1
|
Kanyike AM, Nakawuki AW, Akech GM, Kihumuro RB, Kintu TM, Nalunkuma R, Nakandi RM, Mugabi J, Twijukye N, Bwayo D, Katuramu R. Prevalence, Awareness, and Factors Associated with Hypertension Among People Living with HIV in Eastern Uganda. A Multicentre Cross-Sectional Study. HIV AIDS (Auckl) 2024; 16:325-335. [PMID: 39246302 PMCID: PMC11378986 DOI: 10.2147/hiv.s477809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 08/29/2024] [Indexed: 09/10/2024] Open
Abstract
Introduction Despite advancements in Antiretroviral Therapy (ART), people living with HIV (PLHIV) face increasing risks of HTN, leading to significant morbidity and premature mortality, undermining the hard-earned gains of fighting HIV. The prevalence of hypertension among HIV patients and associated risk factors has not been extensively studied in the rural parts of Uganda. Objective We assessed the prevalence, awareness, and factors associated with hypertension among PLHIV at two health facilities in Eastern Uganda. Methods A cross-sectional study was conducted at Mbale Regional Referral Hospital and Bugobero Health Center IV HIV clinics from May to July 2023. We recruited patients with HIV above the age of 18 years and willing to consent. Participants were interviewed using a structured questionnaire adapted from the WHO STEPwise approach to noncommunicable disease risk factor surveillance (STEPS) and the AIDS Clinical Trials Group. Anthropometric measurements and blood pressure were taken. Bivariate and multivariable logistic regression were performed. A P value <0.2 in the bivariate analysis was transferred to the multivariable logistic regression model. A P value < 0.05 was statistically significant. Results The study surveyed 400 PLHIV with a mean age of 46.5 (SD: 12.4) years; most were female (n=261, 65.3%). Hypertension prevalence was at 37.5%, with 20.5% in stage 2 and 68% ((n=102) of hypertensive participants were unaware. Hypertension was associated with age ≥50 years (aOR: 2.11, 95% CI: 1.33-3.37, p = 0.002), a suppressed viral load (aOR: 3.71, 95% CI: 1.02-5.13, p = 0.046) and BMI ≥25 Kg/m2 (aOR: 1.64, 95% CI: 1.01-2.66, p = 0.044). Conclusion Hypertension is a significant burden among PLHIV in Eastern Uganda, influenced by HIV and lifestyle-related risk factors. Improved screening and diagnosis are needed with close monitoring for patients with viral load suppression due to the possible negative effects of ART on blood pressure.
Collapse
Affiliation(s)
- Andrew Marvin Kanyike
- Department of Internal Medicine, Faculty of Health Sciences, Busitema University, Mbale, Uganda
- Department of Internal Medicine, Mengo Hospital, Kampala, Uganda
| | | | - Gabriel Madut Akech
- Department of Internal Medicine, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | | | - Timothy Mwanje Kintu
- Department of Internal Medicine, Mulago National Referral Hospital, Kampala, Uganda
| | | | | | - Joshua Mugabi
- Department of Internal Medicine, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Nicholas Twijukye
- Department of Internal Medicine, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Denis Bwayo
- Department of Internal Medicine, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Richard Katuramu
- Department of Internal Medicine, Faculty of Health Sciences, Busitema University, Mbale, Uganda
| |
Collapse
|
2
|
Kim CW, Haji M, Lopes VV, Halladay C, Sullivan J, Ross D, Slazinski K, Taveira TH, Menon A, Gaitanis M, Longenecker CT, Bloomfield GS, Rudolph J, Wu WC, Erqou S. Variations in antihypertensive medication treatment and blood pressure control among Veterans with HIV and existing hypertension. Am Heart J 2024:S0002-8703(24)00204-7. [PMID: 39216692 DOI: 10.1016/j.ahj.2024.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 08/14/2024] [Accepted: 08/14/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Hypertension is a leading risk factor for cardiovascular disease among patients living with HIV (PLWH). Understanding the predictors and patterns of antihypertensive medication prescription and blood pressure (BP) control among PLWH with hypertension (HTN) is important to improve the primary prevention efforts for this high-risk population. We sought to identify important patient-level correlates for (e.g., race) and assess inter-facility variations in antihypertension medication prescriptions and BP control among Veterans living with HIV (VLWH) and HTN. METHODS We studied VLWH with a diagnosis of HTN who received care in the Veterans Health Administration (VHA) from January 2018 to December 2019. We evaluated HTN treatment and blood pressure control across demographic variables, including race, and by medical comorbidities. Data were also compared among VHA facilities. Predictors of HTN treatment and control were assessed in two-level hierarchical multivariate logistic regression models to estimate odds ratios (ORs). The VHA facility random-effects parameters from the hierarchical models were used to calculate the median odds ratios to characterize the variation across the different VHA facilities. RESULTS A total of 17,468 VLWH with HTN (mean age 61 years, 97% male, 54% Black, 40% White) who received care within the VHA facilities in 2018-2019 were included. 73% were prescribed antihypertension medications with higher prescription rates among Black versus White patients (75% vs. 71%) and higher prescription rates among patients with a history of cardiovascular disease, diabetes, and kidney disease (>80%), and those receiving antiretroviral therapy and with controlled HIV viral load (∼75%). Only 27% of VLWH with HTN had optimal BP control of systolic BP <130 mmHg and diastolic BP <80 mmHg, with a lower rate of control among Black versus White patients (24% v. 31%). In multivariate regression, Black patients had a higher likelihood of HTN medication prescription (OR 1.32, 95% CI: 1.22-1.42 used Table 3) but were less likely to have optimal BP control (OR 0.82; 0.76-0.88). Important correlates of antihypertensive prescription and optimal BP control included: number of outpatient visits, and histories of diabetes, coronary artery disease, and heart failure. There was about 10% variability in both antihypertensive prescription and BP control patterns between VHA facilities for patients with similar characteristics. There was increased inter-facility variation antihypertensive prescription among those with a history of heart failure and those not receiving antiretroviral therapy. CONCLUSION In a retrospective analysis of large VHA data, we found that VLWH with HTN have suboptimal antihypertensive medication prescription and BP control. Black VLWH had higher HTN medication prescription rates but lower optimal BP control.
Collapse
Affiliation(s)
- Chan Woo Kim
- Department of Medicine, Brown University, Providence, RI
| | - Mohammed Haji
- Department of Medicine, Brown University, Providence, RI
| | - Vrishali V Lopes
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI
| | - Christopher Halladay
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI
| | - Jennifer Sullivan
- Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI; Brown University School of Public Health, Center for Gerontology & Healthcare Research, Providence, RI
| | - David Ross
- Office of Specialty Care Service, US Department of Veterans Affairs, Washington DC; Infectious Disease Section, Washington, DC Department of Veterans Affairs Medical Center, Washington DC
| | - Karen Slazinski
- Department of Medicine, Orland VA Medical Center, Orlando, Fl
| | - Tracey H Taveira
- Department of Medicine, Brown University, Providence, RI; Department of Medicine, Providence VA Medical Center, Providence, RI; Department of Pharmacy, University of Rhode Island, Providence
| | - Anupama Menon
- Department of Medicine, Brown University, Providence, RI; Department of Medicine, Providence VA Medical Center, Providence, RI
| | - Melissa Gaitanis
- Department of Medicine, Brown University, Providence, RI; Department of Medicine, Providence VA Medical Center, Providence, RI
| | | | - Gerald S Bloomfield
- Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University, Durham, NC
| | - James Rudolph
- Department of Medicine, Brown University, Providence, RI; Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI; Brown University School of Public Health, Center for Gerontology & Healthcare Research, Providence, RI; Department of Medicine, Providence VA Medical Center, Providence, RI
| | - Wen-Chih Wu
- Department of Medicine, Brown University, Providence, RI; Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI; Brown University School of Public Health, Center for Gerontology & Healthcare Research, Providence, RI; Department of Medicine, Providence VA Medical Center, Providence, RI; Lifespan Cardiovascular Institute, Rhode Island Hospital, Providence, RI
| | - Sebhat Erqou
- Department of Medicine, Brown University, Providence, RI; Center of Innovation in Long Term Services & Supports, Providence VA Medical Center, Providence, RI; Department of Medicine, Providence VA Medical Center, Providence, RI; Lifespan Cardiovascular Institute, Rhode Island Hospital, Providence, RI; Division of Cardiology, Mary Washington Hospital, Fredericksburg, VA.
| |
Collapse
|
3
|
Schnure MC, Kasaie P, Dowdy DW, Genberg BL, Kendall EA, Fojo AT. Forecasting the effect of HIV-targeted interventions on the age distribution of people with HIV in Kenya. AIDS 2024; 38:1375-1385. [PMID: 38537051 PMCID: PMC11211060 DOI: 10.1097/qad.0000000000003895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/27/2024] [Accepted: 03/21/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVES To provide accurate forecasts of the age distribution of people with HIV (PWH) in Kenya from 2025 to 2040. DESIGN Development of a compartmental model of HIV in Kenya, calibrated to historical estimates of HIV epidemiology. METHODS We forecasted changes in population size and age distribution of new HIV infections and PWH under the status quo and under scale-up of HIV services. RESULTS Without scale-up, new HIV infections were forecasted to fall from 34 000 (28 000-41 000) in 2,025 to 29 000 (15 000-57 000) in 2,040; the percentage of new infections occurring among persons over 30 increased from 33% (20-50%) to 40% (24-62%). The median age of PWH increased from 39 years (38-40) in 2025 to 43 years (39-46) in 2040, and the percentage of PWH over age 50 increased from 26% (23-29%) to 34% (26-43%). Under the full intervention scenario, new infections were forecasted to fall to 6,000 (3,000-12 000) in 2,040. The percentage of new infections occurring in people over age 30 increased to 52% (34-71%) in 2,040, and there was an additional shift in the age structure of PWH [forecasted median age of 46 (43-48) and 40% (33-47%) over age 50]. CONCLUSION PWH in Kenya are forecasted to age over the next 15 years; improvements to the HIV care continuum are expected to contribute to the growing proportion of older PWH.
Collapse
Affiliation(s)
| | - Parastu Kasaie
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David W. Dowdy
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Becky L. Genberg
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | |
Collapse
|
4
|
Surey J, Veitch M, Rogers S, Al Shakarchi N, Burridge S, Leonard M, Munday S, Story A, Banerjee A. Cardiovascular Disease Screening in homeless: A Feasibility Study. J Am Heart Assoc 2024; 13:e034413. [PMID: 38606771 PMCID: PMC11262523 DOI: 10.1161/jaha.124.034413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 03/15/2024] [Indexed: 04/13/2024]
Affiliation(s)
- Julian Surey
- University College London HospitalsFind and Treat ServiceLondonUK
| | - Martha Veitch
- University College London HospitalsFind and Treat ServiceLondonUK
| | - Sally Rogers
- University College London HospitalsFind and Treat ServiceLondonUK
| | - Nader Al Shakarchi
- University College London Medical SchoolLondonUK
- Mayo ClinicRochesterMNUSA
| | | | - Mark Leonard
- University College London HospitalsFind and Treat ServiceLondonUK
| | - Sophie Munday
- University College London HospitalsFind and Treat ServiceLondonUK
| | - Alistair Story
- University College London HospitalsFind and Treat ServiceLondonUK
- Institute of Epidemiology & Health CareUniversity College LondonLondonUK
| | - Amitava Banerjee
- Institute of Health InformaticsUniversity College LondonLondonUK
- Department of CardiologyBarts Health NHS TrustLondonUK
| |
Collapse
|
5
|
Van Hout MC, Akugizibwe M, Shayo EH, Namulundu M, Kasujja FX, Namakoola I, Birungi J, Okebe J, Murdoch J, Mfinanga SG, Jaffar S. Decentralising chronic disease management in sub-Saharan Africa: a protocol for the qualitative process evaluation of community-based integrated management of HIV, diabetes and hypertension in Tanzania and Uganda. BMJ Open 2024; 14:e078044. [PMID: 38508649 PMCID: PMC10961519 DOI: 10.1136/bmjopen-2023-078044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION Sub-Saharan Africa continues to experience a syndemic of HIV and non-communicable diseases (NCDs). Vertical (stand-alone) HIV programming has provided high-quality care in the region, with almost 80% of people living with HIV in regular care and 90% virally suppressed. While integrated health education and concurrent management of HIV, hypertension and diabetes are being scaled up in clinics, innovative, more efficient and cost-effective interventions that include decentralisation into the community are required to respond to the increased burden of comorbid HIV/NCD disease. METHODS AND ANALYSIS This protocol describes procedures for a process evaluation running concurrently with a pragmatic cluster-randomised trial (INTE-COMM) in Tanzania and Uganda that will compare community-based integrated care (HIV, diabetes and hypertension) with standard facility-based integrated care. The INTE-COMM intervention will manage multiple conditions (HIV, hypertension and diabetes) in the community via health monitoring and adherence/lifestyle advice (medicine, diet and exercise) provided by community nurses and trained lay workers, as well as the devolvement of NCD drug dispensing to the community level. Based on Bronfenbrenner's ecological systems theory, the process evaluation will use qualitative methods to investigate sociostructural factors shaping care delivery and outcomes in up to 10 standard care facilities and/or intervention community sites with linked healthcare facilities. Multistakeholder interviews (patients, community health workers and volunteers, healthcare providers, policymakers, clinical researchers and international and non-governmental organisations), focus group discussions (community leaders and members) and non-participant observations (community meetings and drug dispensing) will explore implementation from diverse perspectives at three timepoints in the trial implementation. Iterative sampling and analysis, moving between data collection points and data analysis to test emerging theories, will continue until saturation is reached. This process of analytic reflexivity and triangulation across methods and sources will provide findings to explain the main trial findings and offer clear directions for future efforts to sustain and scale up community-integrated care for HIV, diabetes and hypertension. ETHICS AND DISSEMINATION The protocol has been approved by the University College of London (UK), the London School of Hygiene and Tropical Medicine Ethics Committee (UK), the Uganda National Council for Science and Technology and the Uganda Virus Research Institute Research and Ethics Committee (Uganda) and the Medical Research Coordinating Committee of the National Institute for Medical Research (Tanzania). The University College of London is the trial sponsor. Dissemination of findings will be done through journal publications and stakeholder meetings (with study participants, healthcare providers, policymakers and other stakeholders), local and international conferences, policy briefs, peer-reviewed journal articles and publications. TRIAL REGISTRATION NUMBER ISRCTN15319595.
Collapse
Affiliation(s)
| | | | - Elizabeth Henry Shayo
- Health Systems, Policy and Translational Reseach Section, National Institute for Medical Research, Dar es Salaam, Tanzania, United Republic
| | - Moreen Namulundu
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
| | | | - Ivan Namakoola
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
| | | | - Joseph Okebe
- Institute for Global Health, University College London, London, UK
| | - Jamie Murdoch
- School of Life Course and Population Sciences, King's College London, London, London, UK
| | - Sayoki Godfrey Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research Tanzania, Dar es Salaam, Tanzania, United Republic of
| | - Shabbar Jaffar
- Institute for Global Health, University College London, London, UK
| |
Collapse
|
6
|
Mahalie R, Angula P, Mitonga KH, Oladimeji O. Patterns of availability and accuracy of risk factor data for cardiovascular diseases among people initiated on antiretroviral therapy at selected health facilities in Khomas region, Namibia: a retrospective, cross-sectional, quantitative study. Pan Afr Med J 2024; 47:33. [PMID: 38586067 PMCID: PMC10998256 DOI: 10.11604/pamj.2024.47.33.25340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/27/2023] [Indexed: 04/09/2024] Open
Abstract
Introduction quality data is a prerequisite for timely decision-making and measuring health outcomes in public health settings. Comorbidities such as cardiovascular diseases (CVDs) among people living with HIV (PLHIV), require a robust system that ensures credible data at all data-producing levels. The study at determining the level of availability and completeness of CVDs risk factors data of PLHIV. Methods a quantitative study was conducted to extract CVDs risk factors data retrospectively from 529 patient care booklets (PCBs) between 2004 and 2017. The analysis was done with the Statistical Package for Social Sciences (SPSS) version 25. Pearson Chi-Square was used to test for associations. The level of significance was at p ≤ 0.05. Results the study revealed that 72.8% of patients are at risk of CVDs due to incomplete demographics (73.72%) and other systemic data (41.18%). A significant association was found (Pearson Chi-Square test 19.907; p-value of 0.001) between average visits per year, accurate data recording, and active status of the patient. Lost to follow-up (15%) and true retention (27.2%) was significantly associated with the last Antiretroviral Therapy (ART) status of a patient (Pearson Chi-Square test 87.754; p-value of 0.001). Conclusion the study that despite concerted efforts to improve data quality, the availability and completeness of data remain unsatisfactory. Lack of harmonised data screening and analysis efforts for CVDs risk factors is found to be a significant risk factor in ensuring integrated routine measuring of CVDs health outcomes for PLHIV.
Collapse
Affiliation(s)
- Roswitha Mahalie
- Faculty of Health and Applied Sciences, Namibia University of Science and Technology, Windhoek, Namibia
| | - Penehafo Angula
- School of Public Health, Oshakati Campus, Faculty of Health Sciences, University of Namibia, Oshakati, Namibia
| | - Kabwebwe Honoré Mitonga
- School of Public Health, Oshakati Campus, Faculty of Health Sciences, University of Namibia, Oshakati, Namibia
| | - Olanrewaju Oladimeji
- Department of Epidemiology and Biostatistics, School of Public Health, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| |
Collapse
|
7
|
Spencer SA, Rutta A, Hyuha G, Banda GT, Choko A, Dark P, Hertz JT, Mmbaga BT, Mfinanga J, Mijumbi R, Muula A, Nyirenda M, Rosu L, Rubach M, Salimu S, Sakita F, Salima C, Sawe H, Simiyu I, Taegtmeyer M, Urasa S, White S, Yongolo NM, Rylance J, Morton B, Worrall E, Limbani F. Multimorbidity-associated emergency hospital admissions: a "screen and link" strategy to improve outcomes for high-risk patients in sub-Saharan Africa: a prospective multicentre cohort study protocol. NIHR OPEN RESEARCH 2024; 4:2. [PMID: 39145104 PMCID: PMC11320189 DOI: 10.3310/nihropenres.13512.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 08/16/2024]
Abstract
Background The prevalence of multimorbidity (the presence of two or more chronic health conditions) is rapidly increasing in sub-Saharan Africa. Hospital care pathways that focus on single presenting complaints do not address this pressing problem. This has the potential to precipitate frequent hospital readmissions, increase health system and out-of-pocket expenses, and may lead to premature disability and death. We aim to present a description of inpatient multimorbidity in a multicentre prospective cohort study in Malawi and Tanzania. Primary objectives Clinical: Determine prevalence of multimorbid disease among adult medical admissions and measure patient outcomes. Health Economic: Measure economic costs incurred and changes in health-related quality of life (HRQoL) at 90 days post-admission. Situation analysis: Qualitatively describe pathways of patients with multimorbidity through the health system. Secondary objectives Clinical: Determine hospital readmission free survival and markers of disease control 90 days after admission. Health Economic: Present economic costs from patient and health system perspective, sub-analyse costs and HRQoL according to presence of different diseases. Situation analysis: Understand health literacy related to their own diseases and experience of care for patients with multimorbidity and their caregivers. Methods This is a prospective longitudinal cohort study of adult (≥18 years) acute medical hospital admissions with nested health economic and situation analysis in four hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Malawi; 3) Hai District Hospital, Boma Ng'ombe, Tanzania; 4) Muhimbili National Hospital, Dar-es-Salaam, Tanzania. Follow-up duration will be 90 days from hospital admission. We will use consecutive recruitment within 24 hours of emergency presentation and stratified recruitment across four sites. We will use point-of-care tests to refine estimates of disease pathology. We will conduct qualitative interviews with patients, caregivers, healthcare providers and policymakers; focus group discussions with patients and caregivers, and observations of hospital care pathways.
Collapse
Affiliation(s)
- Stephen A. Spencer
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Alice Rutta
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Gimbo Hyuha
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Gift Treighcy Banda
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | | | - Paul Dark
- Humanitarian and Conflict Response Institute, The University of Manchester, Manchester, England, UK
| | - Julian T. Hertz
- Duke University School of Medicine, Duke University, Durham, North Carolina, USA
| | | | - Juma Mfinanga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rhona Mijumbi
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | - Adamson Muula
- The Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Laura Rosu
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Matthew Rubach
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Duke University School of Medicine, Duke University, Durham, North Carolina, USA
| | - Sangwani Salimu
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Francis Sakita
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | - Hendry Sawe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ibrahim Simiyu
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Miriam Taegtmeyer
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Sarah Urasa
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Sarah White
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Nateiya M. Yongolo
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Jamie Rylance
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Ben Morton
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Eve Worrall
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
| | - Felix Limbani
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | - MultiLink Consortium
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, England, UK
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Humanitarian and Conflict Response Institute, The University of Manchester, Manchester, England, UK
- Duke University School of Medicine, Duke University, Durham, North Carolina, USA
- The Kamuzu University of Health Sciences, Blantyre, Malawi
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Achikondi Women Community Clinic, Lilongwe, Malawi
| |
Collapse
|
8
|
Molefe-Baikai OJ, Kebotsamang K, Modisawakgomo P, Tlhakanelo JT, Motlhatlhedi K, Moshomo T, Youssouf NF, Masupe T, Gaolathe T, Tapela N, Lockman S, Mosepele M. Self-reported cardiovascular disease risk factor screening among people living with HIV vs. members of the general population in Botswana: a community-based study. BMC Public Health 2024; 24:198. [PMID: 38229024 PMCID: PMC10792864 DOI: 10.1186/s12889-024-17651-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/03/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Morbidity and mortality due to cardiovascular diseases (CVDs) are high and increasing in low- and middle-income countries. People living with HIV (PLWH) are more likely to experience CVD than members of the general population. Therefore, we aimed to assess whether PLWH were more likely to have previously been screened for cardiovascular disease risk factors (CVDRFs) than people without HIV. METHODS A population-based, cross-sectional study was conducted among individuals aged 16 to 68 years across 22 communities in Botswana from February to August 2017 as part of a larger community-based cluster randomized HIV treatment-as-prevention trial. Participants were asked if they had been screened for and counselled on cardiovascular disease risk factors (history of hypertension or blood pressure check, blood glucose and cholesterol measurements, weight check and weight control, tobacco smoking and cessation, alcohol use and physical activity) in the preceding 3 years. HIV testing was offered to those with an unknown HIV status. Multiple logistic regression analysis controlling for age and sex was used to assess the relationship between CVDRF screening and HIV status. RESULTS Of the 3981 participants enrolled, 2547 (64%) were female, and 1196 (30%) were PLWH (93% already on antiretroviral therapy [ART]). PLWH were more likely to report previous screening for diabetes (25% vs. 19%, p < 0.001), elevated cholesterol (17% vs. 12%, p < 0.001) and to have had their weight checked (76% vs. 55%, p < 0.001) than HIV-uninfected participants. PLWH were also more likely to have received counselling on salt intake (42% vs. 33%, p < 0.001), smoking cessation (66% vs. 46%, p < 0.001), weight control (38% vs. 29%, p < 0.001), physical activity (46% vs. 34%, p < 0.001) and alcohol consumption (35% vs. 23%, p < 0.001) than their HIV-uninfected counterparts. Overall, PLWH were more likely to have received screening for and/or counselling on CVDRFs (adjusted odds ratio 1.84, 95% CI: 1.46-2.32, p < 0.001). CONCLUSION PLWH were almost two times more likely to have been previously screened for CVDRFs than those without HIV, indicating a need for universal scale-up of integrated management and prevention of CVDs in the HIV-uninfected population.
Collapse
Affiliation(s)
- Onkabetse Julia Molefe-Baikai
- Faculty of Medicine, Department of Internal Medicine, University of Botswana, Princess Marina Hospital, Gaborone, Botswana.
| | - Kago Kebotsamang
- Faculty of Social Sciences, Department of Statistics, University of Botswana, Gaborone, Botswana
| | | | - John Thato Tlhakanelo
- Faculty of Medicine, Department of Family Medicine and Public Health, University of Botswana, Gaborone, Botswana
| | - Keneilwe Motlhatlhedi
- Faculty of Medicine, Department of Family Medicine and Public Health, University of Botswana, Gaborone, Botswana
| | - Thato Moshomo
- Faculty of Medicine, Department of Internal Medicine, University of Botswana, Princess Marina Hospital, Gaborone, Botswana
| | - Nabila Farah Youssouf
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- London School of Hygiene and Tropical Medicine, London, UK
| | - Tiny Masupe
- Faculty of Medicine, Department of Family Medicine and Public Health, University of Botswana, Gaborone, Botswana
| | - Tendani Gaolathe
- Faculty of Medicine, Department of Internal Medicine, University of Botswana, Princess Marina Hospital, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Neo Tapela
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- International Consortium for Health Outcomes Measurement, Boston, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, USA
| | - Shahin Lockman
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, USA
| | - Mosepele Mosepele
- Faculty of Medicine, Department of Internal Medicine, University of Botswana, Princess Marina Hospital, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, USA
| |
Collapse
|
9
|
Blair J, Kempf MC, Dionne JA, Causey-Pruitt Z, Wise JM, Jackson EA, Muntner P, Hanna DB, Kizer JR, Fischl MA, Ofotokun I, Adimora AA, Gange SJ, Brill IK, Levitan EB. Disparities in Hypertension Prevalence, Awareness, Treatment, and Control Among Women Living With and Without HIV in the US South. Open Forum Infect Dis 2024; 11:ofad642. [PMID: 38196400 PMCID: PMC10776242 DOI: 10.1093/ofid/ofad642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024] Open
Abstract
Background Hypertension-related diseases are major causes of morbidity among women living with HIV. We evaluated cross-sectional associations of race/ethnicity and HIV infection with hypertension prevalence, awareness, treatment, and control. Methods Among women recruited into Southern sites of the Women's Interagency HIV Study (2013-2015), hypertension was defined as (1) systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg according to clinical guidelines when data were collected, (2) self-report of hypertension, or (3) use of antihypertensive medication. Awareness was defined as self-report of hypertension, and treatment was self-report of any antihypertensive medication use. Blood pressure control was defined as <140/90 mm Hg at baseline. Prevalence ratios for each hypertension outcome were estimated through Poisson regression models with robust variance estimators adjusted for sociodemographic, behavioral, and clinical risk factors. Results Among 712 women, 56% had hypertension and 83% were aware of their diagnosis. Of those aware, 83% were using antihypertensive medication, and 63% of those treated had controlled hypertension. In adjusted analyses, non-Hispanic White and Hispanic women had 31% and 48% lower prevalence of hypertension than non-Hispanic Black women, respectively. Women living with HIV who had hypertension were 19% (P = .04) more likely to be taking antihypertension medication when compared with women living without HIV. Conclusions In this study population of women living with and without HIV in the US South, the prevalence of hypertension was lowest among Hispanic women and highest among non-Hispanic Black women. Despite similar hypertension prevalence, women living with HIV were more likely to be taking antihypertensive medication when compared with women living without HIV.
Collapse
Affiliation(s)
- Jessica Blair
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mirjam-Colette Kempf
- Schools of Nursing, Public Health, and Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jodie A Dionne
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Zenoria Causey-Pruitt
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jenni M Wise
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth A Jackson
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David B Hanna
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NewYork, USA
| | - Jorge R Kizer
- Cardiology Section, SanFrancisco Veterans Health Care System, and Departments of Medicine, Epidemiology, and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Margaret A Fischl
- Division of Infectious Diseases, Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Igho Ofotokun
- Division of Infectious Diseases, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Adaora A Adimora
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephen J Gange
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ilene K Brill
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
10
|
Te V, Ma S, Por I, Van Damme W, Wouters E, van Olmen J. Diabetes care components effectively implemented in the ASEAN health systems: an umbrella review of systematic reviews. BMJ Open 2023; 13:e071427. [PMID: 37816569 PMCID: PMC10565207 DOI: 10.1136/bmjopen-2022-071427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 09/11/2023] [Indexed: 10/12/2023] Open
Abstract
OBJECTIVES Association of Southeast Asian Nations (ASEAN) is among the hardest hit low-income and middle-income countries by diabetes. Innovative Care for Chronic Conditions (ICCC) framework has been adopted by the WHO for health system transformation towards better care for chronic conditions including diabetes. We conducted an umbrella review of systematic reviews on diabetes care components effectively implemented in the ASEAN health systems and map those effective care components into the ICCC framework. DESIGN An umbrella review of systematic reviews and/or meta-analyses following JBI (Joanna Briggs Institute) guidelines. DATA SOURCES Health System Evidence, Health Evidence, PubMed and Ovid MEDLINE. ELIGIBILITY CRITERIA We included systematic reviews and/or meta-analyses which focused on management of type 2 diabetes, reported improvements in measured outcomes and had at least one ASEAN member state in the study setting. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted the data and mapped the included studies into the ICCC framework. A narrative synthesis method was used to summarise the findings. The included studies were assessed for methodological quality based on the JBI critical appraisal checklist for systematic reviews and research syntheses. RESULTS 479 records were found of which 36 studies were included for the analysis. A multidisciplinary healthcare team including pharmacists and nurses has been reported to effectively support patients in self-management of their conditions. This can be supported by effective use of digital health interventions. Community health workers either peers or lay people with necessary software (knowledge and skills) and hardware (medical equipment and supplies) can provide complementary care to that of the healthcare staff. CONCLUSION To meet challenges of the increased burden of chronic conditions including diabetes, health policy-makers in the ASEAN member states can consider a paradigm shift in human resources for health towards the multidisciplinary, inclusive, collaborative and complementary team.
Collapse
Affiliation(s)
- Vannarath Te
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
- Health Policy Unit, Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
- Department of Family Medicine and Population Health, University of Antwerp, Antwerpen, Belgium
| | - Sokvy Ma
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
| | - Ir Por
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
- Management Team, National Institute of Public Health, Phnom Penh, Cambodia
| | - Wim Van Damme
- Health Policy Unit, Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Edwin Wouters
- Department of Sociology, Centre for Population, Family & Health, University of Antwerp, Antwerp, Belgium
- Center for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
| | - Josefien van Olmen
- Department of Family Medicine and Population Health, University of Antwerp, Antwerpen, Belgium
| |
Collapse
|
11
|
Kivuyo S, Birungi J, Okebe J, Wang D, Ramaiya K, Ainan S, Tumuhairwe F, Ouma S, Namakoola I, Garrib A, van Widenfelt E, Mutungi G, Jaoude GA, Batura N, Musinguzi J, Ssali MN, Etukoit BM, Mugisha K, Shimwela M, Ubuguyu OS, Makubi A, Jeffery C, Watiti S, Skordis J, Cuevas L, Sewankambo NK, Gill G, Katahoire A, Smith PG, Bachmann M, Lazarus JV, Mfinanga S, Nyirenda MJ, Jaffar S. Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic cluster-randomised, controlled trial. Lancet 2023; 402:1241-1250. [PMID: 37805215 DOI: 10.1016/s0140-6736(23)01573-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND In sub-Saharan Africa, health-care provision for chronic conditions is fragmented. The aim of this study was to determine whether integrated management of HIV, diabetes, and hypertension led to improved rates of retention in care for people with diabetes or hypertension without adversely affecting rates of HIV viral suppression among people with HIV when compared to standard vertical care in medium and large health facilities in Uganda and Tanzania. METHODS In INTE-AFRICA, a pragmatic cluster-randomised, controlled trial, we randomly allocated primary health-care facilities in Uganda and Tanzania to provide either integrated care or standard care for HIV, diabetes, and hypertension. Random allocation (1:1) was stratified by location, infrastructure level, and by country, with a permuted block randomisation method. In the integrated care group, participants with HIV, diabetes, or hypertension were managed by the same health-care workers, used the same pharmacy, had similarly designed medical records, shared the same registration and waiting areas, and had an integrated laboratory service. In the standard care group, these services were delivered vertically for each condition. Patients were eligible to join the trial if they were living with confirmed HIV, diabetes, or hypertension, were aged 18 years or older, were living within the catchment population area of the health facility, and were likely to remain in the catchment population for 6 months. The coprimary outcomes, retention in care (attending a clinic within the last 6 months of study follow-up) for participants with either diabetes or hypertension (tested for superiority) and plasma viral load suppression for those with HIV (>1000 copies per mL; tested for non-inferiority, 10% margin), were analysed using generalised estimating equations in the intention-to-treat population. This trial is registered with ISCRTN 43896688. FINDINGS Between June 30, 2020, and April 1, 2021 we randomly allocated 32 health facilities (17 in Uganda and 15 in Tanzania) with 7028 eligible participants to the integrated care or the standard care groups. Among participants with diabetes, hypertension, or both, 2298 (75·8%) of 3032 were female and 734 (24·2%) of 3032 were male. Of participants with HIV alone, 2365 (70·3%) of 3365 were female and 1000 (29·7%) of 3365 were male. Follow-up lasted for 12 months. Among participants with diabetes, hypertension, or both, the proportion alive and retained in care at study end was 1254 (89·0%) of 1409 in integrated care and 1457 (89·8%) of 1623 in standard care. The risk differences were -0·65% (95% CI -5·76 to 4·46; p=0·80) unadjusted and -0·60% (-5·46 to 4·26; p=0·81) adjusted. Among participants with HIV, the proportion who had a plasma viral load of less than 1000 copies per mL was 1412 (97·0%) of 1456 in integrated care and 1451 (97·3%) of 1491 in standard care. The differences were -0·37% (one-sided 95% CI -1·99 to 1·26; pnon-inferiority<0·0001 unadjusted) and -0·36% (-1·99 to 1·28; pnon-inferiority<0·0001 adjusted). INTERPRETATION In sub-Saharan Africa, integrated chronic care services could achieve a high standard of care for people with diabetes or hypertension without adversely affecting outcomes for people with HIV. FUNDING European Union Horizon 2020 and Global Alliance for Chronic Diseases.
Collapse
Affiliation(s)
- Sokoine Kivuyo
- National Institutes for Medical Research, Dar es Salaam, Tanzania; Barcelona Institute for Global Health Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Josephine Birungi
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda; Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda; School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Joseph Okebe
- Institute for Global Health, University College London, London, UK
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kaushik Ramaiya
- Tanzania NCDs Alliance, Dar es Salaam, Tanzania; Shree Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | - Samafilan Ainan
- National Institutes for Medical Research, Dar es Salaam, Tanzania
| | - Faith Tumuhairwe
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | - Simple Ouma
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | - Ivan Namakoola
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Anupam Garrib
- Institute for Global Health, University College London, London, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Ministry of Health, Kampala, Uganda
| | | | - Neha Batura
- Institute for Global Health, University College London, London, UK
| | | | | | | | - Kenneth Mugisha
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | | | | | | | - Caroline Jeffery
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Stephen Watiti
- The National Forum of People Living with HIV Networks in Uganda, Kampala, Uganda
| | - Jolene Skordis
- Institute for Global Health, University College London, London, UK
| | - Luis Cuevas
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Geoff Gill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anne Katahoire
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Peter G Smith
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Max Bachmann
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health Hospital Clinic, University of Barcelona, Barcelona, Spain; CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | - Sayoki Mfinanga
- National Institutes for Medical Research, Dar es Salaam, Tanzania; Institute for Global Health, University College London, London, UK
| | - Moffat J Nyirenda
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Shabbar Jaffar
- Institute for Global Health, University College London, London, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| |
Collapse
|
12
|
Kisigo GA, Peck RN. Integrating HIV, hypertension, and diabetes primary care in Africa. Lancet 2023; 402:1211-1213. [PMID: 37805198 DOI: 10.1016/s0140-6736(23)01884-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/04/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Godfrey A Kisigo
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania; Departments of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania; Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Robert N Peck
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania; Departments of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania; Center for Global Health, Departments of Medicine and Pediatrics, Weill Cornell Medicine, New York, NY, USA.
| |
Collapse
|
13
|
Rohwer A, Toews I, Uwimana-Nicol J, Nyirenda JLZ, Niyibizi JB, Akiteng AR, Meerpohl JJ, Bavuma CM, Kredo T, Young T. Models of integrated care for multi-morbidity assessed in systematic reviews: a scoping review. BMC Health Serv Res 2023; 23:894. [PMID: 37612604 PMCID: PMC10463690 DOI: 10.1186/s12913-023-09894-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 08/10/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND The prevalence of multi-morbidity is increasing globally. Integrated models of care present a potential intervention to improve patient and health system outcomes. However, the intervention components and concepts within different models of care vary widely and their effectiveness remains unclear. We aimed to describe and map the definitions, characteristics, components, and reported effects of integrated models of care in systematic reviews (SRs). METHODS We conducted a scoping review of SRs according to pre-specified methods (PROSPERO 2019 CRD42019119265). Eligible SRs assessed integrated models of care at primary health care level for adults and children with multi-morbidity. We searched in PubMed (MEDLINE), Embase, Cochrane Database of Systematic Reviews, Epistemonikos, and Health Systems Evidence up to 3 May 2022. Two authors independently assessed eligibility of SRs and extracted data. We identified and described common components of integrated care across SRs. We extracted findings of the SRs as presented in the conclusions and reported on these verbatim. RESULTS We included 22 SRs, examining data from randomised controlled trials and observational studies conducted across the world. Definitions and descriptions of models of integrated care varied considerably. However, across SRs, we identified and described six common components of integrated care: (1) chronic conditions addressed, (2) where services were provided, (3) the type of services provided, (4) healthcare professionals involved in care, (5) coordination and organisation of care and (6) patient involvement in care. We observed differences in the components of integrated care according to the income setting of the included studies. Some SRs reported that integrated care was beneficial for health and process outcomes, while others found no difference in effect when comparing integrated care to other models of care. CONCLUSIONS Integrated models of care were heterogeneous within and across SRs. Information that allows the identification of effective components of integrated care was lacking. Detailed, standardised and transparent reporting of the intervention components and their effectiveness on health and process outcomes is needed.
Collapse
Affiliation(s)
- Anke Rohwer
- Centre for Evidence-based Health Care, Division Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Ingrid Toews
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Jeannine Uwimana-Nicol
- Centre for Evidence-based Health Care, Division Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - John L Z Nyirenda
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | | | - Ann R Akiteng
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Charlotte M Bavuma
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Kigali University Teaching Hospital, Kigali, Rwanda
| | - Tamara Kredo
- South African Medical Research Council, Cochrane South Africa, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Taryn Young
- Centre for Evidence-based Health Care, Division Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
14
|
Moloi H, Daniels K, Brooke-Sumner C, Cooper S, Odendaal WA, Thorne M, Akama E, Leon N. Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence. Cochrane Database Syst Rev 2023; 7:CD013603. [PMID: 37466272 PMCID: PMC10355136 DOI: 10.1002/14651858.cd013603.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses. OBJECTIVES To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified. SELECTION CRITERIA We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification. DATA COLLECTION AND ANALYSIS For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population. MAIN RESULTS The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations. AUTHORS' CONCLUSIONS This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.
Collapse
Affiliation(s)
- Hlengiwe Moloi
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Carrie Brooke-Sumner
- Alcohol Tobacco and Other Drug Research Unit, The South African Medical Research Council, Cape Town, South Africa
| | - Sara Cooper
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Social & Behavioural Sciences Division, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | | | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Natalie Leon
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
| |
Collapse
|
15
|
Moloi H, Daniels K, Brooke-Sumner C, Cooper S, Odendaal WA, Thorne M, Akama E, Leon N. Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence. Cochrane Database Syst Rev 2023; 7:CD013603. [PMID: 37434293 PMCID: PMC10335778 DOI: 10.1002/14651858.cd013603.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses. OBJECTIVES To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified. SELECTION CRITERIA We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification. DATA COLLECTION AND ANALYSIS For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population. MAIN RESULTS The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations. AUTHORS' CONCLUSIONS This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.
Collapse
Affiliation(s)
- Hlengiwe Moloi
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Carrie Brooke-Sumner
- Alcohol Tobacco and Other Drug Research Unit, The South African Medical Research Council, Cape Town, South Africa
| | - Sara Cooper
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Social & Behavioural Sciences Division, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | | | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Natalie Leon
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
| |
Collapse
|
16
|
Van Hout MC, Zalwango F, Akugizibwe M, Chaka MN, Birungi J, Okebe J, Jaffar S, Bachmann M, Murdoch J. Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial. BMC Health Serv Res 2023; 23:570. [PMID: 37268916 DOI: 10.1186/s12913-023-09534-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/10/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Sub-Saharan Africa is experiencing a dual burden of chronic human immunodeficiency virus and non-communicable diseases. A pragmatic parallel arm cluster randomised trial (INTE-AFRICA) scaled up 'one-stop' integrated care clinics for HIV-infection, diabetes and hypertension at selected facilities in Uganda. These clinics operated integrated health education and concurrent management of HIV, hypertension and diabetes. A process evaluation (PE) aimed to explore the experiences, attitudes and practices of a wide variety of stakeholders during implementation and to develop an understanding of the impact of broader structural and contextual factors on the process of service integration. METHODS The PE was conducted in one integrated care clinic, and consisted of 48 in-depth interviews with stakeholders (patients, healthcare providers, policy-makers, international organisation, and clinical researchers); three focus group discussions with community leaders and members (n = 15); and 8 h of clinic-based observation. An inductive analytical approach collected and analysed the data using the Empirical Phenomenological Psychological five-step method. Bronfenbrenner's ecological framework was subsequently used to conceptualise integrated care across multiple contextual levels (macro, meso, micro). RESULTS Four main themes emerged; Implementing the integrated care model within healthcare facilities enhances detection of NCDs and comprehensive co-morbid care; Challenges of NCD drug supply chains; HIV stigma reduction over time, and Health education talks as a mechanism for change. Positive aspects of integrated care centred on the avoidance of duplication of care processes; increased capacity for screening, diagnosis and treatment of previously undiagnosed comorbid conditions; and broadening of skills of health workers to manage multiple conditions. Patients were motivated to continue receiving integrated care, despite frequent NCD drug stock-outs; and development of peer initiatives to purchase NCD drugs. Initial concerns about potential disruption of HIV care were overcome, leading to staff motivation to continue delivering integrated care. CONCLUSIONS Implementing integrated care has the potential to sustainably reduce duplication of services, improve retention in care and treatment adherence for co/multi-morbid patients, encourage knowledge-sharing between patients and providers, and reduce HIV stigma. TRIAL REGISTRATION NUMBER ISRCTN43896688.
Collapse
Affiliation(s)
| | - Flavia Zalwango
- MRC/UVRI & LSHTM Research Unit, MRC/UVRI & LSHTM, Entebbe, Uganda
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Iwelunmor J, Ogedegbe G, Dulli L, Aifah A, Nwaozuru U, Obiezu-Umeh C, Onakomaiya D, Rakhra A, Mishra S, Colvin CL, Adeoti E, Badejo O, Murray K, Uguru H, Shedul G, Hade EM, Henry D, Igbong A, Lew D, Bansal GP, Ojji D. Organizational readiness to implement task-strengthening strategy for hypertension management among people living with HIV in Nigeria. Implement Sci Commun 2023; 4:47. [PMID: 37143131 PMCID: PMC10157928 DOI: 10.1186/s43058-023-00425-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 04/04/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Hypertension (HTN) is highly prevalent among people living with HIV (PLHIV), but there is limited access to standardized HTN management strategies in public primary healthcare facilities in Nigeria. The shortage of trained healthcare providers in Nigeria is an important contributor to the increased unmet need for HTN management among PLHIV. Evidence-based TAsk-Strengthening Strategies for HTN control (TASSH) have shown promise to address this gap in other resource-constrained settings. However, little is known regarding primary health care facilities' capacity to implement this strategy. The objective of this study was to determine primary healthcare facilities' readiness to implement TASSH among PLHIV in Nigeria. METHODS This study was conducted with purposively selected healthcare providers at fifty-nine primary healthcare facilities in Akwa-Ibom State, Nigeria. Healthcare facility readiness data were measured using the Organizational Readiness to Change Assessment (ORCA) tool. ORCA is based on the Promoting Action on Research Implementation in Health Services (PARIHS) framework that identifies evidence, context, and facilitation as the key factors for effective knowledge translation. Quantitative data were analyzed using descriptive statistics (including mean ORCA subscales). We focused on the ORCA context domain, and responses were scored on a 5-point Likert scale, with 1 corresponding to disagree strongly. FINDINGS Fifty-nine healthcare providers (mean age 45; standard deviation [SD]: 7.4, 88% female, 68% with technical training, 56% nurses, 56% with 1-5 years providing HIV care) participated in the study. Most healthcare providers provide care to 11-30 patients living with HIV per month in their health facility, with about 42% of providers reporting that they see between 1 and 10 patients with HTN each month. Overall, staff culture (mean 4.9 [0.4]), leadership support (mean 4.9 [0.4]), and measurement/evidence-assessment (mean 4.6 [0.5]) were the topped-scored ORCA subscales, while scores on facility resources (mean 3.6 [0.8]) were the lowest. CONCLUSION Findings show organizational support for innovation and the health providers at the participating health facilities. However, a concerted effort is needed to promote training capabilities and resources to deliver services within these primary healthcare facilities. These results are invaluable in developing future strategies to improve the integration, adoption, and sustainability of TASSH in primary healthcare facilities in Nigeria. TRIAL REGISTRATION NCT05031819.
Collapse
Affiliation(s)
- Juliet Iwelunmor
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, St. Louis, USA.
| | - Gbenga Ogedegbe
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
- Institute for Excellence in Health Equity, New York University Grossman School of Medicine, New York, NY, USA
| | - Lisa Dulli
- Family Health International 360, Durham, USA
| | - Angela Aifah
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Ucheoma Nwaozuru
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Chisom Obiezu-Umeh
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, St. Louis, USA
| | - Deborah Onakomaiya
- Vilcek Institute of Graduate Biomedical Sciences, New York University Grossman School of Medicine, New York, NY, USA
| | - Ashlin Rakhra
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Shivani Mishra
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Calvin L Colvin
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Ebenezer Adeoti
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, St. Louis, USA
| | | | - Kate Murray
- Family Health International 360, Durham, USA
| | - Henry Uguru
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Gabriel Shedul
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
- Department of Family Medicine, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Erinn M Hade
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Daniel Henry
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
| | - Ayei Igbong
- Family Health International 360, Durham, USA
| | - Daphne Lew
- Washington University School of Medicine, Washington University in St. Louis, St. Louis, USA
| | | | - Dike Ojji
- Cardiovascular Research Unit, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
- Department of Internal Medicine, Faculty of Clinical Sciences, College of Health Sciences, University of Abuja, Gwagwalada, Abuja, Nigeria
| |
Collapse
|
18
|
Liu DF, Zhang XY, Zhou RF, Cai L, Yan DM, Lan LJ, He SH, Tang H. Glucose metabolism continuous deteriorating in male patients with human immunodeficiency virus accepted antiretroviral therapy for 156 weeks. World J Diabetes 2023; 14:299-312. [PMID: 37035225 PMCID: PMC10075030 DOI: 10.4239/wjd.v14.i3.299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 12/21/2022] [Accepted: 02/28/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND The dynamic characteristics of glucose metabolism and its risk factors in patients living with human immunodeficiency virus (PLWH) who accepted primary treatment with the efavirenz (EFV) plus lamivudine (3TC) plus tenofovir (TDF) (EFV + 3TC + TDF) regimen are unclear and warrant investigation.
AIM To study the long-term dynamic characteristics of glucose metabolism and its contributing factors in male PLWH who accepted primary treatment with the EFV + 3TC + TDF regimen for 156 wk.
METHODS This study was designed using a follow-up design. Sixty-one male treatment-naive PLWH, including 50 cases with normal glucose tolerance and 11 cases with prediabetes, were treated with the EFV + 3TC + TDF regimen for 156 wk. The glucose metabolism dynamic characteristics, the main risk factors and the differences among the three CD4+ count groups were analyzed.
RESULTS In treatment-naive male PLWH, regardless of whether glucose metabolism disorder was present at baseline, who accepted treatment with the EFV + 3TC + TDF regimen for 156 wk, a continuous increase in the fasting plasma glucose (FPG) level, the rate of impaired fasting glucose (IFG) and the glycosylated hemoglobin (HbA1c) level were found. These changes were not due to insulin resistance but rather to significantly reduced islet β cell function, according to the homeostasis model assessment of β cell function (HOMA-β). Moreover, the lower the baseline CD4+ T-cell count was, the higher the FPG level and the lower the HOMA-β value. Furthermore, the main risk factors for the FPG levels were the CD3+CD8+ cell count and viral load (VL), and the factors contributing to the HOMA-β values were the alanine aminotransferase level, VL and CD3+CD8+ cell count.
CONCLUSION These findings provide guidance to clinicians who are monitoring FPG levels closely and are concerned about IFG and decreased islet β cell function during antiretroviral therapy with the EFV + 3TC + TDF regimen for long-term application.
Collapse
Affiliation(s)
- Da-Feng Liu
- Department of Internal Medicine, Public Health and Clinical Center of Chengdu, Chengdu 610061, Sichuan Province, China
| | - Xin-Yi Zhang
- Department of Endocrinology and Metabolism, Sichuan University West China Hoapital, Chengdu 610041, Sichuan Province, China
| | - Rui-Feng Zhou
- Department of Infectious Disease, Public Health and Clinical Center of Chengdu, Chengdu 610061, Sichuan Province, China
| | - Lin Cai
- Department of Infectious Disease, Public Health and Clinical Center of Chengdu, Chengdu 610061, Sichuan Province, China
| | - Dong-Mei Yan
- Department of Infectious Disease, Public Health and Clinical Center of Chengdu, Chengdu 610061, Sichuan Province, China
| | - Li-Juan Lan
- Department of Internal Medicine, Public Health and Clinical Center of Chengdu, Chengdu 610061, Sichuan Province, China
| | - Sheng-Hua He
- Department of Infectious Disease, Public Health and Clinical Center of Chengdu, Chengdu 610061, Sichuan Province, China
| | - Hong Tang
- Center of Infectious Disease, Sichuan University West China Hoapital, Chengdu 610041, Sichuan Province, China
| |
Collapse
|
19
|
Trifirò S, Cavallin F, Mangi S, Mhaluka L, Maffoni S, Taddei S, Putoto G, Torelli GF. Hypertension in people living with HIV on combined antiretroviral therapy in rural Tanzania. Afr Health Sci 2023; 23:129-136. [PMID: 37545920 PMCID: PMC10398461 DOI: 10.4314/ahs.v23i1.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Exposure to anti-retroviral therapy in HIV infection has been associated with hypertension, but whether and to what extent HIV-related factors and anti-retroviral treatment contribute to hypertension is not well defined; in addition, data are particularly scarce in Sub-Saharan Africa. Aim of the study was to investigate prevalence and awareness of hypertension in a cohort of people living with HIV (PLWHIV) on anti-retroviral therapy in rural Tanzania, and to identify possible predictors of hypertension. A cross-sectional study on hypertension in PLWHIV was conducted at Tosamaganga District Hospital, Iringa Region, Tanzania. Subjects on anti-retroviral therapy, age 26-80 years and with monthly attendance to the HIV clinic, were considered eligible. A total number of 242 patients were included in the analysis. Sixty-two subjects (26%) had hypertension, the majority (77%) of them not aware of the condition and/or not on treatment. Older age, higher BMI and lower baseline T-CD4 count were predictors of hypertension at multivariate analysis. The results of the study suggest that hypertension screening should become part of ordinary care of PLWHIV in Tanzania, particularly in subjects with more severe immunosuppression. Leveraging already existing HIV services could be an option to prevent the burden of non-AIDS complication and related deaths.
Collapse
Affiliation(s)
- Silvia Trifirò
- Doctors with Africa CUAMM, Iringa, Tanzania
- Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | | | - Sabina Mangi
- Tosamaganga Council Designated Hospital, Iringa, Tanzania
| | | | - Silvia Maffoni
- Doctors with Africa CUAMM, Iringa, Tanzania
- University of Pavia, Italy
| | | | | | - Giovanni F Torelli
- Doctors with Africa CUAMM, Dar Es Salaam, Tanzania
- Policlinico Umberto I, Rome, Italy
| |
Collapse
|
20
|
Wamuti B, Owuor M, Magambo C, Ndegwa M, Sambai B, Temu TM, Farquhar C, Bukusi D. 'My people perish for lack of knowledge': barriers and facilitators to integrated HIV and hypertension screening at the Kenyatta National Hospital, Nairobi, Kenya. Open Heart 2023; 10:openhrt-2022-002195. [PMID: 36707130 PMCID: PMC9884934 DOI: 10.1136/openhrt-2022-002195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/04/2023] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION HIV and cardiovascular disease (CVD) are the two main causes of death in Kenya with hypertension as CVD's leading risk factor and HIV infection a risk factor for hypertension. We qualitatively evaluated the feasibility of integrated HIV and hypertension screening at Kenyatta National Hospital. METHODS We conducted two focus group discussions (FGDs) in November 2020 (female FGD: n=7; male FGD: n=8) to elicit facilitators, barriers and viability of integrated diagnosis and management of both conditions at HIV testing service (HTS) facilities. Participants were selected using convenience sampling and were not pair matched. All participants had received HTS. All female clients had confirmed hypertension, while male relatives had been contacted for HIV and hypertension screening through a modified assisted partner services model-where a trained healthcare provider supports notification. Transcripts were coded independently, and the codebook was developed and revised through consensus discussion. Data were analysed using thematic content analysis. RESULTS Main barriers to diagnosis and management included limited public awareness of hypertension risk factors and on improved treatment outcomes for those on lifelong HIV treatment, high cost of hypertension care despite free HIV care and healthcare system challenges especially medication stockouts. Strong support systems at family and healthcare levels facilitated care and treatment for both conditions. Participants recommended improved public awareness through individual-level communication and mass media campaigns, decentralised screening services for both HIV and hypertension, and either free or subsidised hypertension care services delivered alongside HIV treatment services. Most felt that an integrated HIV and hypertension service model was viable and would improve healthcare outcomes. CONCLUSION Patient-centred care models combining HIV and hypertension services hold promise for integrated service delivery.
Collapse
Affiliation(s)
- Beatrice Wamuti
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Mercy Owuor
- Independent Qualitative Researcher, Nairobi, Kenya
| | - Christine Magambo
- Voluntary counselling and testing (VCT) and HIV prevention unit, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Betsy Sambai
- University of Washington - Kenya, Nairobi, Kenya
| | - Tecla M Temu
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, Washington, USA,Department of Medicine, University of Washington, Seattle, Washington, USA,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - David Bukusi
- Voluntary counselling and testing (VCT) and HIV prevention unit, Kenyatta National Hospital, Nairobi, Kenya
| |
Collapse
|
21
|
Wroe EB, Mailosi B, Price N, Kachimanga C, Shah A, Kalanga N, Dunbar EL, Nazimera L, Gizaw M, Boudreaux C, Dullie L, Neba L, McBain RK. Economic evaluation of integrated services for non-communicable diseases and HIV: costs and client outcomes in rural Malawi. BMJ Open 2022; 12:e063701. [PMID: 36442898 PMCID: PMC9710473 DOI: 10.1136/bmjopen-2022-063701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate the costs and client outcomes associated with integrating screening and treatment for non-communicable diseases (NCDs) into HIV services in a rural and remote part in southeastern Africa. DESIGN Prospective cohort study. SETTING Primary and secondary level health facilities in Neno District, Malawi. PARTICIPANTS New adult enrollees in Integrated Chronic Care Clinics (IC3) between July 2016 and June 2017. MAIN OUTCOME MEASURES We quantified the annualised total and per capita economic cost (US$2017) of integrated chronic care, using activity-based costing from a health system perspective. We also measured enrolment, retention and mortality over the same period. Furthermore, we measured clinical outcomes for HIV (viral load), hypertension (controlled blood pressure), diabetes (average blood glucose), asthma (asthma severity) and epilepsy (seizure frequency). RESULTS The annualised total cost of providing integrated HIV and NCD care was $2 461 901 to provide care to 9471 enrollees, or $260 per capita. This compared with $2 138 907 for standalone HIV services received by 6541 individuals, or $327 per capita. Over the 12-month period, 1970 new clients were enrolled in IC3, with a retention rate of 80%. Among clients with HIV, 81% achieved an undetectable viral load within their first year of enrolment. Significant improvements were observed among clinical outcomes for clients enrolled with hypertension, asthma and epilepsy (p<0.05, in all instances), but not for diabetes (p>0.05). CONCLUSIONS IC3 is one of the largest examples of fully integrated HIV and NCD care. Integrating screening and treatment for chronic health conditions into Malawi's HIV platform appears to be a financially feasible approach associated with several positive clinical outcomes.
Collapse
Affiliation(s)
- Emily B Wroe
- Program in Global Noncommunicable Diseases and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Partners In Health, Boston, MA, USA
| | | | - Natalie Price
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | | | - Adarsh Shah
- Harvard Kennedy School, Cambridge, Massachusetts, USA
| | - Noel Kalanga
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Elizabeth L Dunbar
- Department of Human Centered Design, University of Washington, Seattle, WA, USA
| | | | | | - Chantelle Boudreaux
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Liberty Neba
- Clinton Health Access Initiative, Lilongwe, Malawi
| | - Ryan K McBain
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- RAND Corporation, Santa Monica, California, USA
| |
Collapse
|
22
|
Parati G, Lackland DT, Campbell NRC, Ojo Owolabi M, Bavuma C, Mamoun Beheiry H, Dzudie A, Ibrahim MM, El Aroussy W, Singh S, Varghese CV, Whelton PK, Zhang XH. How to Improve Awareness, Treatment, and Control of Hypertension in Africa, and How to Reduce Its Consequences: A Call to Action From the World Hypertension League. Hypertension 2022; 79:1949-1961. [PMID: 35638381 DOI: 10.1161/hypertensionaha.121.18884] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypertension is the leading preventable risk factor for cardiovascular diseases and disability globally. In low- and middle-income countries hypertension has a major social impact, increasing the disease burden and costs for national health systems. The present call to action aims to stimulate all African countries to adopt several solutions to achieve better hypertension management. The following 3 goals should be achieved in Africa by 2030: (1) 80% of adults with high blood pressure in Africa are diagnosed; (2) 80% of diagnosed hypertensives, that is, 64% of all hypertensives, are treated; and (3) 80% of treated hypertensive patients are controlled. To achieve these aims, we call on individuals and organizations from government, private sector, health care, and civil society in Africa and indeed on all Africans to undertake a few specific high priority actions. The aim is to improve the detection, diagnosis, management, and control of hypertension, now considered to be the leading preventable killer in Africa.
Collapse
Affiliation(s)
- Gianfranco Parati
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular Neural and Metabolic Sciences; and Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P.)
| | - Daniel T Lackland
- Division of Translational Neurosciences and Population Studies, Medical University of South Carolina, Charleston (D.T.L.)
| | - Norman R C Campbell
- Department of Medicine, Physiology and Pharmacology and Community Health Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada (N.R.C.C.)
| | - Mayowa Ojo Owolabi
- Faculty of Clinical Sciences; Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Nigeria (M.O.O.)
| | - Charlotte Bavuma
- Kigali University Teaching Hospital, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda (C.B.)
| | - Hind Mamoun Beheiry
- Faculty of Nursing Sciences; Physiology Department, Faculty of Medicine; International University of Africa (IUA), Sudan (H.M.B.)
| | - Anastase Dzudie
- Faculty of Medicine and biomedical sciences, University of Yaounde 1, Cameroon (A.D.)
| | | | | | - Sandhya Singh
- Director; Cluster: Non-Communicable Diseases, National Department of Health, South Africa (S.S.)
| | - Cherian V Varghese
- Department of Noncommunicable Disease, World Health Organization, Geneva, Switzerland (C.V.V.)
| | - Paul K Whelton
- Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana (P.K.W.)
| | - Xin-Hua Zhang
- Beijing Hypertension League Institute, China (X.-H.Z.)
| | | |
Collapse
|
23
|
Alhassan Y, Twimukye A, Malaba T, Myer L, Waitt C, Lamorde M, Colbers A, Reynolds H, Khoo S, Taegtmeyer M. "It's only fatness, it doesn't kill": a qualitative study on perceptions of weight gain from use of dolutegravir-based regimens in women living with HIV in Uganda. BMC Womens Health 2022; 22:246. [PMID: 35729541 PMCID: PMC9210809 DOI: 10.1186/s12905-022-01814-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background Dolutegravir (DTG)-based regimens have been recommended by the WHO as the preferred first-line and second-line HIV treatment in all populations. Evidence suggests an association with weight gain, particularly among black women. Our study investigated perceptions of weight gain from DTG-based regimen use on body image and adherence of antiretroviral therapy in women living with HIV (WLHIV) in Uganda. Methods Between April and June 2021, we conducted semi-structured interviews involving 25 WLHIV (adolescents, women of reproductive potential and post-menopausal women) and 19 healthcare professionals (clinicians, nurses, ART managers and counsellors) purposively selected from HIV clinics in Kampala. The interviews explored perceptions of body weight and image; experiences and management of weight related side effects associated with DTG; and knowledge and communication of DTG-related risks. Data was analysed thematically in NVivo 12 software. Results Our findings indicate WLHIV in Uganda commonly disliked thin body size and aspired to gain moderate to high level body weight to improve their body image, social standing and hide their sero-positive status. Both WLHIV and healthcare professionals widely associated weight gain with DTG use, although it was rarely perceived as an adverse event and was unlikely to be reported or to alter medication adherence. Clinical management and pharmacovigilance of DTG-related weight gain were hampered by the limited knowledge of WLHIV of the health risks of being over-weight and obesity; lack of diagnostic equipment and resources; and limited clinical guidance for managing weight gain and associated cardiovascular and metabolic comorbidities. Conclusions The study highlights the significance of large body-size in promoting psychosocial wellbeing in WLHIV in Uganda. Although weight gain is recognized as a side effect of DTG, it may be welcomed by some WLHIV. Healthcare professionals should actively talk about and monitor for weight gain and occurrence of associated comorbidities to facilitate timely interventions. Improved supply of diagnostic equipment and support with sufficient guidance for managing weight gain for healthcare professionals in Uganda are recommended. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-022-01814-x.
Collapse
Affiliation(s)
- Yussif Alhassan
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | | | - Thokozile Malaba
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Angela Colbers
- Radboud University Nijmegen Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Helen Reynolds
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Saye Khoo
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Tropical Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.,Tropical Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| |
Collapse
|
24
|
Muddu M, Semitala FC, Kimera I, Mbuliro M, Ssennyonjo R, Kigozi SP, Katwesigye R, Ayebare F, Namugenyi C, Mugabe F, Mutungi G, Longenecker CT, Katahoire AR, Ssinabulya I, Schwartz JI. Improved hypertension control at six months using an adapted WHO HEARTS-based implementation strategy at a large urban HIV clinic in Uganda. BMC Health Serv Res 2022; 22:699. [PMID: 35610717 PMCID: PMC9131679 DOI: 10.1186/s12913-022-08045-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 05/05/2022] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To adapt a World Health Organization HEARTS-based implementation strategy for hypertension (HTN) control at a large urban HIV clinic in Uganda and determine six-month HTN and HIV outcomes among a cohort of adult persons living with HIV (PLHIV). METHODS Our implementation strategy included six elements: health education, medication adherence, and lifestyle counseling; routine HTN screening; task shifting of HTN treatment; evidence-based HTN treatment protocol; consistent supply of HTN medicines free to patients; and inclusion of HTN-specific monitoring and evaluation tools. We conducted a pre-post study from October 2019 to March 2020 to determine the effect of this strategy on HTN and HIV outcomes at baseline and six months. Our cohort comprised adult PLHIV diagnosed with HTN who made at least one clinic visit within two months prior to study onset. FINDINGS We enrolled 1,015 hypertensive PLHIV. The mean age was 50.1 ± 9.5 years and 62.6% were female. HTN outcomes improved between baseline and six months: mean systolic BP (154.3 ± 20.0 to 132.3 ± 13.8 mmHg, p < 0.001); mean diastolic BP (97.7 ± 13.1 to 85.3 ± 9.5 mmHg, p < 0.001) and proportion of patients with controlled HTN (9.3% to 74.1%, p < 0.001). The HTN care cascade also improved: treatment initiation (13.4% to 100%), retention in care (16.2% to 98.5%), monitoring (16.2% to 98.5%), and BP control among those initiated on HTN treatment (2.2% to 75.2%). HIV cascade steps remained high (> 95% at baseline and six months) and viral suppression was unchanged (98.7% to 99.2%, p = 0.712). Taking ART for more than two years and HIV viral suppression were independent predictors of HTN control at six months. CONCLUSIONS A HEARTS-based implementation strategy at a large, urban HIV center facilitates integration of HTN and HIV care and improves HTN outcomes while sustaining HIV control. Further implementation research is needed to study HTN/HIV integration in varied clinical settings among diverse populations.
Collapse
Affiliation(s)
- Martin Muddu
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Fred C. Semitala
- grid.11194.3c0000 0004 0620 0548Makerere University College of Health Sciences, Kampala, Uganda
| | - Isaac Kimera
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Mary Mbuliro
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Rebecca Ssennyonjo
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Simon P. Kigozi
- grid.463352.50000 0004 8340 3103Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Rodgers Katwesigye
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Florence Ayebare
- grid.11194.3c0000 0004 0620 0548Makerere University College of Health Sciences, Kampala, Uganda
| | - Christabellah Namugenyi
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Frank Mugabe
- grid.415705.2Ministry of Health, Kampala, Uganda
| | | | - Chris T. Longenecker
- grid.67105.350000 0001 2164 3847Case Western Reserve University School of Medicine, Cleveland, OH USA
| | - Anne R. Katahoire
- grid.11194.3c0000 0004 0620 0548Makerere University College of Health Sciences, Kampala, Uganda
| | - Isaac Ssinabulya
- grid.416252.60000 0000 9634 2734Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Jeremy I. Schwartz
- grid.47100.320000000419368710Yale School of Medicine, 333 Cedar Street, New Haven, CT 06511 USA
| |
Collapse
|
25
|
Garner BR, Gotham HJ, Knudsen HK, Zulkiewicz BA, Tueller SJ, Berzofsky M, Donohoe T, Martin EG, Brown LL, Gordon T. The Prevalence and Negative Impacts of Substance Use Disorders among People with HIV in the United States: A Real-Time Delphi Survey of Key Stakeholders. AIDS Behav 2022; 26:1183-1196. [PMID: 34586532 PMCID: PMC8940836 DOI: 10.1007/s10461-021-03473-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2021] [Indexed: 02/06/2023]
Abstract
Although HIV and substance use disorders (SUDs) constitute a health syndemic, no research to date has examined the perceived negative impacts of different SUDs for people with HIV (PWH). In May 2019, 643 stakeholders in the U.S., representing clients of AIDS service organizations (ASOs), ASO staff, and HIV/AIDS Planning Council members, participated in an innovative Stakeholder-Engaged Real-Time Delphi (SE-RTD) survey focused on the prevalence and individual-level negative impact of five SUDs for PWH. The SE-RTD method has advantages over conventional survey methods by efficiently sharing information, thereby reducing the likelihood that between-group differences are simply due to lack of information, knowledge, and/or understanding. The population-level negative impacts were calculated by weighting each SUD's individual-level negative impact on indicators of the HIV Care Continuum and other important areas of life by the perceived prevalence of each SUD. Overall, we found these SUDs to have the greatest population-level negative impact scores (possible range 0-24): alcohol use disorder (population-level negative impact = 6.9; perceived prevalence = 41.9%), methamphetamine use disorder (population-level negative impact = 6.5; perceived prevalence = 3.2%), and opioid use disorder (population-level negative impact = 6.4; perceived prevalence = 34.6%). Beyond further demonstration of the need to better integrate SUD services within HIV settings, our findings may help inform how finite funding is allocated for addressing the HIV-SUD syndemic within the U.S. Based on our findings, such future efforts should prioritize the integration of evidence-based treatments that help address use disorders for alcohol, methamphetamine, and opioids.
Collapse
Affiliation(s)
- Bryan R. Garner
- RTI International, Research Triangle Park, P. O. Box 12194, Durham, NC 27709 USA
| | - Heather J. Gotham
- Stanford University School of Medicine, 1520 Page Mill Road MC 5265, Palo Alto, CA 94304 USA
| | - Hannah K. Knudsen
- University of Kentucky, 845 Angliana Avenue, Room 204, Lexington, KY 40508 USA
| | | | - Stephen J. Tueller
- RTI International, Research Triangle Park, P. O. Box 12194, Durham, NC 27709 USA
| | - Marcus Berzofsky
- RTI International, Research Triangle Park, P. O. Box 12194, Durham, NC 27709 USA
| | - Tom Donohoe
- Pacific AIDS Education and Training Center, University of California Los Angeles, Los Angeles, CA 90024 USA
| | - Erika G. Martin
- Rockefeller College of Public Affairs and Policy at the University at Albany, Both part of the State University of New York, 1400 Washington Avenue, Milne 300E, Albany, NY 12222 USA
| | - L. Lauren Brown
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Meharry Medical College, Nashville, TN USA
- Infectious Disease Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN USA
| | | |
Collapse
|
26
|
Chan V, Toccalino D, Omar S, Shah R, Colantonio A. A systematic review on integrated care for traumatic brain injury, mental health, and substance use. PLoS One 2022; 17:e0264116. [PMID: 35239715 PMCID: PMC8893633 DOI: 10.1371/journal.pone.0264116] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 02/03/2022] [Indexed: 12/22/2022] Open
Abstract
Traumatic brain injuries (TBI) and mental health or substance use disorders (MHSU) are global public health concerns due to their prevalence and impact on individuals and societies. However, care for individuals with TBI and MHSU remains fragmented with a lack of appropriate services and supports across the continuum of healthcare. This systematic review provided an evidence-based foundation to inform opportunities to mobilize and adapt existing resources to integrate care for individuals with TBI and MHSU by comprehensively summarizing existing integrated activities and reported barriers and facilitators to care integration. MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Sociological Abstracts, and Dissertations & Theses Global were independently reviewed by two reviewers based on pre-determined eligibility criteria. Data on the integration activity, level and type of integration, reported barriers and facilitators, and the strategies aligning with the World Health Organization’s (WHO) Framework on Integrated Person-Centred Care were extracted to form the basis for a narrative synthesis. Fifty-nine peer-reviewed articles were included, describing treatments (N = 49), programs (N = 4), or screening activities (N = 7). Studies discussing clinical integration at the micro- (N = 38) and meso- (N = 10) levels, service integration at the micro- (N = 6) and meso- (N = 5) levels, and functional integration at the meso-level (N = 1) were identified. A minority of articles reported on facilitators (e.g., cognitive accommodations in treatment plans; N = 7), barriers (e.g., lack of education on cognitive challenges associated with TBI; N = 2), or both (N = 6), related to integrating care. This review demonstrated that integrated TBI and MHSU care already exists across a range of levels and types. Given the finite and competing demands for healthcare resources, cognitive accommodations across treatment plans to facilitate integrated TBI and MHSU care should be considered. Multidisciplinary teams should also be explored to provide opportunities for education among health professionals so they can be familiar with TBI and MHSU. Trial registration: Prospero Registration: CRD42018108343.
Collapse
Affiliation(s)
- Vincy Chan
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
| | - Danielle Toccalino
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Samira Omar
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Riya Shah
- Department of Health and Society, University of Toronto Scarborough, Scarborough, Ontario, Canada
- Department of Psychology, University of Toronto Scarborough, Scarborough, Ontario, Canada
- Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Angela Colantonio
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
27
|
Integrating Care for Diabetes and Hypertension with HIV Care in Sub-Saharan Africa: A Scoping Review. Int J Integr Care 2022; 22:6. [PMID: 35136387 PMCID: PMC8815447 DOI: 10.5334/ijic.5839] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 01/06/2022] [Indexed: 11/20/2022] Open
|
28
|
Bukenya D, Van Hout MC, Shayo EH, Kitabye I, Junior BM, Kasidi JR, Birungi J, Jaffar S, Seeley J. Integrated healthcare services for HIV, diabetes mellitus and hypertension in selected health facilities in Kampala and Wakiso districts, Uganda: A qualitative methods study. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000084. [PMID: 36962287 PMCID: PMC10021152 DOI: 10.1371/journal.pgph.0000084] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 11/15/2021] [Indexed: 11/18/2022]
Abstract
Health policies in Africa are shifting towards integrated care services for chronic conditions, but in parts of Africa robust evidence on effectiveness is limited. We assessed the integration of vertical health services for HIV, diabetes and hypertension provided in a feasibility study within five health facilities in Uganda. From November 2018 to January 2020, we conducted a series of three in-depth interviews with 31, 29 and 24 service users attending the integrated clinics within Kampala and Wakiso districts. Ten healthcare workers were interviewed twice during the same period. Interviews were conducted in Luganda, translated into English, and analysed thematically using the concepts of availability, affordability and acceptability. All participants reported shortages of diabetes and hypertension drugs and diagnostic equipment prior to the establishment of the integrated clinics. These shortages were mostly addressed in the integrated clinics through a drugs buffer. Integration did not affect the already good provision of anti-retroviral therapy. The cost of transport reduced because of fewer clinic visits after integration. Healthcare workers reported that the main cause of non-adherence among users with diabetes and hypertension was poverty. Participants with diabetes and hypertension reported they could not afford private clinical investigations or purchase drugs prior to the establishment of the integrated clinics. The strengthening of drug supply for non-communicable conditions in the integrated clinics was welcomed. Most participants observed that the integrated clinic reduced feelings of stigma for those living with HIV. Sharing the clinic afforded privacy about an individual's condition, and users were comfortable with the waiting room sitting arrangement. We found that integrating non-communicable disease and HIV care had benefits for all users. Integrated care could be an effective model of care if service users have access to a reliable supply of basic medicines for both HIV and non-communicable disease conditions.
Collapse
Affiliation(s)
| | - Marie-Claire Van Hout
- Public Health Institute, Liverpool John Moores University, Liverpool, United Kingdom
| | | | - Isaac Kitabye
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | | | | | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Janet Seeley
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
29
|
Zakumumpa H, Kitutu FE, Ndagije HB, Diana NK, Ssanyu JN, Kiguba R. Provider perspectives on the acceptability and tolerability of dolutegravir-based anti-retroviral therapy after national roll-out in Uganda: a qualitative study. BMC Infect Dis 2021; 21:1222. [PMID: 34876050 PMCID: PMC8650263 DOI: 10.1186/s12879-021-06933-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/30/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The World Health Organization recommends dolutegravir (DTG) as the for first-line and second-line antiretroviral therapy (ART) worldwide. However, little is known about the acceptability and tolerability of DTG-based ART at routine points-of-care in Uganda. We set out to explore the perceptions of clinicians in ART clinics regarding the acceptability and tolerability of DTG-based ART since national roll-out in March 2018 in Uganda. METHODS We adopted a qualitative exploratory design involving 49 participants. Between September 2020 and February 2021, we conducted 22 in-depth interviews with clinicians in the ART clinics of 12 purposively selected health facilities across Uganda. The selection of study sites ensured diversity in facility ownership-type (public/private), level of service delivery (tertiary/secondary/primary) and the four major geographic sub-regions of Uganda. We conducted three focus group discussions with 27 clinicians in the participating facilities. Data were analyzed by thematic approach. RESULTS Clinicians in ART clinics acknowledged that DTG-based ART is well tolerated by the majority of their patients who appreciate the reduced pill burden, perceived less side effects and superior viral load suppression. However, they reported that a number of their patients experience adverse drug reactions (ADRs) after being transitioned to DTG. Hyperglycemia is, by far, the most commonly reported suspected ADR associated with DTG-based regimens and was cited in all but two participating facilities. Insomnia, weight gain and reduced libido are among the other frequently cited suspected ADRs. In addition, clinicians in ART clinics perceived some of the suspected ADRs as resulting from drug interactions between dolutegravir and isoniazid. Weak diagnostic capacities and shortage of associated commodities (e.g. glucometers and test kits) were reported as impediments to understanding the full extent of ADRs associated DTG-based ART. CONCLUSION While DTG-based regimens were perceived by clinicians in ART clinics to be well tolerated by the majority of their patients, they also reported that a number of patients experience suspected ADRs key among which were hyperglycemia, insomnia and reduced libido. Based on the perspectives of clinicians, we recommend that future studies examine the prevalence of dolutegravir-induced hyperglycemia in patients in Uganda.
Collapse
Affiliation(s)
- Henry Zakumumpa
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Freddy Eric Kitutu
- Sustainable Pharmaceutical Systems (SPS) Unit, Pharmacy Department, School of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | - Jacquellyn Nambi Ssanyu
- Sustainable Pharmaceutical Systems (SPS) Unit, Pharmacy Department, School of Health Sciences, Makerere University, Kampala, Uganda
| | - Ronald Kiguba
- Department of Pharmacology and Therapeutics, Makerere University College of Health Sciences, Kampala, Uganda
| |
Collapse
|
30
|
Wang H, Jonas KJ. The likelihood of severe COVID-19 outcomes among PLHIV with various comorbidities: a comparative frequentist and Bayesian meta-analysis approach. J Int AIDS Soc 2021; 24:e25841. [PMID: 34797952 PMCID: PMC8604378 DOI: 10.1002/jia2.25841] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/21/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction The SARS‐CoV‐2 virus can currently pose a serious health threat and can lead to severe COVID‐19 outcomes, especially for populations suffering from comorbidities. Currently, the data available on the risk for severe COVID‐19 outcomes due to an HIV infection with or without comorbidities paint a heterogenous picture. In this meta‐analysis, we summarized the likelihood for severe COVID‐19 outcomes among people living with HIV (PLHIV) with or without comorbidities. Methods Following PRISMA guidelines, we utilized PubMed, Web of Science and medRxiv to search for studies describing COVID‐19 outcomes in PLHIV with or without comorbidities up to 25 June 2021. Consequently, we conducted two meta‐analyses, based on a classic frequentist and Bayesian perspective of higher quality studies. Results and discussion We identified 2580 studies (search period: January 2020–25 June 2021, data extraction period: 1 January 2021–25 June 2021) and included nine in the meta‐analysis. Based on the frequentist meta‐analytical model, PLHIV with diabetes had a seven times higher risk of severe COVID‐19 outcomes (odd ratio, OR = 6.69, 95% CI: 3.03–19.30), PLHIV with hypertension a four times higher risk (OR = 4.14, 95% CI: 2.12–8.17), PLHIV with cardiovascular disease an odds ratio of 4.75 (95% CI: 1.89–11.94), PLHIV with respiratory disease an odds ratio of 3.67 (95% CI: 1.79–7.54) and PLHIV with chronic kidney disease an OR of 9.02 (95% CI: 2.53–32.14) compared to PLHIV without comorbidities. Both meta‐analytic models converged, thereby providing robust summative evidence. The Bayesian meta‐analysis produced similar effects overall, with the exclusion of PLHIV with respiratory diseases who showed a non‐significant higher risk to develop severe COVID‐19 outcomes compared to PLHIV without comorbidities. Conclusions Our meta‐analyses show that people with HIV, PLHIV with coexisting diabetes, hypertension, cardiovascular disease, respiratory disease and chronic kidney disease are at a higher likelihood of developing severe COVID‐19 outcomes. Bayesian analysis helped to estimate small sample biases and provided predictive likelihoods. Clinical practice should take these risks due to comorbidities into account and not only focus on the HIV status alone, vaccination priorities should be adjusted accordingly.
Collapse
Affiliation(s)
- Haoyi Wang
- Department of Work and Social Psychology, Maastricht University, Maastricht, the Netherlands
| | - Kai J Jonas
- Department of Work and Social Psychology, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
31
|
Birungi J, Kivuyo S, Garrib A, Mugenyi L, Mutungi G, Namakoola I, Mghamba J, Ramaiya K, Wang D, Maongezi S, Musinguzi J, Mugisha K, Etukoit BM, Kakande A, Niessen LW, Okebe J, Shiri T, Meshack S, Lutale J, Gill G, Sewankambo N, Smith PG, Nyirenda MJ, Mfinanga SG, Jaffar S. Integrating health services for HIV infection, diabetes and hypertension in sub-Saharan Africa: a cohort study. BMJ Open 2021; 11:e053412. [PMID: 34728457 PMCID: PMC8565555 DOI: 10.1136/bmjopen-2021-053412] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND HIV, diabetes and hypertension have a high disease burden in sub-Saharan Africa. Healthcare is organised in separate clinics, which may be inefficient. In a cohort study, we evaluated integrated management of these conditions from a single chronic care clinic. OBJECTIVES To determined the feasibility and acceptability of integrated management of chronic conditions in terms of retention in care and clinical indicators. DESIGN AND SETTING Prospective cohort study comprising patients attending 10 health facilities offering primary care in Dar es Salaam and Kampala. INTERVENTION Clinics within health facilities were set up to provide integrated care. Patients with either HIV, diabetes or hypertension had the same waiting areas, the same pharmacy, were seen by the same clinical staff, had similar provision of adherence counselling and tracking if they failed to attend appointments. PRIMARY OUTCOME MEASURES Retention in care, plasma viral load. FINDINGS Between 5 August 2018 and 21 May 2019, 2640 patients were screened of whom 2273 (86%) were enrolled into integrated care (832 with HIV infection, 313 with diabetes, 546 with hypertension and 582 with multiple conditions). They were followed up to 30 January 2020. Overall, 1615 (71.1%)/2273 were female and 1689 (74.5%)/2266 had been in care for 6 months or more. The proportions of people retained in care were 686/832 (82.5%, 95% CI: 79.9% to 85.1%) among those with HIV infection, 266/313 (85.0%, 95% CI: 81.1% to 89.0%) among those with diabetes, 430/546 (78.8%, 95% CI: 75.4% to 82.3%) among those with hypertension and 529/582 (90.9%, 95% CI: 88.6 to 93.3) among those with multimorbidity. Among those with HIV infection, the proportion with plasma viral load <100 copies/mL was 423(88.5%)/478. CONCLUSION Integrated management of chronic diseases is a feasible strategy for the control of HIV, diabetes and hypertension in Africa and needs evaluation in a comparative study.
Collapse
Affiliation(s)
- Josephine Birungi
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- The AIDS Support Organization, Kampala, Uganda
| | - Sokoine Kivuyo
- Muhimbili Medical Research Centre, National Institute for Medical Research Muhimbili Research Centre, Dar Es Salaam, Tanzania
| | - Anupam Garrib
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Ministry of Health, Kampala, Uganda
| | - Ivan Namakoola
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Janneth Mghamba
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | | | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sarah Maongezi
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | | | | | | | - Ayoub Kakande
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Louis Wihelmus Niessen
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Tinevimbo Shiri
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Janet Lutale
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geoff Gill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Peter G Smith
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Moffat J Nyirenda
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Malawi Epidemiology and Intervention Research Unit (MEIRU), Lilongwe and Karonga, Malawi
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sayoki Godfrey Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research Muhimbili Research Centre, Dar Es Salaam, Tanzania
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
32
|
Edelman EJ, Dziura J, Deng Y, Bold KW, Murphy SM, Porter E, Sigel KM, Yager JE, Ledgerwood DM, Bernstein SL. A SMARTTT approach to Treating Tobacco use disorder in persons with HIV (SMARTTT): Rationale and design for a hybrid type 1 effectiveness-implementation study. Contemp Clin Trials 2021; 110:106379. [PMID: 33794354 PMCID: PMC8478961 DOI: 10.1016/j.cct.2021.106379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/19/2021] [Accepted: 03/26/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Tobacco use disorder is a leading threat to the health of persons with HIV (PWH) on antiretroviral treatment and identifying optimal treatment approaches to promote abstinence is critical. We describe the rationale, aims, and design for a new study, "A SMART Approach to Treating Tobacco Use Disorder in Persons with HIV (SMARTTT)," a sequential multiple assignment randomized trial. METHODS In HIV clinics within three health systems in the northeastern United States, PWH with tobacco use disorder are randomized to nicotine replacement therapy (NRT) with or without contingency management (NRT vs. NRT + CM). Participants with response (defined as exhaled carbon monoxide (eCO)-confirmed smoking abstinence at week 12), continue the same treatment for another 12 weeks. Participants with non-response, are re-randomized to either switch medications from NRT to varenicline or intensify treatment to a higher CM reward schedule. Interventions are delivered by clinical pharmacists embedded in HIV clinics. The primary outcome is eCO-confirmed smoking abstinence; secondary outcomes include CD4 cell count, HIV viral load suppression, and the Veterans Aging Cohort Study (VACS) Index 2.0 score (a validated measure of morbidity and mortality based on laboratory data). Consistent with a hybrid type 1 effectiveness-implementation design and grounded in implementation science frameworks, we will conduct an implementation-focused process evaluation in parallel. Study protocol adaptations related to the COVID-19 pandemic have been made. CONCLUSIONS SMARTTT is expected to generate novel findings regarding the impact, cost, and implementation of an adaptive clinical pharmacist-delivered intervention involving medications and CM to promote smoking abstinence among PWH. ClinicalTrials.govidentifier:NCT04490057.
Collapse
Affiliation(s)
- E Jennifer Edelman
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America.
| | - James Dziura
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, United States of America; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Yanhong Deng
- Yale Center for Analytic Sciences, Yale School of Public Health, New Haven, CT, United States of America
| | - Krysten W Bold
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - Sean M Murphy
- CHERISH Center, Weill Cornell Medicine, New York, NY, United States of America
| | - Elizabeth Porter
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Keith M Sigel
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Jessica E Yager
- State University of New York Downstate Health Sciences University, Brooklyn, NY, United States of America
| | - David M Ledgerwood
- Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, United States of America
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America; Yale Center for Implementation Science, Yale School of Medicine, New Haven, CT, United States of America
| |
Collapse
|
33
|
Bulstra CA, Hontelez JAC, Otto M, Stepanova A, Lamontagne E, Yakusik A, El-Sadr WM, Apollo T, Rabkin M, Atun R, Bärnighausen T. Integrating HIV services and other health services: A systematic review and meta-analysis. PLoS Med 2021; 18:e1003836. [PMID: 34752477 PMCID: PMC8577772 DOI: 10.1371/journal.pmed.1003836] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 10/05/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness. METHODS AND FINDINGS We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41-1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16-1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20-1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05-2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03-1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response. CONCLUSIONS Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of 'ending AIDS by 2030', while simultaneously supporting progress towards universal health coverage.
Collapse
Affiliation(s)
- Caroline A. Bulstra
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- * E-mail:
| | - Jan A. C. Hontelez
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Moritz Otto
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
| | - Anna Stepanova
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
| | - Erik Lamontagne
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
- Aix-Marseille School of Economics, CNRS, EHESS, Centrale Marseille, Aix-Marseille University, Les Milles, France
| | - Anna Yakusik
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Wafaa M. El-Sadr
- ICAP, Columbia University, New York, New York, United States of America
| | | | - Miriam Rabkin
- ICAP, Columbia University, New York, New York, United States of America
| | | | - Rifat Atun
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| |
Collapse
|
34
|
Muddu M, Ssinabulya I, Kigozi SP, Ssennyonjo R, Ayebare F, Katwesigye R, Mbuliro M, Kimera I, Longenecker CT, Kamya MR, Schwartz JI, Katahoire AR, Semitala FC. Hypertension care cascade at a large urban HIV clinic in Uganda: a mixed methods study using the Capability, Opportunity, Motivation for Behavior change (COM-B) model. Implement Sci Commun 2021; 2:121. [PMID: 34670624 PMCID: PMC8690902 DOI: 10.1186/s43058-021-00223-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/30/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Persons living with HIV (PLHIV) receiving antiretroviral therapy (ART) have a high prevalence of hypertension (HTN) and increased risk of mortality from cardiovascular diseases. HTN and HIV care integration is recommended in Uganda, though its implementation has lagged. In this study, we sought to analyze the HTN and HIV care cascades and explore barriers and facilitators of HTN/HIV integration within a large HIV clinic in urban Uganda. METHODS We conducted an explanatory sequential mixed methods study at Mulago ISS clinic in Kampala, Uganda. We determined proportions of patients in HTN and HIV care cascade steps of screened, diagnosed, initiated on treatment, retained, and controlled. Guided by the Capability, Opportunity, Motivation and Behavior (COM-B) model, we then conducted semi-structured interviews and focus group discussions with healthcare providers (n = 13) and hypertensive PLHIV (n = 32). We coded the qualitative data deductively and analyzed the data thematically categorizing them as themes that influenced HTN care positively or negatively. These denoted barriers and facilitators, respectively. RESULTS Of 15,953 adult PLHIV, 99.1% were initiated on ART, 89.5% were retained in care, and 98.0% achieved control (viral suppression) at 1 year. All 15,953 (100%) participants were screened for HTN, of whom 24.3% had HTN. HTN treatment initiation, 1-year retention, and control were low at 1.0%, 15.4%, and 5.0%, respectively. Barriers and facilitators of HTN/HIV integration appeared in all three COM-B domains. Barriers included low patient knowledge of HTN complications, less priority by patients for HTN treatment compared to ART, sub-optimal provider knowledge of HTN treatment, lack of HTN treatment protocols, inadequate supply of anti-hypertensive medicines, and lack of HTN care performance targets. Facilitators included patients' and providers' interest in HTN/HIV integration, patients' interest in PLHIV peer support, providers' knowledge and skills for HTN screening, optimal ART adherence counseling, and availability of automated BP machines. CONCLUSION The prevalence of HTN among PLHIV is high, but the HTN care cascade is sub-optimal in this successful HIV clinic. To close these gaps, models of integrated HTN/HIV care are urgently needed. These findings provide a basis for designing contextually appropriate interventions for HTN/HIV integration in Uganda and other low- and middle-income countries.
Collapse
Affiliation(s)
- Martin Muddu
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Isaac Ssinabulya
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Simon P. Kigozi
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
| | | | - Florence Ayebare
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Mary Mbuliro
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Isaac Kimera
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | | | - Moses R. Kamya
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
| | - Jeremy I. Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Section of General Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06511 USA
| | - Anne R. Katahoire
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fred C. Semitala
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
| |
Collapse
|
35
|
Leveraging HIV Care Infrastructures for Integrated Chronic Disease and Pandemic Management in Sub-Saharan Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182010751. [PMID: 34682492 PMCID: PMC8535610 DOI: 10.3390/ijerph182010751] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 12/31/2022]
Abstract
In Sub-Saharan Africa, communicable and other tropical infectious diseases remain major challenges apart from the continuing HIV/AIDS epidemic. Recognition and prevalence of non-communicable diseases have risen throughout Africa, and the reimagining of healthcare delivery is needed to support communities coping with not only with HIV, tuberculosis, and COVID-19, but also cancer, cardiovascular disease, diabetes, and depression. Many non-communicable diseases can be prevented or treated with low-cost interventions, yet implementation of such care has been limited in the region. In this Perspective piece, we argue that deployment of an integrated service delivery model is an urgent next step, propose a South African model for integration, and conclude with recommendations for next steps in research and implementation. An approach that is inspired by South African experience would build on existing HIV-focused infrastructure that has been developed by Ministries of Health with strong support from the U.S. President’s Emergency Response for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. An integrated chronic healthcare model holds promise to sustainably deliver infectious disease and non-communicable disease care. Integrated care will be especially critical as health systems seek to cope with the unprecedented challenges associated with COVID-19 and future pandemic threats.
Collapse
|
36
|
Mfinanga SG, Nyirenda MJ, Mutungi G, Mghamba J, Maongezi S, Musinguzi J, Okebe J, Kivuyo S, Birungi J, van Widenfelt E, Van Hout MC, Bachmann M, Garrib A, Bukenya D, Cullen W, Lazarus JV, Niessen LW, Katahoire A, Shayo EH, Namakoola I, Ramaiya K, Wang D, Cuevas LE, Etukoit BM, Lutale J, Meshack S, Mugisha K, Gill G, Sewankambo N, Smith PG, Jaffar S. Integrating HIV, diabetes and hypertension services in Africa: study protocol for a cluster randomised trial in Tanzania and Uganda. BMJ Open 2021; 11:e047979. [PMID: 34645657 PMCID: PMC8515479 DOI: 10.1136/bmjopen-2020-047979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION HIV programmes in sub-Saharan Africa are well funded but programmes for diabetes and hypertension are weak with only a small proportion of patients in regular care. Healthcare provision is organised from stand-alone clinics. In this cluster randomised trial, we are evaluating a concept of integrated care for people with HIV infection, diabetes or hypertension from a single point of care. METHODS AND ANALYSIS 32 primary care health facilities in Dar es Salaam and Kampala regions were randomised to either integrated or standard vertical care. In the integrated care arm, services are organised from a single clinic where patients with either HIV infection, diabetes or hypertension are managed by the same clinical and counselling teams. They use the same pharmacy and laboratory and have the same style of patient records. Standard care involves separate pathways, that is, separate clinics, waiting and counselling areas, a separate pharmacy and separate medical records. The trial has two primary endpoints: retention in care of people with hypertension or diabetes and plasma viral load suppression. Recruitment is expected to take 6 months and follow-up is for 12 months. With 100 participants enrolled in each facility with diabetes or hypertension, the trial will provide 90% power to detect an absolute difference in retention of 15% between the study arms (at the 5% two-sided significance level). If 100 participants with HIV infection are also enrolled in each facility, we will have 90% power to show non-inferiority in virological suppression to a delta=10% margin (ie, that the upper limit of the one-sided 95% CI of the difference between the two arms will not exceed 10%). To allow for lost to follow-up, the trial will enrol over 220 persons per facility. This is the only trial of its kind evaluating the concept of a single integrated clinic for chronic conditions in Africa. ETHICS AND DISSEMINATION The protocol has been approved by ethics committee of The AIDS Support Organisation, National Institute of Medical Research and the Liverpool School of Tropical Medicine. Dissemination of findings will be done through journal publications and meetings involving study participants, healthcare providers and other stakeholders. TRIAL REGISTRATION NUMBER ISRCTN43896688.
Collapse
Affiliation(s)
- Sayoki Godfrey Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research Muhimbili Research Centre, Dar Es Salaam, Tanzania
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Republic of Uganda Ministry of Health, Kampala, Uganda
| | - Janneth Mghamba
- Directors office, Ministry of Health Community Development Gender Elderly and Children, Dar es Salaam, Tanzania
| | - Sarah Maongezi
- Non-Communicable Diseases Control Programme, Ministry of Health Community Development Gender Elderly and Children, Dar es Salaam, Tanzania
| | - Joshua Musinguzi
- AIDS Control Programme, Republic of Uganda Ministry of Health, Kampala, Uganda
| | - Joseph Okebe
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sokoine Kivuyo
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | | | | | | | - Max Bachmann
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Anupam Garrib
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Walter Cullen
- School of Medicine, University College Dublin School of Medicine, Dublin, Ireland
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal) Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | - Anne Katahoire
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Elizabeth Henry Shayo
- Policy Analysis and Advocacy, National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Ivan Namakoola
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - L E Cuevas
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Janet Lutale
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | | | - Geoff Gill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Peter G Smith
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | | |
Collapse
|
37
|
Galaviz KI, Colasanti JA, Kalokhe AS, Ali MK, Ofotokun I, Fernandez A. Factors associated with adherence to guideline-recommended cardiovascular disease prevention among HIV clinicians. Transl Behav Med 2021; 12:6371214. [PMID: 34529051 PMCID: PMC8764988 DOI: 10.1093/tbm/ibab125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Integrating cardiovascular disease (CVD) prevention in routine HIV care remains a challenge. This study aimed to identify factors associated with adherence to guideline-recommended CVD preventive practices among HIV clinicians. Clinicians from eight HIV clinics in Atlanta were invited to complete an online survey. The survey was informed by the Consolidated Framework for Implementation Research and assessed the following: clinician CVD risk screening and advice frequency (never to always), individual characteristics (clinician beliefs, self-efficacy, and motivation), inner setting factors (clinic culture, learning climate, leadership engagement, and resources available), and outer setting factors (peer pressure and patient needs). Bivariate correlations examined associations between these factors and guideline adherence. Thirty-eight clinicians completed the survey (82% women, mean age 42 years, 50% infectious disease physicians). For risk screening, clinicians always check patient blood pressure (median score 7.0/7), while they usually ask about smoking or check their blood glucose (median score 6.0/7). For advice provision, clinicians usually recommend quitting smoking, controlling cholesterol or controlling blood pressure (median score 6.0/7), while they often recommend controlling blood glucose, losing weight, or improving diet/physical activity (median score 5.5/7). Clinician beliefs, motivation and self-efficacy were positively correlated with screening and advice practices (r = .55−.84), while inner setting factors negatively correlated with lifestyle-related screening and advice practices (r = −.51 to −.76). Peer pressure was positively correlated with screening and advice practices (r = .57–.89). Clinician psychosocial characteristics and perceived peer pressure positively influence adherence to guideline-recommended CVD preventive practices. These correlates along with leadership engagement could be targeted with proven implementation strategies.
Collapse
Affiliation(s)
- Karla I Galaviz
- Department of Applied Health Science, Indiana University School of Public Health Bloomington, Bloomington, IN, USA
| | - Jonathan A Colasanti
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Division of Infections Disease, Emory University School of Medicine, Atlanta, GA, USA
| | - Ameeta S Kalokhe
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Division of Infections Disease, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohammed K Ali
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Igho Ofotokun
- Division of Infections Disease, Emory University School of Medicine, Atlanta, GA, USA
| | - Alicia Fernandez
- School of Medicine, University of San Francisco California, San Francisco, CA, USA
| |
Collapse
|
38
|
Rohwer A, Uwimana Nicol J, Toews I, Young T, Bavuma CM, Meerpohl J. Effects of integrated models of care for diabetes and hypertension in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Open 2021; 11:e043705. [PMID: 34253658 PMCID: PMC8276295 DOI: 10.1136/bmjopen-2020-043705] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To assess the effects of integrated models of care for people with multimorbidity including at least diabetes or hypertension in low-income and middle-income countries (LMICs) on health and process outcomes. DESIGN Systematic review. DATA SOURCES We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Africa-Wide, CINAHL and Web of Science up to 12 December 2019. ELIGIBILITY CRITERIA We included randomised controlled trials (RCTs), non-RCTs, controlled before-and-after studies and interrupted time series (ITS) studies of people with diabetes and/or hypertension plus any other disease, in LMICs; assessing the effects of integrated care. DATA EXTRACTION AND SYNTHESIS Two authors independently screened retrieved records; extracted data and assessed risk of bias. We conducted meta-analysis where possible and assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation. RESULTS Of 7568 records, we included five studies-two ITS studies and three cluster RCTs. Studies were conducted in South Africa (n=3), Uganda/Kenya (n=1) and India (n=1). Integrated models of care compared with usual care may make little or no difference to mortality (very low certainty), the number of people achieving blood pressure (BP) or diabetes control (very low certainty) and access to care (very low certainty); may increase the number of people who achieve both HIV and BP/diabetes control (very low certainty); and may have a very small effect on achieving HIV control (very low certainty). Interventions to promote integrated delivery of care compared with usual care may make little or no difference to mortality (very low certainty), depression (very low certainty) and quality of life (very low certainty); and may have little or no effect on glycated haemoglobin (low certainty), systolic BP (low certainty) and total cholesterol levels (low certainty). CONCLUSIONS Current evidence on the effects of integrated care on health outcomes is very uncertain. Programmes and policies on integrated care must consider context-specific factors related to health systems and populations. PROSPERO REGISTRATION NUMBER CRD42018099314.
Collapse
Affiliation(s)
- Anke Rohwer
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jeannine Uwimana Nicol
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Ingrid Toews
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Taryn Young
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Charlotte M Bavuma
- Kigali University Teaching Hospital, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Joerg Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| |
Collapse
|
39
|
Bruno SR, Poliseno M, Vichi F, Esperti S, Di Biagio A, Berruti M, Ferrara S, Pisani L, Saracino A, Santantonio TA, Lo Caputo S. General Practitioners as partners for a shared management of chronic HIV infection: An insight into the perspectives of Italian People Living with HIV. PLoS One 2021; 16:e0254404. [PMID: 34242341 PMCID: PMC8270424 DOI: 10.1371/journal.pone.0254404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/28/2021] [Indexed: 01/02/2023] Open
Abstract
Is it possible to achieve a collaboration between Infectious Diseases (ID) Specialists and General Practitioners (GPs) in the management of chronic HIV infection? A cross sectional survey was conducted among People Living with HIV (PLWHIV) attending the outpatient services of four Italian Infectious Diseases Centers to understand to which extent patients trust their GPs and involve them in the management of their chronic condition. Information about level of communication with GPs, subjective perception of the disease, and presence of co-medications were collected and matched with socio-demographic data using χ2statistics. A p<0.05 was considered statistically significant. From December 2019 to February 2020, 672 patients completed the survey, 59% males and 56% >50 years. Overall, 508 patients (76%) had informed GPs about HIV-positivity. Communication of diagnosis was significantly associated with age >50years, lower education level, history of disease >10 years and residency in Northern Italy. The "Undetectable = Untrasmittable" (U = U) concept was investigated as an indirect measure of perceived stigma. 23% of subjects was unaware of its meaning. Despite undetectable status, 50% of PLWHIV found difficult to communicate their condition to GPs, especially married (52% vs 48% of unmarried, p = 0.003), well-educated patients (51% vs 48, p = 0.007), living in Southern vs Northern Italy (52% vs 46%, p< 0.001). More than 75% of the participants consulted the ID specialist for co-medications and DDIs management, often complaining a lack of communication of the former with GPs. Overall, a good level of communication between PLWHIV and GPs was outlined, even if a wider involvement of the latter in HIV care is desirable.
Collapse
Affiliation(s)
- Serena Rita Bruno
- Department of Clinical and Experimental Medicine, Infectious Diseases Unit, A.O.U. “Policlinico Riuniti”, Foggia, Italy
| | - Mariacristina Poliseno
- Department of Clinical and Experimental Medicine, Infectious Diseases Unit, A.O.U. “Policlinico Riuniti”, Foggia, Italy
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari “Aldo Moro”, Bari, Italy
| | - Francesca Vichi
- Unit of Infectious Diseases, Santa Maria Annunziata Hospital—Bagno a Ripoli, Florence, Italy
| | - Sara Esperti
- Unit of Infectious Diseases, Santa Maria Annunziata Hospital—Bagno a Ripoli, Florence, Italy
| | - Antonio Di Biagio
- Department of Health Sciences, Unit of Infectious Diseases, San Martino Policlinico Hospital, University of Genoa, Genoa, Italy
| | - Marco Berruti
- Department of Health Sciences, Unit of Infectious Diseases, San Martino Policlinico Hospital, University of Genoa, Genoa, Italy
| | - Sergio Ferrara
- Department of Clinical and Experimental Medicine, Infectious Diseases Unit, A.O.U. “Policlinico Riuniti”, Foggia, Italy
| | - Luigi Pisani
- Department of Intensive Care, Amsterdam University Medical Centers—Location AMC, Amsterdam, The Netherlands
| | - Annalisa Saracino
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari “Aldo Moro”, Bari, Italy
| | - Teresa Antonia Santantonio
- Department of Clinical and Experimental Medicine, Infectious Diseases Unit, A.O.U. “Policlinico Riuniti”, Foggia, Italy
| | - Sergio Lo Caputo
- Department of Clinical and Experimental Medicine, Infectious Diseases Unit, A.O.U. “Policlinico Riuniti”, Foggia, Italy
| |
Collapse
|
40
|
Adeyemi O, Lyons M, Njim T, Okebe J, Birungi J, Nana K, Claude Mbanya J, Mfinanga S, Ramaiya K, Jaffar S, Garrib A. Integration of non-communicable disease and HIV/AIDS management: a review of healthcare policies and plans in East Africa. BMJ Glob Health 2021; 6:bmjgh-2020-004669. [PMID: 33947706 PMCID: PMC8098934 DOI: 10.1136/bmjgh-2020-004669] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/27/2021] [Accepted: 04/02/2021] [Indexed: 01/08/2023] Open
Abstract
Background Low-income and middle-income countries are struggling to manage growing numbers of patients with chronic non-communicable diseases (NCDs), while services for patients with HIV infection are well established. There have been calls for integration of HIV and NCD services to increase efficiency and improve coverage of NCD care, although evidence of effectiveness remains unclear. In this review, we assess the extent to which National HIV and NCD policies in East Africa reflect the calls for HIV-NCD service integration. Methods Between April 2018 and December 2020, we searched for policies, strategies and guidelines associated with HIV and NCDs programmes in Burundi, Kenya, Rwanda, South Sudan, Tanzania and Uganda. Documents were searched manually for plans for integration of HIV and NCD services. Data were analysed qualitatively using document analysis. Results Thirty-one documents were screened, and 13 contained action plans for HIV and NCDs service integration. Integrated delivery of HIV and NCD care is recommended in high level health policies and treatment guidelines in four countries in the East African region; Kenya, Rwanda, Tanzania and Uganda, mostly relating to integrating NCD care into HIV programmes. The increasing burden of NCDs, as well as a move towards person-centred differentiated delivery of services for people living with HIV, is a factor in the recent adoption of integrated HIV and NCD service delivery plans. Both South Sudan and Burundi report a focus on building their healthcare infrastructure and improving coverage and quality of healthcare provision, with no reported plans for HIV and NCD care integration. Conclusion Despite the limited evidence of effectiveness, some East African countries have already taken steps towards HIV and NCD service integration. Close monitoring and evaluation of the integrated HIV and NCD programmes is necessary to provide insight into the associated benefits and risks, and to inform future service developments.
Collapse
Affiliation(s)
- Olukemi Adeyemi
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mary Lyons
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Tsi Njim
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Kevin Nana
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaounde, Cameroon
| | - Jean Claude Mbanya
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaounde, Cameroon
| | - Sayoki Mfinanga
- Muhimbili Medical Research Centre, National Institute of Medical Research, Dar es Salaam, United Republic of Tanzania
| | - Kaushik Ramaiya
- Shree Hindu Mandal Hospital, Dar es Salaam, United Republic of Tanzania
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anupam Garrib
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
41
|
Smith PJ, Davey DJ, Green H, Cornell M, Bekker LG. Reaching underserved South Africans with integrated chronic disease screening and mobile HIV counselling and testing: A retrospective, longitudinal study conducted in Cape Town. PLoS One 2021; 16:e0249600. [PMID: 33945540 PMCID: PMC8096085 DOI: 10.1371/journal.pone.0249600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/20/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Community-based, mobile HIV counselling and testing (HCT) and screening for non-communicable diseases (NCDs) may improve early diagnosis and referral for care in underserved populations. We evaluated HCT/NCD data and described population characteristics of those visiting a mobile clinic in high HIV disease burden settings in Cape Town, South Africa, between 2008 and 2016. METHODS Trained counsellors registered patients ≥12 years old at a mobile clinic, which offered HCT and blood pressure, diabetes (glucose testing) and obesity (body mass index) screening. A nurse referred patients who required HIV treatment or NCD care. Using multivariable logistic regression, we estimated correlates of new HIV diagnoses adjusting for gender, age and year. RESULTS Overall, 43,938 individuals (50% male; 29% <25 years; median age = 31 years) tested for HIV at the mobile clinic, where 27% of patients (66% of males, 34% of females) reported being debut HIV testers. Males not previously tested for HIV had higher rates of HIV positivity (11%) than females (7%). Over half (55%, n = 1,343) of those previously diagnosed HIV-positive had not initiated ART. More than one-quarter (26%) of patients screened positive for hypertension (males 28%, females 24%, p<0.001). Females were more likely overweight (25% vs 20%) or obese (43% vs 9%) and presented with more diabetes symptoms than males (8% vs 4%). Females (3%) reported more symptoms of STIs than males (1%). Reporting symptoms of sexually transmitted infections (aOR = 3.45, 95% CI = 2.84, 4.20), diabetes symptoms (aOR = 1.61, 95% 1.35, 1.92), and TB symptoms (aOR = 4.40, 95% CI = 3.85, 5.01) were associated with higher odds of a new HIV diagnosis after adjusting for covariates. CONCLUSION Findings demonstrate that mobile clinics providing integrated HCT and NCD screening may offer the opportunity of early diagnosis and referral for care for those who delay screening, including men living with HIV not previously tested.
Collapse
Affiliation(s)
- Philip John Smith
- Faculty of Health Sciences, The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Dvora Joseph Davey
- Faculty of Health Sciences, The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, California, United States of America
- Faculty of Health Sciences, Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Hunter Green
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, California, United States of America
| | - Morna Cornell
- Faculty of Health Sciences, Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Faculty of Health Sciences, The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
42
|
Abstract
OBJECTIVE Sub-Saharan Africa faces twin epidemics of HIV and noncommunicable diseases including hypertension. Integrating hypertension care into chronic HIV care is a global priority, but cost estimates are lacking. In the SEARCH Study, we performed population-level HIV/hypertension testing, and offered integrated streamlined chronic care. Here, we estimate costs for integrated hypertension/HIV care for HIV-positive individuals, and costs for hypertension care for HIV-negative individuals in the same clinics. DESIGN Microcosting analysis of healthcare expenditures within Ugandan HIV clinics. METHODS SEARCH (NCT: 01864603) conducted community health campaigns for diagnosis and linkage to care for both HIV and hypertension. HIV-positive patients received hypertension/HIV care jointly including blood pressure monitoring and medications; HIV-negative patients received hypertension care at the same clinics. Within 10 Ugandan study communities during 2015-2016, we estimated incremental annual per-patient hypertension care costs using micro-costing techniques, time-and-motion personnel studies, and administrative/clinical records review. RESULTS Overall, 70 HIV-positive and 2355 HIV-negative participants received hypertension care. For HIV-positive participants, average incremental cost of hypertension care was $6.29 per person per year, a 2.1% marginal increase over prior estimates for HIV care alone. For HIV-negative participants, hypertension care cost $11.39 per person per year, a 3.8% marginal increase over HIV care costs. Key costs for HIV-positive patients included hypertension medications ($6.19 per patient per year; 98% of total) and laboratory testing ($0.10 per patient per year; 2%). Key costs for HIV-negative patients included medications ($5.09 per patient per year; 45%) and clinic staff salaries ($3.66 per patient per year; 32%). CONCLUSION For only 2-4% estimated additional costs, hypertension care was added to HIV care, and also expanded to all HIV-negative patients in prototypic Ugandan clinics, demonstrating substantial synergy. Our results should encourage accelerated scale-up of hypertension care into existing clinics.
Collapse
|
43
|
Ravicz M, Muhongayire B, Kamagaju S, Klabbers RE, Faustin Z, Kambugu A, Bassett I, O'Laughlin K. Using Intervention Mapping methodology to design an HIV linkage intervention in a refugee settlement in rural Uganda. AIDS Care 2021; 34:446-458. [PMID: 33749418 PMCID: PMC8452793 DOI: 10.1080/09540121.2021.1900532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nearly 80 million people have been forcibly displaced by persecution, violence, and disaster. Displaced populations, including refugees, face health challenges such as resource shortages, food and housing insecurity, violence, and disrupted social support. People living with HIV in refugee settings have decreased engagement with HIV services compared to non-refugee populations, and interventions are needed to enhance linkage to care. However, designing health interventions in humanitarian settings is challenging. We used Intervention Mapping (IM), a six-step method for developing theory- and evidence-based health interventions, to design a program to increase linkage to HIV care for refugees and Ugandan nationals in Nakivale Refugee Settlement in Uganda. We engaged a diverse group of stakeholders (N = 14) in Nakivale, including community members and humanitarian actors, in an interactive workshop focusing on IM steps 1–4. We developed a chronic care program that would integrate HIV care with services for hypertension and diabetes at accessible community sites, thereby decreasing stigma around HIV treatment and improving access to care. IM provided an inclusive, efficient method for integrating community members and program implementers in the intervention planning process, and can be used as a method-driven approach to intervention design in humanitarian settings.
Collapse
Affiliation(s)
- Miranda Ravicz
- Departments of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Robin E Klabbers
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | | | - Andrew Kambugu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ingrid Bassett
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kelli O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, Seattle, WA, USA
| |
Collapse
|
44
|
Schexnayder J, Longenecker CT, Muiruri C, Bosworth HB, Gebhardt D, Gonzales SE, Hanson JE, Hileman CO, Okeke NL, Sico IP, Vedanthan R, Webel AR. Understanding constraints on integrated care for people with HIV and multimorbid cardiovascular conditions: an application of the Theoretical Domains Framework. Implement Sci Commun 2021; 2:17. [PMID: 33579396 PMCID: PMC7881687 DOI: 10.1186/s43058-021-00114-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 01/22/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND People with HIV (PWH) experience increased cardiovascular disease (CVD) risk. Many PWH in the USA receive their primary medical care from infectious disease specialists in HIV clinics. HIV care teams may not be fully prepared to provide evidence-based CVD care. We sought to describe local context for HIV clinics participating in an NIH-funded implementation trial and to identify facilitators and barriers to integrated CVD preventive care for PWH. METHODS Data were collected in semi-structured interviews and focus groups with PWH and multidisciplinary healthcare providers at three academic medical centers. We used template analysis to identify barriers and facilitators of CVD preventive care in three HIV specialty clinics using the Theoretical Domains Framework (TDF). RESULTS Six focus groups were conducted with 37 PWH. Individual interviews were conducted with 34 healthcare providers and 14 PWH. Major themes were captured in seven TDF domains. Within those themes, we identified nine facilitators and 11 barriers to CVD preventive care. Knowledge gaps contributed to inaccurate CVD risk perceptions and ineffective self-management practices in PWH. Exclusive prioritization of HIV over CVD-related conditions was common in PWH and their providers. HIV care providers assumed inconsistent roles in CVD prevention, including for PWH with primary care providers. HIV providers were knowledgeable of HIV-related CVD risks and co-located health resources were consistently available to support PWH with limited resources in health behavior change. However, infrequent medical visits, perceptions of CVD prevention as a primary care service, and multiple co-location of support programs introduced local challenges to engaging in CVD preventive care. CONCLUSIONS Barriers to screening and treatment of cardiovascular conditions are common in HIV care settings and highlight a need for greater primary care integration. Improving long-term cardiovascular outcomes of PWH will likely require multi-level interventions supporting HIV providers to expand their scope of practice, addressing patient preferences for co-located CVD preventive care, changing clinic cultures that focus only on HIV to the exclusion of non-AIDS multimorbidity, and managing constraints associated with multiple services co-location. TRIAL REGISTRATION ClinicalTrials.gov , NCT03643705.
Collapse
Affiliation(s)
- Julie Schexnayder
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106-7343, USA
| | - Chris T Longenecker
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Harrington Heart & Vascular Institute, Cleveland, OH, USA
| | | | | | | | | | - Jan E Hanson
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106-7343, USA
| | | | | | | | - Rajesh Vedanthan
- New York University Grossman School of Medicine, New York, NY, USA
| | - Allison R Webel
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106-7343, USA.
| |
Collapse
|
45
|
Chamie G, Hickey MD, Kwarisiima D, Ayieko J, Kamya MR, Havlir DV. Universal HIV Testing and Treatment (UTT) Integrated with Chronic Disease Screening and Treatment: the SEARCH study. Curr HIV/AIDS Rep 2020; 17:315-323. [PMID: 32507985 DOI: 10.1007/s11904-020-00500-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The growing burden of untreated chronic disease among persons with HIV (PWH) threatens to reverse heath gains from ART expansion. Universal test and treat (UTT)'s population-based approach provides opportunity to jointly identify and treat HIV and other chronic diseases. This review's purpose is to describe SEARCH UTT study's integrated disease strategy and related approaches in Sub-Saharan Africa. RECENT FINDINGS In SEARCH, 97% of adults were HIV tested, 85% were screened for hypertension, and 79% for diabetes at health fairs after 2 years, for an additional $1.16/person. After 3 years, population-level hypertension control was 26% higher in intervention versus control communities. Other mobile/home-based multi-disease screening approaches have proven successful, but data on multi-disease care delivery are extremely limited and show little effect on clinical outcomes. Integration of chronic disease into HIV in the UTT era is feasible and can achieve population level effects; however, optimization and implementation remain a huge unmet need.
Collapse
Affiliation(s)
- Gabriel Chamie
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital / University of California, San Francisco, UCSF Box 0874, San Francisco, CA, 94143-0874, USA.
| | - Matthew D Hickey
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital / University of California, San Francisco, UCSF Box 0874, San Francisco, CA, 94143-0874, USA
| | | | | | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V Havlir
- Division of HIV, Infectious Diseases & Global Medicine, San Francisco General Hospital / University of California, San Francisco, UCSF Box 0874, San Francisco, CA, 94143-0874, USA
| |
Collapse
|
46
|
Wroe EB, Kalanga N, Dunbar EL, Nazimera L, Price NF, Shah A, Dullie L, Mailosi B, Gonani G, Ndarama EPL, Talama GC, Bukhman G, Kerr L, Connolly E, Kachimanga C. Expanding access to non-communicable disease care in rural Malawi: outcomes from a retrospective cohort in an integrated NCD-HIV model. BMJ Open 2020; 10:e036836. [PMID: 33087368 PMCID: PMC7580053 DOI: 10.1136/bmjopen-2020-036836] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 09/25/2020] [Accepted: 10/03/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Non-communicable diseases (NCDs) account for one-third of disability-adjusted life years in Malawi, and access to care is exceptionally limited. Integrated services with HIV are widely recommended, but few examples exist globally. We report descriptive outcomes from an Integrated Chronic Care Clinic (IC3). DESIGN This is a retrospective cohort study. SETTING The study includes an HIV-NCD clinic across 14 primary care facilities in the rural district of Neno, Malawi. PARTICIPANTS All new patients, including 6233 HIV-NCD diagnoses, enrolled between January 2015 and December 2017 were included. This included 3334 patients with HIV (59.7% women) and 2990 patients with NCD (67.3% women), 10% overall under age 15 years. INTERVENTIONS Patients were seen at their nearest health centre, with a hospital team visiting routinely to reinforce staffing. Data were collected on paper forms and entered into an electronic medical record. PRIMARY AND SECONDARY OUTCOME MEASURES Routine clinical measurements are reported at 1-year post-enrolment for patients with more than one visit. One-year retention is reported by diagnosis. RESULTS NCD diagnoses were 1693 hypertension, 668 asthma, 486 epilepsy, 149 diabetes and 109 severe mental illness. By December 2018, 8.3% of patients with NCD over 15 years were also on HIV treatment. One-year retention was 85% for HIV and 72% for NCDs, with default in 8.4% and 25.5% and deaths in 4.0% and 1.4%, respectively. Clinical outcomes showed statistically significant improvement for hypertension, diabetes, asthma and epilepsy. Of the 1807 (80%) of patients with HIV with viral load results, 85% had undetectable viral load. CONCLUSIONS The IC3 model, built on an HIV platform, facilitated rapid decentralisation and access to NCD services in rural Malawi. Clinical outcomes and retention in care are favourable, suggesting that integration of chronic disease care at the primary care level poses a way forward for the large dual burden of HIV and chronic NCDs.
Collapse
Affiliation(s)
- Emily B Wroe
- Partners In Health, Neno, Malawi
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Noel Kalanga
- Department of Health Systems and Policy, College of Medicine, Blantyre, Malawi
| | | | - Lawrence Nazimera
- Ministry of Health, Neno District Health Office, Ministry of Health, Neno, Malawi
| | | | - Adarsh Shah
- Partners In Health, Boston, Massachusetts, USA
| | | | | | - Grant Gonani
- Ministry of Health, Neno District Health Office, Ministry of Health, Neno, Malawi
| | - Enoch P L Ndarama
- Ministry of Health, Neno District Health Office, Ministry of Health, Neno, Malawi
| | | | - Gene Bukhman
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | | |
Collapse
|
47
|
Chan V, Hurst M, Petersen T, Liu J, Mollayeva T, Colantonio A, Sutton M, Escobar MD. A population-based sex-stratified study to understand how health status preceding traumatic brain injury affects direct medical cost. PLoS One 2020; 15:e0240208. [PMID: 33048973 PMCID: PMC7553294 DOI: 10.1371/journal.pone.0240208] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 09/23/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To understand how pre-injury health status present five-years preceding traumatic brain injury (TBI) affects direct medical cost two years post-injury. METHODS Patients age ≥19 years in the emergency department (ED) or acute care for a TBI between April 1, 2007 and March 31, 2014 in Ontario, Canada (N = 55,669) were identified from population-based health administrative data. Forty-three factors of pre-injury health status (i.e., comorbidities and personal, social, and environmental factors) that were internally validated for the TBI population were assessed in this study. The outcome of interest was direct medical cost within two years of discharge. Sex-specific multivariable linear regressions were conducted to understand the associations between direct medical cost within two years of discharge and pre-injury health status. RESULTS Patients who received care in the ED (81.9% of total sample) incurred a median cost of $2,492/male patient (average $12,342/patient) and $3,508/female patient (average $65,285/patient) within two years of injury; 37 pre-injury factors were significantly associated with increased direct medical costs. Patients who first received care for their TBI in acute care (18.1%) incurred a median cost of $25,081/male patient (average $63,060/patient) and $30,277/female patient (average $65,285/patient) within two years of injury; 21 factors were significantly associated with increased direct medical costs. Among more prevalent factors, those associated with increased medical cost by at least 50% included mental health disorders, substance abuse, disorders or medical conditions frequently observed among the elderly, cardiovascular disorders, stroke and emergencies involving the brain, metabolic disorders and abdominal symptoms, conditions and symptoms of abdomen and pelvis, genitourinary disorders and disorders of prostate, and pulmonary abdominal and other emergencies. CONCLUSIONS Direct medical costs two years post-TBI differed significantly between patients with and without adverse pre-existing health status. Interdisciplinary teams to promote early identification of pre-existing health conditions and appropriate management and integration of these conditions in TBI care across the continuum of healthcare may be opportunities to reduce direct medical costs post-injury.
Collapse
Affiliation(s)
- Vincy Chan
- KITE-Toronto Rehab, University Health Network, Toronto, Ontario, Canada
- * E-mail:
| | - Mackenzie Hurst
- KITE-Toronto Rehab, University Health Network, Toronto, Ontario, Canada
| | - Tierza Petersen
- KITE-Toronto Rehab, University Health Network, Toronto, Ontario, Canada
| | - Jingqian Liu
- KITE-Toronto Rehab, University Health Network, Toronto, Ontario, Canada
| | - Tatyana Mollayeva
- KITE-Toronto Rehab, University Health Network, Toronto, Ontario, Canada
| | - Angela Colantonio
- KITE-Toronto Rehab, University Health Network, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Mitchell Sutton
- KITE-Toronto Rehab, University Health Network, Toronto, Ontario, Canada
| | - Michael D. Escobar
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
48
|
Van Hout MC, Bachmann M, Lazarus JV, Shayo EH, Bukenya D, Picchio CA, Nyirenda M, Mfinanga SG, Birungi J, Okebe J, Jaffar S. Strengthening integration of chronic care in Africa: protocol for the qualitative process evaluation of integrated HIV, diabetes and hypertension care in a cluster randomised controlled trial in Tanzania and Uganda. BMJ Open 2020; 10:e039237. [PMID: 33033029 PMCID: PMC7542920 DOI: 10.1136/bmjopen-2020-039237] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION In sub-Saharan Africa, the burden of non-communicable diseases (NCDs), particularly diabetes mellitus (DM) and hypertension, has increased rapidly in recent years, although HIV infection remains a leading cause of death among young-middle-aged adults. Health service coverage for NCDs remains very low in contrast to HIV, despite the increasing prevalence of comorbidity of NCDs with HIV. There is an urgent need to expand healthcare capacity to provide integrated services to address these chronic conditions. METHODS AND ANALYSIS This protocol describes procedures for a qualitative process evaluation of INTE-AFRICA, a cluster randomised trial comparing integrated health service provision for HIV infection, DM and hypertension, to the current stand-alone vertical care. Interviews, focus group discussions and observations of consultations and other care processes in two clinics (in Tanzania, Uganda) will be used to explore the experiences of stakeholders. These stakeholders will include health service users, policy-makers, healthcare providers, community leaders and members, researchers, non-governmental and international organisations. The exploration will be carried out during the implementation of the project, alongside an understanding of the impact of broader structural and contextual factors. ETHICS AND DISSEMINATION Ethical approval was granted by the Liverpool School of Tropical Medicine (UK), the National Institute of Medical Research (Tanzania) and TASO Research Ethics Committee (Uganda) in 2020. The evaluation will provide the opportunity to document the implementation of integration over several timepoints (6, 12 and 18 months) and refine integrated service provision prior to scale up. This synergistic approach to evaluate, understand and respond will support service integration and inform monitoring, policy and practice development efforts to involve and educate communities in Tanzania and Uganda. It will create a model of care and a platform of good practices and lessons learnt for other countries implementing integrated and decentralised community health services. TRIAL REGISTRATION NUMBER ISRCTN43896688; Pre-results.
Collapse
Affiliation(s)
- Marie-Claire Van Hout
- Public Health Institute, Liverpool John Moores University, Liverpool, Merseyside, UK
| | - Max Bachmann
- Norwich Medical School, University of East Anglia Faculty of Medicine and Health Sciences, Norwich, UK
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Catalunya, Spain
| | - Elizabeth Henry Shayo
- Muhimbili Centre, National Institute for Medical Research, Dar es Salaam, Dar es Salaam, Tanzania, United Republic of
| | - Dominic Bukenya
- MRC/UVRI/LSHTM Uganda Research Unit, Medical Research Council Uganda, Entebbe, Uganda
| | - Camila A Picchio
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Catalunya, Spain
| | - Moffat Nyirenda
- MRC/UVRI/LSHTM Uganda Research Unit, Medical Research Council Uganda, Entebbe, Uganda
| | - Sayoki Godfrey Mfinanga
- Muhimbili Centre, National Institute for Medical Research, Dar es Salaam, Dar es Salaam, Tanzania, United Republic of
| | - Josephine Birungi
- MRC/UVRI/LSHTM Uganda Research Unit, Medical Research Council Uganda, Entebbe, Uganda
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| |
Collapse
|
49
|
Garrib A, Birungi J, Lesikari S, Namakoola I, Njim T, Cuevas L, Niessen L, Mugisha K, Mutungi G, Mghamba J, Ramaiya K, Jaffar S, Mfinanga S, Nyirenda M. Integrated care for human immunodeficiency virus, diabetes and hypertension in Africa. Trans R Soc Trop Med Hyg 2020; 113:809-812. [PMID: 30265362 DOI: 10.1093/trstmh/try098] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/07/2018] [Accepted: 09/14/2018] [Indexed: 11/13/2022] Open
Abstract
The rising burden from non-communicable diseases (NCDs) poses a huge challenge for health care delivery in Africa, where health systems are already struggling with the long-term care requirements for the millions of people now on antiretroviral therapy requiring regular visits to health facilities for monitoring, adherence support and drugs. The HIV chronic disease management programme is comparatively well-funded, well-organised and well-informed and offers many insights and opportunities for the expansion of NCD prevention and treatment services. Some degree of human immunodeficiency virus (HIV) and NCD service integration is essential, but how to do this without risking the HIV treatment gains is unclear. Both HIV and NCD services must expand within a resource-constrained environment and policymakers are in urgent need of evidence to guide cost-effective and acceptable changes in these health services.
Collapse
Affiliation(s)
- Anupam Garrib
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Josephine Birungi
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda.,Aids Support Organisation, Old Mulago Complex, Kampala, Uganda
| | - Sokoine Lesikari
- National Institute of Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Ivan Namakoola
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Tsi Njim
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Luis Cuevas
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Louis Niessen
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Kenneth Mugisha
- Aids Support Organisation, Old Mulago Complex, Kampala, Uganda
| | | | - Janneth Mghamba
- Ministry of Health and Social Welfare, 6 Samora Machel Road, Dar es Salaam, Tanzania
| | | | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Sayoki Mfinanga
- National Institute of Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Moffat Nyirenda
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| |
Collapse
|
50
|
Costa AN, Val F, Macedo ÁE, Cubas-Vega N, Tejo PLD, Marques MM, Alencar Filho ACD, Lacerda MVGD. Increased prevalence of hypertension among people living with HIV: where to begin? Rev Soc Bras Med Trop 2020; 53:e20190564. [PMID: 32935775 PMCID: PMC7491555 DOI: 10.1590/0037-8682-0564-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/13/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Cardiovascular diseases (CDVs) have become increasingly important for progressively older people living with HIV (PLHIV). Identification of gaps requiring improvement in the care cascade for hypertension, a primary risk factor for CVDs, is of utmost importance. This study analyzed the prevalence of hypertensive status and described the care cascade for hypertension screening, diagnosis, treatment, treatment adherence, and management in PLHIV. METHODS This cross-sectional study included 298 PLHIV (age >40 years) who visited a referral center in the western Brazilian Amazon. Data were collected through a structured questionnaire interview and medical examinations. Thus, information regarding sociodemographic and clinical aspects, blood pressure, weight, height, body mass index, and laboratory profile was obtained. Descriptive and analytical statistics were performed, and results were considered significant ifp <0.05. RESULTS In total, 132 (44.3%) participants reported that their blood pressure was never measured. The prevalence of hypertension was found to be 35.9% (107/298). Of these 107 participants, only 36 (33.6%) had prior knowledge of their hypertensive status, and 19 of 36 (52.7%) participants had visited a physician or cardiologist to seek treatment. Adherence to the BP-lowering treatment was noted in 11 (10.2%) participants. CONCLUSIONS An increased prevalence of hypertension was found, and most of the hypertensive participants were unaware of their hypertensive status. In addition, blood pressure control was poor in the study population. This indicated that public health professionals did not sufficiently consider the full spectrum of healthcare and disease management for PLHIV.
Collapse
Affiliation(s)
- Aldrey Nascimento Costa
- Universidade do Estado do Amazonas, Escola Superior de Ciências da Saúde, Manaus, AM, Brasil.,Universidade Federal do Amazonas, Manaus, AM, Brasil
| | - Fernando Val
- Universidade do Estado do Amazonas, Escola Superior de Ciências da Saúde, Manaus, AM, Brasil.,Universidade Federal do Amazonas, Manaus, AM, Brasil.,Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, AM, Brasil
| | - Álvaro Elias Macedo
- Universidade do Estado do Amazonas, Escola Superior de Ciências da Saúde, Manaus, AM, Brasil
| | - Nadia Cubas-Vega
- Universidade do Estado do Amazonas, Escola Superior de Ciências da Saúde, Manaus, AM, Brasil.,Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, AM, Brasil
| | - Paola López Del Tejo
- Universidade do Estado do Amazonas, Escola Superior de Ciências da Saúde, Manaus, AM, Brasil.,Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, AM, Brasil
| | - Marly M Marques
- Universidade do Estado do Amazonas, Escola Superior de Ciências da Saúde, Manaus, AM, Brasil.,Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, AM, Brasil
| | | | - Marcus Vinicius Guimarães de Lacerda
- Universidade do Estado do Amazonas, Escola Superior de Ciências da Saúde, Manaus, AM, Brasil.,Instituto Leônidas & Maria Deane, Fundação Oswaldo Cruz, Manaus, AM, Brasil
| |
Collapse
|