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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.
Neno District is a district with population of 165 000 in 2017, situated in the southwest zone in Malawi.47 An extremely rural setting, the majority of the population relies on subsistence agriculture, with only 4.5% of the population with electricity.48 Since 2007 PIH has partnered with the MOH in Neno to strengthen health services. In 2011, the Chronic Care Clinic (CCC) began enrolling patients with NCDs at Neno District Hospital, and in 2013 NCD services opened at Lisungwi Community Hospital. In early 2015, CCC was combined with the HIV programme to form IC3, and decentralised to the 11 primary health centres across the district45 (figure 1). NCD and HIV diagnoses in Neno District over time. NCD, non-communicable disease. The clinic-treated patients with one or more of any of the following conditions: HIV, hypertension, epilepsy, asthma, diabetes and mental illness. Patients were referred to IC3 from several settings including inpatient wards, outpatient clinics and community-screening events. The latter were held in remote parts of the district, with participants receiving age-appropriate and gender-appropriate screening for hypertension, diabetes, HIV, TB and malnutrition. Those with high blood pressure or high blood sugar were referred to their nearest facility for IC3 staff to confirm diagnosis and enrol them into care. In order to ensure the sickest patients were found early and treated, and to avoid clinic overcrowding, the referral threshold for blood pressure was systolic blood pressure (SBP) >160 and/or diastolic blood pressure (DBP) >110. Cut-off for blood sugar for referral was fasting >126 mg/dL and random >200 mg/dL.49 For mental health conditions, patients were referred from inpatient and outpatient clinics and assessed and diagnosed on admission to IC3. Once the diagnosis of mental health was confirmed, patients received both psychotherapy and pharmacotherapy at clinic visits. Mental illnesses included in the cohort are: schizophrenia, mood and anxiety disorders, schizoaffective disorder, psychosis, organic mental disorder, and alcohol and drug use-related mental disorders. Patients with a pre-existing NCD diagnosis and on medications were automatically enrolled. Patients were diagnosed using predefined NCD protocols, set by the IC3 team and HIV protocols from central MOH.50 Patients enrolled in IC3 were seen at the health facility nearest to their home at regular intervals. Patients with a complex diagnosis or those starting care had a scheduled visit every month, while most other patients visited every 3 months. The clinic was staffed by clinical officers, nurses, and support staff employed both by PIH and MOH. Supervision and mentorship were performed by several physicians within the district, also employed both by MOH and PIH. Hospital-based staff would travel out to the health centres 3 or 4 days a week to conduct IC3 with health center-based counterparts. This was a solution for staffing shortages—given high volumes of maternal child health and other acute needs at primary health centres, these facilities were not equipped to handle the large influx of patients with HIV and NCDs. This system, of hospital staff travelling to support health center-based staff, had been in place for Neno’s HIV care for several years.40 The HIV programme, well described elsewhere, was characterised by a strong community footprint with a network of over 900 CHWs who received a monthly stipend to assist patients with adherence, perform missed visit tracking and provide social support to especially vulnerable patients in the form of cash transfers.41 These principles were applied to IC3, with the CHW network undergoing a gradual transformation in 2017 and 2018 so that all patients with NCD were eventually assigned a CHW.51 This is a retrospective cohort comprised of all patients newly enrolled in IC3 at any facility in Neno District in the 36-month period between January 2015 and December 2017. Data were collected at enrolment and at routine clinical visits by clinical staff on paper forms also called master cards, which were approved and standardised by the national MOH. Data from the master cards were then regularly entered into an OpenMRS electronic medical record (EMR) system by data clerks. EMR data were extracted and used in this analysis. Baseline demographics and clinical characteristics specific to each disease are reported using descriptive statistics. Key indicators for each condition were chosen based on available routine clinical measurements that were taken each visit based on MOH protocols, which include: blood pressure for patients with hypertension, random or fasting fingerstick for patients with diabetes, asthma severity for patients with asthma and number of monthly seizures for patients with epilepsy. Routine clinical measurements for patients with mental health illness were not available as part of this analysis. Clinical outcomes are reported at 1-year post-enrolment to the clinic for the 36-month period for all patients with more than one visit. The 1-year values were included in this analysis if it was within 3 months of the patients’ 1-year anniversary. Patients were defined as default if they were still missing from clinic more than 8 weeks past their missed appointment, which is consistent with the national definition for default to care for patients with HIV. One-year survival is also reported as patients known to be alive and retained in care 12 months after their enrolment date. SDs are reported for averages for clinical outcomes such as blood pressure or blood sugar, and statistical significance for comparisons between baseline and 1 year were computed using one-sided paired t-tests for continuous values and McNemar’s Χ2 test for proportions. Data were analysed using Stata V.14.2 statistical software.52 The MOH and Neno District Executive Council (DEC) were involved at the conception of the clinic programme design and responsible for approval for the clinic to enrol patients. The clinical services were implemented in tandem by the MOH and PIH, and routine updates were given to the DEC. Patients were involved informally through discussions on clinic design, and formally through patient satisfaction surveys (unpublished). The design of the intervention was meant to address the burden of disease in Neno District, and patients with any chronic condition were eligible for enrolment into the clinic.
