumarate-based ART had a very high incidence of CKD and rapid eGFR decline. Conversely, albuminuria stabilized with ART use. Expanding access to less-nephrotoxic ART, such as tenofovir alafenamide, is urgently needed throughout sub-Saharan Africa.

Cost-effectiveness of leveraging existing HIV primary health systems and community health workers for hypertension screening and treatment in Africa: An individual-based modeling study

BACKGROUND

Cardiovascular disease (CVD) morbidity and mortality is increasing in Africa, largely due to undiagnosed and untreated hypertension. Approaches that leverage existing primary health systems could improve hypertension treatment and reduce CVD, but cost-effectiveness is unknown. We evaluated the cost-effectiveness of population-level hypertension screening and implementation of chronic care clinics across eastern, southern, central, and western Africa.

METHODS AND FINDINGS

We conducted a modeling study to simulate hypertension and CVD across 3,000 scenarios representing a range of settings across eastern, southern, central, and western Africa. We evaluated 2 policies compared to current hypertension treatment: (1) expansion of HIV primary care clinics into chronic care clinics that provide hypertension treatment for all persons regardless of HIV status (chronic care clinic or CCC policy); and (2) CCC plus population-level hypertension screening of adults ≥40 years of age by community health workers (CHW policy). For our primary analysis, we used a cost-effectiveness threshold of US $500 per disability-adjusted life-year (DALY) averted, a 3% annual discount rate, and a 50-year time horizon. A strategy was considered cost-effective if it led to the lowest net DALYs, which is a measure of DALY burden that takes account of the DALY implications of the cost for a given cost-effectiveness threshold. Among adults 45 to 64 years, CCC implementation would improve population-level hypertension control (the proportion of people with hypertension whose blood pressure is controlled) from mean 4% (90% range 1% to 7%) to 14% (6% to 26%); additional CHW screening would improve control to 44% (35% to 54%). Among all adults, CCC implementation would reduce ischemic heart disease (IHD) incidence by 10% (3% to 17%), strokes by 13% (5% to 23%), and CVD mortality by 9% (3% to 15%). CCC plus CHW screening would reduce IHD by 28% (19% to 36%), strokes by 36% (25% to 47%), and CVD mortality by 25% (17% to 34%). CHW screening was cost-effective in 62% of scenarios, CCC in 31%, and neither policy was cost-effective in 7% of scenarios. Pooling across setting-scenarios, incremental cost-effectiveness ratios were $69/DALY averted for CCC and $389/DALY averted adding CHW screening to CCC.

CONCLUSIONS

Leveraging existing healthcare infrastructure to implement population-level hypertension screening by CHWs and hypertension treatment through integrated chronic care clinics is expected to reduce CVD morbidity and mortality and is likely to be cost-effective in most settings across Africa.

Global elimination of HBV: Is it really achievable?

Hepatitis B virus (HBV) infection is a major cause of premature death worldwide. In 2016, the World Health Organization (WHO) called for HBV elimination and set up very ambitious elimination targets. The development of effective vaccines, accurate diagnostic tools and safe antiviral drugs make HBV elimination a realistic goal. However, the most constrained-resource regions, which bear the highest burden of HBV, are facing major challenges in implementing strategies to reduce HBV incidence and mortality. Developing simplified approaches adapted to resource-limited settings and scaling up interventions for the prevention and control of HBV globally are urgently needed. Whether HBV elimination will be achieved in an equitable manner and in a reasonable timeframe remains highly uncertain.

Worldwide trends in diabetes prevalence and treatment from 1990 to 2022: a pooled analysis of 1108 population-representative studies with 141 million participants

BACKGROUND

Diabetes can be detected at the primary health-care level, and effective treatments lower the risk of complications. There are insufficient data on the coverage of treatment for diabetes and how it has changed. We estimated trends from 1990 to 2022 in diabetes prevalence and treatment for 200 countries and territories.

METHODS

We used data from 1108 population-representative studies with 141 million participants aged 18 years and older with measurements of fasting glucose and glycated haemoglobin (HbA1c), and information on diabetes treatment. We defined diabetes as having a fasting plasma glucose (FPG) of 7·0 mmol/L or higher, having an HbA1c of 6·5% or higher, or taking medication for diabetes. We defined diabetes treatment as the proportion of people with diabetes who were taking medication for diabetes. We analysed the data in a Bayesian hierarchical meta-regression model to estimate diabetes prevalence and treatment.

FINDINGS

In 2022, an estimated 828 million (95% credible interval [CrI] 757-908) adults (those aged 18 years and older) had diabetes, an increase of 630 million (554-713) from 1990. From 1990 to 2022, the age-standardised prevalence of diabetes increased in 131 countries for women and in 155 countries for men with a posterior probability of more than 0·80. The largest increases were in low-income and middle-income countries in southeast Asia (eg, Malaysia), south Asia (eg, Pakistan), the Middle East and north Africa (eg, Egypt), and Latin America and the Caribbean (eg, Jamaica, Trinidad and Tobago, and Costa Rica). Age-standardised prevalence neither increased nor decreased with a posterior probability of more than 0·80 in some countries in western and central Europe, sub-Saharan Africa, east Asia and the Pacific, Canada, and some Pacific island nations where prevalence was already high in 1990; it decreased with a posterior probability of more than 0·80 in women in Japan, Spain, and France, and in men in Nauru. The lowest prevalence in the world in 2022 was in western Europe and east Africa for both sexes, and in Japan and Canada for women, and the highest prevalence in the world in 2022 was in countries in Polynesia and Micronesia, some countries in the Caribbean and the Middle East and north Africa, as well as Pakistan and Malaysia. In 2022, 445 million (95% CrI 401-496) adults aged 30 years or older with diabetes did not receive treatment (59% of adults aged 30 years or older with diabetes), 3·5 times the number in 1990. From 1990 to 2022, diabetes treatment coverage increased in 118 countries for women and 98 countries for men with a posterior probability of more than 0·80. The largest improvement in treatment coverage was in some countries from central and western Europe and Latin America (Mexico, Colombia, Chile, and Costa Rica), Canada, South Korea, Russia, Seychelles, and Jordan. There was no increase in treatment coverage in most countries in sub-Saharan Africa; the Caribbean; Pacific island nations; and south, southeast, and central Asia. In 2022, age-standardised treatment coverage was lowest in countries in sub-Saharan Africa and south Asia, and treatment coverage was less than 10% in some African countries. Treatment coverage was 55% or higher in South Korea, many high-income western countries, and some countries in central and eastern Europe (eg, Poland, Czechia, and Russia), Latin America (eg, Costa Rica, Chile, and Mexico), and the Middle East and north Africa (eg, Jordan, Qatar, and Kuwait).

INTERPRETATION

In most countries, especially in low-income and middle-income countries, diabetes treatment has not increased at all or has not increased sufficiently in comparison with the rise in prevalence. The burden of diabetes and untreated diabetes is increasingly borne by low-income and middle-income countries. The expansion of health insurance and primary health care should be accompanied with diabetes programmes that realign and resource health services to enhance the early detection and effective treatment of diabetes.

FUNDING

UK Medical Research Council, UK Research and Innovation (Research England), and US Centers for Disease Control and Prevention.

Health systems strengthening through surgical and perioperative care pathways: a changing paradigm

Global health has traditionally focused on the primary health development with disease-specific focus such as HIV, malaria and non-communicable diseases (NCDs). As such, surgery has traditionally been neglected in global health as investment in them is often expensive, relative to these other priorities. Therefore, efforts to improve surgical care have remained on the periphery of initiatives in health system strengthening. However, today, many would argue that global health should focus on universal health coverage with primary health and surgery and perioperative care integrated as a part of this. In this article, we discuss the past developments and future-looking solutions on how surgery can contribute to the delivery of effective and equitable healthcare across the world. These include bidirectional integration of surgical and chronic disease pathways and better understanding financing initiatives. Specifically, we focus on access to safe elective and emergency surgery for NCDs and an integrated approach towards the rising multimorbidity from chronic disease in the population. Underpinning these, data-driven solutions from high-quality research from clinical trials and cohort studies through established surgical research networks are needed. Although challenges will remain around financing, we propose that development of surgical services will strengthen and improve performance of whole health systems and contribute to improvement in population health across the world.

Long-term impact of an integrated HIV/non-communicable disease care intervention on patient retention in care and clinical outcomes in East Africa

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.

Exploring the preferred integration approach for HIV, diabetes and hypertension care and associated barriers and facilitators in Central Tanzania: An exploratory qualitative study

Timely diagnosis and management of diabetes and hypertension among people living with HIV (PLWH) is imperative; however, many barriers exist within the current model of care for these comorbidities. We aimed to understand how HIV, diabetes, and hypertension care should be delivered and the associated barriers and facilitators for the preferred delivery approach. We conducted semi-structured interviews with 16 PLWH with comorbidities of diabetes and/or hypertension (referred to hereafter as non-communicable diseases [NCDs]), 10 healthcare professionals (HCPs) that provide care for NCDs, and 10 HCPs that provide care for HIV. Participants were recruited from two healthcare facilities in Dodoma, Tanzania and interviewed in Swahili. Interviews were audio recorded, transcribed verbatim and translated into English. We used the differentiated service delivery building blocks as a framework to determine where, who, what and when care should be provided. We applied the Theoretical Domains Framework (TDF) to HCP transcripts to determine barriers and facilitators for the preferred integration approach. There was a consensus among participants that all care for NCDs should be provided for PLWH at HIV clinics (known as care and treatment centres [CTCs]) by either CTC doctors or NCD specialists. Participants preferred flexible follow-up care for NCDs and for it to be aligned with HIV follow-up appointments. The main barriers were mapped to the TDF domains of environmental context and resources, and social influences; the former included the lack of NCD medications, NCD diagnostic equipment, space, staff and guidelines whereas the latter included negative influences from peers and traditional healers. Several facilitators were mentioned regarding CTC HCPs' knowledge, skills, optimism and beliefs regarding their capabilities to care for PLWH with NCDs. The preferred integration approach should be tested, utilising the enabling factors described. The barriers described must be addressed with or without integration to achieve optimal care for PLWH with NCDs.

Hypertension among people living with human immunodeficiency virus in sub-Saharan Africa: a systematic review and meta-analysis

We performed a systematic review and meta-analysis of hypertension in people living with human immunodeficiency virus (HIV) in sub-Saharan Africa (SSA). We searched the PubMed, Google Scholar, African Index Medicus, and Embase databases to identify studies published from January 1, 2010, to December 31, 2021. We used a random-effects model to estimate the pooled prevalence of hypertension and mean SBP/DBP level on a sex-specific basis. We included 48 studies reporting data on a pooled sample of 193,843 people living with HIV (PLW-HIV) in SSA. The pooled mean SBP/DBP level was 120 (95% CI 113-128)/77 (95%CI 72-82) mmHg, while the overall pooled prevalence of hypertension was 21.9% (95% CI 19.9-23.9%). Further meta-regression analyses suggested that the prevalence of hypertension was 1.33 times greater in males, 1.23 times greater in individuals receiving antiretroviral therapy (ART) and 1.45 times greater in those individuals with a CD4-count ≥ 200. This meta-analysis of the contemporary pattern of BP levels among PLW-HIV in SSA, suggests that around one in five of such individuals also have hypertension. Given the further context of greater access to ART and subsequently greater longevity, study findings support calls to integrate cardiovascular management into routine HIV care.

Quantitative outcomes of a type 2 single arm hybrid effectiveness implementation pilot study for hypertension-HIV integration in Botswana

BACKGROUND

Successful HIV treatment programs have turned HIV into a chronic condition, but noncommunicable diseases such as hypertension jeopardize this progress. Hypertension control rates among people with HIV (PWH) are low owing to gaps in patient awareness, diagnosis, effective treatment, and management of both conditions at separate clinic visits. Integrated management, such as in our study, InterCARE, can enhance HIV-hypertension integration and blood pressure (BP) control.

METHODS

Our pilot study was conducted in two Botswana HIV clinics between October 2021 and November 2022. Based on our formative work, we adopted three main strategies; Health worker training on HTN/cardiovascular disease (CVD) management, adaptation of HIV Electronic Health Record (EHR) for HTN/CVD care, and use of treatment partners to support PWH with hypertension for implementation. We employed the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to assess implementation effectiveness and outcomes for BP control at baseline, 6 and 12 months. HIV viral load (VL) suppression was also measured to assess impact of integration on HIV care.

RESULTS

We enrolled 290 participants; 35 (12.1%) were lost to follow-up, leaving 255 (87.9%) at 12-months. Median age was 54 years (IQR 46-62), and 77.2% were females. Our interventions significantly improved BP control to < 140/90 mmHg (or < 130/80 mmHg if diagnosis of diabetes or chronic kidney disease), from 137/290 participants, 47.2% at baseline to 206/290 participants, 71.0%, at 12 months (p < 0.001). Among targeted providers, 94.7% received training, with an associated significant increase in counseling on exercise, diet, and medication (all p < 0.001) but EHR use for BP medication prescribing and cardiovascular risk factor evaluation showed no adoption. In the intention-to-treat analysis, HIV VL suppression at 12 months decreased (85.5% vs 93.8%, p = 0.002) due to loss to follow-up but the per protocol analysis showed no difference in VL suppression between baseline and 12 months (97.3% vs 93.3%, p = 0.060).

CONCLUSION

The InterCARE pilot study demonstrated that low-cost practical support measures involving the integration of HIV and hypertension/CVD management could lead to improvements in BP control. These results support the need for a large implementation and effectiveness trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05414526. Registered 18th May 2022.

A quantitative comparison between the essential medicines for rheumatic diseases in children and young people in Africa and the WHO model list

BACKGROUND

The World Health Organisation Essential Medicines List (WHO EML) guides National Essential Medicines Lists and Standard Treatment Guidelines for clearly identified disease priorities especially in low- and middle-income countries. This study compares the degree to which the basket of medicines recommended for rheumatic diseases in children and young people in National Essential Medicines Lists of countries in the WHO Africa region, corresponds to the 2021 WHO EML and WHO EML for children, as a proxy of availability.

METHODS

An online search of the WHO medicines and health technology portal, the Health Ministry websites of the 54 African countries, PUBMED and Google Scholar, with search terms for 'National Essential Medicines List', AND/OR 'standard treatment guidelines' AND/OR 'Lista Nacional de Medicamentos Essenciais' AND/ OR 'Liste Nationale de Medicaments Essentiels' AND Africa AND/OR < Name of African country > was conducted. The number of medicines on the national lists were compared according to a predefined template of medicines; and the percentage similarity calculated. Descriptive statistics were derived using STATA.

RESULTS

Forty-seven countries in the WHO Africa region have developed a National Essential Medicines List. Eleven countries do not have any medicines listed for rheumatic diseases. The majority of countries had less than or equal to 50% similarity with the WHO EML for rheumatic disease in children and young people, median 3 medicines (IQR 1- 4). The most common medicines on the national lists from Africa were methotrexate, sulfasalazine and azathioprine, with etanercept available in 6 countries. Seven countries had only one medicine, acetylsalicylic acid listed in the section 'Juvenile Joint diseases'. A multiple linear regression model for the predictors of the number of medicines on the national lists established that 20% of the variability was predicted by health expenditure per capita, socio-demographic index and the availability of rheumatology services (adult and/or paediatric) p = 0.006, with socio-demographic index (p = 0.035, 95% CI 0.64-16.16) and the availability of rheumatology services (p = 0.033, 95% CI 0.13 - 2.90) significant.

CONCLUSION

Four countries (8.5%) in Africa have updated their National Essential Medicines Lists to reflect adequate care for children and young people with rheumatic diseases. Moving forward, efforts should focus on aligning available medicines with the WHO EML, and strengthening healthcare policy for rheumatology and pharmaceutical services, for affordable access to care and medicines.

NIHR Global Health Research Unit on Global Surgery. Access to and quality of elective care: a prospective cohort study using hernia surgery as a tracer condition in 83 countries

BACKGROUND

Timely and safe elective health care facilitates return to normal activities for patients and prevents emergency admissions. Surgery is a cornerstone of elective care and relies on complex pathways. This study aimed to take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia as a tracer condition.

METHODS

This was a prospective, international, cohort study conducted between Jan 30 and May 21, 2023, in which any hospital performing inguinal hernia repairs was eligible to take part. Consecutive patients of any age undergoing primary inguinal hernia repair were included. A measurement set mapped to the attributes of WHO's Health System Building Blocks was defined to evaluate access (emergency surgery rates, bowel resection rates, and waiting times) and quality (mesh use, day-case rates, and postoperative complications). These were compared across World Bank income groups (high-income, upper-middle-income, lower-middle-income, and low-income countries), adjusted for hospital and country. Factors associated with postoperative complications were explored with a three-level multilevel logistic regression model.

FINDINGS

18 058 patients from 640 hospitals in 83 countries were included, of whom 1287 (7·1%) underwent emergency surgery. Emergency surgery rates increased from high-income to low-income countries (6·8%, 9·7%, 11·4%, 14·2%), accompanied by an increase in bowel resection rates (1·2%, 1·4%, 2·3%, 4·2%). Overall waiting times for elective surgery were similar around the world (median 8·0 months from symptoms to surgery), largely because of delays between symptom onset and diagnosis rather than waiting for treatment. In 14 768 elective operations in adults, mesh use decreased from high-income to low-income countries (97·6%, 94·3%, 80·6%, 61·0%). In patients eligible for day-case surgery (n=12 658), day-case rates were low and variable (50·0%, 38·0%, 42·1%, 44·5%). Complications occurred in 2415 (13·4%) of 18 018 patients and were more common after emergency surgery (adjusted odds ratio 2·06, 95% CI 1·72-2·46) and bowel resection (1·85, 1·31-2·63), and less common after day-case surgery (0·39, 0·34-0·44).

INTERPRETATION

This study demonstrates that elective health care is essential to preventing over-reliance on emergency systems. We identified actionable targets for system strengthening: clear referral pathways and increasing mesh repair in lower-income settings, and boosting day-case surgery in all income settings. These measures might strengthen non-surgical pathways too, reducing the burden on society and health services.

FUNDING

NIHR Global Health Research Unit on Global Surgery and Portuguese Hernia and Abdominal Wall Society (Sociedade Portuguesa de Hernia e Parede Abdominal).

Health insurance financing and patient retention in care at diabetics and hypertension clinics in Dar es Salaam and Pwani regions, Tanzania. A cohort study

Hypertension and diabetes are chronic conditions that cause major morbidity and mortality worldwide. Whether health insurance financing is associated with improved retention in chronic care in Tanzania, is unknown. Our study establishes the effect of health insurance on retention and the determinants for retention in care among patients attending diabetes and hypertension clinics. We used a Cohort design to study participants enrolled in a cluster-randomized trial of integrated management of HIV, diabetes, and hypertension compared with standard vertical care in the INTE-AFRICA trial. Fifteen health facilities in Dar es Salam and Pwani regions were enrolled, with 1716 participants. Our sample size had 95% power to detect a 50% to 60% retention difference between the insured and uninsured groups (95% CI). We compared proportions using χ2 tests and obtained prevalence and rate ratios by Generalised Linear Models. We studied 1716 participants for 1612.3 Person-years (PY). At the study's end, 1351 persons were alive and retained in care. Among the insured participants (26.0%), females accounted for 65.9%. Middle-aged adults contributed 58.8% of insured participants. We observed high retention rates (retention incidence rate IR: 83.80/100 PY; 95% CI (79.40-88.40)). There was no difference in retention among insured and uninsured patients (adjusted rate ratio aRR: 1.00; 95% CI, 0.94-1.06). Being middle-aged or senior-aged adults compared to young adults, having diabetes alone or hypertension alone compared to both conditions, having the comorbidity of diabetes or hypertension with HIV compared to a single condition, and attending health centres and hospitals compared to dispensaries were significantly associated with retention in care. This study showed no effect of health insurance on retention in diabetic and hypertension care clinics. However, age, medical diagnosis, morbidity, and type of health facility attended were associated with retention in care.