Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic cluster-randomised, controlled trial.

BACKGROUND: In sub-Saharan Africa, health-care provision for chronic conditions is fragmented. The aim of this study was to determine whether integrated management of HIV, diabetes, and hypertension led to improved rates of retention in care for people with diabetes or hypertension without adversely affecting rates of HIV viral suppression among people with HIV when compared to standard vertical care in medium and large health facilities in Uganda and Tanzania. METHODS: In INTE-AFRICA, a pragmatic cluster-randomised, controlled trial, we randomly allocated primary health-care facilities in Uganda and Tanzania to provide either integrated care or standard care for HIV, diabetes, and hypertension. Random allocation (1:1) was stratified by location, infrastructure level, and by country, with a permuted block randomisation method. In the integrated care group, participants with HIV, diabetes, or hypertension were managed by the same health-care workers, used the same pharmacy, had similarly designed medical records, shared the same registration and waiting areas, and had an integrated laboratory service. In the standard care group, these services were delivered vertically for each condition. Patients were eligible to join the trial if they were living with confirmed HIV, diabetes, or hypertension, were aged 18 years or older, were living within the catchment population area of the health facility, and were likely to remain in the catchment population for 6 months. The coprimary outcomes, retention in care (attending a clinic within the last 6 months of study follow-up) for participants with either diabetes or hypertension (tested for superiority) and plasma viral load suppression for those with HIV (>1000 copies per mL; tested for non-inferiority, 10% margin), were analysed using generalised estimating equations in the intention-to-treat population. This trial is registered with ISCRTN 43896688. FINDINGS: Between June 30, 2020, and April 1, 2021 we randomly allocated 32 health facilities (17 in Uganda and 15 in Tanzania) with 7028 eligible participants to the integrated care or the standard care groups. Among participants with diabetes, hypertension, or both, 2298 (75·8%) of 3032 were female and 734 (24·2%) of 3032 were male. Of participants with HIV alone, 2365 (70·3%) of 3365 were female and 1000 (29·7%) of 3365 were male. Follow-up lasted for 12 months. Among participants with diabetes, hypertension, or both, the proportion alive and retained in care at study end was 1254 (89·0%) of 1409 in integrated care and 1457 (89·8%) of 1623 in standard care. The risk differences were -0·65% (95% CI -5·76 to 4·46; p=0·80) unadjusted and -0·60% (-5·46 to 4·26; p=0·81) adjusted. Among participants with HIV, the proportion who had a plasma viral load of less than 1000 copies per mL was 1412 (97·0%) of 1456 in integrated care and 1451 (97·3%) of 1491 in standard care. The differences were -0·37% (one-sided 95% CI -1·99 to 1·26; pnon-inferiority<0·0001 unadjusted) and -0·36% (-1·99 to 1·28; pnon-inferiority<0·0001 adjusted). INTERPRETATION: In sub-Saharan Africa, integrated chronic care services could achieve a high standard of care for people with diabetes or hypertension without adversely affecting outcomes for people with HIV. FUNDING: European Union Horizon 2020 and Global Alliance for Chronic Diseases.

Association of opioid agonist therapy with the initiation of antiretroviral therapy - a systematic review.

OBJECTIVES: People who inject drugs are at high risk of HIV infection but often face barriers in accessing medical care including access to antiretroviral therapy (ART). Evidence is available about the effectiveness of opioid agonist therapy on drug dependency and risk behaviors. However, it remains scattered regarding access to ART among HIV-positive people who inject drugs. We conducted a systematic review to examine the association of opioid agonist therapy with ART initiation among HIV-positive people who inject drugs. METHODS: We searched the literature for evidence from seven databases. We conducted a narrative synthesis and meta-analysis to examine the association of opioid agonist therapy with ART initiation. RESULTS: Five out of 2,901 identified studies met the inclusion criteria. Three out of five studies reported that, HIV-positive people receiving opioid agonist therapy initiated ART more than those not receiving opioid agonist therapy. In meta-analysis, opioid agonist therapy was associated with ART initiation among HIV positive people who inject drugs (pooled odds ratio: 1.68; 95% confidence interval: 1.03-2.73). CONCLUSIONS: Opioid agonist therapy is positively associated with ART initiation among HIV-positive people who inject drugs. It is important to scale up opioid agonist therapy among people who inject drugs to improve their ART initiation.

A Mismatch between High-Risk Behaviors and Screening of Infectious Diseases among People Who Inject Drugs in Dar es Salaam, Tanzania.

BACKGROUND: People who inject drugs are at risk of various infectious diseases. Despite such a risk, evidence is limited which studied the utilization of screening services for common infectious diseases among people who inject drugs in Tanzania. We aimed to examine their high-risk behaviors; utilization of screening services for HIV infection, hepatitis B/C, any other sexually transmitted infection, and tuberculosis; and their associated factors in Dar es Salaam, Tanzania. METHODS: We conducted a baseline cross-sectional study as part of a prospective cohort study of people who inject drugs. We included 578 participants comprising of new enrollees of the integrated methadone-assisted treatment program and those who were selected from the communities but not enrolled in the program. We interviewed new enrollees preceding their enrollment and receipt of services from the program. We measured participants' high-risk behaviors and their utilization of screening services. We analyzed the data descriptively and used multiple logistic regressions to identify the factors associated with ever being screened for infectious diseases. RESULTS: Of 578 participants, 14.2% shared injection needles. Of 547 sexually active participants, 37.5% had multiple sexual partners and only 17.4% used a condom. Of all participants, however, only 36.0% had ever been screened for HIV infection, 18.5% for tuberculosis, 11.8% for any other sexually transmitted infection, and 11.6% for hepatitis B/C. They were more likely to have ever been screened for HIV infection if they had education levels above primary education (adjusted odds ratio [AOR]: 2.54, 95% CI: 1.54-4.20), had a history of transactional sex (OR: 2.63, 95% CI: 1.01-6.84), and were new enrollees of the program (AOR: 7.41, 95% CI: 4.41-12.86). CONCLUSIONS: People who inject drugs practice high-risk behaviors but their utilization of screening services for infectious diseases is poor in Dar es Salaam, Tanzania. It is crucial to increase the coverage of screening services for them and strengthen the counseling of safer sexual practices.

Correlates of health care seeking behaviour among people who inject drugs in Dar es Salaam, Tanzania.

BACKGROUND: People who inject drugs (PWID) suffer from a high burden of infectious disease. At the same time, they often have poor access to health care. As in other East African countries, the population of PWID is growing in Tanzania, but little is known about their contact with health care services. In this paper we examine patterns of health care use among PWID in Dar es Salaam and identify what factors are associated with regular contact with clinicians during illness. METHODS: We conducted a baseline cross-sectional study as part of a prospective cohort study involving PWID. We recruited 578 PWID, of whom 273 were newly enrolled on an integrated methadone-assisted treatment (MAT) program and 305 were community-recruited. At baseline, we interviewed the MAT program enrollees before they received services at the program clinics. We used bivariate and multiple logistic regression analyses to identify the factors associated with seeking medical care when ill. RESULTS: Only 25.4% of 578 participants reported seeing clinicians regularly when they needed medical care. Participants were more likely to see clinicians regularly if they were employed, (OR: 2.25, 95% CI: 1.28-3.98), had higher income levels (OR: 1.10, 95% CI: 1.00-1.22), were parents (OR: 1.71, 95% CI: 1.09-2.68), or knew where to seek affordable care (OR: 3.42, 95% CI: 2.12-5.52). CONCLUSION: PWID in Dar es Salaam generally did not seek health care when needed. To improve their health care seeking behaviour, it is important to advise PWID about where to seek affordable health care and to increase their income-generating skills.