ICAP in Ethiopia supported a pilot program across six regions of Ethiopia that demonstrated the high burden of non-communicable diseases (NCD) among people living with HIV – and the urgency to strengthen NCD services at HIV clinics nationwide.

Limited research has been done around the burden of NCDs among people living with HIV due to lack of data and information from anti-retroviral treatment (ART) clinics. Historically, there has been no routine NCD screening for people living with HIV during regular clinic visits in Ethiopia, despite increased risk of people living with HIV developing NCDs due to prolonged ART use and other associated factors. The lack of coordination and integration between HIV programs and NCD care has contributed to heavy burdens among people living with HIV as well as Ethiopia’s health care system.

Jointly with Ethiopia’s Ministry of Health, ICAP conducted the pilot among ten hospitals in the Ethiopian regions of Oromia, Addis Ababa City Administration, Amhara, Gambella, Central Ethiopia, and South Ethiopia from March to August 2023. The pilot explored integration of NCD services – such as screening for hypertension, diabetes mellitus, dyslipidemia, and chronic kidney disease – into routine HIV care for all eligible people living with HIV at select ART clinics. Through the integrated approach, people living with HIV would ultimately have access to one-stop care, with the ability to be screened and treated for NCDs directly at ART clinic appointments.

“Effective ART has significantly transformed the national trajectory of HIV infection, now largely considered as a chronic, manageable disease with patients living longer due to reduced mortality,” said Tamrat Assefa, director of regional program support and capacity building at ICAP in Ethiopia. “However, this positive outcome has been affected by the emergence of non-communicable diseases, such as cardiovascular disease, diabetes mellitus, mental health issues, and other illnesses. The combined effects of aging, ART, and the inflammatory impact of HIV infection have led to a growing number of people living with HIV presenting health care providers with the dual challenge of managing HIV alongside NCDs.”

As a first step, ICAP established a technical working group including the Ministry of Health and key implementing partners to consider how to implement small-scale integration of NCD care at ART clinics. In addition, ICAP provided technical assistance, a manual on NCD and HIV service integration, customized capacity building training materials on hypertension and diabetes, job aids, screening tools, intake forms, follow-up forms, NCD registers, reporting forms, and other essential tools directly to implementing health facilities.

ICAP also trained 62 health care workers who initiated NCD screening and care at the ART service delivery points, which are located within the selected health facilities.

“We conducted supportive supervision in the implementing regions and facilities, conducted monthly virtual reviews with ICAP regional offices to ensure quality of care, provided feedback to improve performance, and explored lessons for future national scale-up,” said Shibru Berhanu, ICAP’s regional program support director.

The pilot project screened 18,938 people living with HIV for diabetes (30 percent of all ART visits) and 23,541 for hypertension (41 percent of adult ART visits). Even though laboratory resources were limited, 2,760 clients were screened for dyslipidemia and 2,362 were screened for chronic kidney disease.

This client-focused pilot demonstrated the feasibility of integrating NCD screening and care with focused training for health care providers. Given that the pilot reached 41 percent of all ART visits within six months, extending the approach could mean screening all current ART clients at these facilities over the next 12 months.

The screenings revealed a higher prevalence of previously diagnosed NCDs compared to newly identified cases. However, a significant portion of diagnosed patients were not receiving treatment for those previously diagnosed NCDs. Twenty-four percent of the 558 clients with a history of hypertension and 23 percent of the 449 clients with a history of diabetes were subsequently initiated on treatment, along with all newly identified cases. While resource limitations impacted screening for lipid disorders and chronic kidney disease, the pilot underscored the importance of addressing these conditions due to the metabolic effects of long-term ART use.

Pilot results dissemination meeting

“ICAP and the Ministry of Health, along with regional health bureaus, have a history of integrating HIV care with other health services, such as HIV and tuberculosis, HIV and sexually transmitted infection, HIV and cervical cancer, HIV and mental health, and HIV and gender-based violence, among others,” said Fekadu Yedeta, lead HIV prevention and control executive officer at the Ministry of Health during the results dissemination workshop. “Now, we have moved to integrating HIV with NCD care.”

“Through integrating NCD services with HIV care,” Yedeta added, “we aim to improve the uptake of both NCD and HIV services, enhance retention in care, and improve overall health outcomes among recipients of HIV care.”

Results from the pilot were disseminated to stakeholders, including the Ministry of Health and implementing partners, in June 2024 in Adama, where teams from the various pilot regions developed a scale-up plan for continued integration of HIV and NCD care.

About ICAP

A major global health organization that has been improving public health in countries around the world for two decades, ICAP works to transform the health of populations through innovation, science, and global collaboration. Based at Columbia Mailman School of Public Health, ICAP has projects in more than 40 countries, working side-by-side with ministries of health and local governmental, non-governmental, academic, and community partners to confront some of the world’s greatest health challenges. Through evidence-informed programs, meaningful research, tailored technical assistance, effective training and education programs, and rigorous surveillance to measure and evaluate the impact of public health interventions, ICAP aims to realize a global vision of healthy people, empowered communities, and thriving societies. Online at icap.columbia.edu