Integrated chronic care in Africa can improve outcomes and save money
Across Africa about 2 million premature deaths each year are caused by the effects of diabetes and hypertension.
In contrast, most people living with HIV are in regular care and virally suppressed, and HIV mortality rates have fallen five-fold since their peak of 2 million deaths annually in the early 2000s to less than 500,000 in 2022.
Dr. Josephine Birungi, a co-author and Graduate Researcher-Public Health at La Trobe University, said that the similarities in chronic disease management of HIV and other chronic conditions should make integrated clinics beneficial.
"The only difference is the medicine they take. We're seeing diabetes and hypertension increasing across Africa, causing more deaths than HIV," Dr. Birungi said.
The INTE-Africa study enrolled 7,028 adult patients, 3032 had diabetes alone, hypertension alone or both, and 3365 had HIV alone.
"Retention rates in the integrated care arm were close to 90% which is a historic achievement in primary care across Africa. And, most importantly, integration did not compromise the rates of viral suppression among people living with HIV."
The average monthly provider cost per participant was lower in the integrated care arm for participants with multiple conditions.
Savings were driven by reduced staffing and overhead costs associated with reduced number of total visits required by patients with multiple morbidities.
Another finding highlighted by the authors was that integrating care did not increase stigma towards HIV-positive patients as was initially feared.
One patient in Uganda said, "I have no problem with it because, we are all sick. Me, I'm very comfortable. You can't know about the disease unless the person has told you what they are suffering from, we are all sick…"
Dr. Meg Doherty, Director of the World Health Organization Department of Global HIV, Hepatitis and STI Programmes said "This was a large ambitious and well-conducted study with the potential to change policy and practice."
"It is the first study to test successfully the concept of a fully integrated one-stop clinic for people with HIV or non-communicable conditions, with excellent HIV and NCD outcomes. It is exciting to see that by including hypertension and diabetes screening and care into the HIV clinic in these 2 countries, there was no change in HIV viral load suppression outcomes."
The burden of chronic conditions and multi-morbidity continues to increase in Africa. This study provides a blueprint for re-organizing health system to meet demand and to maximize the use of limited resources.
Participating institutions were from Tanzania, Uganda, United Kingdom and Europe, with the MRC/UVRI/LSHTM Research Unit and The AIDS Support Organization (TASO) as leads in Uganda, the National Institute for Medical Research (NMRI) in Tanzania, and the Liverpool School of Tropical Medicine (LSTM) and the University College of London (UCL) Institute for Global Health in United Kingdom.
The findings are published in The Lancet.
More information: Sokoine Kivuyo et al, Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic cluster-randomised, controlled trial, The Lancet (2023). DOI: 10.1016/S0140-6736(23)01573-8