Integrating HIV, diabetes and hypertension care in Uganda and Tanzania

It is estimated that 2 million people in sub-Saharan Africa die prematurely each year from complications of diabetes or hypertension. These conditions are often known as silent killers as people living with these conditions are often diagnosed only when a major complication such as a heart attack or stroke occurs. In sub-Saharan Africa, three in four people living with diabetes or hypertension have never been diagnosed and fewer than 20% of those diagnosed are still in care after a year. By contrast, most people living with HIV are diagnosed and in regular care and, as a result, HIV mortality has fallen dramatically in Africa. As people living with HIV age, they are increasingly developing other chronic conditions.

The INTE-AFRICA project, conducted between 2019 and 2023, was the first large cluster-randomized controlled trial of a fully integrated, one-stop clinic for HIV, diabetes and hypertension. The aim was to determine whether integrated management led to improved rates of retention in care for people with diabetes or hypertension without adversely affecting HIV viral suppression, compared with standard care in Uganda and Tanzania. Primary health care facilities were randomly allocated to provide either integrated or standard care, with people receiving services from the same healthcare workers within the integrated model.

Ministry of Health officials were part of the study team in both countries. Researchers and policymakers worked closely throughout the project, with researchers attending Ministry of Health technical meetings to share experience and findings, and policymakers visiting and observing the research in the field. The study was designed to provide evidence to support decision making, while researchers also took policymakers’ concerns, such as the potential impact of stigma, into account.

The INTE-AFRICA project found that integrated care was associated with a high level of retention in care among people with diabetes or hypertension, although it was not superior to standard care, and did not adversely affect viral suppression among people with HIV who had previously received specialised care. This is particularly notable given that enrolment and follow-up took place during the COVID-19 pandemic.

Interviews with patients, healthcare workers and other stakeholders found that the model was positively perceived because of benefits including reduced stigma and discrimination, improved quality of care, more efficient use of resources, cost and time savings, reduced duplication of services and earlier detection of undiagnosed conditions.

The project also provided evidence on the value for money of integrated care. Among participants with multiple conditions, mean provider and patient costs per visit were lower in integrated clinics than in standard care. The project’s economic evaluation estimated that if scaled up, integrated care would result in cost savings for providers and for patients with multiple conditions.

Policy impact

Evidence from INTE-AFRICA has contributed to integration becoming part of the chronic care delivery landscape globally. The INTE-AFRICA feasibility study is included as a case study in the WHO implementation guidance on ‘Integrating the prevention and control of noncommunicable diseases in HIV/AIDS, tuberculosis, and sexual and reproductive health programmes’ while the cost-effectiveness data has been included in the WHO guideline on HIV service delivery.

Dr Meg Doherty, Director of the World Health Organization Department of Global HIV, Hepatitis and STI Programmes, said: “This was a large ambitious and well-conducted study with the potential to change policy and practice.” She highlighted the successful testing of a fully integrated one-stop clinic for people with HIV or non-communicable conditions, noting that including hypertension and diabetes screening in HIV clinics did not affect HIV viral load suppression.

The project has also provided evidence for policymakers in Tanzania and Uganda and more widely across Africa, enabling them to provide effective integrated care while saving money.  

Dr Gerald Mutungi, Assistant Commissioner for Non-Communicable Diseases, Uganda: 'This study demonstrates that integrated management is effective and cost-saving.'

Professor Tumaini Nagu, Chief Medical Officer, Tanzania: 'Our study provides clear evidence for policymakers to consider scale up of integrated care for HIV, diabetes and hypertension.'

INTE-AFRICA has informed both policy and practice with signs of uptake in both countries.  Screening and management of common NCDs has been included in HIV treatment and care guidance in Uganda and Tanzania, and in Tanzania’s essential treatment guidelines.  Although no doubt prompted by global funding changes, the policy changes in Uganda could not have been put into place without the evidence of cost savings of integrated care that the INTE-AFRICA study had provided.

In February 2025, Uganda’s Ministry of Health issued a directive requiring health facilities to integrate health care service delivery including phasing out of stand-alone HIV/TB clinics and providing mentorship and training for health workers on how to provide integrated services.  An early assessment of three public facilities in Uganda following the directive found that integration was under way but uneven, held back by staff shortages, interrupted supplies of medicines and diagnostics, and fragmented information systems. Sustained investment in health systems will be needed if integration is to deliver benefits at scale.

In Uganda, managers of four government primary care facilities that hosted the research (Kiswa, Kisugu, Ndejje and Wakiso) began offering integrated chronic care to all their patients, with supportive supervision from the Ministry of Health. In Tanzania, the national HIV management guidelines issued in 2023 include a chapter on the integrated management of hypertension and diabetes in HIV care. By 2024, basic NCD services had been extended to around 700 primary health care clinics in 26 regions and trained more than 3,000 health workers. The Global Fund also supported the integration of NCD care into HIV programmes in Tanzania in 2024.

 The INTE-AFRICA model has also informed follow-on research. The NIHR funded INTE-COMM trial compared facility-based integrated care with a community-based version of the model for people with stable conditions. It found that community-based integrated care was highly acceptable to patients and policymakers and performed as well as facility-based integrated care. 

Although the findings show that integrated care can be delivered effectively in trial settings, the challenge remains to ensure that these results are maintained when integrated care is delivered on a larger scale.

This research was funded by the European Commission under the Global Alliance for Chronic Diseases (GACD) Scale Up Research Programme.

To access publications relating to this project, see GACD’s publications webpage (project SU05 INTE-AFRICA).

For further information about this project, please see the project’s website or contact Shabbar Jaffar, University College London.