Countries in sub-Saharan Africa (SSA), like many low-and-middle-income countries (LMICs), are faced with a dual burden of HIV infection and an emerging noncommunicable disease (NCD) epidemic . By 2015, NCDs including cardiovascular diseases, cancers, chronic respiratory diseases and diabetes combined were overtaking HIV as the leading cause of death in SSA countries including Malawi, South Africa and Kenya (Figs. 1 and 2) . Successful antiretroviral treatment (ART) programs have enabled people living with HIV (PLHIV) to live a near-normal life expectancy . HIV infection is now considered a chronic condition that requires long-term management just like diabetes and cardiovascular diseases. PLHIV are at increased risk of NCDs . Integration of HIV with other programs, such as reproductive health and TB, has occurred in most countries through establishment of inclusive national policies. However, evidence for HIV and NCD integration is scarce. Unlike the well developed HIV screening and treatment programs that have benefitted from funding and development partner engagement, coordinated national NCD control and care programs are relatively new with significant gaps in funding and operational evidence for program implementation . This lack of evidence makes it difficult for countries to develop effective policy and implementation of HIV/NCD integration strategies .
The current article explores the status of current and emerging national level HIV/NCD policies and program strategies in SSA using Malawi, Kenya, South Africa and Swaziland as case studies. Through this review, we identified policy level opportunities and challenges for NCD and HIV care integration as well as evidence generation activities that would support policy decisions surrounding integrated HIV/NCD care. To enhance further HIV/NCD integration policy development efforts in the region and throughout LMICs, we highlighted some best practices for HIV/NCD integration processes in the four study countries.
A cross-sectional review was conducted to explore the status of policies and programs for integrated HIV/NCD care in four SSA countries: Malawi, Kenya, South Africa and Swaziland. Data collection was from January to April 2017. The case study countries were selected based on the countries’ prioritization of NCDs as an emerging issue to be tackled nationally. The disease burden is similar across these countries, yet each is at a different point in their HIV/NCD integration policy and implementation process. We believed that these differences and the specific best practices warranted further investigation and dissemination. We conducted a desk review of NCD and HIV policy documents including all relevant national strategic documents from the four countries (see Table 1). We analyzed the inclusion of either HIV or NCD interventions in the NCD or HIV national policy documents, respectively, or inclusion of integrated strategies, and considered the timelines of the policy documents. Insights into processes for generation of HIV and NCD integration policies or program interventions, including evidence generation activities, were provided by local policy or research experts in HIV or NCD programs. Recognizing that policy making processes are nonlinear and incremental in nature  (see Fig. 3), policies or programs and their processes at all levels (national or subnational), were reviewed.
Findings and discussions
Availability of policies, programs and on-going interventional processes related to HIV/noncommunicable disease integration in the study countries
Malawi, Kenya, South Africa and Swaziland have all included NCDs in their national health strategies [8–11]. However, the degree to which the push for HIV/NCD integration is reflected in the national level policy documents varies across the four case studies. National stakeholders, led by Ministries of Health (MOH), are supporting HIV/NCD integration policy development and implementation through evidence generation and coordination activities. These activities reflect the countries’ priorities for, and capacity to, potentially implement HIV/NCD integration policies. In this section, we describe availability of policies and programs as well as on-going interventional processes related to HIV/NCD integrated care in each country, highlighting emerging opportunities.
Malawi first introduced a policy aimed at controlling NCDs in 2011 when the MOH included NCDs in the National Essential Health Package's (EHP) list of priority conditions in the Malawi Health Sector Strategic Plan, 2011–2016 (M-HSSP) . The M-HSSP is an overarching strategic document that provides oversight for all health sector priorities, and its listed objectives were two-fold: first, to expand the scope of EHP interventions, including NCDs as a national public health problem; and second, to strengthen performance of the health system to improve equity and efficiency in delivering quality EHP services. On the basis of high prevalence of hypertension and diabetes (32.9 and 5.6%, respectively) identified through the NCD Stepwise (STEPS) survey , screening and treatment for these conditions were included in the EHP. Screening and cryotherapy for cervical cancer, the most common cancer in Malawian women, was also included. Other than these specific clinical interventions, the NCD services included in the M-HSSP were primarily awareness of health risks such as smoking and harmful use of alcohol as well as promotion of physical activity and healthy diets . HIV infection was not identified as an NCD risk factor and HIV care interventions among people affected by NCDs were not covered by the HSSP.
The National Action Plan for Prevention and Management of NCDs in Malawi , was Malawi's first NCD-specific strategic programmatic document, formulated under the coordination of the Ministry's NCDs Unit from 2012 and launched in 2013. Although the plan did not specifically mention HIV/NCD integration, its guiding principles included an integrated and holistic approach. The principle of this approach calls for multilevel integration including at the policy level. As such, the National Action Plan for Prevention and Management of NCDs in Malawi acts as a platform for efforts to develop policies for integration of NCD care and other health programs including the HIV prevention and care program.
Integrated cervical cancer and HIV screening was established nationally as a program as early as 2007, yet it was not until 2011 that active screening of cervical cancer was included in the HIV Clinical Treatment Guidelines . This highlights how programs may be implemented prior to specific policy guidance but if successful are likely to be incorporated into national policy. New in Malawi's 2016 HIV Clinical Treatment Guidelines is the inclusion of screening and treatment of hypertension within HIV programs .
Ongoing processes for HIV–noncommunicable disease integration in Malawi: current efforts and opportunities
A coordinated approach to the generation and utilization of HIV/NCD integration policy-relevant evidence in Malawi began in mid-2014 when a national health research prioritization workshop was organized by the Malawi Knowledge Translation Platform (KTPMalawi) and Dignitas International. KTPMalawi is an initiative that engages national-level policymakers, researchers and implementers in a coordinated approach to generate and use health-sector evidence . KTPMalawi's steering committee prioritized the formation of an HIV/NCD integration community of practice (CoP) in 2015, constituted of relevant policymakers, researchers, implementers and civil society members. CoP members were trained by knowledge translation experts from Uganda, Zambia and Canada to develop a systematic evidence brief of policy option for integrating HIV and hypertension care in Malawi. The evidence brief summarized global and local evidence on four potential policy options for improving screening and treatment of NCD and HIV comorbid clients . According to Mitambo, the Knowledge Translation Coordinator , the evidence brief was subsequentally used for a national policy dialogue that concluded and recommended that:
- Available global and local evidence on the best HIV/NCD integration policy option was limited and more evidence was needed prior to recommending a policy direction at a national level.
- The need for further research on the options for HIV/NCD integration to assess health system feasibility was warranted.
Following these recommendations, four geographically and programmatically diverse HIV/NCD integration programs by different implementing partners have been established within Malawi to generate the data needed to choose between the different models of integrated care (, Malawi). To enable standardized monitoring and evaluation of these programs, KTPMalawi established a group to harmonize HIV/NCD indicators that will enable meaningful and policy-relevant comparisons of patient outcomes, program outputs and effectiveness. The integrated M&E tools are currently being utilized for reporting in the four pilot sites. Multisite studies are also underway to further generate local evidence on the extent of HIV and NCD comorbidity and on the integrated service satisfaction levels to providers and clients (Malawi). Findings are likely to inform policymakers about the local needs, feasibility and acceptability of the various HIV/NCD integration policy options.
Among the reviewed policy documents related to overall NCDs and HIV control programs in Kenya (Table 1), several documents include strategies for HIV/NCD integration. The Kenya Health Policy (2014–2030) promotes NCD prevention integration into existing infectious diseases programs to halt and reverse the expanding burden of NCDs . This is in line with the health section of Kenya's Vision 2030 development strategy, which highlights a shifting focus from curative to preventive care, including a flagship project to revitalize Community Health Centers that promote preventive care and healthy lifestyles . Interventions aimed at promoting healthy lifestyles such as diets and physical activity are mentioned for general NCD prevention in both HIV-infected and noninfected individuals.
The National Cancer Control Strategy of Kenya (2011–2016) includes HIV infection as an important preventable risk factor and suggests HIV primary prevention interventions as cost-effective approaches for long-term cancer control . The Kenya AIDS Strategic Framework (2014/15–2018/19) also proposes integration approaches, including strategies to ‘maximize efficiency in service delivery through integration and creation of synergies for HIV prevention’ . In contrast to the limited NCD screening and treatment included in Malawi's HIV guidelines, Kenya's most recent ART guidelines include NCD and mental health screening and management as components of the ‘Standard Package of Care’ for PLHIV. In particular, it highlights hypertension, diabetes mellitus and depression with detailed screening and management protocols . These programmatic interventions have been established even in the absence of an overarching and comprehensive HIV/NCD integration policy.
On-going processes for HIV–noncommunicable disease integration in Kenya: current efforts and opportunities
Even though both NCD research and HIV research is ongoing in Kenya, the extent to which the two communities work together in a meaningful and sustained way is unknown. New and ongoing research initiatives are largely driven by academic and research institutions with varying levels of input from the MOH's NCD Division; hence, uptake of evidence from such research initiatives is not adequate. In addition, researchers tend to work in isolation focusing on specific research areas without a deliberate effort to integrate [Expert opinion, NCD Program Director, MOH, Kenya].
The research community in Kenya is focused on building a substantial body of evidence to shift the levels of awareness to NCDs as a public health problem. The last 5 or so years have been spent trying to have NCDs gain a foothold in the public discourse, budget allocation and program implementation. Research on NCD integration into other disease care platforms constitutes an increasing but still small proportion of studies undertaken in the country [Expert opinion, Researcher, Kenya]. A notable HIV/NCD integration research initiative in Kenya is the Healthy Heart Africa (HHA) project, led by PATH, which is integrating hypertension diagnosis and treatment into HIV care platforms . This project is targeting hard-to-reach populations by integrating hypertension into HIV care (Table 2).
Ultimately, the success of evidence uptake into policy can best be determined when such policies are allocated funds from the treasury. Although evidence has played a role in the formulation of current NCD policy instruments, budget allocation to NCD prevention and control is still vastly underfunded [Expert Opinion, NCD Program Director, MOH, Kenya].
General health systems integration is part of the core focus of the South African Department of Health's Strategic Plan. The approach to HIV/NCD integration focuses on a single integrated policy for chronic diseases as opposed to a set of independent disease-specific policies . In response to a high double burden of communicable and noncommunicable diseases, South Africa piloted a national-level Integrated Chronic Disease Management (ICDM) model in 2011, which includes both communicable diseases such as HIV and tuberculosis and NCDs such as hypertension, diabetes, asthma and mental health illnesses . At the core of ICDM implementation is health promotion including ‘assisted’ self-management, population screening, facility reorganization and clinical management support . The ICDM is the focus model used in South Africa to achieve improved control of NCDs through health systems strengthening and reform, one of three sub-strategies outlined in the South African Strategic Plan for the Prevention and Control of Noncommunicable Diseases . In 2014, the ICDM model was included as part of the ‘ideal clinic,’ which was rolled out to every clinic in South Africa [25,26]. The aim of the ‘ideal clinic,’ defined as a clinic with good infrastructure, adequate staff, adequate medical supplies and good administrative processes, is to improve the quality of care offered in primary healthcare facilities.
On-going processes for HIV/noncommunicable disease integration in South Africa: current efforts and opportunities
The South African National Department of Health (NDoH) developed and implemented the ICDM as a pilot program between January 2011 and January 2013 in 42 of the 3100 primary healthcare clinics across the nine provinces in South Africa . The impact of the model on operational efficiency, quality of care and sustainability was assessed during enactment of the model using implementation research. The NDoH used a five-step framework based on the clinical practice improvement model for continuous quality improvement , as a framework for implementing its ICDM model. This framework, although requiring a considerable amount of resources and planning, provided valuable information on unintended outcomes that can be used to improve the program and direct priority areas for future evaluation and research [27,28]. The NCD cluster at the NDoH was the main sponsor of the project.
Baseline assessments were conducted by district teams to identify the nature of the challenges associated with management of chronic conditions. A quality improvement template was used to brainstorm the causes of the identified challenges. The health interventions to improve outcomes of chronic disease patients were targeted at health system building blocks and were developed and implemented through the ICDM model. After a phased scale-up of the ICDM model, an impact assessment was done to provide evidence to justify permanent implementation of the strategies . Therefore, integrated HIV/NCD care in South Africa has already taken place at pilot and program implementation level through a policy that addressed integration of all chronic diseases rather than a specific HIV/NCD integration policy.
The overarching Swaziland National Health Policy (2007)  was translated into the first National Health Sector Strategic Plan (HSSP) in 2009 . NCDs were recognized as an emerging public health problem in Swaziland, and the control and management of NCDs was included as a strategic priority area. Consequently, the MOH developed a National Strategy for the Prevention and Control of Non-Communicable Diseases 2016–2020. and the National Non-Communicable Diseases Prevention and Control Policy 2016 to guide the strategic direction towards reducing NCDs and controlling their impact in Swaziland . The second HSSP (HSSPII, 2015) includes more specific organizational and departmental work plans, operational protocols and guidelines .
Similar to the other case study countries, strengthening NCD prevention and management is one of the focus areas under the Swazi HSSPII, which seeks to reduce NCD morbidity and mortality. Emphasis on maximizing the use of existing resources and adoption of integrated approaches as a policy for service delivery is among principles and values of the Swazi NHSSP II. The Essential Healthcare Package (EHCP)  for Swaziland clearly outlines the scope of NCD prevention, management and control to cover mental health, cardiovascular diseases, cancers and nutritional conditions. However, HIV/NCD care integration is not specifically indicated in either the NHSSP II or the EHCP.
On the other hand, the Swazi Health Sector Response to HIV/AIDS Plan (HSRP) 2014–2018 and the Extended National Multisectorial HIV and AIDS Framework (eNSF)  recognizes and emphasizes integration of HIV with NCDs as one of health system interventions under strengthening HIV service provision. The HSRP provides a policy framework and strategies to help integrate NCD management into facilities providing TB/HIV services. Integrating NCDs into HIV service delivery approaches (i.e. prevention, screening, diagnosis and management) and integrating NCD indicators into the current Health Management Information System (HMIS) are part of key strategies mentioned in the National Multisectoral Operational Plan on HIV and AIDS, 2014–2017 . Therefore, the HIV program in Swaziland sets a positive platform for implementation of HIV/NCD integration policies.
On-going processes for HIV–noncommunicable disease integration in Swaziland: current efforts and opportunities
Despite multiple policy documents that support integrated HIV/NCD service delivery, national scale-up has been slow. Recognizing the potential to leverage the HIV platform to enhance NCD services, the MOH has taken two key steps:
- Integrating screening, treatment and referral for diabetes, hypertension and cervical cancer into HIV programs;
- Adapting the chronic care models originally developed for HIV for use in NCD management for the general population.
The MOH implemented the steps taken through a pilot in six health facilities over a 1-year period in 2014, supported by ICAP and CDC in Swaziland. According to the Swaziland National ART Coordinator, providers were trained on selected NCDs (hypertension, diabetes mellitus, dyslipidemia, cervical cancer, depression and alcohol misuse disorder). The pilot program also provided equipment for the facilities to aid diagnosis. Lessons learned during the pilot implementation were used to expand HIV provider training to include education on integrated clinical management of HIV and NCDs including mental health especially depression. Additionally, during the pilot, NCD-related indicators were incorporated into the country's electronic HIV medical record systems in order to enhance monitoring and evaluation of the integrated program [Swaziland National ART Coordinator].
Challenges to evidence-informed HIV–noncommunicable disease integration policy development and implementation
Across the four country case studies, we identified four overarching policy challenges that can best be addressed by research and evidence generation (Table 3).
HIV–noncommunicable disease integration evidence gaps
There is inadequate local data to support HIV/NCD integration. As the international research community continues to generate integration evidence, national policymakers must continue to engage and support research that is policy relevant for evidence-informed decision-making. Although there is a growing evidence on the burden of NCDs in PLHIV globally and in selected LMICs , regional, national and subnational context-specific variations are likely. Such variations should inform policy decisions, priority-setting and resource allocation. Thus, documenting accurate burdens of priority NCDs in PLHIV is an initial and necessary step in evidence-informed HIV/NCD integration policy development.
With strong political will and funding, HIV programs across these four countries have documented significant successes. Prior to large scale HIV/NCD integration programs being rolled-out, policymakers require evidence that the hard-fought HIV-specific gains can be sustained when adding NCD screening and treatment interventions to often very busy HIV clinic or community programs . These evidence needs are country-specific and should inform policymakers on the likely effects of HIV/NCD integration on HIV targets, indicators and systems. In most of the SSA countries, local evidence for effects of NCD and HIV integration is not available. In Malawi, national efforts are underway to monitor and document the effects of HIV/NCD integration pilot programs on key HIV outcomes such as treatment adherence and HIV viral suppression.
Further evidence for HIV/NCD integrated polices is needed on: how the stretched pharmaceutical supply chains and human resources for health can be arranged to support strong HIV and NCD outcomes ; costs and cost-effectiveness studies of the integrated interventions ; and how vertical HIV programs can best adapt to serving additional comorbidities .
Finally, it has been argued that integrating NCDs into HIV screening and treatment may reduce HIV stigma , a persistent barrier to improving HIV public health outcomes. However, this must be studied further to elucidate policy options that maximize impact on stigma.
Packaging and disseminating HIV–noncommunicable disease integration evidence
High-quality HIV/NCD integration evidence generation alone will not be adequate to change long-held policymaker's opinions [Expert Opinion, policymaker, Malawi]. Structural barriers will need to be overcome including disease-specific MOH departments that currently focus narrowly on HIV or NCDs. As further policy-relevant HIV/NCD evidence is generated, efforts must be made and sustained to package and communicate this complex evidence in a contextualized and timely manner for different audiences. Malawi has utilized an integrated knowledge translation methodology involving key NCD and HIV stakeholders in setting policy relevant research questions and summarizing global and local HIV/NCD integration evidence for national policy dialogues around policy options [16,40]. South Africa has implemented a similar stakeholder engagement process as they piloted and rolled out their ICDM model. Congruent research and policy plans and effective communication across different audiences and government departments and various sectors is required to break down health system silos .
Funding for development process and evaluation of HIV–noncommunicable disease integration policies
Finally, the HIV/NCD integration policy development process must be adequately supported financially. During the evidence generation coordination phase, Malawi struggled to piece together the necessary funding to allow HIV/NCD pilot programs to be evaluated using a policy-relevant common framework [Expert Opinion, Researcher, Malawi]. Adequate national funding was available during South Africa's early implementation of its ICDM model, allowing stakeholders to rigorously evaluate this policy at scale and inject the evaluation findings into policy and program refinement. Large scale international funders can facilitate HIV/NCD integration process through funding mechanisms that offer national MOHs some capacity to kick-start the pilot research phase of the policy and programming processes implementation. This can be followed closely by national fiscal and programmatic plans to sustain the most effective evidence-based scaled up intervention.
Health system challenges for implementation of integrated HIV–noncommunicable disease programs
Health systems in SSA are continuously faced with critical challenges to infrastructure, human resources, medical supply chain management and program-monitoring systems. The care cascades for both HIV and NCD require space and skilled personnel for early detection, education and counselling for healthy lifestyles, clinical consultation and drug dispensary. Combining the HIV and NCD client cohorts is perceived as a threat to gains made in HIV control programs [Expert opinion, Policy maker, HIV program, Malawi]. In order to effectively and efficiently implement the integrated HIV/NCD care policies, it will be necessary to leverage the existing infrastructure and build NCD care capacity of the personnel that have supported unilateral HIV programs over the years, and all other staff.
Opportunities to develop evidence-informed HIV/NCD-integrated care policies exist in SSA and include the presence of overarching national health policy strategies and documents that recognize the potential value of integration. Coordinated planning and action by policymakers, researchers, implementers and other stakeholders; and the utilization of lessons learned from pilot integration can support larger scale HIV/NCD integration planning and implementation. Leveraging highly funded and successful HIV programs in SSA that employ proven monitoring and evaluation systems will support effective HIV/NCD integration program monitoring and provide an opportunity to improve equity and access of NCD care.
There are several HIV/NCD integration challenges that span across the four countries studied: a lack of HIV/NCD care integration feasibility evidence at a national scale, poor knowledge of the effects of HIV/NCD integration programming on key HIV outcomes, lack of cost-effectiveness data for integration of HIV/NCD care, the potential positive effects of integration on HIV stigma and the vertical nature of national health funding mechanisms that act as a barrier for sustained HIV/NCD integrated care.
The highlighted HIV/NCD integration policy development best practices including: the utilization of integrated knowledge translation methodologies, which engage key policymakers and stakeholders throughout policy development and pilot phases; promising national HIV/NCD integration programs and the early development of HIV/NCD integration monitoring and evaluation systems, can serve to inform further HIV/NCD integration efforts across the SSA region and throughout LMICs. It is important for LMIC's MOHs to continue leading and advocating for policies that are driven by evidence as we push towards comprehensive healthcare for all. Funders and health development partners need to support MOHs by providing funding schemes and technical assistance towards interventions that are evidence-driven.
Author contributions: B.L.M.M. and J.B. designed and drafted the initial annotated article outline and both contributed the Malawi supplementary data. J.B. reviewed all initial inputs from other country teams and compiled the zero draft. B.L.M.M. further reviewed the content and reorganized the zero draft into a logical flow, rewriting the inputs to fit the word limit, organized the manuscript for internal review submission and finalized manuscript with inputs from other authors as well as drafted the responses to comments from external reviewers.
R.K.M. assisted with all data collection, conducted the document reviews, created the original figures and tables and contributed to drafting and assisted B.L.M.M. with finalization of the manuscript.
All other authors – P.B., S.A., C.K., K.J.M.M., A.A., T.H., N.L., P.J., K.K.G., and F.X.G.O. contributed to specific country case inputs and reviewed the draft version of the manuscript as well as endorsement of the final version
Disclaimer: Three of the authors including the first author (i.e. B.L.M.M., N.L. and J.K.M.) were lead Ministry of Health officers in either national NCD or HIV control programs during the data collection period. However, all data presented here were collectively and objectively analyzed.
Source of support: This article as part of the Research to Guide Practice: Enhancing HIV/AIDS Platform to Address Non-Communicable Diseases in sub-Saharan Africa was supported by the U.S. National Institutes of Health Fogarty International Center.
Conflicts of interest
There are no conflicts of interest
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