Periodic Reporting for period 3 - INTE-AFRICA (Integrating and decentralising diabetes and hypertension services in Africa) Reporting period: 2022-01-01 to 2022-12-31 Summary of the context and overall objectives of the project Disease epidemiology has changed rapidly in Africa. Until about a decade or so ago, African health services were dealing principally with acute infections. These continue to constitute a high burden but chronic conditions, which require regular lifelong care, now have an equal or higher burden. The chronic conditions of gravest concern are hypertension, which is the single largest risk factor for death in both resource poor and high-income settings; and diabetes, which has seen a massive increase in prevalence in a short period of time. The challenge that society faces is that while the scale of the burden is high and rising – prevalence of diabetes and hypertension already exceed 5% and 20% respectively across Africa - the coverage of services remains very low. Less than 5% of persons with diabetes are thought to be in regular care and the figure is likely to be similar for persons with hypertension. For those in care, health service provision for the diagnosis and management of diabetes and hypertension is patchy. Diabetes and hypertension, as well as HIV-infection, require lifelong care. The key challenge in Africa is to link patients into, and retain them in, care and enhance their adherence. This requires common approaches and yet the services are mostly stand alone, vertically delivered. This results in duplication and is particularly inconvenient for the many patients who have more than one chronic condition. A major factor in dropouts from care are the crippling costs of accessing health services, which are typically 10-30% of monthly income, as our earlier studies from Uganda and those done by others show.Integration of services for common chronic conditions could be the answer but there is a lack of research that establishes effectiveness and cost-effectiveness on a large scale.The aim of the INTE-AFRICA study is to assess the effectiveness of the integration of health services for diabetes, hypertension and HIV-infection. The objectives are:1. To compare integrated health services for HIV-infection diabetes and hypertension with a standard care approach (i.e. vertical stand-alone care) in Tanzania and in Uganda. 2. To use the evidence and tools developed to strengthen chronic disease management in health facilities and facilitate scale-up of chronic disease services. 3. To describe, using simple auditing of procedures and observations, the challenges faced by health services in delivering the integration models, and disseminate this knowledge, and the tools developed, such as training programmes; in order to improve chronic disease control practices beyond the clinical trial setting. 4. To disseminate the knowledge (the research evidence and process measurements) both nationally and globally so as to facilitate effective control of diabetes and hypertension (alongside HIV control) in low-resource settings. Work performed from the beginning of the project to the end of the period covered by the report and main results achieved so far The project started in January 2019 and will run for 4 years. Enrolment in the cluster randomised trial started in March 2020 but was suspended due to the COVID-19 pandemic. Recruitment restarted in July 2020.All deliverables and milestones for the project to date have been met. Main achievements include: • High and positive engagement from research partners and Ministry of Health in Africa (Tanzania and Uganda) and Europe. • Programme and financial management reporting in place • Data Management Plan which includes capacity building in data for researchers in Tanzania and Uganda• Recruitment into trial started in both countries (Tanzania and Uganda)• Process Evaluation strategy in place• Delphi consensus report on international beat practice completed to identify key components/outcomes and best practice in integrated service provision for the prevention, identification and treatment of HIV, hypertension, and diabetes.• Website launched http://inteafrica.org/• Patient communications developed – posters and leaflets.For 2nd interim report, all deliverables/milestones met and key achievements include:• A total of five manuscripts published• The International Steering Committee met virtually in January 2021 to discuss progress.• The DSMC met for a second time to discuss and agree the data analysis plan.• Two partners within the INTE-AFRICA programme have undertaken Good Financial Grants Practice (GFGP) bronze standard. Whilst not supported through INTE-AFRICA funding, this has provided an opportunity to build research management capacity within our LMIC partners.• LSTM launched the ‘Bump it Forward’ campaign, where money raised through donations was awarded to organisations across Africa to assist in the purchase of Personal Protective Equipment (PPE) for healthcare workers during the ongoing Covid-19 pandemic. In March 2021, our partners in Tanzania and Uganda were awarded a total of almost £50,000 to procure and distribute PPE across health care facilities. • We held a virtual end of year meeting with partners in December 2021 to review progress and achievements in the programme and to celebrate our success as “international collaboration of the year”.• Recruitment was completed in April 2021 (5 months behind schedule due to COVID-19 and the slow return of clinical operations at the facilities). In-country trial activities are expected to be completed by May 2022.• As a result of our individual and institutional capacity strengthening, our African partners have applied for highly competitive research either as lead or joint lead applicants• During this 2nd reporting period, we produced a total of 16 dissemination pieces, including five news pieces, six interviews, and five posts• A series of INTE-AFRICA social sciences training sessions were held in 2021, as joint research teams (Tanzania and Uganda) and separately when research teams were in place, and had preliminary findings to share.For the 3rd interim report, deliverables/milestones include:- Follow up of the final patient- Two dissemination meetings, one in Uganda and one in Tanzania with high level policy makers in the government of both countries. These meetings secured joint by-in to implement the integration of HIV, diabetes and hypertension in both countries- Final process evaluation completed and end of project questionnaire administered Progress beyond the state of the art and expected potential impact (including the socio-economic impact and the wider societal implications of the project so far) • Published an opinion paper on the ethical issues in conducting intervention studies on the prevention and management of diabetes and hypertension in sub-Saharan Africa. BMJ Global Health – Ethical issues in intervention studies on the prevention and management of diabetes and hypertension in sub-Saharan Africa https://gh.bmj.com/content/5/7/e002193• Increased visibility for patient groups in defining the research agenda for management of chronic conditions through community engagement activities and patient clubs.- Upon presentation of the trial results we have secured commitment from Tanzanian and Ugandan governments to roll out and scale up integrated care for HIV, diabetes and hypertension International Steering Committee meeting January 2021 Meeting of partners in Uganda Dec 2019
