The cascade of care and HIV clinical outcomes for diabetes mellitus among people with HIV at two large HIV Clinics in Kampala, Uganda: A sequential explanatory mixed methods study

Abstract

Background: The increased survival of people with HIV (PWH) in sub-Saharan Africa has led to a parallel rise in the prevalence of chronic non-communicable diseases (NCDs), particularly cardiovascular diseases and diabetes mellitus (DM), leading to a dual HIV-NCD epidemic. PWH who have uncontrolled DM are at an elevated risk of developing macrovascular and microvascular complications. Integration of services of DM care into HIV clinics is recommended in Uganda to ensure timely identification and treatment of DM among PWH. We aimed to evaluate the DM care cascade and HIV clinical outcomes of PWH with DM at two large HIV clinics in Kampala, Uganda, and explore facilitators and barriers for implementing the DM cascade of care. Methods: We conducted a sequential explanatory mixed methods study from July to November 2023. Quantitative methods comprised secondary analysis of routinely collected program data of adult PWH at the Mulago ISS and Kisenyi HC IV HIV clinics in Kampala. A subset of this data was used to evaluate HIV clinical outcomes among PWH and DM. We used descriptive statistics to compare baseline characteristics between people with HIV and HIV/DM and a chi-square was used to compare the outcomes between the HIV/DM and HIV/no DM groups. We also conducted six key informants and 12 in-depth interviews with healthcare providers and PWH with DM to explore the facilitators and barriers to HIV/DM service integration. Qualitative results were mapped to the Capability, Opportunity, Motivation and Behaviour (COM-B) model components. Results: Of the 6,303 PWH enrolled in care at the two health facilities from January 2020 to December 2022, 704 (11.2 %) were eligible for DM screening. Of these 704 PWH, 415 (59%) were screened for DM, 50 (12%) were diagnosed with DM, and only 31 (62%) were initiated on treatment. None of the PWH with DM achieved glycaemic control. Regarding HIV clinical outcomes, PWH with comorbid DM showed a significantly higher likelihood of being hospitalised (10.5% vs. 1.4%, p<0.001). Furthermore, retention in care was significantly lower for PWH with DM compared to those without (62.9% vs. 81.7%, p<0.001). The primary facilitators of successfully integrating the DM cascade of care were well-trained healthcare providers, access to treatment guidelines, and a patient-centric approach to service delivery. The main barriers to integrated DM care in HIV included insufficient medical supplies, heavy workload, inadequate referral mechanisms for DM care, misconceptions among PWH, and financial limitations.

Conclusion: Multiple gaps were observed along the entire cascade of DM care, yet the prevalence of DM among those screened was high. Improving access to DM care among PWH will require capitalising on the facilitators while overcoming barriers through targeted efforts to improve screening, facilitate initiation of antidiabetic drugs, and monitor patients to achieve glycaemic control.