“After all, we are all sick”: multi-stakeholder understanding of stigma associated with integrated management of HIV, diabetes and hypertension at selected government clinics in Uganda

Abstract

Background Integrated care is increasingly used to manage chronic conditions. In Uganda, the integration of HIV, diabetes and hypertension care has been piloted, to leverage the advantages of well facilitated and established HIV health care provision structures. This qualitative study aimed to explore HIV stigma dynamics whilst investigating multi-stakeholder perceptions and experiences of providing and receiving integrated management of HIV, diabetes and hypertension at selected government clinics in Central Uganda. Methods We adopted a qualitative-observational design. Participants were purposively selected. In-depth interviews were conducted with patients and with health care providers, clinical researchers, policy makers, and representatives from international nongovernmental organizations (NGOs). Focus group discussions were conducted with community members and leaders. Clinical procedures in the integrated care clinic were observed. Data were managed using Nvivo 12 and analyzed thematically. Results Triangulated findings revealed diverse multi-stakeholder perceptions around HIV related stigma. Integrated care reduced the frequency with which patients with combinations of HIV, diabetes, hypertension visited health facilities, reduced the associated treatment costs, increased interpersonal relationships among patients and healthcare providers, and increased the capacity of health care providers to manage multiple chronic conditions. Integration reduced stigma through creating opportunities for health education, which allayed patient fears and increased their resolve to enroll for and adhere to treatment. Patients also had an opportunity to offer and receive psycho-social support and coupled with the support they received from healthcare worker. This strengthened patient-patient and provider-patient relationships, which are building blocks of service integration and of HIV stigma reduction. Although the model significantly reduced stigma, it did not eradicate service level challenges and societal discrimination among HIV patients. Conclusion The study reveals that, in a low resource setting like Uganda, integration of HIV, diabetes and hypertension care can improve patient experiences of care for multiple chronic conditions, and that integrated clinics may reduce HIV related stigma.

Decentralising chronic disease management in sub-Saharan Africa: a protocol for the qualitative process evaluation of community-based integrated management of HIV, diabetes and hypertension in Tanzania and Uganda

“…Tanzania and Uganda were chosen as study sites, given their pioneering work in this area 29 38–40 62 63 74 75. Their public health services are strongly committed to providing services for NCDs and are struggling to scale up provision for diabetes and hypertension in the face of competing health demands, including from HIV, diabetes and hypertension across all socioeconomic strata 74.…”

“…In response to this, efforts to coordinate NCD programmes with scaled-up NCD medicine supply chains alongside high-quality vertical (stand-alone) HIV programmes have intensified 28. There is a growing evidence base and shift towards the implementation of integrated NCD/HIV care provision in various SSA countries (eg, in Malawi, South Africa, Botswana, Uganda, Kenya and Tanzania) 22 29–41. Integrated health education and concurrent management of HIV, hypertension and diabetes is being scaled up in vertical and one-stop clinics in the region and can reduce duplication and fragmentation of services; support medicine supply chains; streamline detection and care of comorbidities and multimorbidities; support patient uptake, retention and adherence to treatment; increase viral suppression rates and achieve better control of hyperglycaemia and hypertension; encourage health awareness raising and reduce HIV-related stigma 21 42–57.…”

“…We have piloted integrated HIV/NCD care in a feasibility single-arm intervention study in Uganda and Tanzania in the Management of Chronic Conditions in Africa (MOCCA) project (2018–2020) 21 29 38 41. MOCCA was followed by scaled-up integrated care for HIV, diabetes and hypertension in the integrating and decentralising HIV, diabetes and hypertension services in Africa (INTE-AFRICA trial) (2019–2023) 39 40 63 64. INTE-COMM is a 4-year research project funded by the National Institute for Health and Care Research (NIHR) (01/10/2020-30/09/2024).…”

Mapping the evidence on integrated service delivery for non-communicable and infectious disease comorbidity in sub-Saharan Africa: protocol for a scoping review

“…11 12 Patients with such concurrent conditions must deal not only with physical and psychological impacts of each disease, but also multifaceted challenges such as reduced quality of life, stigma and discrimination, complex treatment regimens and higher healthcare costs. [13][14][15][16] However, in resource-limited settings, particularly in LMICs, patients will face unique challenges, dealing with the complexities of accessing fragmented healthcare services that are ill-equipped to meet their intertwined and longterm needs. 13 14 Sub-Saharan Africa (SSA) stands at the epicentre of this complex NCD-ID crisis.…”

“… 32 33 36 37 40 Previous experiences and pilot programmes implementing integrated care models in SSA hold valuable lessons in effectiveness, feasibility and potential challenges. 14 33 36 37 40–43 …”