Title: NIHR Global Health Research Group on prevention and management of non-communicable diseases and HIV-infection in Africa, Liverpool School of Tropical Medicine
Funder: Department of Health and Social Care

Abstract: a) Hosts’ strategy LSTM conducts research that reduces disease burden in low-resource settings. To date its research has been in infection, but the institution recently committed to expand to the interface between infection and non-communicable diseases (NCDs). It has recently made senior appointments to facilitate this expansion and will use its environment in communicable diseases to nurture the new group. b). Why LSTM now? LSTM has made two new appointments to facilitate its move to the interface between communicable diseases and NCDs: Prof Shabbar Jaffar (Epidemiologist) and Prof Louis Niessen (Health Economist). In addition, LSTM is to fund a further senior epidemiologist (currently advertised with a preference for applicants in the HIV- NCDs interface). Support will also be provided by the Head of Clinical Sciences, Prof Luis Cuevas, who desires to move to the interface between tuberculosis and diabetes research. At LSTM, the group will employ and train an epidemiologist, an health economist and a statistician. c). Links to partnerships. The key partners will be the MRC/UVRI Uganda Research Unit and the National Institute of Medical Research (NIMR) in Tanzania. Both have strong backgrounds in HIV research. The MRC/UVRI Unit has just appointed an NCD researcher (Prof Moffat Nyirenda) and provided £2m core funding to expand NCDs research. However, the Unit risks polarised programmes (on HIV and on NCDs) and the proposed group will bring the two together. NIMR now prioritises NCDs research, including providing core-funding for NCDs surveillance and NCDs research capacity development. The formation of a research centre would be catalytic to develop a new research area on integrated approaches.. The research will be done through partnerships with health programme managers and policy makers, and patient and community representatives. We will invest in staff training. The studies outlined will generate data that will be used to design large-scale intervention studies, making our grant proposals competitive. The expertise and research questions will be diverse to ensure that we can target diverse sources of funding. The group members will be part of institutions that have been highly successful in infection-related research. We will have a clear long-term vision in the HIV-NCDs interface with a focus on rigorous innovative globally policy-relevant research to attract and retain staff. d) Proposed activities African countries are undergoing an epidemiological transition, with NCDs increasing rapidly in locations where infections are still highly prevalent (1, 2). Although delivering HIV services continues to be a challenge, these services are now decentralised to primary care centres run by nurses and part-qualified doctors (3). About 50% of HIV-positive African persons know their HIV status (4, 5), and about half of the HIV positive patients who present at health facilities remain in care and have virus suppressed at 12 months (6). For diabetes and hypertension, coverage of services is more limited, services are more centralised and patient outcomes, such as loss from care, are far poorer (7, 8). It will be impossible to increase the coverage of NCD services or make them cost-effective while they are organised as stand-alone services (9). Our group will evaluate integrated approaches for prevention and management in HIV, diabetes and hypertension control, taking account the local context, in particular limited health staff and resources and the challenges that patients face in accessing care. Our initial NCD focus will be hypertension and diabetes as these are very prevalent, lead to severe and costly complications and are, of all NCDs, the most preventable and treatable. What are the knowledge gaps? There has been limited research done, mostly small studies around adding NCDs services for people living with HIV-infection (which exclude those with NCDs who are not HIV-infected) (10-12). Empirical data on integrated services are scarce (13). We don’t know about the effects (beneficial and harmful) of integrating testing and care services for NCDs onto HIV platforms, to what extent can integrated services be decentralised and remain cost-effective, how newly diagnosed persons should be linked into integrated chronic care and what should be the frequency and nature of early treatment support that prevents their subsequent loss from care and ensures high treatment adherence. Collaborations, capacity strengthening We will use our existing partnerships in infection to build collaborations in the HIV and NCDs interface. African partners will contribute equally to decision making. Meetings will be held in each country to define strategy together. We will hold additional consultations with key groups, in particular HIV clinical teams and diabetologists, to understand concerns. An aim will be to develop relations with the World Health Organisation (WHO), who are promoting integration of NCDs with HIV and other infection control programmes (http://www.who.int/global-coordination-mechanism/working-groups/working-group-3-1/en/); our partner in Uganda is part of the WHO working group. Developing research skills We want to develop the future research leaders in both LSTM and Africa. We will support and mentor junior-mid level researchers on-the-job in a range of research studies, including encouraging young scientists to undertake formal training and preparing them for fellowships. Training will be extended to people management and leadership skills. We will offer training to policy makers in interpreting research evidence – crucial skills in linking scientific evidence into policy making. We will share responsibilities with junior-mid level researchers and support them to fulfil these. Data management will be led by Tanzania and social science by Uganda, building on previous capacity developed. Measurable 6-month delivery targets 1. Expand pool of HIV-NCD researchers in each partner country. 2. Meetings held between the partners, Ministries of Health, patient and community representatives and other key stakeholders. Principles of collaboration agreed. 3. Steering committee membership agreed and first meeting held. 4. Initial proposals drafted for ethics clearance. 5. Key job descriptions agreed. 6. Routine existing data identified and basic statistical analysis done. • Medium (1-2 years) objectives 1). Develop and implement integrated testing and management protocols for HIV-infection, diabetes and hypertension and evaluate feasibility. 2). Evaluate the feasibility of decentralising selected services to the community and self-management and peer-support. • Long-term (2-3 years) objectives 3). Set up simple data collection to monitor patient outcomes and identify the best and worst facilities with a view to working with them to improve outcomes. 4). Develop a protocol to submit for further funding to evaluate community-based integrated group delivery and peer support (feasibility done in point 2). 5). Develop a protocol to submit for funding to evaluate the scale up of integrated prevention and management for diabetes, hypertension and HIV-infection. 6) Train two junior-mid level African colleagues to MSc level, one in epidemiology and the other in medical statistics. Support and facilitate other candidates for fellowship applications. • Projects within the first two years. We will pursue the integrated testing and management project (point 1 above). The strategy will be evaluated in a range of health facilities. Participants will be followed up to record linkage into and early retention in care. We will model the data to estimate potential long-term impacts and costs. Social science will be used to better understand local terminology around NCDs to inform prevention and adherence messages. We will do the pilot study to test novel decentralisation and task-shifting for integrated care (point 2 above) and proceed to writing a full proposal. We will also start the study involving monitoring of outcomes and feedback (point 3) but this would not complete until year 3. Data collection will be introduced gradually. We will firstly use mostly paper-based data collection on Case Record Forms (CRFs), scan and digitise these and describe the issues around confidentiality and other challenges of introducing the new system. e). Commissioning research. None planned. We believe we have the existing skills necessary to deliver the research agenda of the group. f). Sustainability The studies outlined will inform large-scale research studies. The initial studies are diverse and this will enable us to target different funders. They are also large enough to publish to enable us to develop credibility and become competitive in grant proposals in this field. We will invest in training and capacity development. The junior researchers will be mentored and supervised by a large group of senior researchers. Selected steering committee meetings will be used to identify scientific gaps and generate research ideas, which junior-mid researchers will be encouraged and supported to take forward into proposals. Experts in the field (who are not members of the steering committee) will be invited to contribute to the ideas. African partners will have an equal say in decision making and there will be regular engagement with different stakeholders. This will ensure that we ask relevant research questions for maximum benefit to patient health and will facilitate uptake of research findings; crucially, we will be in a position to compete for local research funding, and this funding will be used to leverage higher amounts of international funding. Sustainability will depend crucially on the quality of our research and a focus on rigorous high-impact research will be our focus throughout.

Lay abstract: HIV, diabetes and hypertension are major determinants of the massive disease burden in Africa and provision of accessible effective care for these conditions is probably Africa’s biggest health challenge. Our aim is to build a programme of research to inform integrated approaches for the prevention and management of HIV, diabetes and hypertension. The objectives are: 1). To develop a partnership between the Liverpool School of Tropical Medicine (LSTM), African researchers in Uganda and Tanzania, health policy makers and programme managers, patient groups and community representatives for the purposes of conducting research that has maximum immediate benefit on patient outcomes in Africa. 2). To develop and strengthen capacity in NCDs and in research methods 3). To conduct early phase (pilot) studies and assess how diagnostic and treatment services for HIV- infection, diabetes and hypertension should be integrated at health facilities, how these integrated services should be decentralised, how task-shifting should be organised and how patients should be supported and monitored. Our long-term objective is to use this platform and the knowledge acquired to proceed to large-scale comparative studies evaluating different approaches of prevention and management for major chronic conditions. Expected outcomes 1). A partnership between researchers, health care services, with involvement of patients and community, built on trust and equality. 2). Early phase research findings that inform the planning of and make us competitive for a range of larger studies on the prevention and management of HIV, diabetes and hypertension. 3). Development of capacity, in particular early career researchers, in order to grow the research programme Beneficiaries / users Researchers in Africa and the UK will be the primary beneficiaries initially. They will use the data to plan large research studies. We will develop the capacity of early mid-level researchers. Health services and ministries of health will benefit with the various process data generated on how health services operate. Partners: LSTM, MRC/UVRI Uganda Research Unit, National Institute of Medical Research Tanzania (Muhimbili Medical Research Centre). We partner closely with the Heads of the National AIDS and National NCDs programmes in Uganda, the Director of Programmes in The AIDS Support Organisation in Uganda, and Assistant Director of Preventive Services in Tanzania (to whom both the HIV and NCDs programmes are reporting to). We also partner closely with local health service managers including the directors of city councils. Advancing knowledge, delivering measurable benefits This is the only research programme working on the evaluation of integrated health care strategies. Our focus is to conduct high quality clinical and public health research. The partnerships developed will ensure that the research is relevant and its findings are taken up appropriately by policy makers across Africa. Activities: We have had several planning meetings with the different stakeholders. We have written 2 proposals for pilot research studies to be conducted with the NIHR funding and have received clearance on one. We have submitted further 2 proposals for funding on the evaluation of integration of chronic care services for a total of £4m and are currently writing 2 further large proposals.

Research activity codes: 8.5 RESOURCES AND INFRASTRUCTURE (HEALTH SERVICES)
Health categories: CARDIOVASCULAR;GENERIC HEALTH RELEVANCE;INFECTION;METABOLIC AND ENDOCRINE