HIV/AIDS is the leading cause of death among adults in sub-Saharan Africa (SSA), but the burden of noncommunicable chronic diseases (NCD) is high and growing [1
]. The regional prevalence of diabetes mellitus (DM), for example, is expected to double between 2010 and 2030, when 28 million people in SSA are projected to be living with DM [2
]. In addition to DM-specific morbidity and mortality, diabetes contributes to the burden of other noncommunicable diseases (e.g., renal and cardiovascular disease) as well as communicable diseases (e.g., pneumonia and tuberculosis), further increasing its impact on public health [3
]. In 2010, 6% of total mortality in SSA was attributable to DM [4
Unfortunately, access to prevention, care, and treatment services for NCD like DM remains out of reach for most in SSA, and health systems in lower-income countries are rarely designed to provide the continuity services required to effectively identify patients at risk, engage them in care, and retain them for the course of what is usually life-long treatment. The International Diabetes Federation estimates that 78% of those with DM in SSA remain undiagnosed [5
], a consequence of limited access to trained health workers and laboratory testing as well as limited awareness of DM and its risk factors. Although there have been several promising pilot studies of nurse-led DM management and other innovations [6
], glycemic control tends to be suboptimal for those enrolled in care, even at specialized treatment centers [10
]. Out-of-pocket costs for medicines, laboratory tests, and transportation create formidable barriers to adherence, as do stock-outs of drugs and supplies and the absence of effective systems to support chronic care [4
There is a pressing need to expand the coverage, quality, and equity of services for DM and other NCD in SSA. Although often overlooked in this context, HIV programs are the first large-scale chronic disease initiatives in the region and, as such, an important resource for those hoping to expand NCD prevention, care, and treatment. In country after country, Ministries of Health—with support from donors and partners—have developed locally owned, contextually appropriate chronic care programs for HIV. With the expansion of HIV care and treatment programs, health systems that had previously delivered only episodic acute care services have been redesigned to provide longitudinal services and lifetime care for people living with HIV (PLWH). In some cases, these changes represent innovations and new approaches, while in others they represent the availability of unprecedented levels of funding to implement time-tested strategies.
From the health system and program management perspectives, chronic diseases have much in common with one another, whether they are communicable or noncommunicable. For example, both DM and HIV require laboratory diagnosis, daily medication (in some stages), and life-long self-management, including behavior changes. Symptoms of both diseases wax and wane over time, requiring ongoing clinical and laboratory monitoring, patient education, and adherence support. In addition, both HIV and DM may cluster within families and households, the former due to sexual and perinatal transmission and the latter due to shared genetic and environmental risk factors in some settings [4
]. There are also key differences, including the characteristic age groups affected, dissimilar stigma attached to the two conditions, and disease-specific mortality rates. Nonetheless, based on the key similarities, our hypothesis is that the systems, tools, and implementation strategies developed to provide continuity care for HIV in SSA can be rapidly, efficiently, and effectively utilized to support services for DM and other chronic NCD [14
ICAP at Columbia University supports Ministries of Health and other local organizations in 21 countries, including 16 in sub-Saharan Africa. ICAP provides a wide range of HIV-related technical and infrastructure support to more than 2,500 health facilities, enabling the provision of quality comprehensive HIV/AIDS prevention, care, and treatment services. Recognizing the potential to build upon ICAP's experience to support continuity care programs for a range of chronic diseases, we embarked on two pilot studies to further the understanding of the status of NCD services and the feasibility and effectiveness of adapting HIV program-related tools and systems for patients with DM. In Swaziland, we compared systems and services for HIV and DM at 15 health facilities in order to identify opportunities for experience sharing and diffusion of innovations. In Ethiopia, a multi-component intervention adapted the approaches used in HIV clinic to enhance diabetes services at an urban referral hospital (see for additional context).
Disease burden in Swaziland and Ethiopia.