Experiences from the Field: Innovative Approaches to Improving Heart Health in Malawi

As a Medical Program Specialist at the U.S. Centers for Disease Control and Prevention (CDC) in Malawi, I provide HIV technical support at the national and site level. My public health practitioner work with the Ministry of Health’s (MOH) national HIV program and PEPFAR implementing partners has provided many opportunities to engage in implementation science and expand evidence-based comprehensive models for HIV care and treatment. Recognizing the increased burden of noncommunicable diseases (NCDs) among Persons Living with HIV (PLHIV), especially cardiovascular disease, my scope of work has expanded to support the integration of hypertension care at PEPFAR-supported HIV care delivery sites.

Prevalence of heart disease in Africa

According to the World Health Organization’s (WHO) Global Status Report on Noncommunicable Diseases, 2010, Africa will experience the largest increase in death rates from cardiovascular disease over the next ten years.  After HIV/AIDS, cardiovascular disease is the leading overall cause of death in Africa and is the leading cause of death for people over age thirty, making the identification of risk factors important. As hypertension (high blood pressure) is a major risk factor for heart disease and stroke, it is important to find a way to identify this in the population and provide education and treatment.

A recent surveillance study using the WHO STEPwise approach indicated a high prevalence of cardiovascular disease in Malawi with one-third of adults estimated to have high blood pressure. Few people in Malawi are aware that they have high blood pressure as screening is not routinely conducted in health care settings. There is great need in Malawi to improve the quality of health care services, promote early detection, and optimize clinical management of hypertension to reduce illness and avoid premature deaths. Malawi’s improvements in increasing treatment coverage for people living with HIV provides an ideal platform to adapt and replicate a similar approach for NCDs.

Integrating hypertension into existing HIV service delivery models

I am currently involved in a project which aims to integrate hypertension into existing PEPFAR-funded HIV service delivery models. Significant guidance, technical expertise, and support has been provided from CDC’s Division of Global Health Protection and the Division for Heart Disease and Stroke Prevention during the planning and implementation phases of the hypertension project. The aim of this project is to optimize hypertension screening and treatment outcomes in PLHIV using standardized hypertension treatment protocols and patient monitoring at Lighthouse Trust clinics.

The Lighthouse Trust is a Malawian organization which operates standalone HIV care and treatment centers in Lilongwe which provide care to over 25,000 PLHIV. Lighthouse clinics are innovation hubs for the MOH to pilot interventions. Lighthouse also plays a key role in capacity building by providing in service training, clinical mentoring, and supportive supervision of front line health workers at MOH HIV care clinics. The aim for the next phase of implementation is to determine how the same standards of care can be attained at MOH clinics using the model developed for Lighthouse. In addition, there will be a better understanding of how best to support the national health systems in addressing service delivery bottlenecks, supply chain issues, and capacity gaps.

Improving service delivery through phased screening and electronic medical records system

Given the high volume of patients at Lighthouse clinics, this program has been introduced using a phased screening approach, gradually decreasing the age threshold at which patients were screened. This was done to assure quality of care for both HIV and hypertension and, given the high patient burden, it was designed to ensure that clinic flow and HIV management were not compromised.

The concurrent development and application of an electronic medical record system module developed by the Baobab Health Trust, another Malawian organization, is an innovation that has improved the quality of care for PLHIV and is anticipated to have the same benefits as a decision support tool for hypertension case management.

National Strategy for NCD prevention and control

The Ministry of Health recently developed a national strategy on NCDs and the national HIV guidelines will be revised over the coming months. Discussions are underway about the inclusion of NCDs and specific advocacy has been made by PEPFAR partners for the inclusion of hypertension screening and management as part of the routine HIV service delivery. Hypertension is a silent killer and this effort presents an opportunity for Malawi to raise awareness and to address this major public health concern.

This project represents a major milestone in how existing public health delivery platforms can be utilized to provide comprehensive care to communities, increase access to priority services, and reduce common causes of illness and death in the population. It also demonstrates the implementation of effective, low-resource, integrated service delivery models that can be adapted to screen and treat patients at risk for NCDs.