Planning tools: Enhancing HIV/AIDS platforms to address NCDs in low-resource settings

Planning tools: Enhancing HIV/AIDS platforms to address NCDs in low-resource settings

Research to guide practice: Enhancing HIV/AIDS platforms to address NCDs in low-resource settings (the PEPFAR-NCD Project) aims to bring together researchers, implementers and government representatives to articulate practical goals, approaches and a related research agenda to incorporate prevention, care and treatment for noncommunicable diseases (NCDs) into HIV/AIDS platforms in low- and middle-income countries.

The following information may be helpful to those developing programs and funding opportunities to support the implementation of NCD programs through HIV systems.

Updated August 2016

Research Questions | Health Systems Integration | Health Promotion

Research Questions

PEPFAR-NCD project participants updated priority research questions and developed a list of corresponding, suggested activities for enhancing HIV and NCDs services for the purpose of optimizing patient and program outcomes.

  • What is the prevalence of NCDs in HIV populations in SSA?
    What is the prevalence of the NCD’s risk factors in HIV populations in SSA?
    • Suggested activities:
      Encourage the collection of population-based HIV and NCD data with surveillance and registries
      Make meaningful use of electronic medical record data for NCD surveillance and management amongst PLWH
      Establish research agenda for modeling using available data
  • How can we identify best practices for the screening and treatment of NCDs among PLWH in resource-poor countries?
    • Suggested activities:
      Collect available NCD protocols (i.e., screening, treatment, and management) specific to PLWH in resource-poor countries
      Evaluate SSA specific risk stratification protocols that could be developed to better identify patients for screening
      Develop framework and indicators for an enhanced HIV-NCD clinical care platform as part of an enhanced, integrated health systems framework
      Support relevant implementation science research
  • How can we build in-country capacity to improve care for NCDs amongst PLWH?
    • Suggested activities:
      Develop training toolkits for non-physician clinicians and community workers
      Encourage development and adoption of tools to facilitate task-shifting and team-based care (e.g., standardized treatment protocols)
  • How can we ensure that the appropriate NCD diagnostic tests and medications are available for PLWH in resource-poor settings?
    • Suggested activities:
      Support research to develop better technologies to screen and diagnose NCDs as well as medications (e.g., fixed dose combination pills) to treat NCDs in low-resource settings
  • What are the advantages/disadvantages of point-of-care vs. laboratory testing for NCD screening and diagnosis amongst PLWH?
    • Suggested activities:
      Assess, and evaluate laboratory support and point-of-care methodologies currently available for NCD screening and management and develop new methodologies as needed.
  • What is the financial cost and morbidity and mortality impact of population-level scale up of NCD prevention, screening, care, and treatment programs?
    • Suggested activities:
      Conduct program evaluation, disease surveillance, and cost-effectiveness analysis
  • What is the impact of innovative technologies and electronic medical records on the clinical management of people with NCDs and HIV?
    • Suggested activities:
      Support implementation science research programs
  • How do we effectively reach marginalized communities and vulnerable populations?
    How do population differences (e.g., gender and urbanization) inform NCD prevention strategies?
    • Suggested activities:
      Support implementation science research programs
  • How do we assess organizational, site, and community capacity for integration of NCD diagnosis and treatment strategies into current health care structures?
    • Suggested activities:
      Develop research programs to identify criteria for expansion of the current health system capabilities
  • How do we enhance health systems to provide integrated HIV-NCD prevention care and treatment (e.g. using the WHO Health Systems Framework)?
    • Suggested activities:
      Develop an enhanced, integrated HIV-NCD health systems framework
  • How do we improve procurement mechanisms to ensure quality medications for NCDs are available and affordable?
    • Suggested activities:
      Create reliable supply chains to ensure consistent availability of NCD medications
  • How can evidence-based NCD prevention interventions be integrated into HIV prevention initiatives without undermining HIV prevention outcomes?
    • Suggested activities:
      Support implementation research programs
  • What are the policy changes (e.g., taxation of tobacco) necessary for population-wide NCD prevention among PLWH?
    Are they different from those applied to the general population?
    • Suggested activities:
      Support implementation science research programs
  • What are the best practices for optimizing linkage to and retention in care of patients with NCDs in HIV programs?
    • Suggested activities:
      Support implementation science research programs
  • Does integration of NCDs into HIV programs have an impact on HIV treatment, in terms of adherence, retention, or virologic/ immunologic outcomes?
    • Suggested activities:
      Support implementation science research programs
  • Should all patients with NCDs/NCD risk factors be managed in the same way, or should “triage” decisions be made based on risk stratification?
    • Suggested activities:
      Support implementation science research programs

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Health Systems Integration

Health systems need to deliver the same types of quality services for people with high blood pressure, cardiovascular disease, depression, cervical cancer, diabetes and HIV. Integrating these services into a unified chronic care system presents a number of benefits and risks.

  • Benefits
    • Economic integration
      • Systems-oriented: Less fragmentation of funding, supply chain practices, and clinical staffing
      • Patient-oriented: Decreased transport cost, decreases in lost income
    • Managerial integration
      • Systems-oriented: Less fragmentation of funding, supply chain practices, and clinical staffing; Better data collection infrastructure
      • Patient-oriented: Easier to get appropriate care for comorbidities
    • Social integration
      • Systems-oriented: Improved patient adherence and retention to care
      • Patient-oriented: Reduced stigma; Improved sensitivity to patient’s needs
    • Clinical integration
      • Systems-oriented: Complementary styles of treatment; Patient-centered care; Avoids late-stage presentation
        Patient-oriented: Improved treatment outcomes in HIV and NCDs; Access otherwise hard to reach populations
    • Other integration
      • Patient-oriented: Access to early-stage NCD screening
  • Barriers
    • Economic integration
      • Systems-oriented: High up-front costs for clinical staff, procurement of laboratory reagents, and greater supply chain needs; Financial resources needed to retrain staff; High cost of NCD treatment services
      • Patient-oriented: Decreased care access due to cost-of-service fees; Geospatial centralization of services can increase transport costs and other indirect costs
    • Managerial integration
      • Systems-oriented: Need for task-shifting; Bottle-neck of services due to lack of clinical staff; Need for pre-integration infrastructural advancement; Improvements to management practices
      • Patient-oriented: Potential increases in wait times; Potential increases in transport could decrease retention and geographic access to care
    • Social integration
      • Systems-oriented: Lack of political will
      • Patient-oriented: Could increase HIV stigma
    • Clinical integration
      • Systems-oriented: Worsening of clinical outcomes if task-shifting training is done improperly
      • Patient-oriented: Bottle-neck of services due to lack of clinical staff; Maintaining HIV outcomes and retention in care

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Health Promotion

HIV services provide a number of opportunities to assess HIV/NCD integrated, health promotion strategies.

Training health workers/educating patient

Expanding HIV health workers' roles to include NCDs is an opportunity to address the patient as a whole; however, there is little evidence about how to do so.

Examples of NCD health promotion education interventions with potential for HIV integration include:

  • Education intervention: Health workers trained on diabetes screening/management
    • Potential for HIV/NCD integration: This work done in the general population could be integrated into HIV platforms
  • Education intervention: Online training programs on CVD risk reduction launched. One, Policy Depot, is a clearinghouse of CVD health policies and a tool to assist in formulating and implementing evidence-based CVD prevention and risk reduction policies
    • Potential for HIV/NCD integration: Needs additional assessment
  • Education intervention: As part of the WHO mental health GAP Action Program (mhGAP), frontline health workers are trained on how to identify and treat priority mental, neurological and substance abuse disorders
    • Potential for HIV/NCD integration: mhGAP calls for integrating mental health services into existing primary health care systems, including HIV
  • Education intervention: Patients educated on HPV testing, the link between HPV and cervical cancer, and how to perform self-collection
    • Potential for HIV/NCD integration: Education could be included in HIV patient outreach efforts
  • Education intervention: WHO’s Best Buys for NCD Prevention include evidence-based strategies that utilize health worker and patient education to raise awareness about NCDs and risk factors
    • Potential for HIV/NCD integration: Additional evidence needed on how best to integrate these strategies into HIV systems

Community outreach

As PEPFAR expands HIV test and treat efforts, enhanced community engagement could be leveraged to include NCD education, screening, linkage to care.

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Related Resources

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