Integrated HIV, diabetes, and hypertension care in sub-Saharan Africa
Authors: Songtao Cai, Zhijie Xu, Yang Zhao, Liesl Zühlke
Journal: The Lancet (2024)

We read with interest the trial conducted by Sokoine Kivuyo and colleagues in sub-Saharan Africa.1Kivuyo S Birungi J Okebe J et al.Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic cluster-randomised, controlled trial.Lancet. 2023; 402: 1241-1250Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar The study showed that integrated care resulted in a high rate of retention in care for people with diabetes or hypertension, without adversely affecting HIV outcomes. We have two concerns about this trial. First, of the 503 participants with diabetes in the integrated care group, 391 (77·7%) received a fasting blood glucose test at baseline, but this number decreased to 190 (37·8%) at follow-up. This decrease was greater than that observed in the standard care group, where the number of patients receiving a fasting blood glucose test decreased from 670 (94·4%) of 710 at baseline to 467 (65·8%) at follow-up. Meanwhile, the number of individuals in the integrated care group with fasting blood glucose of 6·9 mmol/L or less decreased from 111 (28·4%) of 391 at baseline to 49 (25·8%) of 190 at follow-up. The low rate of patient engagement and control could potentially be attributed to the fact that medical staff had only short-term training in diabetes care and had not established a relationship with the participants.2Mfinanga SG Nyirenda MJ Mutungi G et al.Integrating HIV, diabetes and hypertension services in Africa: study protocol for a cluster randomised trial in Tanzania and Uganda.BMJ Open. 2021; 11e047979Crossref Scopus (7) Google Scholar Systematic and ongoing training in patient-centred care is needed to reduce stigma and increase the engagement of patients.3Asmat K Dhamani K Gul R et al.The effectiveness of patient-centered care vs. usual care in type 2 diabetes self-management: a systematic review and meta-analysis.Front Public Health. 2022; 10994766Crossref Scopus (13) Google Scholar Second, this study showed lower costs among patients with multiple conditions in the integrated care group; however, their clinical outcomes were not analysed. Given the increasing burden of multimorbidity in low-income countries and the potential strengths of integrated care,4Kaluvu L Asogwa OA Marzà-Florensa A et al.Multimorbidity of communicable and non-communicable diseases in low- and middle-income countries: a systematic review.J Multimorb Comorb. 2022; 12 (26335565221112593)Google Scholar further research should focus on the cost-effectiveness of integrated care approaches to managing multimorbidity. Patient-reported outcomes (eg, treatment burden) should also be included to assess the overall effectiveness of integrated care.5Duncan P Murphy M Man MS et al.Development and validation of the Multimorbidity Treatment Burden Questionnaire (MTBQ).BMJ Open. 2018; 8e019413Google Scholar By addressing these concerns and expanding the scope of research, we believe integrated care could be further improved to manage HIV and multimorbidity in sub-Saharan Africa. We declare no competing interests. Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic cluster-randomised, controlled trialIn 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. Full-Text PDF Open Access