1. Integration of Chronic Care Services: Making the HIV-NCD Connection Miriam Rabkin, MD, MPH Associate Clinical Professor of Medicine & Epidemiology Director, Health Systems Strategies at ICAP Columbia Columbia University Mailman School of Public Health 27 July 2012

2. Integration of Chronic Care Services in Lower Income Countries Increasing prevalence of NCD in LMIC, amongst both PLWH and the general population; In many countries, however, health systems are best able to deliver episodic care for acute conditions. HIV programs are often the only exception to this rule; Unifying characteristics of chronic diseases – and their management – may provide insights into key programmatic questions; Many questions remain unanswered and a priority research agenda is evident…but lack of funding is a significant barrier to both implementation science and NCD services. 2

3. Outline 1.Chronic diseases – unifying characteristics 2.Chronic care services – implementation challenges in LMIC 3.Questions for NCD programs 4.Questions for HIV programs 5.Integration: unanswered questions 3

4. ICAP Columbia & Health Systems

5. Characteristics/priorities of chronic disease from the individual’s perspective: Interacting with the health care system on a regular basis over time and for life Incorporating responsibility for managing health and self-care into daily behavior Sustaining healthy behaviors (adherence, nutrition, smoking cessation, etc.) Accessing psychosocial support services to assist with the emotional and social impact of chronic illness Adapted from Stuart 2008

6. Diagnosis and enrollment Identification of risk factors, early diagnosis, opportunistic case-finding, point-of-service diagnostics, standardized diagnostic protocols Retention and adherence Appointment systems, defaulter tracking, patient counseling, expert patients, secure medication supply chains, pharmacy support Multidisciplinary family-focused care A multidisciplinary team of healthcare providers and community members delivers care in partnership with the patient Longitudinal monitoring Health information systems have standardized and easily retrievable data Linkages and referrals Links within the health facility (to lab, pharmacy, others), between facilities, and between facility & community Self management An informed, motivated patient is an effective manager of his/her own health Community linkages and partnerships Need functional partnerships between health facility- based providers and community-based groups that facilitate access to services across the care continuum Characteristics/priorities of chronic disease from the health system’s perspective:

7. Outline 1.Chronic diseases – unifying characteristics 2.Chronic care services – implementation challenges in LMIC 3.Questions for NCD programs 4.Questions for HIV programs 5.Integration: unanswered questions 7

8. Implementing Chronic Care in LMIC: Challenges HIV/AIDSDiabetesCVDChronic Lung Disease CancersMental Health Demand-side barriers ++++++ Inequitable availability ++++++ Health worker shortages ++ Lack of adherence support ++ ++++ Inadequate infrastructure and equipment ++++ + Inconstant supplies of drugs and diagnostics ++++++ Missing linkage and referral systems ++++++ Need for client and community engagement ++++++ Stigma and discrimination ++++ Adapted from Rabkin and El-Sadr, Global Public Health, 2011

9. ICAP-Swaziland NCD Situational Analysis Structured assessment of 15 health care facilities (3 hospitals, 3 health centers, 9 health clinics). All had HIV/AIDS clinics providing continuity care services: 0/15 sites surveyed had appointment systems for HTN or DM 4/15 sites had on-site medical records of any kind for HTN or DM 2/15 sites used any structured charting tool for HTN or DM 3/15 sites had individuals or teams specifically responsible for DM or HTN program Rabkin, Koler, Kamiru et al. Global Health Council Annual Meeting, 2011

10. © Alison Koler for ICAP Columbia

11. Availability of Basic Medical Equipment Rabkin, Koler, Kamiru et al. Global Health Council Annual Meeting, 2011

12. Access to On-site Diagnostics Rabkin, Koler, Kamiru et al. Global Health Council Annual Meeting, 2011

13. Medical Records / Documentation Chart review of 100 randomly-selected diabetic charts at national hospital diabetes clinic – 100% recorded at least one FBSG – 100% recorded at least one BP measurement – 7% documented a foot exam – 4% documented lab tests ordered – 1% documented a fundoscopic exam – 1% documented medications – 0% documented smoking status, adherence assessment, diabetes-related complications Rabkin, Koler, Kamiru et al. Global Health Council Annual Meeting, 2011

14. ICAP-Ethiopia NCD Situational Analysis For all 261 “active” DM patients with on-site medical records: No standardized charting tools in place 80% had documented blood pressure 9% had documented foot exam 8% had documented neurologic exam 7% had documented eye exam (fundoscopy) < 1% had documented weight < 1% had documented cigarette/smoking status Chart review at regional referral hospital

15. Outline 1.Chronic diseases – unifying characteristics 2.Chronic care services – implementation challenges in LMIC 3.Questions for NCD programs 4.Questions for HIV programs 5.Integration: unanswered questions 15

16. Selected Questions for NCD Programs Can NCD programs leverage the successes (and learn from the challenges) of HIV scale up to provide NCD prevention, care and treatment services to patients without HIV? What strategies, systems and tools are locally available? Where will the funding come from? 16

17. 17

18. Lessons from HIV Scale-up The “Public Health Approach” – strategies, systems and tools Coverage targets (based on prevalence) at global, national, regional, and facility levels Engagement of civil society Rights-based approach to prevention, care and treatment services (universal coverage) 18

19. Illustrative Strategies / Policies The “three ones” – one national framework, one national coordinating authority, one national M&E system Simplified, standardized protocols (not just guidelines) for diagnosis, referral, care, and treatment Task-shifting and ↑↑ use of non-physician clinicians A “minimum package” of clinical, laboratory and pharmacy services and equipment Simple powerful programmatic indicators (enrollment, retention, adherence, outcomes) Enhanced linkages and referrals

20. Illustrative Systems Point-of-service diagnostics with real-time linkages to care Adherence support, expert clients Appointment systems, defaulter tracking Links between clinical, lab, and pharmacy services Task-shifting, multidisciplinary teams, decentralization Supportive supervision, clinical mentoring Routine use of data at the site level to guide program improvement Longitudinal / cohort M&E systems

21. Illustrative Tools Appointment logs, referral forms, outreach forms On-site medical records with structured charting tools Flowsheets, algorithms, SOPs Clinical support tools M & E systems, databases, training tools Pharmacy support tools Lab support tools

22. Leveraging HIV Programs to Support Diabetes Services in Ethiopia Melaku, Reja & Rabkin. IAS 2011, Abstract WEPDD0104

23. Outline 1.Chronic diseases – unifying characteristics 2.Chronic care services – implementation challenges in LMIC 3.Questions for NCD programs 4.Questions for HIV programs 5.Integration: unanswered questions and research agenda 23

24. NCD amongst PLWH Mwangemi et al. 2010 (VCT platform in Kenya): 38% of 4,307 newly-diagnosed PLWH had HTN; 30% had elevated BMI Dave et al. 2011 (HIV clinic in South Africa): 26% of 406 ART-naïve patients had dysglycemia Gwarzo et al. 2012 (HIV clinic in Nigeria): 15% of 1,033 patients had HTN; 22% had elevated BMI 24

25. Selected Questions for HIV Programs Can NCD (and risk factor) prevention, care and treatment for PLWH be added to existing HIV programs without compromising coverage, quality and efficiency? What are the optimal models with which to provide these services? – Where: In HIV clinics or in OPD or NCD clinics? – Who: With the same clinical staff? Taskshifting? – When: At what level of program maturity? – How: ?? What is the incremental cost? 25

26. EACS Guidelines

27. Lessons from NCD Programs 27

28. Lessons from NCD Programs 28 Screening for gestational DM in Cameroon: Dr. Eugene Sobngwi, 2010

29. Lessons from Immunization Programs Vaccine programs are a sought-out platform for additional interventions (vitamin A, deworming, ITNs) but outcomes data are mixed “In an attempt to do more with less, it is possible to achieve less with more” – Schuchat & De Cock 2012 Rigorous assessment of integration strategies is needed 29

30. Outline 1.Chronic diseases – unifying characteristics 2.Chronic care services – implementation challenges in LMIC 3.Questions for NCD programs 4.Questions for HIV programs 5.Integration: unanswered questions 30

31. Integration: Unanswered Questions “As with many passionately debated subjects, data on risks and benefits of integration are scarcer than might be expected.” – Schuchat & De Cock 2012 What are the tradeoffs? What is the impact on: Coverage? Quality? Equity? Efficiency? 31

32. Scenario 1: Parallel Services Scenario 2: Coordinated Services Scenario 3: Integrated Services HIV services NCD services HIV servicesNCD services Chronic Disease Services From: Rabkin, Kruk and El-Sadr, AIDS 2012

33. Integration: Unanswered Questions Which elements of chronic disease programs should be integrated in a given context? – “Upstream” vs. “downstream” How can systems be integrated if there are no funds for NCD services? – Are we willing to provide free NCD services only to PLWH? What is the priority research agenda? 33

34. Thank You CDC, USAID, PEPFAR The Rockefeller Foundation Ministries of Health The Ethiopian Diabetes Association ICAP colleagues and partners No conflict of interest to declare © ICAP Columbia/Deirdre Schoo