Curbing the non-communicable disease epidemic: an evaluation of integrating rapid testing for NCD risk factors and navigated linkage to care into a standard HIV testing service platform for adults in Soweto, South Africa
Date
2021
Authors
Hopkins, Kathryn L
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Abstract
BACKGROUND:
The top causes of death and disability worldwide are chronic non-communicable diseases
(NCDs), such as cardiovascular disease (CVD) and diabetes mellitus (DM), which contribute
to more than three in five deaths. South Africa is also the epicentre of the human
immunodeficiency virus / acquired immune deficiency syndrome (HIV/AIDS) epidemic,
containing the world’s highest prevalence of HIV-1. People living with HIV (PLHIV), now
living longer while on treatment, are becoming increasingly at-risk for non-HIV-related
chronic conditions similar to the HIV-uninfected population. In understanding the expected
impact of NCDs on both the general population and amongst PLHIV, it becomes critical to
pursue healthcare strategies that effectively and efficiently prevent, diagnose, treat, and control
NCDs for both HIV-infected and uninfected persons.
AIMS:
This study aimed to provide an overall evaluation of integrating counsellor task-shifted rapid
diagnostic testing (RDT) for NCD risk factors with optional peer-navigated linkage to care
within an HIV Testing Services (HTS) centre in Soweto, South Africa.
Specifically, this study sought to, 1) determine the prevalence patterns of NCD risk factors
amongst adult HTS clients by age, sex, HIV-status and ART-use; 2) describe the client level
of satisfaction with integrated NCD-HTS, as compared to standard of care HTS; 3) assess the
quality and feasibility of task-shifting RDT for NCD risk factors to counsellors; 4) determine
the proportion of integrated NCD-HTS clients linked to care and initiated on treatment using
peer-navigated linkage to care, as compared to standard of care HTS clients using passive
referral; and 5) investigate the barriers to integrated NCD-HTS client linkage to care and
initiation of treatment across chronic diseases.
METHODS:
This study was a prospective evaluation which consisted of a two-phase longitudinal study
design to compare targeted study measures between the three-month standard of care HTS
phase utilising passive referral for HTS clients with abnormal/positive results (19 February to
14 June, 2018) against a subsequent nine-month integrated NCD-HTS phase with optional
peer-navigated referral (18 June 2018 to 28 March 2019). Standard of care HTS provided
counsellor-led height, weight and BP measurements; symptoms screening for sexually
transmitted infections (STIs) and tuberculosis (TB); and HIV rapid testing. Integrated NCD-
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HTS further included counsellor-led BMI categorisations and RDT for blood glucose (both
RPG and average HbA1c) and TC services.
Walk-in, adult clients at the PHRU Zazi HTS Centre who consented to the health screening
programme were enrolled and had HTS client files opened. These paper files collected data on
socio-demographics; health risk behaviour (alcohol and tobacco use); previous health
screening history and treatment use for hypertension (HT), DM, hypercholesterolemia, and
HIV; health screening results; clinic flow start and stop times; number of correct and incorrect
counsellor-provided referrals; and peer-navigated referral uptake. These clients were then able
to consent into an embedded study, comprised of HTS client clinic exit surveys and linkage to
care follow-up surveys (only for clients with at least one referral for an abnormal result with
follow-up conducted up to three month post-clinic visit). Surveys included both open and
closed-ended questions using a five-point Likert scale to investigate HTS client satisfaction
with HTS clinic flow time and services provided; time to linkage to care and treatment
initiation; and reasons for not choosing peer-navigated referral, linking to care, and/or linking
to care but not initiating on treatment.
All quantitative statistical analyses were conducted in SAS Enterprise Guide 7.1 (SAS Institute,
Cary, NC) using SAS/STAT procedures. Descriptive statistics (e.g. medians, means,
interquartile ranges [IQR], and standard deviation) were reported for continuous variables.
Frequencies and associated percentages were determined for categorical variables, stratified
where appropriate by age group (18-24, 25-34, 35-44 and ≥45 years), sex, HIV status, ART
use, and HTS phase. Fisher’s exact or chi-square tests were conducted to test statistical
significance for categorical measures stratified by HTS phase. Comparisons for descriptive
statistics by HTS phase were determined using the Kruskal-Wallis test and Student’s T-Test.
Survey responses to close-ended and open-ended questions (once thematically sorted) were
tabulated.
RESULTS:
There were 325 and 780 clients with aggregate data collected within standard of care HTS and
integrated NCD-HTS, respectively. Of the 780 enrolled integrated NCD-HTS clients who were
screened, 19.2% (n=149/775) were HIV-infected, 37.5% (n=289/770) were overweight/obese,
18.0% (n=139/772) had high BP, 10.8% (n=83/766) had high HbA1c (four clients had high
random glucose), and 8.1% (n=62/768) had high TC. Women had significantly more
overweight/obese BMI than men (46.8% [n=237/506] vs 19.7% [n=52/264]; p<0.0001); and
39.8% (n=127/319) of 18-34 year old women were overweight/obese. Males had significantly
higher BP than women (23.9% [n=63/264] vs. 15.0% [n=76/508]; p=0.0023). Of 18-34 year
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olds, 7.2% (n=31/433) had high blood glucose; and there were over three times as many women
aged 25-34 years with high TC as compared to men of the same age group (18.2% [n=20/110]
vs 5.6% [n=4/71]; p=0.0151). The majority of HIV-infected clients were female (72.5%
[n=108/149]). HIV-infected clients had significantly more high HbA1c than HIV-uninfected
clients (16.1% [n=24/149] vs 9.6% [n=59/614]; p=0.0223). HIV-infected individuals on ART
had significantly higher TC than those not on ART (21.7% [n=10/46] vs. 4.9% [n=5/103];
p=0.0016).
Of the HIV-infected participants, 48.3% (n=72/149) already knew their HIV-status, and of
those, 63.9% (n=46/72) were on ART. Of all participants screened with elevated BP, high
HbA1c and high TC, 72.4% (n=97/134), 96.1% (n=73/76), and 93.3% (n=56/60) were newly
diagnosed for each condition, respectively. Of the clients who self-reported as being previously
diagnosed, 83.8% (n=31/37) of hypertensive clients, two (n=2/3) clients with high HbA1c, and
one (n=1/4) client with high TC self-reported they had already been initiated on treatment. All
clients were found to have uncontrolled disease after screening.
There were 284 and 333 HTS client clinic exit surveys analysed for standard of care HTS and
integrated NCD-HTS, and therefore clinic flow time was analysed for the same sample size.
Standard of care HTS clients spent significantly shorter time in minutes in the clinic from start
to finish as compared to integrated NCD-HTS clients (86.0, IQR: 72.0-108.0, [n=283/284] vs
102.0, IQR: 87.0-136.0, [n=331/333]; p<0.0001). Of the integrated NCD-HTS clients, 97.9%
(n=320/327) were ‘very satisfied’ with integrated NCD-HTS, overall, despite standard of care
HTS having significantly shorter median time for counsellor-led HTS.
Regarding quality of task-shifting RDT of NCDs to counsellors, there was one (n=1/3, 33.3%)
and five (n=5/59, 8.5%) incorrect referrals made by counsellors for low and high BP,
respectively. There were 2.4% (n=2/83) and 6.5% (n=4/62) incorrect referrals given for high
blood glucose and blood cholesterol, respectively.
There were 82 standard of care HTS and 238 integrated NCD-HTS client study participants
with at least one abnormal health screening result enrolled for follow-up. Of the 320 referrals
across both HTS phases, 40.0% were HIV-infections, 11.9% STIs, 6.6% TB, and 28.8%
high/low BP. Of referred integrated NCD-HTS study participants, 29.4% were referred for
glucose and 23.5% cholesterol. Integrated NCD-HTS had significantly more clients linked to
care for HIV (76.7% [n=66/86] vs 52.4% [n=22/42], p=0.0052) and clients linked to care within
a shorter average time (6-8 days [IQR:1–18.5] vs 8–13 days [IQR:2–32]) as compared to
standard of care HTS. Integrated NCD-HTS clients initiated HIV/STIs/BP treatment on
average more quickly as compared to standard of care HT (5 days for STIs [IQR:1-21], 8 days
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for HIV/BP [IQR:5-17 and 2-13, respectively] vs 10 days for STIs [IQR: 4-32], 19.5 days for
HIV [IQR:6.5-26.5], 8 days for BP [IQR: 2–29]). The majority of participants chose passive
over peer-navigated referral (89.1% vs 10.9%; p<0.0001). Participants rejecting peer-navigated
referral preferred to go alone (55.7% [n=39/70]). Non-linkage to care was due to being busy
(41.1% [n=39/95]) and not being ready/refusing treatment (31.6% [n=30/95]). Non-initiation
of treatment post-linkage to care was due to normalised results assessed at clinic (49.7%
[n=98/196]), prescribed lifestyle modification/monitoring (30.9% [n=61/196]), and poor clinic
flow/congestion and/or further testing required (10.7% [n=21/196]).
CONCLUSIONS:
There is a chronic NCD health transition plaguing South Africa, and amongst relatively young
adults (18-34 years), especially women. The current risk-factor based, gated-approach to
chronic disease screening, as recommended within South African national guidelines, do not
adequately allow for the most effective screening for and prevention of DM or
hypercholesterolemia, or their pre-cursors amongst the general population or PLHIV.
It is feasible to integrate quality counsellor-led NCD rapid testing into standard of care HTS
within historical HTS timeframes, yielding client satisfaction with HTS services and clinic
flow. The integration of universal rapid HbA1c and TC screening amongst adults into standard
of care practice within the public health sector, regardless of BMI categorization, HIV status
or ART use, is recommended. While optional peer-navigated linkage to care did connect
significantly more patients to the point of entry to care and more efficiently than standard of
care passive referral, it did not translate to increased treatment. Same-day treatment initiation
was not achieved across chronic diseases.
While the implementation of integrated NCD-HTS within the study site was found to be
feasible and clients also deemed the clinic flow time and services provided to be highly
satisfactory, the transferability and scale-up of such healthcare systems strengthening strategies
within the public sector may not be as successfully. A more robust, multi-site, nation-wide
study is required to determine if similar results would occur within government HTS clinics.
There is a need for linkage strategies to also address various, complex levels of psychosocial
and health systems barriers at the point of entry into care and treatment. A revision of current
health screening and management guidelines and the implementation of cost-effective, multi level interventions to assist in identifying individuals with unknown disease and both engaging
and retaining patients in care is recommended
Description
A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, 2021