The burden of non-communicable diseases among people living with HIV and the extent, cost and framework development of integrated HIV and non-communicable diseases care at primary health care facilities in Southern Africa

Abstract

Background Sub Saharan Africa (SSA) grapples with a complex health landscape battling both HIV/AIDS and non-communicable diseases (NCDs). The adoption of integrated care for HIV and NCDs in SSA holds promise in curbing premature mortality from NCDs among people living with HIV (PLHIV) by 2030, aligning with Target 3.4 of Sustainable Development Goal (SDG) 3. In addition to mental illnesses, cardiovascular diseases, cancers, chronic respiratory diseases and diabetes stand as significant NCDs accounting for a considerable portion of global mortality, particularly in low and middle income countries (LMICs), where they contribute to 78% of NCD deaths and 85% of premature deaths. With seven out of the top ten global causes of death being NCDs, the urgency to address this issue is paramount. As the Southern and Eastern Africa region is home to 55% of PLHIV globally, it is a focal point for integrating HIV and NCD care. However, the current burden, extent and frameworks of HIV/NCD integrated care in SSA remains inadequately documented. Aim and Objectives The main aim of this study is to develop a framework for the integration of NCD care with HIV services in primary health care facilities in limited resource Southern Africa. The objectives of this study are to carry out a systematic review and meta-analysis on the burden of NCDs among PLHIV, to determine the extent of HIV/NCD care integration in primary health care facilities in Southern African countries, to measure the cost of integrating HIV/NCD care at primary health care in South Africa as a case study of a Southern African country and to develop a framework for integrating HIV/NCD care in primary health care facilities in Southern African countries, where one does not exist, including the determination of acceptability of the proposed framework by national HIV programme managers. Methods Multi-methods were employed to achieve the thesis objectives. The systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA-20) guidelines. To determine the extent of HIV/NCD care integration in Southern African countries, a qualitative study was conducted using 45 to 60 minute online semi-structured interviews with national HIV programme managers, complemented by a documentary data collection instrument. For the costing study, the activity-based costing method was used to compare the costs of integrating HIV/NCD care at two primary health care facilities in South Africa, analysed as case studies. Additionally, a framework for integrating HIV/NCD care was developed using a modified “Best fit” framework synthesis method. Results The systematic review analysed 188 studies from 21 countries in SSA, revealing a significant burden of NCDs among PLHIV. Obesity/overweight and depression were the most common conditions among PLHIV in SSA, at 32.20% (95%CI: 29.70, 34.70) and 30.4 % (95%CI: 25.30, 35.40), respectively. Hypertension was also notable, affecting 20.1 % (95 % CI: 17.5, 22.70) of PLHIV in SSA. Cervical cancer and chronic respiratory diseases had the least number of studies. Significant progress has been made in Southern African countries in integrating screening and treatment (where applicable) for hypertension, diabetes, cervical cancer and chronic respiratory diseases within HIV services. Despite this, there is a need to strengthen the screening of mental health conditions. The comparative costing study at two primary health care facilities in South Africa found that the annual cost of integrated HIV/NCD care per patient, assuming no complications was $261.6 and $226.3 respectively. Additionally, seven new themes emerged to constitute the developed framework for integrated HIV/NCD care at primary health care facilities in Southern Africa. Conclusion The study highlighted a significant burden of NCDs among PLHIV and revealed varying extent of HIV/NCD integrated care levels across Southern African countries. Despite the notable progress, there is a need to further strengthen health systems. Significant advancements have been achieved in integrating screening for diabetes, chronic respiratory diseases and cardiovascular conditions but there remains gaps for mental health care. The cost analysis found that the average annual HIV/NCD integration cost per patient (stable and without complications), at the primary health care level is at $200. The analysis also underscored the importance of developing cost databases. These findings have led to the creation of a framework for implementing integrated NCD care within HIV programmes at primary healthcare facilities, influencing both current practices and future research in this area.