More than 5 million people in sub-Saharan Africa who are living with HIV and taking antiretroviral therapy (ART) are not effectively controlling the virus – about 25% may have low levels of the virus, increasing the risk of transmission and treatment failure. Additionally, 25%-72% of these individuals also suffer from uncontrolled hypertension (HTN), highlighting the urgent need for integrated healthcare. While differentiated service delivery (DSD) has improved access to ART, community-based DSD often overlooks non-communicable diseases (NCDs) like hypertension and lacks proper monitoring and evaluation of patients. This is especially difficult with aging ART populations. Challenges such as reduced funding, healthcare system limitations, and shortages of healthcare workers contribute to the difficulty of expanding DSD.
To address these issues without burdening healthcare workers, innovative solutions are needed to enhance integrated patient care and provide quality monitoring and evaluation evidence for decision-making. The Lighthouse Trust (LT) operates clinics in Lilongwe, Malawi, with over 34,000 ART patients. They use an electronic medical record system (EMRs) to streamline care and reduce the workload.
LT’s successful DSD model, the nurse-led community-based ART program (NCAP), delivers ART to over 5200 patients across urban and rural facilities. However, the current EMRs do not effectively support DSD patients, leaving them with fragmented services and healthcare providers with inadequate monitoring tools.
In 2021, the 2wT team used human-centered design (HCD) to create an open-source, offline-first Community-based ART REtention and Suppression (CARES) App. This app mirrors EMRs’ clinical decision support, is user-friendly for nurses, and has shown short-term improvements in viral load outcomes. The goal is to optimize and expand CARES across NCAP sites and demonstrate its sustained impact on patient outcomes and program efficiency. CARES+ strengthens referrals for non-communicable diseases like hypertension, provides decision-making prompts for healthcare providers and patients, and ensures quality monitoring and evaluation data while reducing the workload in various healthcare settings.
The team plans to rigorously evaluate CARES+ impact on patient outcomes (hypertension, viral load suppression) and program efficiency (monitoring and evaluation, costs) to inform the Ministry of Health-led scale. The evaluation will use a quasi-experimental, step-wedge design to assess CARES+ expansion on patient outcomes and program efficiency, optimizing reach, effectiveness, implementation, adoption, and maintenance. Additionally, the team will assess the budget impact of CARES+ efficiency gains and its potential to prevent severe hypertension-related complications.
This locally-led team aims to demonstrate that CARES+ innovations can lead to long-term improvements in controlling hypertension and enhance short-term indicators of integrated care delivery. The real-world data generated will support the expansion of CARES+ innovations in similar settings in Malawi and beyond.