Models of integration of HIV and noncommunicable disease care in sub-Saharan Africa

Njuguna, Benson; Vorkoper, Susan; Patel, Pragna; Reid, Mike; Vedanthan, Rajesh; Pfaff, Colin; Park, Paul H.; Fischer, Lydia; Laktabai, Jeremiah; Pastakia, Sonak D.

doi:10.1097/qad.0000000000001887

Cited by 101 publications

(103 citation statements)

References 52 publications

(77 reference statements)

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“…There is need for deepening the capacity of suppliers for managing the dramatic increase in demand or the sheer volumes of ART medicines to be dispensed occasioned by DSD implementations such as multimonth scripting [7]. Our findings point to the need for harmonizing appointment spacing in HIV care with the management of other co-morbidities such as diabetes and hypertension [36], [37]. We found that older patients (50 years and above) who had well-controlled sugar levels or blood pressure and were also stable on ART were still required to make monthly clinic visits regardless of the DSD provision of 3-monthly visits.…”

Section: Study Implications For Countries With Similar Setting As Ugandamentioning

confidence: 83%

“…We found that older patients (50 years and above) who had well-controlled sugar levels or blood pressure and were also stable on ART were still required to make monthly clinic visits regardless of the DSD provision of 3-monthly visits. This calls for the integrated management of HIV and other comorbidities that is becoming increasingly important priority due to ageing cohorts of clients and the need to revisit treatment guidelines even in non-HIV services [36], [37], [45].…”

Section: Study Implications For Countries With Similar Setting As Ugandamentioning

confidence: 99%

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Understanding implementation barriers in the national scale-up of Differentiated ART delivery in Uganda

Zakumumpa

Rujumba

Kwiringira

et al. 2020

Preprint

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Background Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)’s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients’ and HIV service managers’ perspectives on barriers to implementation of Differentiated ART delivery in Uganda. Methods We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n=18), District Health Team leaders (n=24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context. Results Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. Context: Frequent changes in physical addresses among urban clients were reported as an impediment to the running of patient groups of rotating ART refill pick-ups. Conclusion This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

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Section: Study Implications For Countries With Similar Setting As Ugandamentioning

confidence: 83%

Section: Study Implications For Countries With Similar Setting As Ugandamentioning

confidence: 99%

Understanding implementation barriers in the national scale-up of Differentiated ART delivery in Uganda

Zakumumpa

Rujumba

Kwiringira

et al. 2020

Preprint

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“…A recent systematic review [16], which incorporated prior findings from SEARCH, demonstrated the resources and strategies most conducive to integrated care for HIV/AIDS and chronic disease-for example, patientcentered delivery models and a clear implementation strategy-and called for standardized care checklists and service coordinators to achieve it. However, other recent reviews of lowresource CVD care-including those leveraging HIV programs-report unclear and incompletely implemented treatment protocols, which impairs measuring and achieving consistent outcomes [16,16,20,21].…”

Section: Discussionmentioning

confidence: 99%

“…Most successful models have leveraged nurses, community health workers, and other non-physicians [14,15,16,17]. Recent studies demonstrate that programs for control of HIV can be leveraged for the control of chronic diseases such as HTN [18,19], though quantitative data on care linkage, blood pressure control, and other operational outcomes are scarce [20,21,22]. Pilot projects to date have been small and local in scope, with mixed results in linking HTN patients to care and achieving blood pressure control [2,3,4,23,24,25,26].…”

Section: Introductionmentioning

confidence: 99%

Hypertension testing and treatment in Uganda and Kenya through the SEARCH study: An implementation fidelity and outcome evaluation

Heller¹,

Balzer

Kazi

et al. 2020

PLoS ONE

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Background Hypertension (HTN) is the single leading risk factor for human mortality worldwide, and more prevalent in sub-Saharan Africa than any other region [1]-although resources for HTN screening, treatment, and control are few. Most regional pilot studies to leverage HIV programs for HTN control have achieved blood pressure control in half of participants or fewer [2,3,4]. But this control gap may be due to inconsistent delivery of services, rather than ineffective underlying interventions. Methods We sought to evaluate the consistency of HTN program delivery within the SEARCH study (NCT01864603) among 95,000 adults in 32 rural communities in Uganda and Kenya from 2013-2016. To achieve this objective, we designed and performed a fidelity evaluation of the step-by-step process (cascade) of HTN care within SEARCH, calculating rates of HTN screening, linkage to care, and follow-up care. We evaluated SEARCH's assessment of each participant's HTN status against measured blood pressure and HTN history. Findings SEARCH completed blood pressure screens on 91% of participants. SEARCH HTN screening was 91% sensitive and over 99% specific for HTN relative to measured blood pressure and patient history. 92% of participants screened HTN+ received clinic appointments, and

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“…Evidence from integrated models of care for chronic conditions in low-resource settings has shown that leveraging of existing human resource, decentralisation of care, task redistribution (including to lay health cadres), and continued training and mentorship are key to successful treatment and control of non-communicable diseases. 9,10 An innovative and integrated model of care for diabetes and tuberculosis should therefore be informed by these experiences.…”

Section: The Challenge Of Worldwide Tuberculosis Control: and Then Camentioning

confidence: 99%

The challenge of worldwide tuberculosis control: and then came diabetes

Amberbir

2019

The Lancet Global Health

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Models of integration of HIV and noncommunicable disease care in sub-Saharan Africa

Cited by 101 publications

References 52 publications

Understanding implementation barriers in the national scale-up of Differentiated ART delivery in Uganda

Understanding implementation barriers in the national scale-up of Differentiated ART delivery in Uganda

Hypertension testing and treatment in Uganda and Kenya through the SEARCH study: An implementation fidelity and outcome evaluation

The challenge of worldwide tuberculosis control: and then came diabetes

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