In 2022, the NCD alliances of Rwanda, Malawi and Tanzania developed national reports on the integration of NCD and HIV services at the primary care level. This work was the first of its kind in all three countries.

‘Integration’ centres on the premise that for countries to build health systems that work for everyone, services must “adapt to a clearer focus on the person and their health throughout the life course, not only on the single health crisis or condition that leads them to seek care.” [1] This means integration of NCD services with primary care services for other global health priority areas, including HIV/AIDS, tuberculosis, and maternal and child health, as a means of advancing towards universal health care.

Integration of NCD and HIV services a natural starting point

For Rwanda, Malawi and Tanzania, integration of NCD and HIV services was a natural starting point, as HIV care at the primary level in these countries is highly developed compared to other health areas. There are also distinct overlaps between NCDs and HIV, as people living with HIV face higher risk of NCD comorbidities, attributable to HIV treatment or lack of adherence to treatment, and populations are ageing thanks to advances in HIV services. [2] There are also synergies between the services needed as both are chronic conditions requiring repeated interactions with health systems.

Developing the integration reports entailed building links between the NCD and HIV communities in-country and conducting consultative activities. The three final reports outline shared priorities and recommendations for decision-makers to advance the integration agenda, specifically integration of NCD and HIV services in-country.

Rwanda

Rwanda’s integration report, People Centred Care: Integration of Non-Communicable Diseases (NCDs) and HIV/AIDS Services, was released in November 2022. It was developed through a desk review on the integration landscape, roundtable discussions with five organisations working on HIV and NCDs in Rwanda [3], and community conversations with 93 people living with NCDs and HIV through 10 selected health centres. Two of these health centres are already planning to introduce NCD screening in HIV clinics in response to this work.

The research revealed that integration of NCD and HIV services is not a new concept, and is actually outlined in three key national strategic frameworks. [4] However, consultations revealed that HIV and NCD services still operate in siloes. Stigma and late NCD detection due to no NCD awareness and screening at HIV clinics are also common. HIV clinic nurses expressed concern about workloads, and the need for training to accomplish required tasks if NCD and HIV services are integrated. Finally, financing was flagged as many people living with HIV do not subscribe to health insurance due to free HIV care, so they experience delays in accessing NCD services.

Tanzania

Tanzania NCD Alliance released its brief on integration, Policy Brief: NCD-HIV Services Integration, in December 2022. It was developed in collaboration with the HIV community, including the National Council of People Living with HIV, who, alongside four hospitals, helped to recruit 67 people living with HIV and NCDs for consultations. Representatives from nine other key organisations from both the HIV and NCD communities also took part. [5]

Through this research it was found that most people living with HIV and NCDs in Tanzania receive their care separately, and that at HIV clinics ‘patients only receive HIV treatment and counselling, and are not provided with any NCD services besides basic health screenings, such as checking of heights and weights.’ [6] It was noted that integration would reduce duplication and fragmentation of services, reduce costs for people living with NCDs and HIV, and improve NCD detection and therefore overall health outcomes.

Malawi

Malawi NCD Alliance launched its Report on Integration of NCDs With HIV Prevention and Care in January 2023. It calls for urgent integration of NCDs into HIV services to ensure equitable access, and sheds light on the HIV community’s recognition of the importance of integration. Resulting from this work, Paul Manyamba, Executive Director of National Association of People Living With HIV/AIDS in Malawi (NAPHAM) – a key collaborator – says that “NAPHAM is planning to integrate NCDs in its operations more, especially in the ART clinics, and this integration will bring the issues related to HIV and NCDs together and improve in service delivery”. [7]

The report was developed through a meeting with 28 leaders from the NCD and HIV community, and community consultations with 28 people living with NCDs and HIV. These revealed that Malawi has not fully invested in health infrastructure for integration of NCDs and HIV, as most facilities are poorly equipped with NCD diagnostic equipment. Further, health providers in HIV clinics lack NCD-related knowledge, and HIV and NCD services must be sought separately. There is also no dedicated budget for NCDs and reports of high out-of-pocket payments required for NCD services, as public hospitals do not have adequate facilities, all of which hinders implementation of the integration agenda.

Development of these reports on integration are key milestones in efforts by the NCD alliances of Rwanda, Malawi, and Tanzania to advance the integration agenda in-country, which will be central to national efforts to achieve UHC. This work has also engaged communities living with HIV and NCDs to ensure a bottom-up approach in exploring a shared agenda. Alliances have engaged with key organisations from the HIV community, outlining policy recommendations and creating a strong base to explore future collaborations.

Work in the three countries was carried out through grants administered under the NCD Alliance’s Our Views, Our Voices initiative, possible thanks to NCD Alliance’s partnership with the Leona M. and Harry B. Helmsley Charitable Trust.

About the author:

Katrina Barker is Public Engagement Officer at NCD Alliance, where her responsibilities include working with national NCD Alliances to advance capacity-building at country level through grant administration and technical support. Prior to NCDA, Katrina earned a Master of Public Administration degree in Science, Technology, Engineering and Public Policy from UCL, and worked as a consultant and researcher internationally and across the public and social sectors for clients including the UK government, UN agencies, and the European and Developing Countries Clinical Trials Partnership.