Experiences with thermal ablation for cervical precancer treatment after self-collection HPV-based screening in the ASPIRE Mayuge randomized trial.

Cervical cancer remains a significant public health burden in low-resourced countries. Thus, the WHO prioritized cervix screening, and recently recommended thermal ablation treatment for cervical precancer. However, there is limited information on side effects during treatment and recovery, and acceptability among those treated. The ASPIRE Mayuge trial recruited women to participate in self-collection cervix screening between 2019 and 2020 (N = 2019). Screen-positive women (N = 531, 26.3%) were referred for visual inspection with acetic acid and thermal ablation treatment, per Uganda Ministry of Health recommendations; 71.2% of those referred attended follow-up. Six months post-screening, a subset of trial participants were recontacted. Those who received thermal ablation completed a survey assessing side effects during and after the procedure, and willingness to recommend the treatment to others. We summarized the results to describe the side effects and acceptability of thermal ablation treatment. Of 2019 participants, 349 (17%) received thermal ablation. A subset of 135 completed the follow-up survey, where 90% reported pain during treatment; however, intensity and duration were low. Over a third of women reported problems with recovery for reasons including pain, discharge and bleeding. Regardless, 98% reported they would recommend the treatment to others. The use of thermal ablation to treat cervical precancer appears to be highly acceptable in this population. While many women reported side effects during the procedure and recovery, the majority said they would recommend the treatment to others. However, given the substantial proportion who reported problems with recovery, efforts should be made to provide additional resources to women after receiving thermal ablation treatment for cervical precancer.

"We Shall Tell them with Love, Inform them what we have Learnt and then Allow them to go" - Men's Perspectives of Self-Collected Cervical Cancer Screening in Rural Uganda: A Qualitative Inquiry.

Uganda has high incidence rates of cervical cancer (47.5/100,000/year) due to limited screening access. In settings where men hold most of the decision-making power, they play an important role in women's uptake of cervical cancer screening. We aimed to capture men's knowledge, beliefs and perspectives about cervical cancer, community-based screening and health system barriers. Focus group discussions were conducted with men in rural Uganda. Data were verbatim translated and transcribed into English. Transcripts were analysed in ATLAS.ti using a deductive approach of thematic content analysis and applied to an implementation research framework. Twenty-three men participated in focus groups. Men held poor knowledge of cervical cancer, its causes and treatment. Men felt screening would be acceptable by women if men and women were educated. Men highlighted health system barriers to accessing screening including: 1) poor-quality health services, 2) large distances to facilities/lack of affordable transportation and 3) lack of health workers/mistreatment by health workers. Men described supporting women through assisting with transportation, psychosocial support and sharing information. They requested services for men to be decentralized alongside community outreaches for cervical cancer screening. Engaging men in the implementation, education and planning of community-based cervical cancer screening programs is critical. Not engaging men is a missed opportunity to provide them with services and education. Concerted efforts must be made in educating men and reducing health system barriers to ensure rural women receive cervical cancer screening and follow-up care in low-income settings. Clinicaltrials.gov, NCT04000503; Registered 27 June 2019.

Integrated cervical cancer screening in Mayuge District Uganda (ASPIRE Mayuge): a pragmatic sequential cluster randomized trial protocol.

BACKGROUND: Cervical cancer is almost entirely preventable through vaccination and screening, yet remains one of the 'gravest threats to women's lives' according to the World Health Organization. Specific high-risk subtypes of human papillomavirus (HR-HPV) are well-established as the primary cause of cervical cancer. Uganda has one of the highest cervical cancer incidence rates in the world (54.8 per 100,000) as a result of limited screening access and infrastructure. The integration of a self-collected cervical cancer screening program using HPV testing within existing community-based primary health care services could increase access to screening and reduce cervical cancer rates among Ugandan women. METHODS: Using a pragmatic, sequential, cluster randomized trial design; we will compare the effectiveness of two cervical cancer screening models for self-collected HPV testing: 1) community health worker recruitment (door-to-door); and 2) community health meetings. In Mayuge district, Uganda, 31 villages are randomized to one of two treatment arms. Due to the nature of this trial, blinding is not possible. Women are eligible to participate if they have no previous history of hysterectomy or treatment for cervical cancer or pre-cancer and are aged 25-49 years old. All participants receive an integrated package of cervical cancer screening and education. Samples are tested for HPV using GeneXpert point of care testing. All women who test positive for HR-HPV types are referred to a designated health centre for follow-up inspection by Visual Inspection with Acetic acid (VIA) and treatment with thermal ablation. The primary outcome for the trial is the number of women who attend follow-up for VIA screening at a designated Health Centre after a positive HR-HPV test out of all women screened per arm. Secondary outcomes include: cervical cancer screening knowledge; patient-reported experience measures for self-collected cervical cancer screening; and HPV incidence. DISCUSSION: Results from this study will inform the national scale-up of cervical cancer screening in Uganda, aligning with the World Health Organization's target of achieving cervical cancer elimination through the pillar of increased HPV screening coverage. TRIAL REGISTRATION: ISRCTN, ISRCTN12767014. Registered 14 May 2019, https://doi.org/10.1186/ISRCTN12767014; clinicaltrials.gov, NCT04000503; Registered 27 June 2019, https://clinicaltrials.gov/ct2/show/NCT04000503 PROTOCOL VERSION: January 8, 2020, version 1.

Acceptability of Integrated Community-Based HIV and Cervical Cancer Screening in Mayuge District, Uganda.

PURPOSE: To assess the acceptability of integrated screening for cervical cancer and HIV in the community setting. METHODS: We developed surveys for patients and community health workers (CHWs) who participated in the Advances in Screening and Prevention in Reproductive Cancers (ASPIRE) Mayuge trial that compared self-collected human papillomavirus testing at home versus community health meetings in Mayuge district, Uganda. Quantitative data were summarized using descriptive statistics. Open-ended questions were analyzed using an inductive approach with thematic content analysis. RESULTS: We conducted 102 patient surveys and 31 CHW surveys between June and August 2021. Ninety-nine percent of patients and 100% of CHWs indicated that they would find the addition of an HIV test to their self-collected cervical cancer test acceptable. The most frequently stated reasons in favor of adding an HIV test to the ASPIRE Mayuge cervical cancer screening pathways were time-saving, privacy, and support from other women and CHWs. The most frequently stated reasons against integrated screening were related to concerns about confidentiality, most often in reference to women's family members and other women in their village. CONCLUSION: Integrated community-based cervical cancer and HIV testing would be highly acceptable to both women and CHWs.

The contribution of community health systems to resilience: Case study of the response to the 2015 earthquake in Nepal.

Methods: Key informant interviews and focus group discussions were utilised. Participants included FCHVs, primary healthcare workers, community leaders and mothers, district health managers, representatives from the Ministry of Health and Population, multilateral health organisations, bilateral development partners, local non-governmental organisations, community-based organisations, and international non-governmental organisations. We used thematic content analysis to identify emerging themes. Results: Seventy-seven people participated in the study in September 2016 from communities (n = 53, 69%), districts (n = 8, 10%), and national levels (n = 16, 21%). Strong coordination, international and national support, and community engagement and participation were reported as successes of the earthquake response. Challenges included a lack of preparedness and supplies, a lack of earthquake-resistant infrastructure, and the centralisation of the response. FCHVs continued to work, despite being victims of the earthquake themselves. Facilitators of the continuation of the FCHVs' duties included their strong ties with the communities and facilities, international support, and the ability to mobilise existing community resources. Barriers included fear, communities' attitudes, high workloads, large geographic distances, and difficult geography. Participants identified the importance of having strong, connected, and supported communities, adaptable funding and policies, and decentralised decision-making within strong health systems. Conclusions: Building resilience in community-based health systems must start with strong communities that are prepared, trained, equipped, and empowered. Health systems must be decentralised and adaptable, with strong coordination and leadership. Capable community health workers such as FCHVs were an important part of building resilience during the earthquake. These lessons can assist countries in strengthening decentralised health systems to better respond to a multitude of shocks, while still providing essential health services for communities.

Health System Considerations for Community-Based Implementation of Automated Respiratory Counters to Identify Childhood Pneumonia in 5 Regions of Ethiopia: A Qualitative Study.

BACKGROUND: In Ethiopia, childhood pneumonia is diagnosed in primary healthcare settings by measuring respiratory rate (RR) along with the presence of cough, chest indrawing, difficulty breathing, and fast breathing. Our aim was to identify health system-level lessons from implementing two automated RR counters, Children's Automated Respiration Monitor (ChARM) by Phillips® and Rad-G by Masimo®, to provide considerations for integrating such devices into child health programmes and health systems. This study was part of an initiative called the Acute Respiratory Infection Diagnostic Aids (ARIDA). METHODS: Key informant interviews (KIIs) were conducted with 57 participants (health workers in communities and facilities, trainers of health workers, district management, and key decision-makers) in five regions of Ethiopia. Data were analyzed in ATLAS.ti using thematic content analysis and themes were categorized using the Tanahashi bottleneck analysis. RESULTS: All participants recommended scaling up the ARIDA initiative nationally as part of Integrated Management of Newborn and Childhood Illness (IMNCI) in primary healthcare. Health workers perceived the devices as: time saving, acceptable by parents and children, and facilitating diagnosis and referrals. Health workers perceived an increased demand for services and reduced numbers of sick children not seeking care. Participants recommended increasing the number of devices distributed and health workers trained. Strengthening drug supply chains, improving oxygen gas availability, and strengthening referral networks would maximize perceived benefits. While training improved knowledge, more supportive supervision, integration with current guidelines and more guidance related to community engagement was recommended. CONCLUSION: Automatic RR counters for the decentralized diagnosis of childhood pneumonia could have positive impact on improving the quality of diagnosis and management of pneumonia in children. However, the study has shown that a health system approach is required to ensure all steps along the pneumonia pathway are adequate, including drug and oxygen supply, community engagement, health worker training and support, and referral pathways.

Global HIV control: is the glass half empty or half full?

The massive scale-up of HIV treatment and prevention over the past two decades has resulted in important reductions in new infections and mortality globally. Reduction in HIV incidence, however, has been unequal, with worsening epidemics in regions where the reach and scale of HIV control programmes have been insufficient, especially in eastern Europe, central Asia, the Middle East, north Africa, and Latin America where HIV epidemics are concentrated among key populations, including people who inject drugs, men who have sex with men, transgender people, and some minority racial and ethnic groups. The global state of the HIV pandemic highlights disparities in HIV control efforts and provides a roadmap for what should be done, including investment to better implement the effective HIV prevention and treatment tools that are available, but whose adoption and scale-up are not yet sufficient to get us close to an AIDS-free generation. To achieve the full potential of global HIV control, we call for urgent, evidence-informed implementation at scale of our existing and novel HIV prevention and treatment strategies in ways that are better, faster, more efficient, and cost-effective, especially in key populations and regions where the HIV pandemic continues to expand.

Long-acting antiretrovirals and HIV treatment adherence.

Intramuscular injection of long-acting cabotegravir and rilpivirine is a novel, long-acting antiretroviral therapy (ART) combination approved for use as a fully suppressive regimen for people living with HIV. Long-acting cabotegravir with rilpivirine ART has reduced required dosing frequency from once daily to once every month or every 2 months injections. This new era of long-acting ART, which includes other antiretrovirals and formulations in various stages of clinical development, holds tremendous promise to change the standard of HIV treatment. Although long-acting ART has high potential to be revolutionary in the landscape of HIV care, prevention, and treatment cascade, more data are needed to substantiate its efficacy and cost-effectiveness among patients at risk of non-adherence and across age groups, pregnancy, and post partum. Advocacy efforts and policy changes to optimise a sustained, high-quality, equitable reach of long-acting ART, especially in low-income and middle-income countries where most people living with HIV reside, are needed to realise the full benefits of long-acting ART.

The Human Mpox Global Outbreak: Available Control Tools and the Opportunity to Break a Cycle of Neglect in Endemic Countries.

The 2022 global outbreak of human Mpox (formerly monkeypox) virus (MPXV) infection outside of the usual endemic zones in Africa challenged our understanding of the virus's natural history, transmission dynamics, and risk factors. This outbreak has highlighted the need for diagnostics, vaccines, therapeutics, and implementation research, all of which require more substantial investments in equitable collaborative partnerships. Global multidisciplinary networks need to tackle MPXV and other neglected emerging and reemerging zoonotic pathogens to address them locally and prevent or quickly control their worldwide spread. Political endorsement from individual countries and financial commitments to maintain control efforts will be essential for long-term sustainability.

Advancing detection and response capacities for emerging and re-emerging pathogens in Africa.

Recurrent disease outbreaks caused by a range of emerging and resurging pathogens over the past decade reveal major gaps in public health preparedness, detection, and response systems in Africa. Underlying causes of recurrent disease outbreaks include inadequacies in the detection of new infectious disease outbreaks in the community, in rapid pathogen identification, and in proactive surveillance systems. In sub-Saharan Africa, where 70% of zoonotic outbreaks occur, there remains the perennial risk of outbreaks of new or re-emerging pathogens for which no vaccines or treatments are available. As the Ebola virus disease, COVID-19, and mpox (formerly known as monkeypox) outbreaks highlight, a major paradigm shift is required to establish an effective infrastructure and common frameworks for preparedness and to prompt national and regional public health responses to mitigate the effects of future pandemics in Africa.

Community-integrated self-collected HPV-based cervix screening in a low-resource rural setting: a pragmatic, cluster-randomized trial.

Effective approaches to improve coverage of self-collected human papillomavirus (HPV)-based cervix screening (SCS) as well as attendance at treatment for HPV-positive participants are needed to inform policy on optimal integration of cervical cancer screening programs within existing infrastructure in low-resource settings. ASPIRE Mayuge was a pragmatic cluster-randomized trial in rural Mayuge district, Uganda, comparing the superiority of two recruitment implementation strategies for SCS: Door-to-Door versus Community Health Day. Villages were randomized (unblinded) to a strategy, and participants aged 25-49 years with no previous history of hysterectomy or treatment for cervical cancer or pre-cancer were eligible. Participants completed a survey and participated in SCS. The primary outcome was rate of attendance at treatment after a positive SCS. The trial randomized 31 villages and 2,019 participants included in these analyses (Door-to-Door: 16 clusters, 1,055 participants; Community Health Day: 15 clusters, 964 participants). Among HPV-positive participants, attendance at treatment rates were 75% (Door-to-Door) and 67% (Community Health Day) (P = 0.049). Participants in the Community Health Day intervention were less likely to attend treatment compared to Door-to-Door (risk ratio = 0.78, 95% confidence interval: 0.64-0.96). No adverse events were reported. Policymakers in low-resource settings can use these results to guide implementation of SCS programs. ISRCTN registration: 12767014 . ClinicalTrials.gov registration: NCT04000503 .

Interferon Treatments for SARS-CoV-2: Challenges and Opportunities.

Interferon (IFN) therapies are used to treat a variety of infections and diseases and could be used to treat SARS-CoV-2. However, optimal use and timing of IFN therapy to treat SARS-CoV-2 is not well documented. We aimed to synthesize available evidence to understand whether interferon therapy should be recommended for treatment compared to a placebo or standard of care in adult patients. We reviewed literature comparing outcomes of randomized control trials that used IFN therapy for adults diagnosed with SARS-CoV-2 between 2019 and 2021. Data were extracted from 11 of 669 screened studies. Evidence of IFN effectiveness was mixed. Five studies reported that IFN was a better therapy than the control, four found no or minimal difference between IFN and the control, and two concluded that IFN led to worse patient outcomes than the control. Evidence was difficult to compare because of high variability in outcome measures, intervention types and administration, subtypes of IFNs used and timing of interventions. We recommend standardized indicators and reporting for IFN therapy for SARS-CoV-2 to improve evidence synthesis and generation. While IFN therapy has the potential to be a viable treatment for SARS-CoV-2, especially when combined with antivirals and early administration, the lack of comparable of study outcomes prevents evidence synthesis and uptake.

Resilient Clinical Trial Infrastructure in Response to the COVID-19 Pandemic: Lessons Learned from the TOGETHER Randomized Platform Clinical Trial.

In response to the COVID-19 pandemic, clinical research groups across the world developed trial protocols to evaluate the safety and efficacy of treatments for COVID-19. Despite this initial enthusiasm, only a small portion of these protocols were implemented. Of those implemented, a fraction successfully recruited their target sample size to analyze and disseminate findings. More than a year and a half into the COVID-19 pandemic, only a few clinical trials evaluating treatments for COVID-19 have generated new evidence. Productive randomized platform clinical trials evaluating COVID-19 treatments may attribute their success to intentional investments in developing resilient clinical trial infrastructures. Health system resiliency discourse provides a conceptual framework for characterizing attributes for withstanding shocks. This framework may also be useful for contextualizing the attributes of productive clinical trials evaluating COVID-19 therapies. We characterize the successful attributes and lessons learned in developing the TOGETHER Trial infrastructure using a health system resiliency framework. This framework may be considered by clinical trialists aiming to build resilient trial infrastructures capable of responding rapidly and efficiently to global health threats.

Integrated Management of Type 2 Diabetes and Gestational Diabetes in the Context of Multi-Morbidity in Africa: A Systematic Review.

Introduction: Many adults diagnosed with gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM) also have other known or unknown comorbid conditions. The rising prevalence of GDM and T2DM within a broader context of multimorbidity can best be addressed through an integrated management response, instead of stand-alone programs targeting specific infectious and/or chronic diseases. Aim: To describe GDM and T2DM screening, care and cost-effectiveness outcomes in the context of multimorbidity through integrated interventions in Africa. Methods: A systematic review of all published studies was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk Of Bias in Non-randomised Studies of Interventions (ROBINS-I) was used to assess risk of bias. Data synthesis was conducted using narrative synthesis of included studies. Results: A total of 9 out of 13 included studies reported integrated diabetes mellitus (DM) screening, 7 included integrated care and 9 studies addressed cases of newly detected DM who were asymptomatic in pre-diabetes stage. Only 1 study clearly analysed cost-effectiveness in home-based care; another 5 did not evaluate cost-effectiveness but discussed potential cost benefits of an integrated approach to DM screening and care. Compared to partial integration, only 2 fully integrated interventions yielded tangible results regarding DM screening, care and early detection of cases despite many that reported barriers to its sustainability. Conclusion: Though few, integrated interventions for screening and/or care of DM in the context of multimorbidity within available resources in health systems throughout Africa exist and suggest that this approach is possible and could improve health outcomes.

The contribution of community health systems to resilience: Case study of the response to the drought in Ethiopia.

Background: Ethiopia's exposure to the El Niño drought (2015-2016) resulted in high malnutrition, internally displaced people, and epidemics of communicable diseases, all of which strained the health system. The drought was especially challenging for mothers and children. We aimed to identify salient factors that can improve health system resilience by exploring the successes and challenges experienced by a community-based health system during the drought response. Methods: We collected data via key informant interviews and focus group discussions to capture diverse perspectives across the health system (eg, international, national, district, facility, and community perspectives). Data were collected from communities in drought-affected regions of: 1) Somali, Sitti Zone, 2) Hawassa, Southern Nations, Nationalities, and Peoples' Region (SNNPR), and 3) Tigray, Eastern Zone. Data were analysed using a deductive-inductive approach using thematic content analysis applied to a conceptual framework. Results: A total of 94 participants were included (71 from the communities and 23 from other levels). Key themes included the importance of: 1) organized community groups linked to the health system, 2) an effective community health workforce within strong health systems, 3) adaptable human resource structures and service delivery models, 4) training and preparedness, and 5) strong government leadership with decentralized decision making. Conclusions: The results of this study provide insights from across the health system into the successes and challenges of building resilience in community-based health systems in Ethiopia during the drought. As climate change exacerbates extreme weather events, further research is needed to understand the determinants of building resilience from a variety of shocks in multiple contexts, especially focusing on harnessing the power of communities as reservoirs of resilience.

Toward a New Paradigm of North-South and South-South Partnerships for Pandemic Preparedness: Lessons Learned from COVID-19 and Other Outbreaks.

COVID-19 underscores the need to reimagine North-South partnerships and redefine best practices for building public health and research capacity to address emergent health threats and pandemic preparedness in low- and-middle income countries (LMICs). Historically, outbreak and emergency responses have failed to ensure that the Global South has the autonomy and capacity to respond to public health threats in a timely and equitable manner. The COVID-19 response, however, has demonstrated that innovations and solutions in the Global South can not only fill resource and capacity gaps in LMICs but can also provide solutions to challenges globally. These innovations offer valuable lessons about strengthening local manufacturing capacity to produce essential diagnostic, treatment, and prevention tools; implementing high-quality research studies; expanding laboratory and research capacity; and promoting effective cooperation and governance. We discuss specific examples of capacity-building from Rwanda, South Africa, and Senegal. To fulfill promises made to the Global South during the COVID-19 pandemic, restore and resume health service delivery, and effectively prevent and respond to the next health threat, we need to prioritize equitable access to local manufacturing of basic health tools while building health systems capacities in the Global South.

Acceptability and preferences for self-collected screening for cervical cancer within health systems in rural Uganda: A mixed-methods approach.

OBJECTIVE: To understand the knowledge, preferences, and barriers for self-collected cervical cancer screening (SC-CCS) and follow-up care at the individual and health system level to inform the implementation of community-based SC-CCS. METHODS: Surveys and focus group discussions (FGDs) with women and FGDs with healthcare providers were conducted in Uganda. Survey data were analyzed using frequencies and FGD data were analyzed using thematic content analysis. Data were triangulated between methods. RESULTS: Sixty-four women were surveyed and 58 participated in FGDs. Facilitators to screening access included decentralization, convenience, privacy, confidentiality, knowledge, and education. Barriers to accessing screening included lack of transportation and knowledge, long wait times, difficulty accessing health care, and lack of trust in the health system. Additional implementation challenges included insufficiently trained human resources and lack of infrastructure. CONCLUSION: Integrating SC-CCS within rural health systems in low-resource settings has been under-evaluated. Community-based SC-CSS could prevent high cervical cancer-related mortalities while working within the human and financial resource limitations of rural health systems. SC-CCS is acceptable to women and healthcare providers. By addressing rural women's preferences and barriers to care, decision-makers can build health systems that provide community-centered care close to women's homes across the care continuum.

Integrated management of type 2 diabetes and gestational diabetes within multi-morbidity conditions in Africa: a systematic review protocol.

INTRODUCTION: Multi-morbidity, defined as the co-existence of more than one chronic condition in one person, has been increasing due to comorbid non-communicable and infectious chronic diseases (CNCICDs). Type 2 diabetes (T2D) and gestational diabetes mellitus (GDM) incidences within the CNCICDs conditions are increasing and overwhelming already weak and under-resourced healthcare systems in Africa. There is then an urgent need for the integrated management of CNCICDs. We aim to review the integrated management of T2D and GDM within multi-morbidity conditions in Africa. METHODS: Studies that have assessed the integrated management of T2D and GDM within multi-morbidity conditions in Africa will be considered based on the Population, Intervention, Comparator and Outcome method: population (adult diagnosed with T2D and GDM, who also have other diseases, non-communicable diseases (NCDs) and infectious, in public primary and secondary healthcare facilities in Africa); Intervention (integrated management of T2D and GDM, also suffering from other diseases in Africa), Comparator (Unintegrated management of T2D and GDM in Africa) and Outcomes (integrated management of T2D and GDM in Africa). The following databases Cochrane Library, MEDLINE, PubMed and SCOPUS, the WHO International Clinical Trials Registry Platform, among others will be searched. Two reviewers (JCM and MW) will independently screen, select eligible studies and extract data. Discrepancies will be resolved by consensus or by a discussion with the third author (AR). Quality of included studies will be assessed using both the newly developed tool, 'the Cochrane Collaboration Risk of Bias Tool' and 'Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I)". A narrative synthesis of extracted data and meta-analysis, if necessary will be conducted and then reported according to the preferred reporting items for systematic review and meta-analysis. ETHICS CONSIDERATION AND DISSEMINATION: By only using the published data, there is no ethics approval required for this study. This systematic review will be included in JCM's PhD thesis and its findings will also be disseminated through peer-reviewed publication and conference presentation. PROSPERO REGISTRATION NUMBER: CRD42016046630.

Integrated HIV-Care Into Primary Health Care Clinics and the Influence on Diabetes and Hypertension Care: An Interrupted Time Series Analysis in Free State, South Africa Over 4 Years.

BACKGROUND: Noncommunicable diseases (NCDs), specifically diabetes and hypertension, are rising in high HIV-burdened countries such as South Africa. How integrated HIV care into primary health care (PHC) influences NCD care is unknown. We aimed to understand whether differences existed in NCD care (pre- versus post-integration) and how changes may relate to HIV patient numbers. SETTING: Public sector PHC clinics in Free State, South Africa. METHODS: Using a quasiexperimental design, we analyzed monthly administrative data on 4 indicators for diabetes and hypertension (clinic and population levels) during 4 years as HIV integration was implemented in PHC. Data represented 131 PHC clinics with a catchment population of 1.5 million. We used interrupted time series analysis at ±18 and ±30 months from HIV integration in each clinic to identify changes in trends postintegration compared with those in preintegration. We used linear mixed-effect models to study relationships between HIV and NCD indicators. RESULTS: Patients receiving antiretroviral therapy in the 131 PHC clinics studied increased from 1614 (April 2009) to 57, 958 (April 2013). Trends in new diabetes patients on treatment remained unchanged. However, population-level new hypertensives on treatment decreased at ±30 months from integration by 6/100, 000 (SE = 3, P < 0.02) and was associated with the number of new patients with HIV on treatment at the clinics. CONCLUSIONS: Our findings suggest that during the implementation of integrated HIV care into PHC clinics, care for hypertensive patients could be compromised. Further research is needed to understand determinants of NCD care in South Africa and other high HIV-burdened settings to ensure patient-centered PHC.