Early experiences integrating hypertension and diabetes screening and treatment in a human immunodeficiency virus clinic in Malawi

Pfaff, Colin; Singano, Victor; Akello, Harriet; Amberbir, Alemayehu; Berman, Josh; Kwekwesa, Aunex; Banda, Victor; Speight, Colin; Allain, Theresa J.; Oosterhout, Joep J. van

doi:10.1093/inthealth/ihy049

Cited by 16 publications

(28 citation statements)

References 26 publications

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“…23-25 25-29 29 There exist many examples of combining HIV with other clinical programmes and into primary care; however, much of the early work in HIV-NCD integrated chronic care focuses primarily on screening and treating NCDs within HIV cohorts exclusively. [30][31][32][33][34][35][36][37][38] Fully integrated HIV and NCD care is put forward as a model by several authors, but examples of fully integrated HIV-NCD clinics, serving patients with and without HIV, are limited. 29 30 39 Practical experience and implementation research is needed to assess the feasibility and outcomes of fully integrated HIV-NCD care.…”

Section: Introductionmentioning

confidence: 99%

Expanding access to non-communicable disease care in rural Malawi: outcomes from a retrospective cohort in an integrated NCD–HIV model

Wroe

Kalanga²,

Dunbar³

et al. 2020

BMJ Open

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ObjectivesNon-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).DesignThis is a retrospective cohort study.SettingThe study includes an HIV–NCD clinic across 14 primary care facilities in the rural district of Neno, Malawi.ParticipantsAll 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.InterventionsPatients 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 measuresRoutine clinical measurements are reported at 1-year post-enrolment for patients with more than one visit. One-year retention is reported by diagnosis.ResultsNCD 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.ConclusionsThe 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.

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Section: Introductionmentioning

confidence: 99%

Expanding access to non-communicable disease care in rural Malawi: outcomes from a retrospective cohort in an integrated NCD–HIV model

Wroe

Kalanga²,

Dunbar³

et al. 2020

BMJ Open

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“…In October 2015, Dignitas International, a medical and research organization, together with the Malawi Ministry of Health, established cervical cancer screening at the HIV clinic at Zomba Central Hospital. This was part of a broader initiative to fully integrate HIV and non-communicable disease (NCD) care where all adults accessing care in the HIV clinic are screened and treated for hypertension, diabetes and cervical cancer 22. We describe the process and outcomes of the integration of HIV care with cervical cancer screening, including innovations used and challenges encountered.…”

Section: Introductionmentioning

confidence: 99%

Early experiences in integrating cervical cancer screening and treatment into HIV services in Zomba Central Hospital, Malawi

Pfaff

2018

Mal. Med. J

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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.

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“…Studies on integrated HIV-NCD care demonstrate that improving patient flow processes such as sorting appointments and referring patients to the appropriate service stations (e.g. for drug refill or consultation with a clinician) could be beneficial to facilities experiencing high-volume patient load and operating within limited space [22,24,34,49]. As part of primary prevention strategies and policy recommendations, including multi-disease screening within triage processes promotes early detection and management of complications associated with chronic diseases, though it requires ensuring diagnostics are regularly available [23,50].…”

Section: Discussionmentioning

confidence: 99%

“…In our study context, a further engagement of state-paid health surveillance assistants in absorbing tasks such as patient education, triage, and documentation could help ease clinician's workload and allow them to focus on technical tasks. Complementary to these efforts, requires ensuring the requisite clinical resources are available, offering regular training and supportive supervision to health professionals and other personnel offering community-based services [49,52]. The gaps in service provision at facility level that were reported could be mitigated by expanding service points at community level.…”

Section: Discussionmentioning

confidence: 99%

Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district

et al. 2020

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Background: With the increasing double burden of communicable and non-communicable diseases (NCDs) in sub-Saharan Africa, health systems require new approaches to organise and deliver services for patients requiring longterm care. There is increasing recognition of the need to integrate health services, with evidence supporting integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This study investigates current practices of delivering and implementing integrated care for chronically-ill patients in rural Malawi, focusing on the primary level. Methods: A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017, with a sub-analysis performed on the data following a document analysis to understand the policy context and how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities, selected purposively to represent different levels of care (primary and secondary), and ownership (private and public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities. Meetings with five non-governmental organisations to study their projects and support towards chronic care in Phalombe. Data were analysed using a thematic approach and managed in NVivo.Results: Our study found that, while policies supported integration of various disease-specific programmes at point of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g. inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems.

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Early experiences integrating hypertension and diabetes screening and treatment in a human immunodeficiency virus clinic in Malawi

Abstract: Integrated HIV-NCD services provision was feasible in our clinic.

Cited by 16 publications

References 26 publications

Expanding access to non-communicable disease care in rural Malawi: outcomes from a retrospective cohort in an integrated NCD–HIV model

Expanding access to non-communicable disease care in rural Malawi: outcomes from a retrospective cohort in an integrated NCD–HIV model

Early experiences in integrating cervical cancer screening and treatment into HIV services in Zomba Central Hospital, Malawi

Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district

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