Treatment outcomes among adults with HIV/non-communicable disease multimorbidity attending integrated care clubs in Cape Town, South Africa

Abstract

Background The growing burden of the HIV and non-communicable disease (NCD) syndemic in Sub- Saharan Africa has necessitated introduction of integrated models of care in order to leverage existing HIV care infrastructure for NCDs. However, there is paucity of literature on treatment outcomes for multimorbid patients attending integrated care. We describe 12-month treatment outcomes among multimorbid patients attending integrated antiretroviral treatment (ART) and NCD clubs in Cape Town, South Africa. Methods As part of an integrated clubs (IC) model pilot implemented in 2016 by the local government at two primary health care clinics in Cape Town, we identified all multimorbid patients who were enrolled for IC for at least 12 months by August 2017. Mean adherence percentages (using proxy of medication collection and attendance of club visits) and optimal disease control (defined as the proportion of participants achieving optimal blood pressure, glycosylated haemoglobin control and HIV viral load suppression where appropriate) were calculated at 12 months before, at the point of IC enrolment and 12 months after IC enrolment. Predictors of NCD control 12 months post IC enrolment were investigated using multivariable logistic regression. Results As of 31 August 2017, 247 HIV-infected patients in total had been enrolled into IC for at least 12 months. Of these, 221 (89.5%) had hypertension, 4 (1.6%) had diabetes mellitus and 22 (8.9%) had both diseases. Adherence was maintained before and after IC enrolment with mean adherence percentages of 92.2% and 94.2% respectively. HIV viral suppression rates were 98.6%, 99.5% and 99.4% at the three time points respectively. Retention in care was high with 6.9% lost to follow up at 12 months post IC enrolment. Across the 3 time-points, optimal blood pressure control was achieved in 43.1%, 58.9% and 49.4% of participants while optimal glycaemic control was achieved in 47.4%, 87.5% and 53.3% of participants with diabetes respectively. Multivariable logistic analyses showed no independent variables significantly associated with NCD control. Conclusion Multimorbid adults living with HIV achieved high levels of HIV control in integrated HIV and NCD clubs. However, intensified interventions are needed to maintain NCD control in the long term.

Health System Determinants of Hypertension Care and Outcomes in Sub-Saharan Africa: A Systematic Review

“…The integration of hypertension and other non-communicable diseases services into the well-established health services was explored in 18% (7/39) of the studies in 6 different countries [35, 43, 45, 46, 49, 60, 61]. The most frequent form of cross-integration was the provision of non-communicable diseases services in the Human Immunodeficiency Virus (HIV) and Sexually Transmitted Diseases clinics and the use of existing patient follow-up mechanisms in managing non-communicable diseases.…”

“…Predominantly, the cross-integration of services has shown significant improvements in hypertension control. A cohort of patients in South Africa increased in controlled BP from 43% before integration of services to 49% one year after integration [45]. Another cohort of patients in Uganda and Tanzania had a 10% decline in the risk of uncontrolled BP [43].…”

“…The cross integration of hypertension services is another system-level intervention explored for the management of hypertension. The hypertension services have been frequently integrated with HIV clinics, and this strategy has demonstrated to be effective in helping patients achieve controlled blood pressure in Sierra Leone [46], South Africa [45], and Tanzania and Uganda [43], to name a few examples. There are some reasons why taking lessons from the management of chronic infectious diseases could be effective in hypertension care.…”

“…Five quasi-experimental studies were conducted in Nigeria (n=2) [37,38], Cameroon (n=1) [39], Kenya (n=1) [40], and Sierra Leone (n=1) [41]. Eight cohort studies were conducted in Ethiopia (n=1) [42], Uganda and Tanzania (n=1) [43], Tanzania (n=1) [44], South Africa (n=1) [45], Sierra Leone (n=1) [46], Ghana and Kenya (n=1) [47], Kenya (n=1) [48], The Democratic Republic of the Congo (n=1) [49].…”

Chronic disease care integration into primary care services in sub-Saharan Africa: a ‘best fit’ framework synthesis and new conceptual model

“…A new theme that emerged from 11 of the studies was that of improving patient access to chronic disease care. Barriers to patient access were long distances to travel to clinic, a lack of public transport, low vehicle ownership,34 35 45 a loss of income resulting from time away from the workplace, very long waiting times, and separate appointments for those with more than one chronic disease 35 36 41 42 46. Several studies identified the need for decentralisation of chronic care to primary care level to reduce travel time and costs 32 34 45 47.…”