Assessing the capacity of HIV treatment clinics to manage hypertension and diabetes in HIV patients : a case of Kiryandongo district, Midwestern Uganda

Abstract

Background: Both HIV and Non Communicable diseases are major public health problems in developing countries like Uganda. Throughout Sub-Saharan Africa, epidemiological studies have reported an increasing burden of Non Communicable Diseases (NCDs) among HIV patients, which have become a major cause of morbidity and mortality. With the longer lifespans that antiretroviral therapy programs have made possible, diabetes and hypertension and other non-communicable diseases are occurring due to a mix of chronic immune activation, medication adverse effects, co-infections, and the aging process itself. The Uganda Ministry of Health’s 2018 guidelines for the management of HIV in Uganda emphasize the screening for and management of hypertension and diabetes among people living with HIV as part of the minimum service package for this population. However, limited information exists on the capacity of HIV clinics to implement the guidelines. This study assessed the capacity of HIV clinics in Kiryandongo District, Western Uganda to integrate Hypertension (HTN) and Diabetes (DM) management in their routine HIV care. Methods: This was a cross-sectional study conducted in December 2018, at all the 10 health facilities that have HIV clinics in Kiryandongo district, Mid-western Uganda. Capacity for management of HTN and DM was assessed in terms of: knowledge and training of staff who manage patients in the HIV clinics, availability of guidelines/protocols, basic medicines for treatment of DM and HTN, and availability and functionality of equipment for HTN and DM diagnosis and monitoring. The assessment was conducted using three instruments; a questionnaire that was developed using questions extracted from the Service Availability and Readiness Assessment (SARA) tool which was administered to HIV clinic in-charges, a self-reported questionnaire that assessed the knowledge of health care workers at HIV clinics in the management of DM and HTN as well as an interview guide that was used to conduct in-depth interviews with the clinic in-charges to assess linkage and referral for People Living with HIV (PLHIV) who are diagnosed with these two conditions as well as support supervision. Quantitative data was analyzed using STATA version 14. Transcripts were developed from the qualitative data, themes and sub-themes identified and codes developed afterwards. Results: All the 10 health facilities reported having either diagnostic or treatment services for diabetes and hypertension or both. Guidelines for the management of hypertension and diabetes were available in 9/10 of the health facilities. Only 2/10 assessed facilities had staff trained in management of DM and HTN. Also, 6/10 of the facilities had functional blood pressure machines and 6/10 had glucometers though only 4/10 had glucometer strips. In regard to anti diabetic drugs, only 2/10 had insulin and 3/10 had metformin in stock at the time of the study. As for anti-hypertensive, 5/10 of the facilities had thiazide diuretics and calcium channel blockers in stock and 4/10 had beta blockers. Only 43% of the interviewed facility staff were knowledgeable about management of DM and HTN. None of the facilities reported having had support supervision in the area of management of HTN and DM in HIV patients in the last one year. In addition, facilities referred HIV patients with DM and HTN to OPD for medicines and those with complications were referred to Kiryandongo general Hospital. Conclusions: The capacity of HIV clinics in Kiryandongo to manage diabetes and hypertension in HIV patients is suboptimal. Various capacity strengths at the health facility HIV clinics were however found including the availability of guidelines for management of DM and HTN. However, there were also capacity gaps that the study identified which need to be addressed to strengthen management of hypertension and diabetes in HIV patients at HIV clinics in Kiryandongo district. These capacity gaps include shortage of antidiabetic and antihypertensive drugs, lack of basic diagnostic equipment and poor knowledge of health workers in the management of DM and HTN. Recommendations: We therefore recommend that the Ministry of health, Kiryandongo District Health Office and other stakeholders improve access to and availability of basic functional diagnostic equipment and medicines, train health workers attached to HIV clinics in management of hypertension and diabetes in people living with HIV, implement support supervision and establish special non communicable disease clinics in order to effectively integrate management of hypertension and diabetes in HIV care.