Integrating care of diabetes and high blood pressure for people without HIV into existing HIV clinic systems in primary care in Uganda and Tanzania had no negative effect on the outcomes of people with HIV, an African research group reports in The Lancet.
The integrated care model retained people with diabetes or high blood pressure in care just as well as the standard model of care, in which people with different conditions receive care in different clinics.
Uncontrolled high blood pressure and diabetes cause approximately two million premature deaths in Africa each year. The burden of non-communicable diseases (NCDs) is increasing substantially in Africa and the World Health Organization estimates that the number of Africans with diabetes will increase from 19 million in 2019 to 47 million in 2045.
In comparison, WHO estimates that 25 million people were living with HIV and approximately 380,000 people died from HIV-related causes in Africa in 2022
“We are probably where we were with HIV control in sub-Saharan Africa 20 years ago, but face a bigger challenge going forward, as the burden of non-communicable conditions is very high,” Sokoine Kivuya and colleagues from the RESPOND-Africa research group write in The Lancet, presenting results of their study of integrated care for HIV, hypertension and diabetes.
In an accompanying commentary, Dr Godfrey Kisigo of Tanzania’s National Institute for Medical Research and Dr Robert Peck of Cornell Medical School ask: “What can be learned from the highly successful HIV programmes in Africa to address the growing problem of NCDs, and can we build on existing HIV infrastructure to address NCDs without compromising HIV programmes?”
One approach is to integrate non-communicable disease care with HIV primary care, using good practices developed in HIV care over the past 20 years to improve retention in care and use resources more efficiently.
The INTE-AFRICA study was a cluster-randomised trial comparing standard, non-integrated care for HIV, diabetes and hypertension to an integrated care model in which the three conditions were managed by the same health care workers, pharmacy and laboratory services. In the integrated care model, all patients attended the same clinic at the same times, waited in the same waiting room and had almost identical medical records, with nothing visible to distinguish patients with HIV from other patients in the clinic.
Clinics delivering integrated care adopted track-and-trace procedures already used in HIV clinics for patients who missed appointments. They also introduced medical records where none had been kept previously for patients with diabetes and hypertension. For all participating clinics, the research programme ensured consistent supply of medications for treatment of diabetes and hypertension, which had sometimes been lacking in the past.
The study was not designed to look at the management of NCDs in people with HIV, but to examine the feasibility and effectiveness of managing NCDs in people without HIV through the same clinic pathways as HIV care.
The study randomly allocated 17 health facilities in Uganda and 15 in Tanzania to standard care or integrated care. Within these health facilities, 7028 people had at least one of the health conditions and were eligible for inclusion in the study. The study recruited 3032 people with diabetes or hypertension or both and 3335 with HIV alone. Seventy-two percent of participants were women.
Among those diagnosed with hypertension, 40% in the integrated care arm and 32% in the standard care arm had controlled blood pressure at baseline (<140mmHg/<90mmHg) at baseline. Among those with diabetes, satisfactory glucose control was unusual; 28% in the integrated care arm and 20% in the standard care arm had glucose below 6.9mmol/L at baseline. In people with HIV, viral load was well controlled: around 95% had viral load below 1000 copies/ml, and 88% in the integrated arm and 86% in the standard of care arm had viral load below 400 copies/ml.
The trial had three primary outcomes: retention in care for people with diabetes, retention in care for people with hypertension, and viral suppression below 1000 copies/ml for people with HIV. Study participants were followed for 12.5 months. At the end of the follow-up period, 89% of participants with diabetes or hypertension or both were retained in each study arm. Ninety-five percent of people with HIV in each study arm were virally suppressed below 1000 copies/ml at the end of follow-up.
As well as showing no difference in retention in care between the two models, the study also found no significant difference in secondary outcomes of glucose, blood pressure or hypertension control between study arms, with the exception of change in blood glucose from baseline (favouring the integrated care group).
The study investigators noted that only half of those with hypertension and a quarter of those with raised glucose levels reached target levels during the study. They say that there is an urgent need to investigate ways to improve the control of blood pressure and glucose in African settings, as retaining people in care without achieving this control will not be sustainable.
The study found that while integrated care cost slightly more than standard care for single conditions, the cost of care for people with multiple conditions was substantially reduced due to reductions in the staff time required to manage them. People with multiple conditions required fewer appointments and health care workers could deal with multiple conditions at one appointment. Integrated clinics also needed less space, reducing rental and maintenance costs.
“Integration of NCD and HIV primary care provides us with a new standard of care through which governments and funding agencies can catalyse the next transformation in global health,” the study investigators conclude.
Kivuya S et al. Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic, randomised, controlled trial. Lancet: 402: 1241-50, 2023.
Kisigo GA, Peck RN. Integrating HIV, hypertension, and diabetes primary care in Africa. Lancet 402: 1211-13, 2023.