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Chronic Care Delivery Models for HIV and NCDs in Africa

Explore the challenges of integrating HIV and NCD care in Africa, research gaps, and experiences from ART programs, with a focus on delivery models for chronic care. Learn about the need for more research to enhance care organization.

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Chronic Care Delivery Models for HIV and NCDs in Africa

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  1. HIV and NCDs: models of chronic care delivery in Africa Shabbar Jaffar London School of Hygiene and Tropical Medicine

  2. This talk • The problem and why AIDS and NCDs together • What’s the evidence on delivery of chronic care in Africa? • How can we integrate NCD and HIV care? • Where are the research gaps?

  3. The Problem • NCDs are rising rapidly and affecting young adults. Miranda, Trop Med Int Health. 2008;13:1225-34; Lopez, Lancet 2006; 367: 1747 Addo,. Hypertension. 2007;50:1012; Mbanya, Lancet 2004;364:900. • Limited services for the detection or treatment of hypertension, diabetes and other chronic conditions. • HIV is the first large chronic care programme in Africa. From a health service perspective, HIV and NCD control have similarities. • ART increases CVD risk. Links between TB and smoking, TB and diabetes. Lifestyle changes greater among patients on ART? Bates, Arch Intern Med 2007;167: 335; Wen, BMC Infect Dis 2010; 10:156 Jeon, Plos Med 2008; 5: e152

  4. WE MUST THINK ABOUT AIDS AND NCD CONTROL TOGETHER

  5. Why is chronic care such a challenge? • Very severe shortage of doctors (<1 in 10,000 population in many countries). • HIV care models are hospital, doctor and nurse time intensive. Little research to inform delivery of care. • Delivering NCD care will be particularly challenging: • Knowledge of hypertension, diabetes etc is limited among patients • Conditions are generally silent. Patients should start treatment when healthy

  6. 10km Karonga District, Malawi 120km long. 240,000 population and 1 government doctor

  7. Jinja District, Uganda. Population ~0.5m and 8 doctors in the district + an additional 6-8 at the regional hospital

  8. Experiences from ART programmes. • In rural /peri-urban areas Uganda, 25% of people eligible for ART either die or drop out before treatment can be started (primary reason – can’t afford transport) Amuron, BMC Public Health. 2009;9:290 • Median CD4 count at ART initiation ~ 130 /µl. Getting people into care earlier has proved difficult even with strong community relations. • Patients are often helped financially by relatives during the early months. • Survival and retention are poor in the first 6-12 months after starting ART. Fox, TMIH 2010; 15 suppl 1:1 Lawn, AIDS 2008;22:1897 • Sustained care is a challenge: • In Uganda, each clinic visit in costs >10% of a man’s and 20% of woman’s monthly salary. • Patients want to “normalise”, work, have relationships and lose the HIV badge Jaffar, Lancet 2009; 374: 280 Allen, Cult Health Sex 2011; 13: 529

  9. Models of care for NCDs • Little evidence from Africa. The few studies show poor retention even in trial settings. Labhardt TMIH 2011 (epub) Mendis, Bull WHO 2010; 88: 412 • Feasibility study done in Cambodia with HIV/AIDS, diabetes and hypertension services offered from doctor-run clinics. Retention of diabetics< 75% at 12 months Janssens, Bull WHO 2007; 85:880 -885

  10. Models of HIV care • Vary considerably between settings: • Hospital based, doctor and nurse time intensive: common • Nurse-led management from primary care centres: becoming more common: • Home care using lay-workers: still rare • Policies are not driven by evidence

  11. HIV delivery models – the evidence • Nurses versus doctor management in SA: • Similar clinical outcomes • Only 800 patients followed for 2y. Sanne, Lancet 2010; 376: 33-40 • Home care vs clinic care in Uganda: • Similar survival. Home care slightly cheaper for health service and hugely cost saving for patients. • Only 1453 patients studied for 2.5y. Jaffar, Lancet 2009; 374: 280-89 • Mobile phones and adherence in Kenya: • Text messaging led to better adherence and virological suppression. • Only 538 patients followed for 12m. Lester, Lancet 2010; 376: 1838-45 + 15 other small studies with weak endpoints Lazarus, GFATM; personal communication + evidence from observational studies on task shifting, mostly doctors to nurses. Callaghan Human Resour Health 2010, 8:8

  12. MUCH MORE RESEARCH IS NEEDED ON HOW TO DELIVER AND ORGANISE CARE

  13. Minimal model: clinic-based NCD and ART services • Integrate detection and treatment for hypertension, diabetes and other NCD related conditions into hospital-run ART programmes. • Provide services from the same clinic. • Adherence counselling, drug procurement etc. common to both. • Easier for patients with both conditions • May lower stigma • But will add pressure to severely limited human resources.

  14. Nurse managed HIV and NCD care • Task shifting from doctors to nurses is now common but nature of tasks shifted varies considerably. Need a more standardised model. Callaghan Human Resour Health 2010, 8:8 • Nurse-managed HIV and NCD care: • Integrated services for ART and NCDs delivered from primary care. • Drug initiation, management, monitoring done by nurses with referral to doctors as necessary. • Use of trained lay workers supporting nursing staff. • Targeted intensive support for some patients (e.g. Home care for patients presenting with very advanced disease or those with multiple conditions). • More support at the beginning of treatment initiation and minimal support for patients stable on therapy. • Policy to integrate NCD care into such models will be slow unless rigorous evaluation is done.

  15. Evaluating nurse-led integrated care • Roll-out into clinics sequentially over a number of time periods. By the end, all participants receive the intervention. • Randomise the sequence of introduction • Called a “step-wedge” design

  16. ExampleBrown, BMC methodology 2006; 6:54

  17. Step-wedge designs • Ideal for short-term endpoints: e.g. retention, mortality. • Has many uses – for example evaluate: • E.g. ART at 350 compared to previous guidelines • geneXpert for TB diagnosis

  18. Home care for HIV/NCDs using lay workers • Particularly suited to rural settings where access is difficult. • Lay-workers lead to better outcomes in some service delivery and in some settings; but evidence from Africa is limited. Lewin, Cochrane Database Syst Rev. 2010:CD004015. • In Uganda, HIV home care was delivered by lay workers who : • were paid, trained and supported • were responsible for drug delivery, adherence support and clinical monitoring using checklists and mobile phones for discussions with clinic staff • gave patients more time and built a stronger bond than that possible in clinic settings. • Rates of death, adherence etc were similar in the home and clinic care models; but home care was cheaper for the health service and considerably cheaper for patients. Jaffar, Lancet 2009; 374: 280-89

  19. Lay-workers and chronic care? • Can lay-workers provide integrated HIV and NCD care in the home? • Services which could be provided: • Drug delivery • Adherence support • Clinical monitoring using a checklist. Limited laboratory sample collection • Information on diet and lifestyle • Which type of lay-worker is best (e.g. can one lay worker do all?). How long do we need to provide home care for? What are the costs and benefits of lay-worker care? • Needs evaluation of costs and benefits on a large-scale to shift policy, probably using cluster-randomised trials. Amuron Open AIDS J. 2007; 1: 21-7

  20. Expanding the lay-worker model • In Uganda, home-based HIV VCT offered to households of people starting ART had much higher uptake than clinic models. Other community-based HIV VCT and TB testing approaches have had good uptake. Lugada et al JAIDS 2010; 55: 245 Corbett, Lancet 2010; 376: 1244 Sweat, Lancet Infect Dis 2011; 11: 525 • Could we visit homes of patients starting ART – index patients - and offer testing to family members for blood pressure, diabetes testing, HIV, TB etc? • “Family care” might lead to better adherence and retention; but needs evaluation, probably using cluster-randomised trials.

  21. Chronic care for people without HIV-infection? • Likely to be the big challenge • Is community-based testing for multiple conditions feasible? (e.g. door to door methods of detection versus mobile van at different locations) • Integrate blood pressure testing in HIV VCT activities? • Likely to need community-based models of care with greater roles for lay-workers than in HIV care.

  22. Other important questions • Research on health care workers: costs and benefits of packages aimed at increasing retention of health care workers and quality of service provision. • E.g. audit and constructive feedback. Haines, Bull WHO 2004; 82: 724-31 • Effectiveness of health information provided to communities on diet and lifestyle? Information could be provided by lay-workers, local radio, and other means.

  23. Evaluation methods • Research needs to be kept simple with minimal impact on service delivery. • Needs large studies, ideally in 2-3 sites, to aid generalisability. • Research needs to be integrated into health services and done in close to real-life conditions. Jaffar, TMIH 2008; 13: 795 • Needs a genuine partnership between policy makers, programme mangers, researchers and with patient groups. • Needs strong process evaluation and trial sites which act as a place of learning for other parts of the country.

  24. Big barriers • Researchers, review bodies, funders think about single diseases and single problems. • Many HIV and NCD programme managers don’t communicate. • High impact research will drive the change

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