In this survey of 14 HIV CTCs in Dar es Salaam, Tanzania, significant gaps in the services and resources available to diagnose and treat NCD were identified. These included a lack of access to treatment protocols, HCW training, and functioning equipment to adequately diagnose and manage NCD. This study is one of the first to report on the current capacity of HIV care and treatment facilities in SSA to screen and manage NCD.
While 50 % of the clinics reported treating NCD, many of these clinics reported managing NCD without access to protocols or training for disease management. Only 21 % of clinics had at least one healthcare worker trained in NCD. Farzadfar and colleagues demonstrated in rural and urban Iran that trained HCW and well-established guidelines for disease management are important factors for NCD prevention and management . A clinic in Cambodia demonstrated over a 3-year period that HCW training for the management of lifelong diseases was effective for both HIV and diabetes care . Importantly, guidelines are useful for standardization of medical care and optimize the utility of basic equipment, laboratory tests, and medications, particularly in settings where care is delivered primarily by mid-level providers and nurses. Guidelines also provide a means to decide which NCD-related complications are appropriate to be managed in HIV clinics, and when patients should be referred to a higher-level institution.
Overall, none of the surveyed facilities met all the ECHO International Health standards for essential clinic equipment used routinely in the diagnosis and management of NCD. Most clinics were equipped with functioning scales, however, only one-third had functioning blood pressure cuffs. Our results were similar to a program assessment of diabetes clinics in Swaziland in which variable access to basic equipment and NCD drugs was observed . Similar gaps in access to basic technologies and essential medicines for NCD was found in a large multicenter WHO feasibility study of primary care facilities in eight LMICs . While the ECHO standards for essential equipment are designed for a primary health clinic (rather than an HIV clinic) , used in the context of this survey, they provide a measurement of the readiness of the surveyed facilities for NCD care. Without reliable equipment, HCW will be unable to monitor and screen for important risk factors for NCD such as hypertension, nutritional status, and hyperglycemia. These represent missed opportunities within these clinics to provide reliable and adequate NCD care and save lives.
The majority of clinics did not stock medications for the management of NCD and NCD risk factors. Many of these medications are available through the outpatient pharmacy located in the general health clinics and hospitals often located adjacent to the HIV clinics (personal communication, A. Mhalu). However, their personnel and operations are largely separate, so it cannot be assumed that HIV patients have the same level of access to NCD care as those in the general health clinics. Encouragingly, basic lab testing including blood glucose, chemistry and lipid panel testing were found to be widely available, which is in contrast to surveys conducted in LMIC primary healthcare or other non-HIV clinics . However, laboratory testing has the greatest utility if used in in a clinic that uses other comprehensive strategies for NCD screening and prevention. Ensuring access and availability of medications and laboratory tests for diagnosis and monitoring therefore is essential for NCD care.
We observed differences between small dispensaries and large hospital clinics with regard to NCD service provision and equipment availability, although due to the limited sample size, calculations for statistical significance were not performed. However, we noted that dispensaries tended to outperform their larger counterparts in terms of diseases treated (67 % vs. 25 % hypertension, 50 % vs. 12.5 % COPD, 33.3 % vs. 25 % dyslipidemia), equipment availability (64 % vs. 56.3 %), and education topics covered (100 % vs. 50 %), despite similar patient–provider ratios. This may be a reflection of the physicians in the smaller clinics electing to “do more” for their patients because smaller clinics are usually located further away from referral and specialist facilities.
An encouraging finding from the survey was the strong emphasis on patient education within the sites. All facilities offered weekly patient education sessions and individualized patient counseling during every patient visit. While the majority of sessions were devoted to maternal and child health and communicable diseases, these sessions offer a unique opportunity to educate patients on an array of NCD at no additional cost or personnel. A second strength was the high level of awareness of NCD in the clinic facilities. All of the survey respondents reported at least one gap in NCD care with a lack of training and equipment reported as the most significant limitations.
The study findings have significant implications for local Tanzanian policy. The gaps in our findings in NCD care can be grossly categorized in Paul Farmer’s four S’s, “stuff, staff, space, and systems” for effective care delivery . HIV care in this setting is a framework – a “system” and a “space.” However, basic equipment, medications, staff training, and guidelines for NCD management are crucial to extending this system to include the identification and management of co-morbid NCD risk factors and to prevent the development of preventable, late-stage NCD complications (i.e., renal disease, myocardial infarction). Without a progressive approach towards medical care for this patient population, NCD threaten to undermine the success of ART for PLWH, causing premature morbidity and mortality.
Peck et al. recently reported on the preparedness of outpatient primary care facilities in Tanzania to manage NCD . They report low rates of NCD care in general practice health centers and dispensaries, likely due to a lack of clear guidelines, basic supplies, appropriate medications, HCW training, and diagnostic equipment. Our study found similar gaps in NCD care in the HIV CTCs. This is in stark contrast to the strength of the HIV care model in Tanzania, which includes strong leadership by the Ministries of Health, national guidelines, HCW training opportunities, and available medication and diagnostic equipment.
Vertical, health-condition specific systems of care can create fragmented care that fosters inefficient resource utilization and gaps in care for patients with multi-morbidities . While expanding NCD resources in general health clinics should be an eventual goal, leveraging the existing strengths of the HIV care system for NCD care may increase both the quality and efficiency of care delivery with minimal cost. Our study supports and expands upon the observations of Peck et al by identifying gaps in NCD care in existing HIV clinics, and supporting the authors’ recommendation that NCD care should be integrated with the complex primary care of HIV clinics . Similarly, the WHO global strategy for People–Centered and Integrated Health Services calls for a fundamental shift in health care delivery away from vertical care systems towards integrated health care delivery to meet the burden of treating long-term, chronic conditions including HIV and NCD . The implications of this study align with the Tanzania HIV and AIDS Strategic Plan, which includes a priority to implement HIV collaborative activities to reduce co-morbidities including cancers, hypertension, diabetes, and coronary heart disease . In a resource-limited setting, the results of our survey provide a clearer understanding of the gaps in NCD care in outpatient HIV clinic settings that will help prioritize the most effective strategies for integrating NCD diagnosis and management into HIV care.
This study is limited by its sample population and type of data. The participating clinics in this survey were intended to be a representative sample of the public HIV CTCs in Dar es Salaam, the gold standard urban setting in Tanzania. CTCs included may not be representative of HIV care in the rest of the country, particularly more rural areas. However, it is likely that changes in HIV care in Dar es Salaam will have a ripple effect on other areas of Tanzania and SSA countries. Additionally, this study is based on self–reported data, and descriptive and cross–sectional in design, intending only to elucidate a qualitative understanding of the state of NCD care in HIV clinics, rather than report on outcomes. Additional studies examining quality of NCD care provided, evaluating effective and efficient care strategies at individual and health systems levels, and evaluating cost–effective prevention strategies are needed.