HIV and NCDs: models of chronic care delivery in Africa

Shabbar JaffarLondon School of Hygiene and

Tropical Medicine

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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?

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

The Problem• NCDs are rising rapidly and affecting young adults.

Miranda, Trop Med Int Health. 2008;13:1225-34; Lopez, Lancet 2006; 367: 1747Addo,. 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; 10:156Jeon, Plos Med 2008; 5: e152

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

WE MUST THINK ABOUT AIDS AND NCD CONTROL TOGETHER

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

10km

Karonga District, Malawi120km long. 240,000 population and 1 government doctor

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

HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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: 280Allen, Cult Health Sex 2011; 13: 529

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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 endpointsLazarus, GFATM; personal communication

+ evidence from observational studies on task shifting, mostly doctors to nurses. Callaghan Human Resour Health

2010, 8:8

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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.

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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.

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

Example Brown, BMC methodology 2006; 6:54

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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: 245Corbett, 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.

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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.

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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.

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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.

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HIV and Non-communicable Diseases Pre-Conference,

July 15-16, 2011, Rome

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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