Leveraging existing HIV infrastructure for NCD care is feasible with various approaches possible depending on available program capacity. Process and clinical outcomes for existing models of care integration are not yet described but are urgently required to further advise policy decisions on HIV/NCD care integration.
BackgroundHypertension and diabetes prevalence is high in Africans. Data from HIV infected populations are limited, especially from Malawi. Integrating care for chronic non-communicable co-morbidities in well-established HIV services may provide benefit for patients by preventing multiple hospital visits but will increase the burden of care for busy HIV clinics.MethodsCross-sectional study of adults (≥18 years) at an urban and a rural HIV clinic in Zomba district, Malawi, during 2014. Hypertension and diabetes were diagnosed according to stringent criteria. Proteinuria, non-fasting lipids and cardio/cerebro-vascular disease (CVD) risk scores (Framingham and World Health Organization/International Society for Hypertension) were determined. The association of patient characteristics with diagnoses of hypertension and diabetes was studied using multivariable analyses. We explored the additional burden of care for integrated drug treatment of hypertension and diabetes in HIV clinics. We defined that burden as patients with diabetes and/or stage II and III hypertension, but not with stage I hypertension unless they had proteinuria, previous stroke or high Framingham CVD risk.ResultsNine hundred fifty-two patients were enrolled, 71.7% female, median age 43.0 years, 95.9% on antiretroviral therapy (ART), median duration 47.7 months. Rural and urban patients’ characteristics differed substantially. Hypertension prevalence was 23.7% (95%-confidence interval 21.1–26.6; rural 21.0% vs. urban 26.5%; p = 0.047), of whom 59.9% had stage I (mild) hypertension. Diabetes prevalence was 4.1% (95%-confidence interval 3.0–5.6) without significant difference between rural and urban settings. Prevalence of proteinuria, elevated total/high-density lipoprotein-cholesterol ratio and high CVD risk score was low. Hypertension diagnosis was associated with increasing age, higher body mass index, presence of proteinuria, being on regimen zidovudine/lamivudine/nevirapine and inversely with World Health Organization clinical stage at ART initiation. Diabetes diagnosis was associated with higher age and being on non-standard first-line or second-line ART regimens.ConclusionAmong patients in HIV care 26.6% had hypertension and/or diabetes. Close to two-thirds of hypertension diagnoses was stage I and of those few had an indication for antihypertensive pharmacotherapy. According to our criteria, 13.0% of HIV patients in care required drug treatment for hypertension and/or diabetes.
BackgroundMany patients on antiretroviral therapy (ART) in Malawi have or will develop non-communicable diseases (NCDs). The current capacity of ART sites to provide care for NCDs is not known.AimThis study aimed to assess the capacity of ART sites to provide care for hypertension and diabetes in rural Malawi.SettingTwenty-five health centres and five hospitals in two rural districts in northern Malawi.MethodsA cross-sectional survey was performed between March and May 2014 at all facilities. Qualitative interviews were held with three NCD coordinators.ResultsTreatment of hypertension and diabetes was predominantly hospital-based. Sixty percent of hospitals had at least one clinician and one nurse trained in NCD care, whereas 5% of health centres had a clinician and 8% had a nurse trained in NCD care. Hundred percent of hospitals and 92% of health centres had uninterrupted supply of hydrochlorothiazide in the previous 6 months, but only 40% of hospitals and no health centres had uninterrupted supply of metformin. Hundred percent of hospitals and 80% of health centres had at least one blood pressure machine, and 80% of hospitals and 32% of health centres had one glucometer. Screening for hypertension amongst ART patients was only conducted at one hospital and no health centres. At health centres, integrated NCD and ART care was more common, with 48% (12/25) providing ART and NCD treatment in the same consultation.ConclusionsThe results reflect the status of the initial stages of the Malawi NCD programme at sites currently providing ART care.
BackgroundMalawi has the highest rate of cervical cancer globally and cervical cancer is six to eight times more common in women with HIV. HIV programmes provide an ideal setting to integrate cervical cancer screening.MethodsTisungane HIV clinic at Zomba Central Hospital has around 3,700 adult women receiving treatment. In October 2015, a model of integrated cervical cancer screening using visual inspection with acetic acid (VIA) was adopted. All women aged 20 and above in the HIV clinic were asked if they had cervical cancer screening in the past three years and, if not, were referred for screening. Screening was done daily by nurses in a room adjacent to the HIV clinic. Cold coagulation was used to treat pre-cancerous lesions. From October 2016, a modification to the HIV programme's electronic medical record was developed that assisted in matching numbers of women sent for screening with daily screening capacity and alerted providers to women with pre-cancerous lesions who missed referrals or treatment.ResultsBetween May 2016 and March 2017, cervical cancer screening was performed in 957 women from the HIV clinic. Of the 686 (71%) women who underwent first ever screening, 23 (3.4%) were found to have VIA positive lesions suggestive of pre-cancer, of whom 8 (35%) had a same-day cold coagulation procedure, seven (30%) deferred cold coagulation to a later date (of whom 4 came for treatment), and 8 (35%) were referred to surgery due to size of lesion; 5/686 (0.7%) women had lesions suspicious of cancer.ConclusionIncorporating cervical cancer screening into services at HIV clinics is feasible. A structured approach to screening in the HIV clinic was important.
Integrated HIV-NCD services provision was feasible in our clinic.
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