Periodic Reporting for period 4 - INTE-AFRICA (Integrating and decentralising diabetes and hypertension services in Africa)
Período documentado: 2023-01-01 hasta 2023-06-30
Probably the biggest health challenge of today is the rapid rise in non-communicable disease, which in sub-Saharan Africa, is occurring alongside a continuing high burden of HIV. In Africa at least 2 million people are dying annually from the complications of diabetes and hypertension and this is rising rapidly.
One contributing factor to high mortality is that health care for people with chronic conditions is fragmented. Resulting in less than 50% retention in care, even in good clinical settings.
The challenge is that health care is organised from separate clinics. Over one-third of patients diagnosed with a chronic condition will have one or more other chronic conditions if they are tested. These of patients have the worst health outcomes. For health services, delivering care from separate clinics leads to duplication of services costing more whilst treating less patients.
HIV is now a chronic condition requiring lifelong care. HIV care is organised separately from other services and is well run, achieving remarkably good outcomes compared to services for non-communicable conditions. However, due to the separation of services, lessons learnt from HIV programmes are not applied to other services. Moreover, people with HIV still suffer from stigma and treating HIV separately, worsens the stigma.
An alternative approach is to integrate services for chronic conditions by having one clinic that manages patients with any chronic condition, whether this occurs alone or the patient is living with multiple conditions. This overcomes the problems outlined above but there are risks. The change could adversely affect outcomes for people with HIV, which have been gained painstakingly over many decades. People with chronic conditions may also suffer adverse outcomes if they move from a dedicated vertical care clinic to a more general clinic.
Decisions about changes to health care are made by policy-makers and managers of national disease control programmes. For such major changes affecting millions of people, rigorous evidence is required to generate clear answers. Our role was to generate the evidence needed to inform policy and the overall objective for the INTE-AFRICA study was to assess the effectiveness of the integration of health services for diabetes, hypertension and HIV-infection.
One contributing factor to high mortality is that health care for people with chronic conditions is fragmented. Resulting in less than 50% retention in care, even in good clinical settings.
The challenge is that health care is organised from separate clinics. Over one-third of patients diagnosed with a chronic condition will have one or more other chronic conditions if they are tested. These of patients have the worst health outcomes. For health services, delivering care from separate clinics leads to duplication of services costing more whilst treating less patients.
HIV is now a chronic condition requiring lifelong care. HIV care is organised separately from other services and is well run, achieving remarkably good outcomes compared to services for non-communicable conditions. However, due to the separation of services, lessons learnt from HIV programmes are not applied to other services. Moreover, people with HIV still suffer from stigma and treating HIV separately, worsens the stigma.
An alternative approach is to integrate services for chronic conditions by having one clinic that manages patients with any chronic condition, whether this occurs alone or the patient is living with multiple conditions. This overcomes the problems outlined above but there are risks. The change could adversely affect outcomes for people with HIV, which have been gained painstakingly over many decades. People with chronic conditions may also suffer adverse outcomes if they move from a dedicated vertical care clinic to a more general clinic.
Decisions about changes to health care are made by policy-makers and managers of national disease control programmes. For such major changes affecting millions of people, rigorous evidence is required to generate clear answers. Our role was to generate the evidence needed to inform policy and the overall objective for the INTE-AFRICA study was to assess the effectiveness of the integration of health services for diabetes, hypertension and HIV-infection.
Working with policymakers, health care providers and community stakeholders, we evaluated integrated management of HIV, diabetes and hypertension. We conducted a large, pragmatic cluster randomised trial in 32 health facilities in Tanzania and Uganda and collected data on various clinical parameters, cost-effectiveness and qualitative indicators.
Integrated management involved setting up a single clinic where patients with either one or more of our target conditions (HIV, diabetes or hypertension) attended the same clinic and the standard care arm provided care separately for these conditions.
The trial was done in close to normal health service conditions with trial participants managed by government staff (hence called pragmatic trial). It had two primary endpoints: rate of retention in care among participants with either hypertension, diabetes or both and rate of HIV viral suppression among participants with HIV. We chose these endpoints because retention in care is the first essential step of effective disease control and HIV viral suppression is an objective marker of HIV control. We also calculated costs of care and acceptability to patients.
Participants were adults who had either HIV, diabetes, hypertension or combinations of these conditions and said that they were planning to remain in the area for at least 6 months. They were recruited consecutively or through systematic sampling at each facility. We enrolled about 7,000 participants and followed them for 12 months.
In the integrated care and standard care respectively, 3544 and 3705 patients were eligible, respectively, 106 (3.0%) and 115 (3.0%) declined to join, and 329 (9.3%) and 302 (7.8%) had concomitant HIV and either diabetes or hypertension.
Among participants with diabetes, hypertension or both, mean age (standard deviation) was 60.1 (12.7) years in the integrated care arm and 57.7 (12.2) in the standard care arm; among participants with HIV, these figures were 42.6 (11.2) and 42.7 (10.8) respectively.
The study found that among participants with diabetes, hypertension or both, retention in care at study end was very high in both trial arms (the proportion retained were 1254/1409 (89.0%) in the integrated care arm and 1457/1623 (89.8%) in the standard care am).
Among participants with HIV, the proportion who had sustained control of the HIV virus was also very high in both arms (the proportion with plasma viral load <1,000 copies per ml at the study end was 1412/1456 (97.0%) in the integrated care and 1451/1491 (97.3%) in the standard care arm.
There were substantial costs for patients and for health services (from a societal perspective, which sums provider and patient costs, integrated care for people living with multiple conditions generated mean cost-savings of Int$ 41.54 (95% CI 29.42 53.67 p<0.0001) per patient per visit when compared with standard care).
Integrated care was popular with participants and for some with HIV, led to a reduction in stigma.
The bottom line is that integrated management of people with HIV, diabetes or hypertension:
- was associated with a high level of retention in care for people with diabetes or hypertension
- did not adversely affect the rate of viral suppression among people with HIV
- Is cost-saving for health services and patients
Control of hypertension and diabetes in Africa has been a huge challenge in Africa. Our research shows integrated management could achieve a high quality of care for these conditions while maintaining good outcomes for people with HIV.
This was the first randomised trial to evaluate a fully integrated model of HIV, hypertension and diabetes care in Africa. That is, people with either HIV, diabetes or hypertension were studied. In the integrated care arm of the trial, this was first time in Africa that care for people with HIV was delivered alongside care for people with diabetes or hypertension from the same clinics, by the same clinical staff, supported by the same pharmacy, laboratory and medical records services.
The implications of the results are that the study provides clear evidence for policy-makers to start to scale up integrated care for HIV, diabetes and hypertension. As the burden of non-communicable conditions increases in Africa and more and more people require care for multiple conditions, integrated management is likely to be an essential and cost-effective approach for the continent. The study also serves as a proof-of-concept for integrated management more broadly, which will inform research and clinical practice in other parts of the world.
Integrated management involved setting up a single clinic where patients with either one or more of our target conditions (HIV, diabetes or hypertension) attended the same clinic and the standard care arm provided care separately for these conditions.
The trial was done in close to normal health service conditions with trial participants managed by government staff (hence called pragmatic trial). It had two primary endpoints: rate of retention in care among participants with either hypertension, diabetes or both and rate of HIV viral suppression among participants with HIV. We chose these endpoints because retention in care is the first essential step of effective disease control and HIV viral suppression is an objective marker of HIV control. We also calculated costs of care and acceptability to patients.
Participants were adults who had either HIV, diabetes, hypertension or combinations of these conditions and said that they were planning to remain in the area for at least 6 months. They were recruited consecutively or through systematic sampling at each facility. We enrolled about 7,000 participants and followed them for 12 months.
In the integrated care and standard care respectively, 3544 and 3705 patients were eligible, respectively, 106 (3.0%) and 115 (3.0%) declined to join, and 329 (9.3%) and 302 (7.8%) had concomitant HIV and either diabetes or hypertension.
Among participants with diabetes, hypertension or both, mean age (standard deviation) was 60.1 (12.7) years in the integrated care arm and 57.7 (12.2) in the standard care arm; among participants with HIV, these figures were 42.6 (11.2) and 42.7 (10.8) respectively.
The study found that among participants with diabetes, hypertension or both, retention in care at study end was very high in both trial arms (the proportion retained were 1254/1409 (89.0%) in the integrated care arm and 1457/1623 (89.8%) in the standard care am).
Among participants with HIV, the proportion who had sustained control of the HIV virus was also very high in both arms (the proportion with plasma viral load <1,000 copies per ml at the study end was 1412/1456 (97.0%) in the integrated care and 1451/1491 (97.3%) in the standard care arm.
There were substantial costs for patients and for health services (from a societal perspective, which sums provider and patient costs, integrated care for people living with multiple conditions generated mean cost-savings of Int$ 41.54 (95% CI 29.42 53.67 p<0.0001) per patient per visit when compared with standard care).
Integrated care was popular with participants and for some with HIV, led to a reduction in stigma.
The bottom line is that integrated management of people with HIV, diabetes or hypertension:
- was associated with a high level of retention in care for people with diabetes or hypertension
- did not adversely affect the rate of viral suppression among people with HIV
- Is cost-saving for health services and patients
Control of hypertension and diabetes in Africa has been a huge challenge in Africa. Our research shows integrated management could achieve a high quality of care for these conditions while maintaining good outcomes for people with HIV.
This was the first randomised trial to evaluate a fully integrated model of HIV, hypertension and diabetes care in Africa. That is, people with either HIV, diabetes or hypertension were studied. In the integrated care arm of the trial, this was first time in Africa that care for people with HIV was delivered alongside care for people with diabetes or hypertension from the same clinics, by the same clinical staff, supported by the same pharmacy, laboratory and medical records services.
The implications of the results are that the study provides clear evidence for policy-makers to start to scale up integrated care for HIV, diabetes and hypertension. As the burden of non-communicable conditions increases in Africa and more and more people require care for multiple conditions, integrated management is likely to be an essential and cost-effective approach for the continent. The study also serves as a proof-of-concept for integrated management more broadly, which will inform research and clinical practice in other parts of the world.
• The trial has produced positive evidence in support of the integration of diabetes, hypertension and HIV services in both Tanzania and Uganda. Analysis has demonstrated that integration does not have a negative impact on HIV outcomes and that there are substantial efficiencies and savings to be made by integrating the services.
• Following dissemination of the trial results we have secured commitment from Tanzanian and Ugandan governments to explore rolling out and scaling up integrated care for HIV, diabetes and hypertension
• Following dissemination of the trial results we have secured commitment from Tanzanian and Ugandan governments to explore rolling out and scaling up integrated care for HIV, diabetes and hypertension