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

Women living with HIV, diabetes and/or hypertension multimorbidity in Uganda: A qualitative exploration of experiences accessing a ‘one stop’ 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. Design: 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: 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

“After all, we are all sick”: Multi-stakeholder understandings of stigma associated with integrated management of HIV, Diabetes and Hypertension at selected government clinics in Uganda.

Background: Integrated care is increasingly used to manage chronic conditions. In Uganda, the integration of HIV, diabetes and hypertension care has been piloted leveraging the well facilitated and established HIV health care provision structures. This qualitative study aimed to investigate the perceptions and experiences of patients, health care providers, clinical researchers, representatives from international NGOs, community members/leaders and policy makers on integrated management of HIV, diabetes and hypertension at selected government clinics in Central Uganda. Methods: We adopted a qualitative-observational design and participants were purposively selected. In-depth interviews were conducted with patients and with health care providers, clinical researchers, policy makers, and representatives from international NGOs. Focus group discussions were conducted with community members and leaders. Clinical procedures in the integrated care clinic were also observed. Data were managed using Nvivo 12 and analyzed thematically. Results: Triangulated findings revealed perceptions of integration reducing the frequency with which patients with comorbidities (HIV, diabetes, hypertension) visited health facilities, reduced the associated treatment costs, increased interpersonal relationships among patients and healthcare providers, and promoted capacity of health care providers to manage multiple chronic conditions. Integration also reduced stigma mainly through creating opportunities for health education, which allayed patient fears and increased their resolve to enroll for and adhere to treatment. Patients also had an opportunity to offer and receive psycho-social support and coupled with the support they received from healthcare workers, this strengthened the patient-patient relationship and provider-patient relationship, one of the building blocks of integration. Although, the integrated model significantly reduced stigma in general, it did not eradicate service level challenges and societal discrimination among HIV patients. Conclusion: The study narratives reveal that, in low resource settings like Uganda, integration of HIV, diabetes and hypertension care has potential to support patient experiences of co-morbid care. Integrated clinics may function as a central stigma mitigation strategy, operating independently of existing clinics and treating a range of conditions including HIV and other STIs

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 human immunodeficiency virus (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. Whilst integrated health education and concurrent management of HIV, hypertension and diabetes is being scaled up in clinics, innovative, more efficient and cost-effective interventions which include decentralisation into the community are required to respond to increased burden of co-morbid HIV/NCD disease. Methods and analysis: This protocol describes procedures for a process evaluation running concurrently with a pragmatic cluster-randomized trial (INTE-COMM) in Tanzania and Uganda which will compare community-based integrated care (HIV, diabetes, hypertension) with standard facility-based integrated care. The INTE-COMM intervention will manage multiple conditions (HIV, hypertension, diabetes) in the community via health monitoring and adherence/lifestyle advice (medicine, diet, exercise) provided by community nurses and trained lay-workers, and the devolvement of NCD drug dispensing to community level. Based on Bronfenbrenner’s ecological systems theory, the process evaluation will use qualitative methods to investigate socio-structural factors shaping care delivery and outcomes in up to 10 standard care facilities and/or intervention community sites with linked healthcare facilities. Multi-stakeholder interviews (patients, community health workers/volunteers, healthcare providers, policymakers, clinical researchers, international and non-governmental organisations), focus group discussions (community leaders, members) and non-participant observations (community meetings, 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 under 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

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 (INTEAFRICA) 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 hours 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