HIV testing is often shunned in community settings due to the stigma of HIV-centric services. Our recent pilot study strongly suggest that integration of a package of screening that include HIV, diabetes, and hypertension hold promise of substantially increasing the uptake of HIV testing while simultaneously providing direly needed community screening for non-communicable disease (NCDs) like diabetes and hypertension, which themselves are at epidemic levels in Sub-Saharan Africa. In our pilot study we found that HIV testing almost doubled when diabetes and hypertension screening was added. Moreover, once HIV-infected individuals are identified, many are reluctant to enter care due to the stigma of HIV-centric care programs, and over time attrition of clients is a serious problem undermining the clinical and public health benefits of these programs. Our preliminary studies strongly suggest that integration of NCD care within HIV care would increase enrollment and retention in HIV care by destigmatizing the clinics for all attendees, and by providing tangible clinical therapies for the estimated 79% of HIV-infected clients who also have NCDs, especially those waiting to become eligible for ART, who are also those with the highest attrition. We will assess: (a) the client characteristics and patterns of utilization at the 6 HIV Care and Treatment Centers (CTCs) in Kisarawe District, Tanzania; (b) trends in HIV testing; (c) history of HIV intervention (d) census data; (e) conduct community mapping in each CTC?s catchment area; (f) consult with community leaders and Medical Officers , and (g) match two similar CTCs . Next, one of the two CTCs will be randomized as an enhanced intervention site. At both CTCs we will conduct community mobilization to alert community of available services. At the enhanced intervention CTC we will also provide screening for diabetes and hypertension. The Health Center (always adjacent to the CTC) will be assisted with treating positive NCD cases. HIV-infected clients will be referred to the CTC at both sites, and the first 89 patients at each CTC will be enrolled in a cohort and followed for 24- months (total N=178 across 2 clinics). Those in the cohort at the enhanced intervention CTC who are NCD positive will have care for NCDs integrated with their HIV care. We will assess how NCD screening affects uptake of HIV testing at the community-level over ~18-months. We will establish whether adding NCD care to HIV care improves linkage and enrollment in HIV care. We will determine if retention in HIV care among newly enrolled clients is enhanced over 24-months with the addition of NCD care. We will then cost all intervention components to determine the incremental cost per added client tested for HIV, enrolled in HIV care, and retained in HIV care by adding NCD screening and care.
To maximize the public health benefit of expenditures on HIV prevention and care in Sub-Saharan Africa programs are needed that improve on the substantial investments made to HIV testing and care programs. There is a dire need to substantially expand knowledge of HIV infection status in the region, and enroll and retain persons with HIV in care. This has both direct benefits to improving the health of those with HIV, but also would significantly prevent new infections. Improved retentio n in HIV care would also make investments in HIV more cost-effective. Against this backdrop, there is also an emerging epidemic of non-communicable diseases (NCDs), such as diabetes and hypertension, in low- and middle-income countries, and the burden of disease from NCDs is now rivaling that of HIV in many regions. The goal of this study is to test the efficacy and cost-effectiveness of a novel integration of diabetes and hypertension screening with HIV testing and explore its impact on increasing the rate of HIV testing. Our pilot data suggests that it may be possible to double the uptake of HIV testing with this low-cost strategy. We will also examine whether NCD care integrated with HIV care will improve retention in HIV care. A large proportion of those entering HIV care in sub-Saharan Africa dropout, especially clients not yet eligible for antiretroviral therapy. Our data show that approximately 79% of new entrants to HIV care also have clinically significant diabetes or hypertension, and integrating N CD care with HIV care hold promise of significantly enhancing retention in HIV care. The interventions we will explore, if found efficacious and cost-effective, would provide needed program and policy guidance highly significant to public health. In addition, if these strategies could also ultimately lead to substantial savings to US programs that address AIDS, diabetes, and hypertension control and treatment.
