Controlling chronic diseases in Africa: development and evaluation of an integrated community-based management for HIV-infection, diabetes and hypertension in Tanzania and Uganda. The INTE-COMM study

We are the NIHR Group on the Management and Prevention of HIV-infection, Diabetes and Hypertension. In our NIHR Group award we had an ambitious objective to bring together vertically delivered HIV services (generally well-resourced and protected) and diabetes and hypertension care (currently less structured and poorly resourced), under one roof in Tanzania and Uganda. This approach was innovative, unique and risky. With support and in partnership with policy makers and disease control programme managers, we have successfully established and are currently evaluating this “integrated care clinic” model. However, the prevalence of chronic conditions is so high that clinic-based care alone cannot meet demand. Our NIHR Group is being urged by health services to evaluate decentralising integrated care to the community-level. Our primary research question for the proposed research is: How can we design community-based integrated management of HIV-infection, diabetes and hypertension, and what is its effectiveness in comparison to clinic-based integrated management of these conditions in terms of patient outcomes? Moreover, we want to know how an effective model of community-based integrated management can be scaled up and sustained across different country contexts in Africa. The proposed research will likely be more challenging than clinic-based integration, in part, because examples of community management, particularly of an integrated nature, are rare. The agenda has been defined after almost 2 years of discussions with African health policy makers in Tanzania and Uganda, and with input from patient and community representatives. We plan a 12-18 month formative phase to build and pilot test different components of integrated community care using a mixed research methods approach. We will adapt the community-based model of HIV care that include provision of medicines, peer-support and self-management. The integrated community care model will be built following interviews with different stakeholders. It will then be evaluated rigorously against standard clinic-based care in a randomised study. Dissemination of findings and community engagement will be a crucial component of the research programme in order facilitate uptake of findings. Using our existing links, we will engage with national and district level policy makers at least 3-monthly to ask what kinds of evidence, training and other materials they need for their policy considerations. We will write policy briefs and hold meetings to explain the research findings, offer materials and training to government health facility staff and contribute to discussions to tackle some of the bottlenecks, such as local planning around drugs provision. The stakeholders will be involved with monitoring the progress of the research, as they are doing for our current NIHR programme, through a formal national steering committee. If the research demonstrates that community care is effective, it could bring about transformational change in how chronic care services are organised in low-resource settings. If there is no benefit, then this research will demonstrate that such approaches may not work and would represent an important advance in knowledge. Alongside this research, we will include substantial capacity development, to add to the capacity development conducted in our current NIHR Group, so that this branch of research can be sustained.