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Integrated management of HIV, diabetes and hypertension in sub Saharan Africa: a pragmatic multi-country cluster-randomised trial

Kivuyo, S, Birungi, J, Okebe, J, Wang, D, Ramaiya, K, Ainan, S, Tumuhairwe, F, Ouma, S, Namakoola, I, Garrib, A, van Widenfeldt, E, Mutungi, G, Jaoude, GA, Batura, N, Musinguzi, J, Ssali, MN, Etukoit, BM, Mugisha, K, Shimwela, M, Ubuguyu, OS , Makubi, A, Jeffery, C, Watiti, S, Skordis, J, Cuevas, L, Sewankambo, NK, Gill, G, Katahoire, A, Smith, PG, Bachmann, M, Lazarus, J, Mfinanga, S, Nyirenda, MJ, RESPOND-AFRICA, , Picchio, C, Cullen, W, Combe, G, Snell, H, Moyo, F, Willitts, J, Bates, K, Van Hout, MC, Baptista, E, Hinderaker, SG and Shayo, E (2023) Integrated management of HIV, diabetes and hypertension in sub Saharan Africa: a pragmatic multi-country cluster-randomised trial. The Lancet, 402 (10409). pp. 1241-1250. ISSN 0140-6736

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Abstract

Introduction: In Africa, health care provision for chronic conditions is fragmented. We evaluated integrated management of HIV, diabetes and hypertension in Dar es Salaam, Tanzania and Kampala, Uganda. Methods: We conducted a pragmatic, cluster-randomised trial. Primary health care facilities were randomised to provide either integrated or standard care. In integrated care, participants with HIV, diabetes or hypertension were managed by the same healthcare workers, used the same pharmacy, had similarly designed medical records, shared the same registration and waiting area and had an integrated laboratory service. In standard care , these services were delivered vertically for each condition. Analyses used Generalised Estimating Equations. Recruitment was between 30th June 2020 and 1st April 2021 and follow-up was for 12 months. This trial is registered: ISCRTN 43896688. Findings: 32 health facilities were randomised. Just 3% of patients declined to join. Among participants with diabetes, hypertension or both, mean age (standard deviation) was 60.1 (12.7) years in the integrated care arm and 57.7 (12.2) in the standard care arm; among participants with HIV, these figures were 42.6 (11.2) and 42.7 (10.8) respectively. Among participants with diabetes, hypertension or both, the proportion alive and retained in care at study end was 1254/1409 (89.0%) in integrated care and 1457/1623 (89.8%) in standard care. The differences (95% CI were -0.65% (-5.76, 4.46; p=0.80) unadjusted and - 0.60% (-5.46, 4.26; p=0.81) adjusted. Among participants with HIV, the proportion who had plasma viral load <1,000 copies per ml was 1412/1456 (97.0%) in integrated care and 1451/1491 (97.3%) in standard care. The differences were -0.37% (One-sided 95% CI -1.99, 1.26; p-value for non-inferiority <0.0001 unadjusted) and -0.36% (-1.99, 1.28; p-value for non-inferiority <0.0001 adjusted). Conclusion: In sub-Saharan Africa, integrated chronic care services could improve outcomes for people with diabetes or hypertension without adversely affect outcomes for people with HIV.

Item Type: Article
Subjects: R Medicine > R Medicine (General)
R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
Divisions: Public Health Institute
Publisher: Elsevier
SWORD Depositor: A Symplectic
Date Deposited: 01 Aug 2023 14:14
Last Modified: 06 Oct 2023 11:00
DOI or Identification number: 10.1016/S0140-6736(23)01573-8
URI: https://researchonline.ljmu.ac.uk/id/eprint/20541

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