How do we leverage infectious disease platforms to address the growing burden of noncommunicable diseases (NCDs) in low- and middle-income countries? This seminar explored approaches to integrating services for NCDs into HIV, TB, and Malaria control programming globally. This seminar has ended. We invite you to explore the information below to learn about our experiences and lessons integrating services in Ethiopia, Nigeria, and Malawi and read participants’ insights.
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Q2: What NCD services are most easily integrated? Why?
December 13, 2017 at 4:10 pm #16014
There are many NCDs that affect people living with HIV and TB in developing countries. Some are more easily integrated than others, due to human resources, laboratory capacity, availability of medicines, and other reasons. In your experience, what are the low-hanging fruits for incorporating NCD screening, detection, or treatment services?
December 14, 2017 at 3:17 am #16018
NCDs are of many types but the major classes include cardiovascular diseases, cancers, diabetes mellitus, chronic respiratory diseases, mental disorders, musculoskeletal diseases and violence and injury. Of these, the first five are considered priority NCDs in Ethiopia (Note: mental health was not included in the global action framework).
In my experience, some components of NCD services can easily be integrated into the existing longitudinal HIV care model, although there will always be some additional resource implications. Such services include:
• Education and counseling: mass, group, individual and peer-education and counseling services that have been effectively implemented in HIV service outlets can easily be expanded to include NCD topics.
• Blood pressure measurement: This is part of the routine package for any clinical practice and should therefore be done more easily. Also, it can be done by community health workers during their outreach activities or even by the patients themselves.
• Screening and referral for common mental disorders: With short additional training and follow-up mentoring, generalist health workers are able to identify common mental disorders and link them to a specialist care.
• Screening for diabetes mellitus. Determining blood glucose levels at baseline and on regular intervals on subsequent sessions can be integrated into the existing follow up system. Simplified risk scoring systems can be used as initial screeners, to improve the efficiency of the screening approach, as blood testing can be resource intensive.
• Cancer screening. Of notable experience here is screening for cervical cancer. This requires significant additional skill sets but its feasibility is proven in Ethiopia and other RLS.
December 14, 2017 at 4:45 am #16019
At the policy level:The mechanism of close collaboration and coordination between NCD and HIV, TB and Malaria needs to be integrated at the national level. The guidelines and SOP for the implementers to follow very strictly
At the implementation level:
1/ Health education and awareness program on main NCDs may be incorporated with the TB, HIV and Malaria programs
2/ The screening for DM, measuring of blood pressure and other NCDs along with the HIV, TB and Malaria test at he same time by the same health workers since they are capable of performing the test.
December 14, 2017 at 9:14 am #16020
Regarding program/policy level integrations, there are rich experiences and tools from the TB/HIV world which can easily be adopted for NCD integration. The 2011 WHO Framework for TB/Diabetes collaborative activities (http://www.who.int/diabetes/publications/tb_diabetes2011/en/), for example, draws upon the accumulated experience of TB/HIV collaborative activities.
The decentralized service delivery model, task-shifting, training and mentorship, supportive supervision, recording and reporting experiences from HIV and TB programs can easily be adapted for integrating/establishing NCD services.
December 14, 2017 at 9:49 am #16026
There are some more examples of how best to use experiences from the HIV program to integrate NCD care into HIV services in Ethiopia and other RLS. The Integrated Management of Adolescent and Adult Illness (IMAI)-based training and mentorship approach, extensively used throughout Africa and other high HIV burden countries, was successfully piloted for mental health integration in HIV services. Similar approaches can be used for diabetes and hypertension integration. The use of expert patients as training facilitators, peer supporters, case managers and adherence supporters can be applied in diabetes and hypertension integration
Here are some useful resources on such experiences:
(1) Collaboratively reframing mental health for integration of HIV care in Ethiopia. https://academic.oup.com/heapol/article/30/6/791/738419
(2) Factors promoting and inhibiting sustained impact of a mental health task shifting program for HIV providers in Ethiopia. https://www.cambridge.org/core/journals/global-mental-health/article/factors-promoting-and-inhibiting-sustained-impact-of-a-mental-health-taskshifting-program-for-hiv-providers-in-ethiopia/309266808C8D4E867DA5ED7F2264C8B3
(3) Non-communicable diseases and HIV care and treatment: models of integrated service delivery. http://onlinelibrary.wiley.com/doi/10.1111/tmi.12901/abstract
December 14, 2017 at 2:00 pm #16040
Integrating NCDs is an ideal and makes lots of sense from the program perspective and patient perspective. The challenges are that the MoH structures are organized by infectious disease, NCDs, Maternal health, neglected disease and name it, which might not necessarily talk to each other. A strong coordination system in the strategy design and annual planning is the first step to be taken at MoH level.
The other major challenge for NCDs was that it is shadowed by the infectious diseases in the low and middle income countries and enough resources are not allocated for NCDs. NCDs were considered low in low and middle income countries, but it is not true.
The infectious disease unlike NCDs had also attracted donor countries because they have a security and economic impact. As a result NCDs are underfunded and even in the international level a focus was not given. We need an advocacy at international and national levels to show the increasing NCD magnitude and in fact NCDs can be also affect the infectious disease like TB and HIV/AIDs transmission and/or outcomes.
December 14, 2017 at 7:40 pm #16052
The common NCD that are easy-going to CD are labratory investigation particularly when it specimen like blood, Urine etc
December 14, 2017 at 9:37 pm #16054
A question for practitioners – in your experience, what NCDs services are most critical for people living with HIV?
December 14, 2017 at 11:04 pm #16056
In Nigeria, integration ( which is most times screening) of Diabetes in pregnancy( blood sugar screening) , Hypertension ( Blood pressure checks on clinical visit), cervical cancer screening 6 weeks post partum for HIV + women have been easily integrated. However, the big challenge is what happen next after screening? . most of our programs are donor funded ( which allows access to medication to client), however in the absence of universal health coverage , most of the patients identified from screening are unable to fund thier treatment. This remains another firm position for increased advocacy towards UHC
December 15, 2017 at 1:51 am #16060
NCD services critical for people living with HIV:
All services are important but some are critical:
-Screening and managing mental disorders is a critical service for PLHIV, as mental disorders are too common and they have significant negative impact on treatment outcome
-with the ageing of people on ART, screening and managing cardiovascular disorders is critical. since HIV infection itself needs to accelerated ageing, even young patients can develop some of the CVS complications seen in older patients
-addressing modifiable NCD risk factors (smoking, alcohol/drug use, physical inactivity, unhealthy diets) is another critical service for PLHIV
-for women, cervical cancer screening is critically important
December 15, 2017 at 2:44 am #16062
Many NCD services can be integrated into HIV services – Cervical cancer screening for HIV positive women, DM, etc. – But screening for mental health disorders among PLHIV is an NCD service that can be most easily integrated into comprehensive HIV treatment, care and support services.
– Screening for mental health disorders do not require complex and specialized training. Capacity of regular service providers can be built within a short period of time to screen clients during routine service provision using a simple screening tool. Suspects will be escorted to psychiatric unit for further evaluation and treatment. Those diagnosed with mild depression undergo counselling sessions and easily return to ART.
December 15, 2017 at 7:35 am #16074
Just today there was a research paper on BMC Medicine focused on depression and its impact on TB. The authors used data from the World Health Survey and found that depression is highly prevalent in adults with TB, and is associated with worse health status compared to TB without depression.
December 15, 2017 at 8:14 am #16076
Thanks for sharing, Luis. Sadly, these findings do not surprise me. Living with a chronic or long-term disease can be extremely taxing. Managing regular doctor visits, prescription refills, dosing and timing, not to mention side effects, is a lot of work. Combined with stigma, which often accompanies HIV, TB, and some NCDs, this is a lot for any one person to manage. This is why strategic integration and other strategies to reduce the burden on patients and make services more convenient and less costly, like differentiated models of care, are so critical.
December 15, 2017 at 8:56 am #16077
HIV/AIDS is a complex disease and as it is becoming a chronic illness like TB, NCDs are also causes of mortality among HIV/AIDS patients. Diabetes, hypertension, cardiovascular complications, renal complications and different cancers are becoming common co-morbidities. Mental health is for sure an established co-morbidity.
December 15, 2017 at 8:59 am #16078
Is there any experience of integrating HIV/AIDS and screening of cancer?
December 15, 2017 at 10:53 am #16083
Hi Muluken, this question reminded me of a program at the Georgetown Public Hospital Corporation and the MOH in Guyana – it took place in ANC clinics but focused on HIV+ women and provided cervical cancer screening. They did the screening via visual inspection with acetic acid so got immediate results and could refer. Under the program, they reached 95% of HIV+ women and developed SOPs and provided training to make this screening routine. I am attaching a link to the report from 2012 with the details:
I know this approach has been used in other places, do others have experience with this?
December 17, 2017 at 2:48 am #16091
Dear all, greetings from Afghanistan. The context could be different from countries to country. In Afghanistan context and from experiences during past few years, we suggest, mental disordered clinics, Diabetic centers, harm reduction centers or drug demand reduction projects, Expansion Program of Immunization (EPI) and nutrition programs and programs such as kidney chronic disease and cancers programs.
I belief, integration of these programs leading to bringing higher outcomes such as early diagnosis and treatment and avoiding disease complication among the patients. Further, it will led to find additional cases of communicable and non communicable diseases.
in my opinion and in first phase, the above mentioned programs could be mutually integrated (both programs should screen the patients or TB and also for NCDs). This will led to early detection, diagnosis and treatment of both communicable and non communicable diseases in Afghanistan and ultimately avoid deaths and morbidity and disability.
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