HIV and Non-Communicable Diseases: Strengthening Systems to Provide Integrated Chronic Care Services in Low-Resource Settings

Slides from an August 2017 webinar on HIV and NCD

Germany, the European Union and the Economist 1989-1999

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal

Clinical decision tools are needed to identify HIV-positive patients at high risk for poor outcomes after initiation of antiretroviral therapy

Over the past decade, the scale-up of HIV programs in resource-limited settings has been remarkable, with over 17 million persons initiating lifesaving antiretroviral therapy (ART) by the end of 2015 . However, in order to reduce HIV-related morbidity and mortality and decrease the number of new infections, it is critical to double the number of HIV-positive patients on treatment by 2020. It is equally important for health outcomes among children and adults on ART to be optimized. To achieve these two goals—i.e., a massive increase in the number of patients on ART as well as an enhancement in the quality of care—the global health community has recognized the need for tailored HIV services to meet the unique needs of different patient groups, often referred to as differentiated models of service delivery

Missed Opportunities to Improve the Health of Postpartum Women: High Rates of Untreated Hypertension in Rural Tanzania

Objectives To assess the prevalence of high blood pressure amongst postpartum women in rural Tanzania, and to explore factors associated with hypertension prevalence, awareness, treatment, and control. Methods 1849 women in Tanzania’s Pwani Region who delivered a child in the prior year participated in the study. We measured blood pressure, administered a structured questionnaire and assessed factors associated with the prevalence, awareness, treatment, and control of hypertension (HTN) using bivariable and multivariable logistic regressions. Findings 26.7% of women had high blood pressure and/or were taking antihypertensive medication. Women were on average 27.5 years old (range 15–54). Nearly all women (99.5%) reported contact with the health system during their pregnancy and delivery, with an average of 5.2 visits for their own care in the past year. Only 23.5% of those with HTN were aware of their diagnosis, 17.4% were taking medication, and only 10.5% had controlled blood pressure. In multivariable analysis, facility delivery, health insurance, and increased distance from a hospital were associated with increased likelihood of HTN awareness; facility delivery and hospital distance were associated with current hypertensive treatment; younger age and increased hospital distance were associated with control of HTN. Conclusion The prevalence of high blood pressure in this postpartum population was high, and despite frequent recent contacts with the health system, awareness, treatment and control of HTN were low. These findings highlight an important missed opportunity to improve women’s health during antenatal and postnatal care

Re-Engineering Primary Health Care: A Formative Process Evaluation of rPHC Implementation in King Sabata Dalindyebo sub-District in the Eastern Cape Province of South Africa

In 2010, the Department of Health of South Africa launched a “Re-engineering Primary Health Care” (rPHC) initiative, aiming to shift the focus of primary health care to a health-promoting community-based model. At the heart of the program are ward-based primary health care outreach teams, comprised of generalist community health workers (CHWs) supervised by facility-based nurses. With the support of the Eastern Cape Department of Health (ECDOH), ICAP at Columbia University conducted a formative process evaluation to describe the implementation of ward-based rPHC activities in one sub-district between January 2012 and December 2013. King Sabato Dalyindebo (KSD) sub-district of OR Tambo District was selected by ECDOH as the evaluation location. The process evaluation used both qualitative and quantitative methods, including in-depth interviews with implementers and nurses, focus group discussions with CHWs and community members, structured surveys of knowledge and satisfaction completed by nurses and CHWs, and review of existing DOH data on training and service delivery. Key findings included: 1. Ward-based outreach teams were launched by December 2013. By the end of 2013, KSD sub-district had trained, staffed and launched ward-based outreach teams in all 35 wards, with more than 100 CHWs engaged in community-level activities. 2. Outreach, counseling, and adherence support services were being delivered to communities. CHW encouraged community members to seek facility-level health care services, and assisted in the identification and referral of HIV and tuberculosis (TB) defaulters, linking these patients back to treatment. 3. The outreach teams have added value, but their performance has not been rigorously evaluated. Although implementers and nurses indicated that investments in CHW training had improved the capacity of outreach teams, quality had yet to be assessed. Community members were deeply appreciative of CHW outreach services, but noted some concerns about confidentiality. Lower-than-expected CHW test scores on the evaluation surveys suggest that retention of knowledge may be a challenge. CHWs reported low levels of field-based supervision and minimal feedback or performance reviews, and fewer than half the CHWs rated their own team’s work as good or excellent. 4. Household profiling data have yet to be utilized to guide programming. Although a very large amount of household “profiling” data had been collected, implementers and DOH noted concerns about data quality. In addition, information about the prevalence and distribution of illness had not been aggregated or analyzed by the sub-district or District DOH, and there were substantial backlogs in the aggregation of descriptive data about rPHC activities (e.g., number and type of visits) and entry into the Demographic and Health Information System (DHIS). This prevented DOH from using the data to inform policy or guide programs. In summary, the rPHC program has tremendous potential to link communities with prevention, care and treatment services. The process evaluation highlighted achievements and challenges, as well as areas where intensified support could have substantive impact

Can the Success of HIV Scale-Up Advance the Global Chronic NCD Agenda?

Noncommunicable diseases (NCD) are the leading causes of death and disability worldwide but have received suboptimal attention and funding from the global health community. Although the first United Nations General Assembly Special Session (UNGASS) for NCD in 2011 aimed to stimulate donor funding and political action, only 1.3% of official development assistance for health was allocated to NCD in 2015, even less than in 2011. In stark contrast, the UNGASS on human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) in 2001 sparked billions of dollars in funding for HIV and enabled millions of HIV-infected individuals to access antiretroviral treatment. Using an existing analytic framework, we compare the global responses to the HIV and NCD epidemics and distill lessons from the HIV response that might be utilized to enhance the global NCD response. These include: 1) further educating and empowering communities and patients to increase demand for NCD services and to hold national governments accountable for establishing and achieving NCD targets; and 2) evidence to support the feasibility and effectiveness of large-scale NCD screening and treatment programs in low-resource settings. We conclude with a case study from Swaziland, a country that is making progress in confronting both HIV and NCD. In September 2011, the United Nations (UN) convened a UN General Assembly Special Session (UNGASS) on noncommunicable diseases (NCD). The event was the second UN High Level Meeting ever held for a health issue, following the successful UNGASS on human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) in 2001. Modeled after its predecessor, the 2011 meeting was intended to catalyze a response to what the World Health Organization (WHO) called an epidemic of “silent killers” that were the leading causes of death and disability worldwide, yet receive little attention from the global health community [1]. Looking back to the prior UNGASS on HIV/AIDS a decade earlier, the NCD meeting aspired to similar goals: rallying multisectoral and cross-national partnerships; stimulating robust donor funding; spurring ambitious targets and commitments on the part of national governments; and catalyzing rapid scale-up of NCD services in resource-limited settings [2]. Advocates highlighted similarities between chronic NCD and HIV/AIDS, including a stark mismatch between the burden of disease and available funding, and the need for programmatic innovation, continuity care, and health systems strengthening 3, 4 and 5. The UNGASS on NCD was successful at producing a Political Declaration to combat NCD [6], and many countries affirmed a commitment to ambitious NCD targets and to implementing evidence-based “best buys” 7 and 8. Yet 5 years later, the global NCD response has languished in what some have called an environment of “malignant neglect” [9]. Despite the fact that NCD account for 37% of disability-adjusted life years in low-income countries [10], only 1.3% of official development assistance for health was allocated to NCD in 2015 [11], a proportion that decreased between 2011 and 2015 [12]. Few resource-limited countries have operational national NCD strategies or adequate NCD services, awareness of and treatment-seeking rates for NCD have not improved [13], and the vast majority of people with cardiovascular disease, diabetes, cancer, and chronic respiratory disease remain undiagnosed and untreated 14 and 15. In contrast, in the years that followed the 2001 UNGASS, global spending on HIV increased by billions of dollars and the number of people initiating antiretroviral treatment (ART) in low- and middle-income countries soared from 400,000 in 2003 to nearly 17 million in 2015 [16]

Integrated vs. referred management of CVD risk factors for HIV positive patients on antiretroviral therapy in Swaziland

Cardiovascular disease risk factors (CVDRF) are prevalent in people living with HIV (PLHIV), but the optimal clinical management strategy for patients with both HIV and CVDRF in low resource settings is unknown. In some contexts, care for both HIV and CVDRF is provided in the HIV clinic (“integrated care”), which may be more convenient for patients. In others, PLHIV are referred to specialist clinics for management of their CVDRF (“referred care”) which may lead to higher quality CVDRF management. We compared integrated vs. referred strategies for patients with HIV and CVDRF at an urban health facility in Swaziland, exploring linkage to and retention in CVDRF care, intervention fidelity, and HIV and CVDRF-related health outcomes

Increased utilisation of PEPFAR-supported laboratory services by non-HIV patients in Tanzania

Background: It is unknown to what extent the non-HIV population utilises laboratories supported by the President’s Emergency Plan for AIDS Relief (PEPFAR). Objectives: We aimed to describe the number and proportion of laboratory tests performed in 2009 and 2011 for patients referred from HIV and non-HIV services (NHSs )in a convenience sample collected from 127 laboratories supported by PEPFAR in Tanzania. We then compared changes in the proportions of tests performed for patients referred from NHSs in 2009 vs 2011. Methods: Haematology, chemistry, tuberculosis and syphilis test data were collected from available laboratory registers. Referral sources, including HIV services, NHSs, or lack of a documented referral source, were recorded. A generalised linear mixed model reported the odds that a test was from a NHS. Results: A total of 94 132 tests from 94 laboratories in 2009 and 157 343 tests from 101 laboratories in 2011 were recorded. Half of all tests lacked a documented referral source. Tests from NHSs constituted 42% (66 084) of all tests in 2011, compared with 31% (29 181) in 2009. A test in 2011 was twice as likely to have been referred from a NHS as in 2009 (adjusted odds ratio: 2.0 [95% confidence interval: 2.0–2.1]). Conclusion: Between 2009 and 2011, the number and proportion of tests from NHSs increased across all types of test. This finding may reflect increased documentation of NHS referrals or that the laboratory scale-up originally intended to service the HIV-positive population in Tanzania may be associated with a ‘spillover effect’ amongst the general population

How Can the Health System Retain Women in HIV Treatment for a Lifetime? A Discrete Choice Experiment in Ethiopia and Mozambique

Introduction: Option B+, an approach that involves provision of antiretroviral therapy (ART) to all HIV-infected pregnant women for life, is the preferred strategy for prevention of mother to child transmission of HIV. Lifelong retention in care is essential to its success. We conducted a discrete choice experiment in Ethiopia and Mozambique to identify health system characteristics preferred by HIV-infected women to promote continuity of care. Methods: Women living with HIV and receiving care at hospitals in Oromia Region, Ethiopia and Zambézia Province, Mozambique were shown nine choice cards and asked to select one of two hypothetical health facilities, each with six varying characteristics related to the delivery of HIV services for long term treatment. Mixed logit models were used to estimate the influence of six health service attributes on choice of clinics. Results: 2,033 women participated in the study (response rate 97.8% in Ethiopia and 94.7% in Mozambique). Among the various attributes of structure and content of lifelong ART services, the most important attributes identified in both countries were respectful provider attitude and ability to obtain non-HIV health services during HIV-related visits. Availability of counseling support services was also a driver of choice. Facility type, i.e., hospital versus health center, was substantially less important. Conclusions: Efforts to enhance retention in HIV care and treatment for pregnant women should focus on promoting respectful care by providers and integrating access to non-HIV health services in the same visit, as well as continuing to strengthen counseling

“I attend at Vanguard and I attend here as well”: barriers to accessing healthcare services among older South Africans with HIV and non-communicable diseases

Background: HIV and non-communicable disease (NCD) are syndemic within sub-Saharan Africa especially among older persons. The two epidemics interact with one another within a context of poverty, inequality and inequitable access to healthcare resulting in an increase in those aged 50 and older living with HIV and experiencing an NCD comorbidity. We explore the challenges of navigating healthcare for older persons living with HIV and NCD co-morbidity. Methods: In-depth semi-structured interviews were conducted with a small sample of older persons living with HIV (OPLWH). The perspectives of key informants were also sought to triangulate the evidence of OPLWH. The research took place in two communities on the outskirts of Cape Town, South Africa. All interviews were conducted by a trained interviewer and transcribed and translated for analysis. Thematic content analysis guided data analysis. Results: OPLWH experienced an HIV-NCD syndemic. Our respondents sought care and accessed treatment for both HIV and other chronic (and acute) conditions, though these services were provided at different health facilities or by different health providers. Through the syndemic theory, it is possible to observe that OPLWH and NCDs face a number of physical and structural barriers to accessing the healthcare system. These barriers are compounded by separate appointments and spaces for each condition. These difficulties can exacerbate the impact of their ill-health and perpetuate structural vulnerabilities. Despite policy changes towards integrated care, this is not the experience of OPLWH in these communities. Conclusions: The population living with HIV is aging increasing the likelihood that those living with HIV will also be living with other chronic conditions including NCDs. Thus, it is essential that health policy address this basic need to integrate HIV and NCD care