The acceptability of integrated healthcare services for HIV and non-communicable diseases: experiences from patients and healthcare workers in Tanzania

Stakeholders' perspectives on the status of family planning integration into differentiated antiretroviral therapy service delivery models in Uganda: A qualitative assessment

INTRODUCTION

Facility- and community-based differentiated antiretroviral therapy service delivery models (DSDM) for stable patients can offer a convenient platform for integrating self-care-oriented family planning (FP) services into HIV care. However, little evidence exists on the status of FP integration within self-care-oriented DSDM (SC-DSDM). We explored the status of FP integration into SC-DSDM, stakeholders' perspectives about and barriers to integrating FP into SC-DSDM and suggestions for improving FP integration into SC-DSDM.

METHODS

This qualitative study was conducted in 18 purposely-selected health facilities in 17 districts across four high HIV-prevalence regions between September and October 2022. We conducted 36 in-depth interviews with women living with HIV (i.e., clients), receiving ARV drug refills through SC-DSDM, and 47 key informant interviews with selected stakeholders including healthcare providers, district health managers, implementing partner representatives and policymakers. Data were collected on the different forms of FP integration into SC-DSDM; perspectives on integrating FP into SC-DSDM, and barriers to and suggestions for improving FP integration into SC-DSDM. Data were analyzed following a thematic framework approach.

RESULTS

We found two forms of FP integration into SC-DSDM: a) one-stop center (in which ART and FP services were provided at the same service delivery point) and b) collaboration/referral to another service delivery point. Only four health facilities offered ART and FP services through the one-stop center; the rest of the health facilities referred clients to the maternal and child health/FP clinic or to other health facilities. All categories of stakeholders agreed that the one-stop center is more convenient and less time-consuming since referral to another service delivery point can increase patient waiting time or result in multiple clinic visits if ART and FP services are offered on separate days. Staff shortages, stock-outs of short-term FP supplies, shortage of adequate office space and lack of integrated registers continue to hamper effective integration of FP into SC-DSDM.

CONCLUSION

Despite the potential benefits of FP-HIV integration, FP and ART services continue to be offered as stand-alone programs with limited FP integration into SC-DSDM. These findings call for policy guidance from the Ministry of Health in integrating FP into SC-DSDM in Uganda.

Access to adolescent-responsive oral, mental, sexual, and reproductive healthcare services in Africa through dental clinics

In many healthcare systems, oral healthcare is provided separately from other clinical services. For 10-19-year-old adolescents in particular, this separation of care perpetuates the underutilization of oral health services and the neglect of oral health. Available evidence indicates that there are interconnections between oral, mental, sexual, and reproductive health (OMSRH) in adolescents. For African countries, there are opportunities to draw on lessons learned from HIV-centered models of integrated care to develop and evaluate dental clinic-centered models for integrating adolescent OMSRH services. This article makes a case for evidence-based adolescent OMSRH service integration in African countries. Integration is expected to align with the principles of sustainable development goals, universal healthcare, and the World Health Organization's calls for adolescent-responsive health services. We present a conceptual framework and propose an implementation science-guided blueprint for the integration of adolescent OMSRH care. The focus on dental clinics for integration can potentially increase access to, and use of oral healthcare while addressing adolescents' mental, sexual and reproductive health needs. OMSRH integration for adolescents in African settings will require intensive engagement of adolescents and other crucial stakeholders. Further exploratory and implementation research is also needed to design and evaluate OMSRH integration models to establish best practices for long-term impact on adolescent health outcomes.

Assessment of community knowledge on non-communicable diseases to inform the pilot of WHO PEN-Plus initiatives in selected two districts in Tanzania

BACKGROUND

Non-communicable diseases (NCDs) have increased significantly in Tanzania, accounting for 33% of mortality in the country. Having adequate knowledge translated into practice has a significant effect on the health of individuals through adoption of positive behaviours and influencing better health seeking behaviours. For those already affected by NCDs, it promotes secondary and tertiary prevention by helping them effectively cope with the disease. In this study, we aimed to determine the level and determinants of NCDs knowledge in the community to inform the implementation of WHO PEN- Plus initiatives.

METHODS

This cross-sectional study was conducted from May to June 2023 involving 528 adults aged 25-64 years from two purposely selected districts and 11, 22 and 528 randomly selected wards, villages, and households respectively. Information on socio-economic, demographic, NCDs knowledge were collected from each participant. Chi-square test and Modified Poisson Regression were applied to assess the association and determinants of NCDs knowledge level.

RESULTS

The median age of study participants was 40.5 years. Less than half 42.6%(n=225) were aware of the term NCD and less than one third were aware of the NCD conditions such as Type 1 Diabetes Mellitus (T1DM) 15.3%(n=70), Sickle Cell Disease (SCD) 25.2%(n=133), Rheumatic fever 28.6%(n=151) and Heart failure 33.1%(n=175). Good level of awareness was reported on Type 2 Diabetes Mellitus (T2DM) 79.5%(n=364). More than three quarters of the respondents had low knowledge on T1DM (90.3%), SCD (84.1%), Rheumatic fever (81.3%), NCDs (80.5%) and Heart failure (76.1%). Furthermore, more than half (56.4%) of respondents had low knowledge for T2DM. Adjusted analysis indicated that, for all NCDs except SCD, low knowledge was significantly associated with the district of residence (Kondoa). Low knowledge of NCDs, T2DM, and SCD was significantly associated with having no education, or having only primary or secondary education. Individuals from the lowest, second, middle, and fourth socio-economic status families were significantly associated with low knowledge of NCDs, while the lowest and fourth socio-economic status levels were associated with low knowledge of T2DM and SCD.

CONCLUSION

Low knowledge was observed for all NCDs conditions and socio-economic and demographic characteristics were associated with low knowledge. Interventions to increase NCDs knowledge should consider the socio-economic determinants.

Mortality, loss to follow-up and advanced HIV disease following virologic success in West African HIV-2 patients

BACKGROUND

People living with HIV-2 are mainly found in West Africa and their identification and treatment have been impaired by diagnostic challenges and availability of effective antiretroviral treatment (ART). With the roll out of first line dolutegravir (DTG)-based regimen, the situation may have improved, emphasizing the need for data on long-term treatment outcomes and advanced HIV disease among ART-experienced people living with HIV-2.

METHOD

A prospective cohort was initiated in 2012 in Côte d'Ivoire and Burkina Faso. All adult patients from Côte d'Ivoire with an undetectable viral load, were included and followed up. HIV-2 viral load and CD4 counts were done during the routine follow-up visits and a detailed clinical assessment was done during the last follow up visit of the year 2018 corresponding to the censor date of the cohort. Outcomes were described as follow: in care (known alive and present during the last ART follow up visit), loss to follow-up (absent for more than 90 days and not reported dead), and dead (reported dead with a date of event). Advanced HIV disease followed WHO definition and virologic failure was define as viral load > 50 copies/mm3. The Kaplan-Meier curve was used to estimate mortality and Loss to follow-up probability.

RESULTS

Among the 108 HIV-2 patients in virologic success in 2012, 95 agreed to participate and were enrolled in the "success cohort". Their median age was 53 [47-60] years and all of them were receiving boosted-lopinavir-based ART regimen. Of the 95 participants, 65 (68.4%) remained in care, 20 (21.1%) were loss to follow-up and 10 (10.5%) were reported dead. The survival analysis retrieved a decreasing probability of remaining alive and in care over the time, moving from 90% to 80.7% and to 73.0% after 24, 48 and 72 months respectively. Overall, 36 (37.9%) patients presented with advanced HIV disease at their last visit, higher among those dead/ loss to follow-up compared to those remaining in care (60.0% vs 27.7%; p-0.003).

CONCLUSION

High advanced HIV disease rate was found in HIV-2 patients, six years after an initial virologic success. This emphasizes the need to enable the one-stop-shop model that allow an early management of opportunistic infections while integrating non-communicable diseases services in HIV-2 care.

Experiences of Older People Living with Human Immunodeficiency Virus Comorbidity Attending Coordinated Healthcare Services

BACKGROUND

Older people living with human immunodeficiency virus (OPLWHIV) on antiretroviral therapy are aging and face an increased risk of non-communicable diseases. The burden is costly and demands sustainable care for HIV comorbidity. The aim is to understand the experiences of OPLWHIV comorbidity attending healthcare services.

METHODS

The 28 reviewed articles focused on experiences of OPLWHIV comorbidity attending healthcare services. The scoping review employed content analysis. A literature search was conducted on databases like PubMed, EBSCOhost, Google Scholar, and Subnet. Articles were restricted to English and published between 2013 and 2024. The study population included 50-85 years old.

RESULTS

OPLWHIV comorbidity needs standardized, coordinated, and resourced healthcare services because of the unique difficulties of older adults.

CONCLUSIONS

OPLWHIV comorbidity experienced difficulties accessing coordinated services addressing complex pharmacoeconomics and psycho-social issues in resourced primary health care institutions, with promotive and preventive care to strengthen the healthcare system.

Perceptions and management of diabetes and obesity among people living with HIV in Côte d'Ivoire: a qualitative study

INTRODUCTION

The prevalence of both type 2 diabetes mellitus (T2DM) and obesity is increasing among people living with HIV (PLHIV) in sub-Saharan Africa. We examined the perceptions and management of these two conditions among PLHIV and healthcare workers in Côte D'Ivoire.

METHOD

From June to August 2022, we conducted semi-structured face-to-face interviews with PLHIV diagnosed with T2DM and/or obesity, as well as healthcare workers, in one of the major HIV clinics in Abidjan, Cote d'Ivoire. We explored topics such as experiences, perceptions and acceptability of the diagnosis and management of T2DM and obesity among PLHIV. Among healthcare workers, professional experience, professional relationships with patients diagnosed with T2DM/obesity, involvement in patient management and care provision were explored. Interviews were audio recorded and transcribed manually. Data were analysed using thematic analysis.

RESULTS

A total of 15 PLHIV and 5 healthcare workers participated in semi-structured in-depth interviews. Perceptions towards T2DM and obesity were largely influenced by cultural factors, PLHIV reported negative perceptions of T2DM and positive perceptions of obesity. Both patients and healthcare providers considered the management of these conditions as sub-optimal. Patient-reported barriers to care for these metabolic disorders were mainly socio-economic and environmental, while healthcare workers emphasized patients' denial of their illness and the limited range of treatment options available at the clinic.

CONCLUSION

These results highlight the complexity surrounding the perceptions and management of T2DM and obesity among PLHIV in Abidjan, Côte d'Ivoire. In order to implement innovative and efficient intervention strategies to prevent and treat these metabolic conditions, cultural beliefs as well as socio-economic barriers must be addressed.

Healthcare provider perspectives on barriers and facilitators to integration of cardiovascular disease-related care into HIV care and treatment clinics in urban Tanzania

Background

The increase in the dual burden of HIV and cardiovascular diseases (CVD), calls for the provision of integrated HIV/CVD care. This study aimed to explore barriers and facilitators to the integration of HIV/CVD care within HIV care and treatment clinics (CTCs) in urban, Tanzania.

Methods

Between March and April 2023, we conducted 12 key informant interviews with healthcare providers at six HIV CTCs in urban, Tanzania. Guided by the Consolidated Framework for Implementation Research (CFIR 1.0), we designed the interview guide and conducted a thematic analysis.

Results

Out of the 11 CFIR constructs explored, three were barriers (cost, availability of resources, and access to information and knowledge), six were facilitators (complexity, relative advantage, patient needs, external policies and incentives, relative priority, and knowledge and belief about the intervention), and two (compatibility and self-efficacy) were both barriers and facilitators. Barriers to integration included a lack of equipment, such as BP machines, lack of space, unavailability of an electronic data-capturing tool at the HIV CTCs for monitoring CVD outcomes, and a shortage of trained healthcare workers, particularly in managing CVD comorbidities according to current recommendations. Providers acknowledged the increasing demand for CVD care among ALHIV and regarded integration as not a complex task. Providers reported that both services could be delivered simultaneously without disrupting client workflow and were determined to offer integrated care within HIV CTCs. Providers expressed concerns about medication costs and recommended that medications should be provided for free as part of the integrated care.

Conclusion

Effective and sustainable HIV/CVD integrated care requires an understating of the existing barriers and facilitators within the HIV CTCs. This study identifies key barriers at HIV CTCs that must be addressed and facilitators to be leveraged before CVD care is integrated into HIV CTCs to ensure that CVD care is delivered effectively within an integrated system.

Opportunities and challenges for the integration of managing non-communicable diseases within HIV care and treatment services in Tanzania

BACKGROUND

People living with HIV and non-communicable diseases (NCDs) are reported to experience challenges in accessing affordable and high-quality NCD care services. Consequently, the World Health Organization (WHO) recommends care integration of NCDs within the HIV services in resource-limited regions. The available opportunities and challenges need to be understood and addressed for an effective integration process. This study explored opportunities and challenges for integrating NCDs within HIV care and treatment services in Tanzania.

METHODS

An exploratory qualitative case study was conducted in Tanzania between April and July 2022. A total of 22 key informants working at the ministerial level, supervising the provision of healthcare services in Tanzania, were recruited purposefully for in-depth interviews. Thematic analysis was employed during the study.

RESULTS

Several opportunities were identified in the study for HIV/NCD services integration including the existence of an integration policy, the availability of regulations and guidelines, the existence of donor support, the presence of physical space and reliable information and communication systems, human resources adequacy, and political will to support the process. However, participants voiced concerns over the costs related to service integration, difficulties in reallocating donor funds, and hesitance of the healthcare providers as likely challenges to effective integration.

CONCLUSION

The findings of this study underscore that the effective and sustainable care integration of NCDs within HIV services relies on the availability of policy, funds, infrastructures, human resources, and stakeholders' willingness to support the process.

Lessons Learnt from HIV and Noncommunicable Disease Healthcare Integration in Sub-Saharan Africa

In sub-Saharan Africa (SSA), a rising burden of noncommunicable diseases (NCDs) coexists with a persistent high burden of human immunodeficiency virus (HIV). Integrating care for chronic conditions is potentially beneficial, but the optimal approach remains unclear. By use of a narrative review of 14 recent case studies from different SSA countries, examples of NCD and HIV healthcare integration were described. Case studies were categorized into three models: integrating NCD care into existing HIV care (n = 8), integrating HIV care into existing NCD care (n = 2), and simultaneous implementation of HIV and NCD services (n = 4). Facilitators include staff and patient education, while barriers encompass the lack of guidelines and inadequate infrastructure. Providers, patients, and policymakers support integrated care but note several challenges. Available health economics data suggest cost-effectiveness in the long run. Concluding, NCD and HIV healthcare integration in SSA was deemed feasible with models of service integration related to the implementation context.

Challenges in managing HIV and non-communicable diseases and health workers' perception regarding integrated management of non-communicable diseases during routine HIV care in South Central Uganda: A qualitative study

BACKGROUND

Non-communicable diseases are highly prevalent among adults living with HIV, emphasizing the need for comprehensive healthcare strategies. However, a dearth of knowledge exists regarding the health systems challenges in managing HIV and non-communicable diseases and the perception of health workers regarding the integrated management of non-communicable diseases during routine HIV care in rural Ugandan settings. This study aims to bridge this knowledge gap by exploring the health system challenges in managing HIV and non-communicable diseases and health workers' perception regarding the integration of non-communicable diseases in routine HIV care in South Central Uganda.

METHODS

In this qualitative study, we collected data from 20 purposively selected key informants from Kalisizo Hospital and Rakai Hospital in South Central Uganda. Data were collected from 15th December 2020 and 14th January 2021. Data were analyzed using a thematic content approach with the help of NVivo 11.

RESULTS

Of the 20 health workers, 13 were females. In terms of work duration, 9 had worked with people living with HIV for 11-15 years and 9 were nurses. The challenges in managing HIV and non-communicable diseases included difficulty managing adverse events, heavy workload, inadequate communication from specialists to lower cadre health workers, limited financial and human resources, unsupportive clinical guidelines that do not incorporate non-communicable disease management in HIV care and treatment, and inadequate knowledge and skills required to manage non-communicable diseases appropriately. Health workers suggested integrating non-communicable disease management into routine HIV care and suggested the need for training before this integration.

CONCLUSION

The integration of non-communicable disease management into routine HIV care presents a promising avenue for easing the burden on health workers handling these conditions. However, achieving successful integration requires not only the training of health workers but also ensuring the availability of sufficient human and financial resources.

Post-Intervention Acceptability of a Multicomponent Intervention for Hypertension Management in Primary Care Clinics by Health Care Providers and Patients: A Qualitative Study of a Cluster RCT in Singapore

Background

Hypertension is a major public health challenge, globally. Recently, we reported findings from cluster randomized trial in 8 primary care clinics in Singapore and showed that a multicomponent "SingHypertension" intervention comprising 1) motivational conversation by trained nurses, 2) telephone-based follow-ups, 3) standardized algorithm with single-pill combination (SPC) antihypertensive medications, and 4) subsidy on SPC antihypertensive drugs was effective on improving BP control. This paper presents the acceptability of SingHypertension multicomponent intervention among the key stakeholders.

Methods

We conducted post-implementation interviews of 38 stakeholders, including 18 patients and 20 healthcare providers (HCPs) in 4 primary care clinics randomized to the multicomponent "SingHypertension" intervention in Singapore. We used Theoretical Framework for Acceptability (TFA) framework with a focus on affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness and self-efficacy to assess stakeholders' acceptability of the intervention.

Results

SingHypertension multicomponent intervention had high perceived effectiveness and a good fit with the value system and ethics of patients and HCPs. Physicians appreciated the guidance from standardized training in hypertension management. Although workload was increased, the nurses felt rewarded for their positive interactions with the patients during motivational conversation sessions and the telephone follow-ups. Most patients reported high self-efficacy levels, improved lifestyles, and adherence to antihypertensive medications. The limited choice of SPC medication, lack of subsidy beyond the trial duration, and shortage of nurses were significant challenges to wide-scale implementation. All HCPs and patients supported scaling up the intervention across primary care clinics.

Conclusion

SingHypertension multicomponent intervention is acceptable to the key stakeholders in Singapore. Taken together with the effectiveness of the intervention, our findings make a compelling case for scaling-up SingHypertension in primary care clinics in Singapore and possibly other countries with similar healthcare infrastructure.

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

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

Integrated Diagnosis in Africa's Low- and Middle-Income Countries: What Is It, What Works, and for Whom? A Realist Synthesis

Introduction

Integrated diagnosis can improve health outcomes and patient experiences through early diagnosis and identification of cases that could otherwise be overlooked. Although existing research highlight the feasibility of integrated diagnosis across various conditions, a significant evidence gap remains regarding its direct impact on patient experiences and health outcomes. This review explores the conceptualizations of integrated diagnosis by different stakeholders along the healthcare pathway and examines the necessary contexts and mechanisms crucial for its effectiveness.

Methods

This study adopts a realist methodology to explore integrated diagnosis. Using a systematic approach, the research aims to collect, assess, and synthesize existing evidence on integrated diagnosis, guided by a program theory developed through literature review and expert consultations. Primary studies and reviews related to integrated diagnosis, multi-disease testing, or integrated healthcare with a diagnostic focus were sourced from major databases and global health organization websites. The collected evidence was used to construct and refine the evolving theoretical framework.

Results

This study identified three models of integrated diagnosis interventions: individual/human resource integration, facility or mobile-based integration, and technology integration. Successful implementation of these models relies on understanding the values and perceptions of both healthcare workers and patients/clients. This research emphasizes a holistic approach that considers all elements within the health system and underscores their interdependence. Using the WHO health systems framework to contextualise factors, the study positions diagnosis as an integral component of the broader health ecosystem. A key finding of the research is the importance of addressing the barriers and facilitators of integrated diagnosis interventions. This includes policy frameworks, diagnostic tools, funding mechanisms, treatment pathways, and human resource issues. Improving patient experiences requires cultivating positive relationships with healthcare workers ensuring elements such as respect, confidentiality, accessibility, and timeliness of services are prioritised.

Discussion and Conclusion

The diverse conceptualisations of integrated diagnosis highlight the importance of clear definitions for each intervention. This clarity is essential for transferring lessons learned, comparing programs, and effectively measuring results. The success of integrated diagnosis is not a one-size-fits-all scenario; decisions regarding the approach, conditions to be integrated, and timing of integration must be guided by local contexts to ensure sustainable outcomes. The review findings suggest that integrated diagnosis may be suitable at the primary care level in LMICs under specific circumstances. Successful implementation hinges on addressing the perspectives of healthcare workers and patients/clients alike, requiring adequate time, resources, and a well-defined intervention model.

Mapping the evidence on integrated service delivery for non-communicable and infectious disease comorbidity in sub-Saharan Africa: protocol for a scoping review

INTRODUCTION

The concurrent occurrence of infectious diseases (IDs) and non-communicable diseases (NCDs) presents complex healthcare challenges in sub-Saharan Africa (SSA), where healthcare systems often grapple with limited resources. While an integrated care approach has been advocated to address these complex challenges, there is a recognised gap in comprehensive evidence regarding the various models of integrated care, their components and the feasibility of their implementation. This scoping review aims to bridge this gap by examining the breadth and nature of evidence on integrated care models for NCDs and IDs within SSA, thereby updating the current evidence base in the domain.

METHODS AND ANALYSIS

Based on the Joanna Briggs Institute (JBI) framework for scoping reviews, this study will include peer-reviewed and grey literature reporting on integrated care models for NCD-ID comorbidities in SSA. A comprehensive search of published sources in electronic databases (PubMed, Scopus, Embase, the Cochrane Library, Health System Evidence and Research4Life) and grey literature (Google Scholar, EBSCO Open Dissertations and relevant organisational websites) will be conducted to identify sources of information reported in English from 2018 onwards. The review will consider sources of evidence reporting on integrated care model for NCDs such as diabetes; chronic cardiovascular, respiratory and kidney diseases; cancers; epilepsy; and mental illness, and comorbid IDs such as HIV, tuberculosis and malaria. All sources of evidence will be considered irrespective of the study designs or methods used. The review will exclude sources that solely focus on the differentiated or patient-centred care delivery approach, and that focus on other conditions, populations or settings. The reviewers will independently screen the sources for eligibility and extract data using a JBI-adapted data tool on the Parsifal review platform. Data will be analysed using descriptive and thematic analyses and results will be presented in tables, figures, diagrams and a narrative summary.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review as it will synthesise published data and does not involve human participants. The final report will be submitted for publication in a peer-reviewed journal. The findings will be used to inform future research.

STUDY REGISTRATION

OSF: https://doi.org/10.17605/OSF.IO/KFVEY.

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

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.

Lived experiences of people living with HIV and hypertension or diabetes access to care in Ethiopia: a phenomenological study

BACKGROUND

People living with HIV (PLWH) are more likely to develop hypertension and diabetes than people without HIV. Previous studies have shown that HIV stigma, discrimination and exclusion make it difficult for PLWH to access care for hypertension and diabetes.

OBJECTIVES

This study aimed to explore the lived experiences of PLWH with comorbid hypertension or diabetes to access hypertension and diabetes care in southern Ethiopia.

DESIGN

We conducted a qualitative study using a semistructured interview guide for an in-depth, in-person interview.

SETTINGS

From 5 August to 25 September 2022, PLWH with comorbid hypertension or diabetes were purposefully selected from five primary healthcare (PHC) facilities in the Wolaita zone of southern Ethiopia.

PARTICIPANTS

A total of 14 PLWH with comorbid hypertension or diabetes who were receiving antiretroviral therapy from PHC were interviewed. Among them, 10 were women, and 4 were men.

METHODS

In-person, in-depth interviews were conducted. Qualitative data analysis software (NVivo V.12) was used to assist with the data organisation, and Colaizzi's (1978) inductive thematic analyses were conducted to explore key concepts.

RESULT

This study yielded two main themes: Theme 1: barriers to accessing care as individual barriers to access (low awareness of non-communicable diseases, misperceptions, lack of health insurance and cost of treatment); healthcare system barriers (shortage of supplies, drugs and equipment; long wait times; lack of integrated services; absence of routine screening and lack of respect from providers); community barriers (lack of support from families, friends and the community) and stigma and discrimination access to hypertension and diabetes. Theme 2: accessibility facilitators (support from family, friends and organisations; health insurance coverage).

CONCLUSION

PLWH recommended that access to services can be improved by service integration, awareness-raising activities, no user fee charges for hypertension and diabetes care and routine screening.

Patients' and Care Providers' Reported Barriers and Suggestions for Improving HIV Viral Load Testing in Tanzania: A Qualitative Study in Dar es Salaam

The study explores barriers and suggestions for improving viral load testing (VLT) uptake in Tanzania, revealing that only 58% of patients receive VLT annually, contrary to the Tanzanian National Guidelines toward the 95-95-95 UNAIDS targets. Twelve individual interviews and three patient-focus groups were conducted as part of a qualitative study conducted in six human immunodeficiency virus (HIV) clinics in Dar es Salaam to identify potential suggestions for access enhancement, as well as barriers to VLT uptake. Using King's theory of goal attainment, we found that missing appointments was the primary individual barrier to VLT uptake, along with limited knowledge among individuals living with HIV. Participants also face system-level barriers, such as a lack of integrated care and evening service availability. The study suggests that, despite challenges, there is potential for improvement in the uptake and quality of VLT services in Tanzanian public health facilities through a holistic approach.

Facilitators and barriers to integration of noncommunicable diseases with HIV care at primary health care in Ethiopia: a qualitative analysis using CFIR

Background

The rise in non-communicable diseases (NCD), such as hypertension and diabetes among people living with human immunodeficiency virus (PLWH), has increased the demand for integrated care due to multiple chronic care needs. However, there is a dearth of evidence on contextual factors implementing integrated hypertension and diabetes care with HIV care. This study aimed to identify facilitators and barriers that could affect the integration of hypertension and diabetes with HIV care at primary health care in Ethiopia.

Methods

Five primary health facilities from five districts of the Wolaita zone of South Ethiopia were included in the qualitative study. Fifteen key informant interviews were conducted with healthcare providers and managers from the zonal, district, and facility levels from October to November 2022. Data collection and analysis were guided by a consolidated framework of implementation research (CFIR).

Results

Ten CFIR constructs were found to influence the integration. Perceived benefit of integration to patients, healthcare providers, and organization; perceived possibilities of integration implementation; availability of NCD guidelines and strategies; a supportive policy of decentralization and integration; perceived leaders and healthcare provider commitment were found to be facilitators. Perceived increased cost, insufficient attention to NCD care needs, inadequate number of trained professionals, inadequate equipment and apparatus such as blood pressure measurement, glucometers, strips, and NCD drugs, inadequate allocation of budget and weak health financing system and poor culture of data capturing and reporting were identified as barriers to integration.

Conclusion

It is important to address contextual barriers through innovative implementation science solutions to address multiple chronic care needs of PLWH by implementing integrated hypertension and diabetes with HIV care in primary healthcare. Training and task shifting, pairing experienced professionals, and strengthening the health care financing system to implement evidence-based integration of hypertension and diabetes are recommended.

Six month incidence of major adverse cardiovascular events among adults with HIV in northern Tanzania: a prospective observational study

OBJECTIVES

We aimed to prospectively describe incident cardiovascular events among people living with HIV (PLWH) in northern Tanzania. Secondary aims of this study were to understand non-communicable disease care-seeking behaviour and patient preferences for cardiovascular care and education.

DESIGN

A prospective observational study.

SETTING

This study was conducted at the Majengo HIV Care and Treatment Clinic, an outpatient government-funded clinic in Moshi, Tanzania PARTICIPANTS: Adult patients presenting to an HIV clinic for routine care in northern Tanzania were enrolled from 1 September 2020 to 1 March 2021.

INTERVENTIONS

At enrolment, participants completed a survey and a resting 12-lead ECG was obtained. At 6 month follow-up, a repeat survey regarding interim health events and repeat ECG was obtained.

PRIMARY AND SECONDARY OUTCOME MEASURES

Interim major adverse cardiovascular events (MACE) were defined by: self-reported interim stroke, self-reported hospitalisation for heart failure, self-reported interim myocardial infarction, interim myocardial infarction by ECG criteria (new pathologic Q waves in two contiguous leads) or death due to cardiovascular disease (CVD).

RESULTS

Of 500 enrolled participants, 477 (95.4%) completed 6 month follow-up and 3 (0.6%) died. Over the 6 month follow-up period, 11 MACE occurred (3 strokes, 6 myocardial infarctions, 1 heart failure hospitalisation and 1 cardiovascular death), resulting in an incidence rate of 4.58 MACE per 100 person-years. Of participants completing 6 month follow-up, 31 (6.5%) reported a new non-communicable disease diagnosis, including 23 (4.8%) with a new hypertension diagnosis.

CONCLUSIONS

The incidence of MACE among PLWH in Tanzania is high. These findings are an important preliminary step in understanding the landscape of CVD among PLWH in Tanzania and highlight the need for interventions to reduce cardiovascular risk in this population.

Management of chronic conditions in resource limited settings: multi stakeholders' perception and experiences with receiving and providing integrated HIV, diabetes and hypertension services in Tanzania

BACKGROUND

The rising prevalence of non-communicable diseases (NCDs) alongside the continuing high burden of HIV poses a serious challenge to middle- and low-income countries' healthcare systems. Pilot studies of integrated models of service delivery for HIV, hypertension and diabetes have demonstrated that they are feasible and acceptable among patients and care providers. This study assessed multi-stakeholders' perspectives of the delivery and receipt of integrated care in Tanzania.

METHODS

A qualitative process evaluation was conducted in Dar es Salaam region of Tanzania where the integrated service delivery model was implemented from July to November 2021. In-depth interviews were held with seven key informants at the national, regional and district levels, eight healthcare providers, two researchers working at the integrated clinic and forty patients benefiting from integrated services at a large hospital. Three focus group discussions were held with community leaders and residents of the hospital's catchment area, and clinic level observations were conducted. Thematic analysis was conducted followed by the use of Bronfenbrenner's ecological model to identify factors pertinent to sustaining and scaling up of the integrated model.

RESULTS

Participants of the study at all levels were aware of the increased prevalence of NCDs specifically for hypertension and diabetes and were concerned about the trend of increasing co-morbid conditions among people living with HIV (PLHIV). The integrated service delivery model was positively perceived by stakeholders because of its multiple benefits for both patients and the healthcare system. These include stigma and discrimination reduction, improved quality of care, efficient use of limited resources, cost and time saving, reduced duplication of services and fostering of early detection for undiagnosed conditions. The organisation of the clinic was critical in increased satisfaction. Several challenges were observed, which included costs for NCD services relative to free care for HIV and inconsistent availability of NCD medications.

CONCLUSION

Stakeholders reported numerous benefits of the integrated service delivery model that are fundamental in improving the health of many Tanzanians living with NCDs and HIV. These benefits highlight the need for policy and decision-makers to sustain and expand the integrated service delivery model as a solution to many challenges facing the health system especially at the primary care level.

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

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.

National Evaluation of HIV Service Resource Allocation in Tanzania

Using time-driven activity-based costing (TDABC), we examined resource allocation and costs for HIV services throughout Tanzania at patient and facility levels. This national, cross-sectional analysis of 22 health facilities quantified costs and resources associated with 886 patients receiving care for five HIV services: antiretroviral therapy, prevention of mother-to-child transmission, HIV testing and counseling, voluntary medical male circumcision, and pre-exposure prophylaxis. We also documented total provider-patient interaction time, the cost of services with and without inclusion of consumables, and conducted fixed-effects multivariable regression analyses to examine patient- and facility-level correlates of costs and provider-patient time. Findings showed that resources and costs for HIV care varied significantly throughout Tanzania, including as a function of patient- and facility-level characteristics. While some variation may be preferable (e.g., needier patients received more resources), other areas suggested a lack of equity (e.g., wealthier patients received more provider time) and presented opportunities to optimize care delivery protocols.

Using the RE-AIM framework to evaluate the implementation and effectiveness of a WHO HEARTS-based intervention to integrate the management of hypertension into HIV care in Uganda: a process evaluation

BACKGROUND

World Health Organization (WHO) HEARTS packages are increasingly used to control hypertension. However, their feasibility in persons living with HIV (PLHIV) is unknown. We studied the effectiveness and implementation of a WHO HEARTS intervention to integrate the management of hypertension into HIV care.

METHODS

This was a mixed methods study at Uganda's largest HIV clinic. Components of the adapted WHO HEARTS intervention were lifestyle counseling, free hypertension medications, hypertension treatment protocol, task shifting, and monitoring tools. We determined the effectiveness of the intervention among PLHIV by comparing hypertension and HIV outcomes at baseline and 21 months. The RE-AIM framework was used to evaluate the implementation outcomes of the intervention at 21 months. We conducted four focus group discussions with PLHIV (n = 42), in-depth interviews with PLHIV (n = 9), healthcare providers (n = 15), and Ministry of Health (MoH) policymakers (n = 2).

RESULTS

Reach: Among the 15,953 adult PLHIV in the clinic, of whom 3892 (24%) had been diagnosed with hypertension, 1133(29%) initiated integrated hypertension-HIV treatment compared to 39 (1%) at baseline. Among the enrolled patients, the mean age was 51.5 ± 9.7 years and 679 (62.6%) were female.

EFFECTIVENESS

Among the treated patients, hypertension control improved from 9 to 72% (p < 0.001), mean systolic blood pressure (BP) from 153.2 ± 21.4 to 129.2 ± 15.2 mmHg (p < 0.001), and mean diastolic BP from 98.5 ± 13.5 to 85.1 ± 9.7 mmHg (p < 0.001). Overall, 1087 (95.9%) of patients were retained by month 21. HIV viral suppression remained high, 99.3 to 99.5% (p = 0.694). Patients who received integrated hypertension-HIV care felt healthy and saved more money. Adoption: All 48 (100%) healthcare providers in the clinic were trained and adopted the intervention. Training healthcare providers on WHO HEARTS, task shifting, and synchronizing clinic appointments for hypertension and HIV promoted adoption.

IMPLEMENTATION

WHO HEARTS intervention was feasible and implemented with fidelity. Maintenance: Leveraging HIV program resources and adopting WHO HEARTS protocols into national guidelines will promote sustainability.

CONCLUSIONS

The WHO HEARTS intervention promoted the integration of hypertension management into HIV care in the real-world setting. It was acceptable, feasible, and effective in controlling hypertension and maintaining optimal viral suppression among PLHIV. Integrating this intervention into national guidelines will promote sustainability.

Integrating global HIV services with primary health care: a key step in sustainable HIV epidemic control

Ending the HIV epidemic relies in part on integrating stand-alone HIV programming with primary health-care platforms to improve population-level health and ensure sustainability. Integration of HIV and primary health care services in sub-Saharan Africa improves both outcomes. Existing models support both integrating primary health care services into existing HIV services, and incorporating HIV services into primary health care platforms, with optimal programming based on local contexts and local epidemic factors. Person-centred differentiated service delivery, community-based interventions, and a well supported health workforce form the backbone of successful integration. Strategic financing to optimise HIV and primary health care integration requires well-coordinated partnerships with host governments, private sector companies, multilateral stakeholders, development banks, and non-government organisations. Programme success will require increased flexibility of international donors' implementation guidance as well as involvement of local communities and civil society organisations. As we seek to end the HIV epidemic by 2030 amidst a constrained global economic climate, integration of HIV programming with primary health care offers an avenue of opportunity and hope.

Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomised controlled trial

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.

Prevalence of Cardiometabolic Disease Risk Factors in People With HIV Initiating Antiretroviral Therapy at a High-Volume HIV Clinic in Kampala, Uganda

Background

Cardiometabolic diseases are a leading cause of HIV-related morbidity and mortality, yet routine screening is not undertaken in high-burden countries. We aimed to assess the prevalence and risk factors of the metabolic syndrome (MetS) and its components in adult Ugandan people with HIV (PWH) initiating dolutegravir-based antiretroviral therapy (ART).

Methods

We conducted a cross-sectional study using baseline sociodemographic and clinical data of PWH aged ≥18 years enrolled in the Glucose metabolism changes in Ugandan HIV patients on Dolutegravir (GLUMED) study from January to October 2021. MetS was defined as having ≥3 of the following: abdominal obesity, hypertension (HTN), hyperglycemia, elevated triglycerides, and low high-density lipoprotein cholesterol. Multiple logistic regression was used to assess associations between potential risk factors and MetS and its components.

Results

Three hundred nine PWH were analyzed (100% ART-naïve, 59.2% female, median age 31 years, and median CD4 count 318 cells/mm3). The prevalence of MetS was 13.9%. The most common cardiometabolic condition was dyslipidemia (93.6%), followed by abdominal obesity (34.0%), hyperglycemia (18.4%), and HTN (8.1%). In adjusted analysis, MetS was associated with age >40 years (adjusted odds ratio [aOR], 3.33; 95% CI, 1.45-7.67) and CD4 count >200 cells/mm3 (aOR, 3.79; 95% CI, 1.23-11.63). HTN was associated with age >40 years (aOR, 2.96; 95% CI, 1.32-6.64), and dyslipidemia was associated with urban residence (aOR, 4.99; 95% CI, 1.35-18.53).

Conclusions

Cardiometabolic risk factors were common in this young Ugandan cohort of PWH initiating dolutegravir-based ART, underscoring the need for programmatic implementation of surveillance and management of comorbidities in Uganda and similar settings.

The impacts of COVID-19 and its policy response on access and utilization of maternal and child health services in Tanzania: A mixed methods study

The SARS-Cov-2 virus (COVID-19) has had a global social and economic impact. Despite the growing evidence, its effects on access and delivery of maternal and child health services in low-income countries are still unclear. This cross-sectional case study was conducted in Mjini Magharibi, Chake Chake, and Ilala districts in Tanzania to help fill this gap. The study combined qualitative and quantitative data collection methods, providing an account of the evolution of the pandemic and the associated control measures in Tanzania. We drew from 34 in-depth interviews, 60 semi-structured interviews, and 14 focus group discussions with key informants, patients, and health providers, and complemented the findings with a review of pandemic reports and health facility records. We followed the Standards for Reporting Qualitative Research (SRQR) to provide an account of the findings. Our account of the pandemic shows that there was at times an inconsistent policy response in Tanzania, with diverse control measures adopted at various stages of the epidemic. There was a perception that COVID-19 services were prioritized during the epidemic at the expense of regular ones. There were reports of reorganisation of health facilities, reallocation of staff, rescheduled antenatal and postnatal clinics, and reduced time for health education and child monitoring. Scarcity of essential commodities was reported, such as vaccines, equipment, and medical supplies. Such perceptions were in part supported by the routine utilization evidence in the three districts, showing a lower uptake of antenatal, postnatal, family planning, and immunization services, as well as fewer institutional deliveries. Our findings suggest that, although the policy response in Tanzania was erratic, it was rather fear of the pandemic itself and diversion of resources to control COVID-19, that may have contributed most to lower the utilization of mother and child services. For future emergencies, it will be crucial to ensure the policy response does not weaken the population's demand for services.

Six-month blood pressure and glucose control among HIV-infected adults with elevated blood pressure and hyperglycemia in northern Tanzania: A prospective observational study

BACKGROUND

People with HIV in sub-Saharan Africa are increasingly developing age-related comorbidities. The purpose of this prospective observational study was to describe 6-month outcomes among Tanzanians with HIV and elevated blood pressure or hyperglycemia under current care pathways.

METHODS

Adults presenting for routine HIV care were enrolled and underwent blood pressure and blood glucose measurements. Participants with abnormal blood pressure or glucose were referred for further care, as per current guidelines. Participants' blood pressure and point-of-care glucose were re-evaluated during their 6-month follow-up visit. Elevated blood pressure was defined as systolic ≥140 mmHg or diastolic ≥90 mmHg. Hyperglycemia was defined as fasting glucose ≥126 mg/dl or random glucose ≥200 mg/dl. An electrocardiogram was obtained at enrollment and at follow-up. Interim myocardial infarction and interim myocardial ischemia were defined as new pathologic Q waves and new T-wave inversions, respectively.

RESULTS

Of 500 participants, 155 had elevated blood pressure and 17 had hyperglycemia at enrolment. At 6-month follow-up, 7 (4.6%) of 155 participants with elevated blood pressure reported current use of an anti-hypertensive medication, 100 (66.2%) had persistent elevated blood pressure, 12 (7.9%) developed interim myocardial infarction, and 13 (8.6%) developed interim myocardial ischemia. Among 17 participants with hyperglycemia, 9 (56%) had persistent hyperglycemia at 6 months and 2 (12.5%) reported current use of an anti-hyperglycemic medication.

CONCLUSIONS

Interventions are needed to improve non-communicable disease care pathways among Tanzanians with HIV.

Women living with HIV, diabetes and/or hypertension multi-morbidity in Uganda: a qualitative exploration of experiences accessing an integrated care service

Purpose

Women experience a triple burden of ill-health spanning non-communicable diseases (NCDs), reproductive and maternal health conditions and human immunodeficiency virus (HIV) in sub-Saharan Africa. Whilst there is research on integrated service experiences of women living with HIV (WLHIV) and cancer, little is known regarding those of WLHIV, diabetes and/or hypertension when accessing integrated care. Our research responds to this gap.

Design/methodology/approach

The INTE-AFRICA project conducted a pragmatic parallel arm cluster randomised trial to scale up and evaluate “one-stop” integrated care clinics for HIV-infection, diabetes and hypertension at selected primary care centres in Uganda. A qualitative process evaluation explored and documented patient experiences of integrated care for HIV, diabetes and/or hypertension. In-depth interviews were conducted using a phenomenological approach with six WLHIV with diabetes and/or hypertension accessing a “one stop” clinic. Thematic analysis of narratives revealed five themes: lay health knowledge and alternative medicine, community stigma, experiences of integrated care, navigating personal challenges and health service constraints.

Findings

WLHIV described patient pathways navigating HIV and diabetes/hypertension, with caregiving responsibilities, poverty, travel time and cost and personal ill health impacting on their ability to adhere to multi-morbid integrated treatment. Health service barriers to optimal integrated care included unreliable drug supply for diabetes/hypertension and HIV linked stigma. Comprehensive integrated care is recommended to further consider gender sensitive aspects of care.

Originality/value

This study whilst small scale, provides a unique insight into the lived experience of WLHIV navigating care for HIV and diabetes and/or hypertension, and how a “one stop” integrated care clinic can support them (and their children) in their treatment journeys.