Facility-level integration of hypertension and diabetes services with HIV treatment in sub-Saharan Africa: Evidence from Malawi, South Africa, and Zambia

BackgroundA growing number of people living with HIV (PLHIV) also have non-communicable diseases (NCDs). Shifting the health systems paradigm from vertical, parallel care to an integrated delivery model may facilitate better care-seeking and ultimately improve outcomes for people with a dual burden of HIV and NCDs. We describe the current state of integration of hypertension and diabetes care into HIV treatment in primary healthcare facilities in Malawi, South Africa and Zambia. MethodsWe administered structured interviews to HIV treatment providers in 41 primary healthcare facilities across the three countries to evaluate how NCD care is provided to PLHIV accessing antiretroviral therapy (ART). We defined integration as provision of all NCD services to PLHIV in the HIV clinic. The potential degree of integration in HIV clinics ranged from not integrated at all (no NCD services) to fully integrated (all NCD services). We also surveyed a sample of ART clients at the same facilities about their access to integrated HIV and non-HIV care. ResultsThe degree of integration varied across the facilities and by country. All facilities (n=17) in South Africa reported being fully integrated for HIV care and hypertension and diabetes, and most providers in South Africa identified no barriers to integration. Integration was much less complete in Malawi and Zambia, with most facilities offering hypertension and diabetes screening/diagnosis and support but no treatment or disease monitoring services. Frequently cited barriers to integration in Malawi and Zambia were limited staff knowledge of integrated care provision and facility space constraints. Experience of ART clients experience with integrated services mirrored provider responses. Over 90% of survey participants in South Africa reported HIV and non-HIV visit and medication collection alignment, compared to fewer than half in Malawi and Zambia. ConclusionsThe level of integration of hypertension and diabetes care with HIV treatment varies widely across facilities and within districts in Malawi, South Africa, and Zambia, despite each country having national guidelines that promote integration. Interventions to increase integration must take into account differences among facilities at baseline. South Africas strategy for integrated chronic disease care has resulted in greater integration than have approaches in neighboring countries.