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Original research
Expanding access to non-communicable disease care in rural Malawi: outcomes from a retrospective cohort in an integrated NCD–HIV model
  1. Emily B Wroe1,2,
  2. Noel Kalanga3,
  3. Elizabeth L Dunbar1,
  4. Lawrence Nazimera4,
  5. Natalie F Price5,
  6. Adarsh Shah5,
  7. Luckson Dullie1,
  8. Bright Mailosi1,
  9. Grant Gonani4,
  10. Enoch P L Ndarama4,
  11. George C Talama1,
  12. Gene Bukhman2,
  13. Lila Kerr1,
  14. Emilia Connolly1,
  15. Chiyembekezo Kachimanga1
  1. 1Partners In Health, Neno, Malawi
  2. 2Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
  3. 3Department of Health Systems and Policy, College of Medicine, Blantyre, Malawi
  4. 4Ministry of Health, Neno District Health Office, Ministry of Health, Neno, Malawi
  5. 5Partners In Health, Boston, Massachusetts, USA
  1. Correspondence to Dr Emily B Wroe; emwroe{at}gmail.com

Abstract

Objectives Non-communicable diseases (NCDs) account for one-third of disability-adjusted life years in Malawi, and access to care is exceptionally limited. Integrated services with HIV are widely recommended, but few examples exist globally. We report descriptive outcomes from an Integrated Chronic Care Clinic (IC3).

Design This is a retrospective cohort study.

Setting The study includes an HIV–NCD clinic across 14 primary care facilities in the rural district of Neno, Malawi.

Participants All new patients, including 6233 HIV–NCD diagnoses, enrolled between January 2015 and December 2017 were included. This included 3334 patients with HIV (59.7% women) and 2990 patients with NCD (67.3% women), 10% overall under age 15 years.

Interventions Patients were seen at their nearest health centre, with a hospital team visiting routinely to reinforce staffing. Data were collected on paper forms and entered into an electronic medical record.

Primary and secondary outcome measures Routine clinical measurements are reported at 1-year post-enrolment for patients with more than one visit. One-year retention is reported by diagnosis.

Results NCD diagnoses were 1693 hypertension, 668 asthma, 486 epilepsy, 149 diabetes and 109 severe mental illness. By December 2018, 8.3% of patients with NCD over 15 years were also on HIV treatment. One-year retention was 85% for HIV and 72% for NCDs, with default in 8.4% and 25.5% and deaths in 4.0% and 1.4%, respectively. Clinical outcomes showed statistically significant improvement for hypertension, diabetes, asthma and epilepsy. Of the 1807 (80%) of patients with HIV with viral load results, 85% had undetectable viral load.

Conclusions The IC3 model, built on an HIV platform, facilitated rapid decentralisation and access to NCD services in rural Malawi. Clinical outcomes and retention in care are favourable, suggesting that integration of chronic disease care at the primary care level poses a way forward for the large dual burden of HIV and chronic NCDs.

  • epilepsy
  • HIV & AIDS
  • diabetes & endocrinology
  • cardiology
  • health services administration & management
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Footnotes

  • Contributors EBW, CK and NK conceptualised the study. EBW, CK, NK, ELD, LN, LD, BM, GG, EPLN, GCT, LK and EC designed and implemented the program and data systems, and oversaw data collection and interpretation. ELD, LK, CK, NK and EBW designed the data collection system. EBW, AS, NFP, CK and NK contributed to the analysis plan. EBW drafted the manuscript. AS and NFP led the analysis, and ELD supported the analysis. GB, CK, EBW, NK, BM, EPLN and LN provided contextual information for framing of the manuscript background and importance. All authors were involved in the design and execution of the clinic and oversaw the clinical work. Each author provided revisions and comments to the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval All data for this study were routinely collected and de-identified clinical data, and no patient was enrolled in a study outside of routine care. Ethical approval was received by the Malawi National Health Sciences Research Committee (NHSRC) and Partners Healthcare Institutional Review Board at Brigham and Women’s Hospital in Boston, Massachusetts, USA.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. No additional data available, but data questions may be directed to the lead author at ewroe@pih.org.