Sage Journals: Discover world-class research

Abstract

Objectives:

To map the evidence on the barriers to and facilitators of diagnosing noncommunicable diseases among people living with HIV in low- and middle-income countries in Africa.

Introduction:

Noncommunicable diseases are increasing among people living with HIV. Thus, strengthened and sustained diagnosis of noncommunicable diseases through integrated noncommunicable diseases and HIV care is needed to improve patient outcomes. However, there is paucity of evidence on the barriers and facilitators diagnosing noncommunicable diseases among people living with HIV in low- and middle-income countries.

Methods:

The Arksey and O’Malley methodological framework was used. A comprehensive systematic search of academic databases (MEDLINE, Academic Search Complete, APA PsycInfo, CAB, and Health Source/Nursing) was performed via EBSCO search and PubMed. The articles were reviewed independently by three reviewers. The results were structured using Capability-Opportunity-Motivation-Behavior model and Theoretical Domains Framework.

Results:

A total of 152 articles were retrieved for full-text review. Forty-one articles met the inclusion criteria. The identified barriers were relevant to all the Capability-Opportunity-Motivation-Behavior constructs and 14 Theoretical Domains Framework domains. A lack of knowledge and awareness of noncommunicable diseases, fear of stigma, financial problems and out-of-pocket payments were the most cited patient-level barriers. Healthcare providers (knowledge and awareness gaps, skill and competence deficiencies, unwillingness, burnout, low motivation, and apathy) were frequently cited. Lack of equipment, noncommunicable disease medications and supply chain challenges, lack of integrated noncommunicable disease and HIV care, and shortage of trained healthcare providers were identified as health-system-level barriers.

Conclusion:

This scoping review is the first to identify barriers and facilitators using a theoretical framework. The most cited barriers include a lack of integrated HIV and noncommunicable disease care, equipment and logistics chain challenges for noncommunicable diseases, patients’ and healthcare providers’ lack of knowledge and awareness of noncommunicable diseases, and healthcare provider’s skill and competency deficiencies. Addressing these issues is crucial for improving patient outcomes and reducing the burden on healthcare providers and health systems.

Keywords

Noncommunicable diseases HIV PLWH HIV-NCD comorbidity barriers to diagnosis facilitators

Introduction

Noncommunicable diseases (NCDs) pose a global public health challenge and account for three-quarters of deaths globally.^1,2 NCDs are more prevalent in low- and middle-income countries (LMICs) than in high-income countries, with an earlier age of onset and increased premature mortality.³ Furthermore, persons living with HIV (PLWH) are exposed to the same NCD risk factors as their HIV-negative counterparts and may be exposed to additional risk factors as a result of contracting HIV and some antiretroviral therapy (ART) medications.^1,4 The multimorbidity of HIV and NCDs affects PLWH compared to the general population, contributing to decreased health-related quality of life, increased hospitalization, and increased risk of death.^5,6

The availability of ART has improved life expectancy.⁷ However, in the ART age, along with increasing life expectancy, there is increased vulnerability to NCDs, and multimorbidity remains.^5,6 PLWH have a higher incidence and prevalence of NCDs such as depression, cardiovascular disease (CVD), cervical cancer, diabetes, obesity, and hypercholesterolemia than people without HIV^1,8–12; CVD is one of the leading causes of non-AIDS morbidity and death among PLWH.^1,9,13

In LMICs, there is a substantial burden of comorbid NCDs among PLWH,^14–16 especially NCDs, which are increasing among PLWH in sub-Saharan African (SSA) countries.⁸ As the burden of NCDs among PLWH in LMICs increases, the quality of life and health benefits associated with HIV/AIDS are at risk.^15,16 As a result, PLWH may require frequent screening for NCD detection, diagnosis, and treatment.^17,18 However, LMICs in African countries struggle to manage growing chronic NCDs, as health systems primarily provide episodic care for acute symptomatic conditions.¹⁹

The growing burden of HIV infection and NCD comorbidity implies a focus on healthcare systems that provide chronic multimorbidity care in an integrated manner²⁰; thus, there have been increased calls for the integration of HIV and NCD services to increase efficiency and improve the coverage of NCD care.²¹ Furthermore, the needs of PLWH with multimorbidities are critical since they are more prone to care fragmentation due to the involvement of several health providers.^22,23 For PLWH, the provision of NCD care and outcomes may be inferior to those of their HIV-negative counterparts.⁶ The barriers to CVD screening and management across the patient, provider, and health system levels in LMICs among PLWH require urgent attention.⁷ Some barriers include a lack of adequate knowledge and perceptions of NCDs among patients and providers.⁷

Strengthening health-system-based approaches to NCD risk factor measurement at appropriate and routine intervals and empowering patients and healthcare providers to respond to NCDs need due attention; in particular, more emphasis is required to address the growing multiple chronic care needs of PLWH.⁷ However, there is a paucity of evidence on the barriers to and facilitators of the early detection and diagnosis of NCDs among PLWH in LMICs. Therefore, the current scoping review aimed to systematically map evidence on the barriers to and facilitators of the diagnosis of NCDs, with a focus on depression, hypercholesterolemia, hypertension, obesity, and diabetes for PLWH in LMICs in Africa.

Methods

This scoping review was carried out following the method suggested by Arksey and O’Malley²⁴; The following five steps were used: Step 1: Identifying the research question; Step 2: Searching relevant studies; Step 3: Selecting appropriate studies; Step 4: Charting the data, and Step 5: Collating, summarizing, and reporting the results. The optional step 6, consultation with relevant stakeholders, has been excluded from this review. The incorporation of recommendations made by Levac and colleagues²⁵ was considered. A scoping study approach enables systematic searching, selecting and examining literature, knowledge synthesis, and mapping of evidence to address research questions.²⁴

The Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR) proposed by Tricco et al.²⁶ was used to present the scoping review report. The PRISMA-ScR provides a reporting guideline containing 20 essential items and two optional items included in scoping reviews.²⁶ This guideline also facilitates methodological transparency and acceptance of research findings.²⁶ The protocol for this scoping review has been registered on the Open Science Frameworks (https://osf.io/xvtwd/).

Step 1: Identifying the research question: The present scoping review aims to answer the following questions:

What are the barriers to diagnosing major NCDs (depression, hypercholesterolemia, hypertension, obesity, and diabetes) among PLWH in LMICs in Africa?

What are the facilitators of diagnosing major NCDs (depression, hypercholesterolemia, hypertension, obesity, and diabetes) among PLWH in LMICs in Africa?

The research question was identified using the people concept and context framework approach (Table 1).

Table 1.

People, concept, and context used to identify review questions.

People	Studies include people living with HIV and comorbid with NCD
Concept	Barriers to the diagnosis of major NCDs (depression, hypercholesterolemia, hypertension, obesity, and diabetes). Facilitators of diagnosing major NCDs (depression, hypercholesterolemia, hypertension, obesity, and diabetes)
Context	Low- and middle-income countries in Africa (developing countries, Africa)

Step 2. Identifying relevant studies

Information sources

A thorough systematic search was carried out in the MEDLINE, Academic Search Complete, APA PsycInfo, CAB, and Health Source/nursing academic databases retrieved using the EBSCO search engine, as well as PubMed for advanced searches. A comprehensive search strategy based on medical subject headings (MeSH) and keywords was employed. Boolean terms (AND and OR) were used to separate keywords, and MeSH was used in the advanced search of articles. After an advanced search of the included studies from the database, further relevant papers from the reference list were scanned or tracked as a secondary search using the snowball technique.

A sample of the search strategy was used (Table 2).

Table 2.

The sample search strategy used to identify relevant articles using keywords.

S.no	Search strategy	Database used	Number of articles
1	(Barriers OR Challenges OR influence OR facilitators OR Opportunities OR Enablers) AND (Diagnosis OR access OR early detection OR Screening OR Treating OR management) AND (Noncommunicable disease OR depression OR hypercholesterolemia OR obesity OR diabetes) AND (People Living with Human Immunodeficiency virus OR AIDS OR PLWH OR PLHIV OR HIV OR People Living with HIV OR Human Living HIV) AND (“Low-and middle-income countries” OR Africa OR “developing countries” OR “low resource settings”)	PubMed	1617

Step 3. Study selection

Three authors independently evaluated the titles and abstracts of the included articles. Full-text papers were collected for all eligible titles and abstracts, and three authors independently reviewed the full-text publications to determine which articles should be included in the review based on eligibility criteria.

The eligibility criteria

This scoping review consisted of the following eligibility criteria for including articles in this scoping review:

Studies involving people living with HIV

Studies on the diagnosis of NCDs in PLWH have focused on depression, hypercholesterolemia, hypertension, obesity, and diabetes.

Studies from LMICs in Africa.

All research designs (interventional, observational, mixed, quantitative, and qualitative).

We decided to include studies published between 2013 and 2023 in this scoping analysis to acquire new information on NCDs after the World Health Assembly endorsed the Global NCD Action Plan in 2013.²⁷

Exclusion criteria

Non-English language articles were excluded due to time constraints, financial limitations, and a lack of language resources and language abilities in the review team to address non-English studies and access to non-English databases.

Selection process

The three review authors conducted a thorough title screening using electronic databases guided by eligibility criteria. All relevant articles were imported into an EndNote library. Then, the articles were uploaded to the online reviewing system Rayyan (Qatar Computing Research Institute)²⁸ software for deduplication and were shared with the review team for the next stage of the study screening and selection process. Duplicate records were checked and removed. A screening process for the abstract and full-text screening phases was developed using eligibility criteria. Three review authors independently completed the abstract and full-text screening phases and collected data to include categories. Discrepancies in abstract screening were addressed through discussion by the review team until a consensus was reached. The PRISMA flow diagram²⁹ was used to report the screening results (Figure 1).

Figure 1.

PRISMA 2020 flow diagram for new systematic reviews, which included searches of databases, registers and other sources.

Step 4: Charting the data

Microsoft Excel was used for the extraction of data. All relevant data from the included articles including study authors, title, country/setting, aim/purpose of the study, sample size, study design, population, and type of NCDs were extracted after the full texts were read, and the study characteristics, including the study authors, title, country/setting, aim/purpose, and findings relevant to the review question were extracted.

Step 5: Organizing, summarizing, and reporting the findings

Scoping reviews, according to Arksey and O’Malley,²⁴ require thematic frameworks to present narrative accounts of selected literature. The qualitative software NVivo version 12 was used to organize the data, and thematic analysis was performed. The data were grouped thematically by reading and rereading the data items and grouping similar/related items into iteratively developed themes. The data were analyzed and synthesized using a data-driven bottom-up approach. Thomas and Harden’s³⁰ thematic synthesis method was used to inductively code, develop, and generate themes from the barriers and facilitators identified across the included studies. Inductive data-driven themes were deductively categorized using the relevant domains of the COM-B model^31,32 and the TDF.^33,34

Each theme was analyzed and mapped to the COM-B system construct and the 14 TDF domains and categorized as patient-, provider-, and health-system-level barriers and facilitators of diagnosing NCDs. To confirm that the theme was correctly mapped to the TDF domain, we double-checked that the extracted data inside each theme matched the domain content (i.e., the component constructs in each TDF domain). TDF domains were mapped to COM-B components as defined by Cane and colleagues.³³ Disagreements among the reviewers were settled by consensus. The results were tabulated, and a narrative synthesis of the findings was provided, structured around the themes of barriers and facilitators at the patient, provider, and health system levels.

Step 6: Methodological quality appraisal

A methodological quality appraisal step is not mandatory in scoping reviews, and this step was excluded from the current scoping review.

Results

A total of 2326 articles were retrieved, exported to the EndNote library, and imported to Rayyan for deduplication and further review. Three reviewers independently screened 2309 articles’ titles and abstracts; disagreements in 42 articles were resolved through discussion. Finally, 148 articles were included for full-text review, and four additional articles were identified from the references of the selected articles. A total of 152 articles were retrieved for full-text review. The full texts of 152 records were screened, resulting in 41 articles meeting the inclusion criteria and reported in the current scoping review.

Study characteristics

Twenty-eight articles in the review identified barriers to diagnosing NCDs (hypertension and diabetes).^{14,15,20,35–61} The included studies reported barriers to and facilitators of diagnosing depression among PLWH.^{42,50,62–73} Two studies reported both NCDs and depression. No studies included in this review reported the barriers to and facilitators of diagnosing hypercholesterolemia and obesity.

Among the included 41 articles met the inclusion criteria (16 cross-sectional, 2 cohort, 1 case-control, and 5 RCTs, as well as 9 qualitative, 4 mixed, 2 commentary, and 2 review studies) (Table 3).

Table 3.

Descriptive characteristics of the final included studies.

S.No	Author, year	Country	Study design	Type of NCDs	Barriers	Facilitators
1	Basenero et al.⁵³	Namibia	Cross-sectional	HTN	Inadequate number of HCPs trained NCDs. Lack of equipment for NCD screening and diagnosis (malfunction of BP machines). Stockout of NCD medications (drugs, medication shortages and supply chain difficulties). Lack of integrated NCD and HIV care. Difficulties tracking patient referrals
2	Bauer et al.³⁶	Zambia	Cohort study	HTN	Patients lack knowledge and low awareness of NCD. HCPs lack knowledge and awareness of NCD. Limited capacity of clinics and lack of health system readiness for NCD services
3	Batte et al.⁴⁹	Uganda	Qualitative	HTN	Financial constraints and higher out-of-pocket payment. Long distance and long waiting time
4	Benzekri et al.⁵⁹	Senegal	Cohort study	HTN	Lack of attention to NCDs
5	Buzaalirwa et al.⁴¹	Uganda	Mixed method	HTN	HCPs’ inadequate knowledge communication gaps. Inadequate number of trained HCPs on NCDs. Lack of equipment for NCD screening and diagnosis (BP and RBS machines and strips). Drugs, medication shortages, and supply chain difficulties. Non availability of HTN and DM medication at ART sites. Long distance and waiting time. Lack of emphasis on screening for NCD. High patient load and provider apathy
6	Clouse et al.⁴⁵	South Africa	Qualitative	NCDs	Increased transportation costs, long travel distances
7	Ezeanolue et al.⁴²	Nigeria	Qualitative	Mental health	Patient low awareness on mental health. HCP lack of knowledge and awareness on mental health. Inadequate human resources. HCP-related mental health stigma. HCP poor attention to mental health service needs. Policy gaps and lack of guidelines. Stigma associated with HIV and mental health problems. HCP burnout, unwillingness, and lack of confidence. Excessive workload for HCPs. Unwillingness of HCPs to take responsibility	Leveraging existing HIV/AIDS care. Community health workers. Community support groups such as faith-based organizations and traditional leaders
8	Gebrie⁶⁰	Ethiopia	Cross sectional	NCD	Lack of emphasis and attention on NCD screening
9	George et al.¹⁴	South Africa	Cross sectional	NCD	Lack of integrated NCD and HIV care. Lack of active and routine screening of NCD offered as part of HIV care delivery. Lack of integrated registration and separated folders of HIV and NCD
10	Gimbel et al.⁵⁶	Mozambique	RCT	HTN	No availability of HTN and DM medication at ART sites. Poor integration of hypertension screening and management with chronic care services. Limited capacity of clinics and lack of health system readiness for NCD services. Lack of accountability for health worker performance. Uneven health workers motivation. Lack of attention to NCDs
11	Godongwana et al.⁴⁰	South Africa	Qualitative	NCDs (HTN and DM)	Inadequate patient knowledge and low awareness of NCDs. Inadequate skills of HCPs in HIV clinics to detect and manage NCDs. HCPs’ skill deficiency is due to inadequate training and practice. Transportation problems. Financial constraints and higher OOP. Lack of adequate training for HCPs on NCD. Inadequate number of trained HCPs on NCDs. Long distance and waiting time. Lack of guidelines to manage NCDs. Fear of pill burden
12	Goldstein et al.⁴⁷	Eswatini and south Africa	Commentary	HTN and DM	Transportation problems and long travel distances. Drugs, medication shortages and supply chain difficulties
13	Gonah et al.⁴⁸	Zimbabwe	Qualitative	NCD (HTN and DM)	Transportation problems. Financial constraints and higher OOP. Inadequate number of trained HCPs on NCDs. Drugs, medication shortages and supply chain difficulties. Long distance and waiting time
14	Gonah et al.³⁷	Zimbabwe	Case control	NCD	Preference for alternative medication. Financial constraints. High cost and OOP
15	Gonah et al.⁴⁶	Zimbabwe	Cross sectional	NCD (HTN, DM)	Lack of integrated NCD and HIV care. Patients lack knowledge and low awareness of NCD
16	Gonah et al.⁵⁸	Zimbabwe	Scoping review	NCD	Limited capacity of ART clinics and lack of health system readiness for NCD services
17	Hyle et al.⁵⁷	South Africa	Cross sectional	NCD risk (HTN, DM)	Lack of integrated NCD and HIV care. Lack of active and routine screening of NCD offered as part of HIV care delivery
18	Kamkuemah et al.⁶¹	South Africa	Cross sectional	NCD	Poor documentation. Lack of attention to NCDs. Missed opportunities for NCD screening
19	Kintu et al.⁵⁴	SSA	Commentary	NCD	Stock out of NCD medications at clinics and NCD drug supply chain problems. Low funding for NCDs. High cost and OOP
20	Leung et al.⁴³	Tanzania	Cross sectional	NCDs	Lack of adequate training for HCPs on NCD. Inadequate number of trained HCPs on NCDs. Lack of equipment for NCD screening and diagnosis. Drugs, medication shortages and supply chain difficulties. HCPs’ skill deficiency
21	Magodoro et al.¹⁵	Zimbabwe	Cross sectional	NCD (HTN and DM)	HCPs’ lack of knowledge. Lack of integrated NCD and HIV care
22	Manavalan et al.³⁸	Tanzania	Cross sectional	HTN	Inadequate patient knowledge and low awareness of NCDs
23	Manavalan et al.³⁵	Tanzania	Qualitative	HTN	Inadequate patient knowledge and low awareness of NCDs. HCPs’ inadequate knowledge and awareness of NCDs. Communication gaps. Transportation problems. Lack of funding for transportation. Inadequate number of trained HCPs on NCDs. Drugs, medication shortages and supply chain difficulties. Nonavailability of HTN and DM medication at ART sites. Challenges of NCD drug supply chains. Poor integration of hypertension screening and management with chronic care services. Long distance and waiting time. High cost of services and high OOP. Stigma from family, HCPs, and community
24	Murudi-Manganye et al.⁴⁴	South Africa	Mixed method	NCDs	Lack of adequate training for HCPs on NCD screening and management. An imbalance in HIV and NCD training and practice. Lack of equipment for NCD. Challenges of NCD drug supply chains. Lack of NCD guidelines in PHC. Nurses feel that NCD diagnosis is the responsibility of medical doctors. HCPs’ skill deficiency is due to inadequate training and practice. HCPs lack confidence in diagnosing NCDs. Lack of NCD screening and health promotion
25	Peer et al.²⁰	South Africa	Mixed method	NCD (HTN and DM)	Lack of integrated NCD and HIV care. Long distance and waiting time. HCPs lack confidence in diagnosing NCDs. Lack of attention to NCDs
26	Van Hout et al.⁵⁵	Uganda	Qualitative	NCD (HTN and DM)	Lack of sustainably funded supply chain for NCDs. Drugs, medication shortages and supply chain difficulties. High cost and OOP
27	Pfaff et al.⁵¹	Malawi	Mixed method	NCD	Lack of adequate training for HCPs. Inadequate number of trained HCPs on NCDs. Lack of equipment for NCD screening and diagnosis. Drugs, medication shortages and supply chain difficulties. Lack of integrated NCD and HIV care
28	Venables et al.⁵²	Kenya	Qualitative	NCD	Lack of adequate training for HCPs. Inadequate number of trained HCPs on NCDs. Lack of guidelines to manage NCDs. High cost and OOP
29	Bankole et al.⁷¹	Nigeria	Cross sectional	Depression	Patients’ poor attention to mental health service needs. HCP poor attention to mental health service needs
30	Bernard et al.⁶²	SSA	Systematic review	Depression	Lack of knowledge and awareness of the HCP on mental health. Lack of standard, validated, culturally sensitive screening tools and therapies. Lack of integrated depression and HIV care. Patients’ poor attention to mental health service needs. HCP poor attention to mental health service needs. lack of integrated depression and HIV care. Inadequate trained human resources
31	Bernard et al.⁶³	Senegal and cotedivor	Cross sectional	Mental health	Insufficient or inadequate training on depression and mental health. Lack of integrated depression and HIV care. Inadequate trained human resources. Lack of knowledge of HCPs in depression screening and management. Lack of mental health specialists and trained mental HCPs. HCPs perception of diagnosis and management of depression needed to be performed by a specialist
32	Bhana et al.⁷³	South Africa	Cross sectional	Depression		Use of short and valid screening tools
33	Breuer et al.⁶⁷	South Africa	Cross sectional	Depression	Lack of standard, validated, culturally sensitive screening tools and therapies. Lengthy complex screening protocols
34	Chibanda et al.⁶⁵⁸	Zimbabwe	Cross sectional	depression	Use of unstandardized screening tools
35	Dow et al.⁷²	Tanzania	RCT	Mental health	Poor attention to mental health service needs of PLWH
36	Nakimuli-Mpungu et al.⁶⁶	Uganda	RCT	Depression	Poverty and financial constraints on patients. HCP related stigma. Ignorance of cultural context of care. Mental health stigma
37	Kawiya et al.⁶⁴	Malawi	Cross sectional	Mental disorders	Insufficient training on mental health. Lack of integrated depression and HIV care. Inadequate human resources. HCP burnout, unwillingness, and lack of confidence. HCP poor attention to mental health service needs. Nonspecialized mental healthcare workers feel that they need more time to treat mental health problems. Patient’s poor attention to the mental health service needs of PLWH
38	Kim et al.⁷⁰	Malawi	Cross sectional	Depression	Inadequate human resources. Lack of qualified psychiatrists
39	Abas et al.⁵⁰	Zimbabwe	RCT	Depression	Lack of adequate training for HCPs. Lack of confidence and willingness of HCP. Lack of standard, validated, culturally sensitive screening tools and therapies. Inadequate human resources. HCP burnout, unwillingness, and lack of confidence. Patient’s concerns about pill burden and possible interactions with ART. Poverty and financial limitations. Lack of mental health specialists and trained mental HCPs. Lack of confidence and unwillingness of medical staff in the HIV clinic to diagnose and prescribe depression drugs	Reinforcement strategies such as providing incentives for bus fares and refreshments facilitated uptake services
40	Udedi et al.⁶⁹	Malawi	Qualitative	Depression	Inadequate human resources. Lack of mental health specialists and trained mental HCPs
41	Safren et al.⁶⁸	South Africa	RCT	Depression	Inadequate human resources. Lack of mental health specialists and trained mental HCPs	Task-shifting approach. Using community health workers

The theoretical framework used for the analysis of the findings

The barriers to diagnosing NCDs (hypertension, diabetes, and depression) identified were mapped to the domains of the Capability-Opportunity-Motivation-Behavior system (COM-B)/Theoretical Domains Framework (TDF). According to the COM-B model, behavior change depends on an individual having the capacity, opportunity, and motivation to change their behavior/practice.^31,32 The TDF is a 14-domain model that builds on the COM-B model to better understand the underlying barriers to and facilitators of evidence-based behavior change^33,34 and is used to analyze and present this scoping review (Figure 2).

Figure 2.

COM-B and TDF frameworks used identify barriers to diagnosing NCD among PLWH in the LMICs of Africa: a scoping review.^31,32

Barriers to the diagnosis of NCDs

Barriers to diagnosing NCD among PLWH presented using the COM-B domain and TDF theoretical domain as patient-, provider-, and health-system-level barriers.

Capability construct of COM-B: The COM-B model’s capability domain corresponds to an individual’s psychological (involving a person’s mental function) and physical capability (involving a person’s physique and musculoskeletal function) to participate in an activity.

The psychological component of the capability domain of behavioral change model includes knowledge and the ability to comprehend information and to reason, while the physical component of capability includes skill, dexterity, and strength required for the behavior change practices. Barriers and facilitators were not identified under physical capability domain in this review.

Knowledge

Knowledge (TDF domain) was reported as a barrier at the patient and provider levels.

Patient level barriers

Seven included studies from Zambia, South Africa, Zimbabwe, Tanzania, and Nigeria reported inadequate patient knowledge and low awareness of NCDs,^35–40 including poor mental health awareness and poor health-seeking behavior related to depression,⁴² as a barrier to the early diagnosis of NCDs.

Provider level barriers

Nine studies from SSA, including Zambia, Uganda, Zimbabwe, Tanzania, Senegal, Ivory coast, Nigeria, and Malawi, reported that HCPs’ had inadequate knowledge and awareness of NCDs, including depression.^{15,35,36,41,42,50,62–64} Among these studies, five reported a lack of knowledge of HCPs in depression screening and management.^{42,50,62–64} For example, HCPs perceive depression as a logical outcome of HIV infection and perceive it as difficult to diagnose.⁶² In addition, HCPs’ lack of conﬁdence in prescribing depression drugs resulting from inadequate training on depression and mental health.^50,63,64 was reported as a barrier to diagnosing NCDs.

Skills

The skill domain of TDF was identified as a provider-level barrier. Four studies from South Africa, Tanzania, and Zimbabwe^40,43,44,65 reported HCP deficiency in diagnosing NCDs, mainly due to inadequate training and practice. For example, three studies reported that HIV clinic HCPs had inadequate skills to detect and manage NCD in the context of HIV care.^40,43,44 Newly trained nurses come into practice without proper training in diagnosing and managing NCD.⁴⁴ In addition, the use of unstandardized screening tools resulted in the inclusion of participants who were not clinically depressed,⁶⁵ which was reported a provider-level barrier.

Memory, attention, and decision processes

Two studies identified the memory attention and decision process domains as barriers. Studies from Uganda and Tanzania reported a gap in patient–provider communication and discussion.^35,41 For instance, a study conducted in Tanzania reported that PLWH with comorbid hypertension did not inform their HIV status to hypertension care providers and their hypertension status HIV care providers because these two diseases are managed in different clinics and by different providers.³⁵

Behavioral regulation

Two studies from Zimbabwe and South Africa reported the behavioral regulation of the TDF domain at the patient and provider levels as barriers.^45,46 For example, a study from Zimbabwe reported patients’ preference for the use of alternative medication,⁴⁶ and a South African study reported disrespectful treatment by staff.⁴⁵

Opportunity construct of COM-B

The opportunity domain has two subcomponents. Physical opportunities are created by environments, for example, access to resources that enable factors or hinder toward the practice of intended behavior. Social opportunities are norms and expectations of the social environment, which could be facilitators of or hindrances to intended behavior change practices. The environmental context and resources and the social influence of the TDF domains were identified as patient-, provider- and health-system-level barriers under physical opportunity for behavioral change.

Physical opportunity

Environmental context and resources

The environmental context and resources of the TDF domain were frequently reported as patient-, provider-, and health-system-level barriers.

Patient-level barriers

Transportation and long travel distance

Five studies from South Africa, Eswatini, Zimbabwe, and Tanzania reported patients’ transportation problems and the need to travel long distances.^{35,40,45,47,48} For example, two studies conducted in South Africa and Zimbabwe reported increased transportation costs to patients,^45,48 whereas a lack of funding for patients for transportation was reported in Tanzania, Eswatini, and South Africa.^35,47

Financial constraints and out-of-pocket payments

Six studies conducted in Uganda, South Africa, Zimbabwe, and Tanzania reported financial constraints, and higher OOP^{40,46,48–50,66} was reported. For example, studies conducted in Tanzania and Zimbabwe reported that due to financial constraints caused by poverty, PLWHs failed to visit clinics for depression diagnosis and care.^50,66

Provider-level barriers

Six studies conducted in South Africa, Tanzania, Zimbabwe, Malawi, and Kenya reported inadequate training for HCPs on NCD screening and management.^{40,43,44,50–52} For instance, a South African study reported that an imbalance in HIV and NCD training and practice leads to newly trained nurses who come into practice without proper training on NCD.⁴⁴

Health-system-level barriers

Health-system-level barriers were frequently reported in the environmental context and resources domain of the TDF.

Inadequate number of trained HCPs

Sixteen studies conducted in SSA, including Namibia, Uganda, South Africa, Zimbabwe, Tanzania, Malawi, Kenya, Senegal, Cotidivor, and Nigeria, reported inadequate numbers of HCPs trained on NCDs^{35,40,41,43,48,51–53} including depression screening and diagnosis.^{42,50,62–64,68–70}

Lack of NCD equipment and screening tools

Eight studies from Uganda, Zimbabwe, Tanzania, South Africa, Malawi, and Zambia reported a lack of equipment for NCD prevention, including depression screening and diagnosis.^{41,43,44,48,50,51,62,67} For example, lack of blood pressure (BP) measurement devices and random blood sugar (RBS) machines and strips^{41,43,44,48,51} and malfunctions of BP machines,⁵³ a lack of laboratory testing⁴⁸, and a lack of standard, validated, culturally sensitive screening tools and therapies for depression and mental health problems.^50,62,67 have frequently been reported.

NCD drug, medication, and supply chain problems

Eight studies from SSA, including Namibia, Uganda, Zimbabwe, Tanzania, and Malawi, reported NCD drugs, medication shortages, and supply chain difficulties.^{35,41,43,48,51,53–55} For example, stock out of NCD medications,^43,51,53,54 including the nonavailability of HTN and DM medication at ART sites,^35,41,48 and challenges of NCD drug supply chains^44,47,54,55 were reported.

Lack of integrated NCDs and HIV care

Eleven studies from SSA, including Namibia, South Africa, Mozambique, Zimbabwe, Tanzania, Malawi, and Senegal,^{14,15,35,51,53,57,62–64} reported a lack of integrated HIV and NCDs, including depression screening among PLWH. For example, lack of active and routine screening of NCD offered as part of HIV care delivery.^14,15,53,57 A study from Mozambique reported poor integration of hypertension screening and management with chronic care services.⁵⁶

Long waiting times

Six included studies from Uganda, South Africa, Zimbabwe, and Tanzania reported long distances and long waiting times.^{20,35,40,41,48,49}

Lack of health system readiness

Three studies from Zambia, Mozambique, and Zimbabwe reported the limited capacity of ART clinics and lack of health system readiness for NCD services.^36,56,58

High out-of-pocket payments

Six studies from SSA, including Zimbabwe, Tanzania, Kenya, and Uganda, reported that high OOP payments and high costs of services^{35,46,48,52,54,55} were barriers.

Lack of NCD guidelines and guidance

Four studies from South Africa, Kenya, and Nigeria reported a lack of updated guidelines for managing NCDs, including depression screening and diagnosis.^40,42,44,52 For instance, the updated guidelines are unavailable for PHC facilities in South Africa.^44,52 At the same time, a systematic review conducted in SSA reported that a lack of standard screening tools and culture-sensitive therapies for depression⁶² were identified as barriers.

Social opportunity

Four studies from Tanzania, South Africa, Nigeria, and Zimbabwe^35,40,42,66 reported the social opportunity of the TDF domain as a barrier to patients, providers, and health systems. At the person level, a lack of clear communication and discussion with HCP providers and patients’ fear of stigma and isolation due to their HIV and mental health issues were reported as barriers. In addition, at the provider level, gaps in communication and clear discussion with patients and HCP-related stigma were reported as barriers. Due to the lack of HIV and chronic disease support programs, poor information provided to patients on chronic disease and medication not delivered on time were identified as health-system-level barriers. For instance, a study from Tanzania reported gaps in patient and HCP communication and discussion.³⁵ A South African study reported poor information provided and a lack of chronic care support programs,⁴⁰ whereas studies from Nigeria and Tanzania reported PLWH fear stigma associated with HIV and mental health problems and cultural ignorance.⁴²

Motivation construct of COM-B

Motivation is an aggregate of mental processes that energizes and directs behavior. The motivation domain of the COM-B can be either automatic (such as habits) or reflective motivation (such as planning and decision-making). Beliefs about the capabilities, intentions, optimism, goals, and social/professional role domain of TDF were identified as patient-, provider-, and health-system-level barriers.

Beliefs about the capabilities

Five studies from South Africa, Nigeria, Malawi, and Zimbabwe reported low confidence and beliefs about the ability of HCPs to diagnose NCD, including depression and mental health.^{20,42,44,50,64} For example, a study in South Africa reported that a lack of HCP conﬁdence in managing NCDs in a PHC facility contributes to the underdiagnosis of NCDs,⁴⁴ whereas HCPs believe that specialized clinics could offer better care for HIV infection and that NCDs are neglected.²⁰ A study in Malawi reported that nonspecialized mental healthcare workers feel that they need more time to treat mental health problems,⁶⁴ which were identified as provider-level barriers.

Intention

Twelve studies from SSA, including South Africa, Mozambique, Senegal, Uganda, Ethiopia, Tanzania, Nigeria, and Malawi,^{20,40,41,56,59,60–62,64,71,72} reported a lack of attention given to NCDs, including depression as a patient-, provider-, and health-system-level barrier.

Beliefs about the consequences

One study from Zimbabwe reported concerns about pill burden and possible interactions with ART drugs with NCDs⁵⁰ as barriers at the patient level.

Optimism

Two studies from Mozambique and Nigeria^42,56 reported barriers in the optimism domain of TDF. For example, a lack of HCP motivation⁵⁶ and burnout⁴² were identified as provider-level barriers.

Goals

Three studies from Namibia, Uganda, and South Africa^41,53,57 reported TDF’s goal domain as a barrier to diagnosing NCDs. For instance, even though the PLWH have frequent follow-ups in HIV clinics, NCDs were underdiagnosed, undertreated, and poorly controlled.⁵⁷

Social/professional role

Five studies from Tanzania, South Africa, Uganda, Senegal, and the Ivory Coast^{35,41,44,63,66} reported barriers. For instance, a lack of open discussion with patients, HCPs and patients was identified as a patient-level barrier,³⁵ whereas nurses who feel that an NCD diagnosis is the responsibility of medical doctors,⁴⁴ provider apathy,⁴¹ and HCP perception of diagnosis and management of depression needed to be performed by a specialist⁶³ were identified as provider-related barriers (Table 4).

Table 4.

Barriers to diagnosing NCD among PLWH using COM-B and TDF included in studies of a scoping review.

COM-B system	COM-B components	TDF	Codes
Capability	Psychological	Knowledge	Patient level• Patients lack knowledge and low awareness of NCD, including mental health^35-40,42
		Knowledge	Provider level• HCPs lack knowledge of NCD, including mental health^15,35,41 and awareness of NCD^36,42,62 • Lack of confidence and willingness of HCP^42,50,62 • Insufficient or inadequate training^63,64 • Use of unstandardized screening tools⁶⁵ Health system level• Lack of guidelines for monitoring and evaluation⁴² • Insufficient or inadequate training on NCDs^63,64
		Skill	Providers level• HCPs’ skill deficiency^40,43,44 Use of unstandardized screening tools⁶⁵
		Memory, attention and decision processes	Patient level• A gap in communication and discussion with HCPs³⁵ Provider level• Gaps in communication, counseling, and discussion^35,41
		Behavioral regulation	Patient level• Preferences alternative medication⁴⁶ Provider level• Disrespectful treatment by staff⁴⁵
Opportunity	Physical	Environmental context and resources	Patient level• Transportation problems and long travel distances^{35,40,45,47,48} • Financial constraints and higher OOP^{40,46,48–50,66} Provider levels• Lack of adequate training for HCPs on NCD^{40,43,44,50–52} Health system level• Inadequate number of trained HCPs on NCDs^{35,40,41–43,48,50–53,62–64,69–70} • Lack of equipment for NCD screening and diagnosis^{42,43,44,48,51,53} • Drugs, medication shortages, and supply chain difficulties^{35,37,41,43,47,48,51,53–55} • Lack of integrated NCD including depression and HIV care^{14,15,35,51,53,56,57,62–64} • Long distance and waiting time^{20,35,40,41,48,49} • Limited capacity clinics and lack of health system readiness for NCD^36,56,58 • High cost and OOP^{35,46,48,52,54,55} • Lack of guidelines and policy gaps to manage NCDs^40,42,44,52 • Lack of standard, validated, culturally sensitive screening tools, and therapies^50,62,67
	Social	Social influence	Patient level• Lack of clear communication and discussion with HCP provider³⁵ • Stigma and social isolation^35,42 Provider level• Communication gaps³⁵ • Stigma by HCP and community³⁵ Health services level• Medication not delivered on time⁴⁰ • Poor information provided to patients on chronic disease⁴⁰ • Lack of HIV and chronic disease support programs⁴⁰
Motivation	Reflective	Beliefs about capabilities	Provider level• HCP lack of confidence, unwillingness and burnout to diagnose NCDs^{20,42,44,50,64}
		Intentions	Patient level• Fear of pill burden (taking more than one treatment)⁴⁰ • Patients’ poor attention to mental health service needs^62,71 Provider level• Lack of attention to NCDs, including mental health^{20,35,41.42,56,59–62,64,71,72} Health services level• Lack of attention to NCDs^{20,35,41,56,59–61}
		Belief about consequences	Patient level• Fear of pill burden and possible interactions with ART⁵⁰
		Optimism	Providers level• Lack of motivation and burnout^42,56
		Goals	Health system• Underdiagnosed and missed opportunities^57,61 • Lack patient follow-up and tracking system⁵³ • High patient load⁴¹ • Lack of NCD screening and health promotion^44,61
		Social/Professional role and identity	Patients level• Lack of clear communication and³⁵ Provider level• Lack of clear communication and discussion³⁵ • Lack of proper screening for NCDs⁴⁴ • Nurses feel that diagnosing NCDs is a medical doctor’s responsibility⁴⁴ • Provider apathy⁴¹ • HCPs believe that depression diagnosis and management should be conducted by a specialist⁶³ • Mental health stigma and cultural ignorance⁶⁶ Health services level• Cultural ignorance to provide comprehensive HIV care⁶⁶

Facilitators for diagnosing depression among PLWH

Four studies from South Africa, Nigeria, and Zimbabwe^42,50,68,73 reported facilitators of the diagnosis of depression.

Environmental context and resource domain of TDF

Three studies from South Africa and Nigeria identified TDF’s environmental context and resource construct as a health-system-level facilitator.^42,68,73 For instance, a study reported that leveraging existing HIV/AIDS structures could help individuals diagnose depression.⁴² The Nigeria and South Africa study reported a task-shifting approach,^42,68 and utilizing available human resources from HIV care and engaging community health workers in mental health⁴² could facilitate early diagnosis of depression.

Reinforcement

One study reported that reinforcement strategies such as providing incentives for bus fares and refreshments were identified as facilitators of diagnosis⁵⁰ (Table 5).

Table 5.

Facilitators for diagnosing depression among PLWH using the COM-B and TDF frameworks included studies in the scoping review.

COM-B system	COM-B components	TDF	Codes
Opportunity	Physical	Environmental context and resources	Health system level• Leverage of existing HIV/AIDS services for NCD⁴² • Task-shifting approaches such as community health workers^42,68 • Community support groups (faith-based organizations and traditional leaders)⁴² • Available human resources in HIV programs⁴² Use of short and valid screening tools⁷³
Motivation	Automatic	Reinforcement	• Bus fare incentives and refreshments⁵⁰

Discussion

The findings of this scoping review provide an overview of the available literature on the barriers and facilitators of diagnosing NCDs (hypertension, diabetes, and depression) among PLWH in LMICs of Africa. This review identified various barriers linked to the capability, opportunity, and motivation of the COM-B system and TDF domains. A theory-informed method combining the COM-B and TDF theoretical domains to map evidence systematically ensures the exploration of various behavioral determinants. Knowing how identified barriers align with theoretical understandings of behavioral changes is critical for improving intervention design and strengthening the likelihood of successful implementation. A broad range of barriers and potential unknown influences were identified that can be targeted in designing interventions to improve the diagnosis of NCD among PLWH with the increasing chronic care needs. Collectively, these studies provide corroborative evidence of barriers identified at the patient, provider, and health system levels for diagnosing NCD among PLWH.

All of the barriers and facilitators identified in the diagnosis of NCDs were relevant to all of the COM-B constructs and all of the 14 TDF domains (knowledge, skills, environmental context and resources, social influences, beliefs about capabilities, beliefs about consequences, social/professional role and identity, reinforcement, intentions, goals, and emotion). A large number of barriers were reported in the COM-B construct and TDF domains and categorized as patient-, provider-, and health-system-related barriers in the included studies.

At the patient level, the identified barriers to the diagnosis of NCD among PLWH were lack of knowledge and awareness of NCDs, patients longing for alternative medications, fear of the stigma associated with HIV and mental health problems, fear of pill burden, financial problems, and prohibitive OOP payments.

In LMICs, patients, particularly PLWH, face challenges in NCD care due to limited access to accurate information and prevailing social, economic, and cultural conditions⁷⁴ and a lack of awareness of their disease due to low health literacy and a lack of knowledge on NCDs and risk factors.⁷⁵ When compared to high-income nations, patients living with NCDs in LMICs rely on large OOPs to receive NCD care services. Thus, many people are unable to obtain NCD services because they are unable to pay for OOP. Many OOP expenses (medication, outpatient appointments, diagnostics, hospitalization, and transportation) exacerbate poverty.⁷⁶

Low knowledge, awareness, skill, competence deficiencies, lack of confidence due to inadequate training and practice, disrespectful care, unwillingness, burnout, low motivation, and apathy were cited as provider-level barriers for diagnosing NCD among PLWH. Our review report, which was consistent with the WHO report on the African region, indicated that health workers in PHC facilities have insufficient knowledge to diagnose and treat NCDs and provide counseling.⁷⁷

The main barriers at the health system level identified were lack of equipment, scarcity of NCD medications and supply chain challenges, lack of integrated NCD and HIV care, lack of health system readiness and guidelines, lack of monitoring and tracking patient referrals and documentation, and inadequately trained human resources and culture-sensitive therapies.

Our review findings were consistent with those of the WHO Africa Regional Report, which found that NCD services are limited, fragmented, and of poor quality. Furthermore, NCDs are not fully integrated into PHC services. Medicine stockouts are common, as are poor implementation and poor supply chain management systems.⁷⁷ A shortage of skilled human resources negatively impacts the delivery of NCD services.⁷⁷ The availability and affordability of NCD medicines and technologies are much lower in LMICs than in high-income countries (HICs).^78,79

Patient-level obstacles could be addressed through activities that improve NCD literacy. Health literacy is critical for preventing and controlling NCDs. It could support people, communities, and organizations in addressing NCDs.⁸⁰ Improving health literacy on NCDs and risk factors and awareness creation activities focused on the patient level could be prioritized. Strategies that reduce OOP, such as health stewardship, creating resources, healthcare financing mechanisms, and delivering health services, could help address high OOP.⁸¹

Qualified HCPs responsive to and embedded within communities should be selected with rigorous training and supervisor support. Training related to HCPs is critical for enhancing knowledge and skills on NCDs and could address motivational issues. An appropriately skilled and deployed primary care workforce can optimize the care and management of NCDs, a critical enabler for achieving UHC and realizing global health targets of SDGs.⁸² There is a need to prioritize strengthening the health workforce for effective NCD care particularly for PLWH through integrated HIV and NCD services.

The health system can facilitate diagnosis by integrating NCDs, including mental healthcare, with HIV/AIDS services, including leveraging existing structures and implementing a task-shifting approach. Health systems should be strengthened to provide a consistent supply chain of essential drugs, an efficient system for their distribution to patients, and training on appropriate use.

Implication of the findings

The outcome of this study has broad implications for policy makers, decision makers, international and national donors, service providers, researchers, and associations such as people living with HIV and communities at large for NCD response in LMICs in Africa including Ethiopia, particularly for addressing gaps identified through health system strengthening, redesigning service provisions, research and funding to improve early detection and linkage to care to address the multiple chronic care needs of PLWH. Moreover, increase in NCDs among PLWH needs to be addressed by strengthening the PHC system through the design and implementation of evidence based interventions. Thus, this study plays a crucial role in identifying and mapping evidence on the barriers to and facilitators of the diagnosis of NCD among PLWH (at the individual, provider, and health system levels) in LMICs in Africa.

Limitations of the study

This review had the following limitations. We limited our search to English-only papers due to a lack of language experts on the review team. As with most reviews, there is a possibility that some papers could have been missed during the search process. It is also possible that some papers used terminologies different from what we used to search for literature. We did not consider the quality of the studies in the review while synthesizing the findings.

Conclusion

This scoping review is the first to identify barriers to and facilitators of diagnosing NCDs among PLWH using a theoretical domain of COM-B and TDF to map evidence. Various factors, including lack of knowledge and awareness, HCP skill deficiency and shortage of trained HCPs, lack of integrated care, and equipment and logistics chain challenges for NCDs hinder the diagnosis of NCDs among PLWH. Addressing these issues is crucial for improving patient outcomes and reducing the burden on HCPs in LMICs’ health systems struggling with acute care.

The integration of NCDs with HIV care at the PHC level is recommended, with sufficient resources to address supply difficulties and reduce patient OOP expenses for the sustained delivery of services to address the multiple chronic care needs of PLWH.

The contextual factors affecting the integration of NCDs with HIV care at the PHC level need to be explored through primary research.

Footnotes

Acknowledgements

The authors would like to thank the University of KwaZulu-Natal in South Africa, the Health Economics and AIDS Research Division (HEARD), for providing a PhD scholarship to the primary author and the Swedish International Development Cooperation Agency and Wolaita Sodo University in Ethiopia. The current scoping review protocol was published at Plos One journal .

Author contributions

ASB and OHM designed the review. ASB, DDW, and DBD screened articles. ASB analyzed the review article. ASB, DDW and DBD drafted the scoping review paper, while OHM reviewed the manuscript. All the authors have read and approved the manuscript.

Availability of data and materials

All data analyzed for and in this study are included in the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics approval and consent to participate

The study did not involve human subjects.

Informed consent

Not applicable.

Consent for publication

Not applicable.

ORCID iD

Abebe Sorsa Badacho

References

World Health Organization. Integrating the prevention and control of noncommunicable diseases in HIV/AIDS, tuberculosis, and sexual and reproductive health programs. Geneva, Switzerland: WHO, 2023.

Noncommunicable diseases: key facts [Internet], https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases (2021, accessed 17 February 2022).

Juma

Mohamed

, et al. First Africa non-communicable disease research conference 2017: sharing evidence and identifying research priorities. J Global Health 2019; 8(2): 020301.

Hyle

Mayosi

Middelkoop

, et al. The association between HIV and atherosclerotic cardiovascular disease in sub-Saharan Africa: a systematic review. BMC Public Health 2017; 17(1): 954.

Kaptoge

Pennells

De Bacquer

, et al. World Health Organization cardiovascular disease risk charts: revised models to estimate risk in 21 global regions. Lancet Global Health 2019; 7(10): e1332–e1345.

Collini

Mawson

RL.

A new era of HIV care for age-associated multimorbidity. Curr Opin Infect Dis 2023; 36(1): 9–14.

Okello

Amir

Bloomfield

, et al. Prevention of cardiovascular disease among people living with HIV in sub-Saharan Africa. Prog Cardiovasc Dis 2020; 63(2): 149–159.

Moyo-Chilufya

Maluleke

Kgarosi

, et al. The burden of non-communicable diseases among people living with HIV in Sub-Saharan Africa: a systematic review and meta-analysis. EClinicalMedicine 2023; 65: 102255.

Coogan

Castro-Webb

, et al. Active and passive smoking and the incidence of asthma in the Black Women’s Health Study. Am J Respir Crit Care Med 2015; 191(2): 168–176.

10.

Hirschhorn

Kaaya

Garrity

, et al. Cancer and the “other” noncommunicable chronic diseases in older people living with HIV/AIDS in resource-limited settings: a challenge to success. AIDS (London, England) 2012; 26(Suppl 1): S65–S75.

11.

Gooden

Gardner

Wang

, et al. Incidence of cardiometabolic diseases in people with and without human immunodeficiency virus in the United Kingdom: a population-based matched cohort study. J Infect Dis 2021; 225(8): 1348–1356.

12.

Gooden

Mkhoi

Mdoe

, et al. Barriers and facilitators of people living with HIV receiving optimal care for hypertension and diabetes in Tanzania: a qualitative study with healthcare professionals and people living with HIV. BMC Public Health 2023; 23(1): 2235.

13.

Patel

Rose

Collins

, et al. Noncommunicable diseases among HIV-infected persons in low-income and middle-income countries. AIDS (London, England) 2018; 32(Supplement 1): S5–S20.

14.

George

McGrath

Oni

The association between a detectable HIV viral load and non-communicable diseases comorbidity in HIV positive adults on antiretroviral therapy in Western Cape, South Africa. BMC Infect Dis 2019; 19(1): 348.

15.

Magodoro

Esterhuizen

Chivese

A cross-sectional, facility based study of comorbid non-communicable diseases among adults living with HIV infection in Zimbabwe. BMC Res Notes 2016; 9(1): 379.

16.

Guaraldi

Orlando

Zona

, et al. Premature age-related comorbidities among HIV-infected persons compared with the general population. Clin Infect Dis 2011; 53(11): 1120–1126.

17.

Narayan

Miotti

Anand

, et al. HIV and noncommunicable disease comorbidities in the era of antiretroviral therapy: a vital agenda for research in low- and middle-income country settings. J Acquir Immune Defic Syndr 2014; 67(Suppl 1): S2–S7.

18.

Nigatu

Oldenburg

Elliott

, et al. The incidence of cardiovascular disease, cancer and type 2 diabetes comorbidities in HIV infection: a systematic review. J Nurs Educ Pract 2013; 3(7); 58–67.

19.

Rabkin

Kruk

El-Sadr

WM.

HIV, aging and continuity care: strengthening health systems to support services for noncommunicable diseases in low-income countries. AIDS (London, England) 2012; 26: S77–S83.

20.

Peer

de Villiers

Jonathan

, et al. Care and management of a double burden of chronic diseases: Experiences of patients and perceptions of their healthcare providers. PLoS One 2020; 15(7): e0235710.

21.

Adeyemi

Lyons

Njim

, et al. Integration of non-communicable disease and HIV/AIDS management: a review of healthcare policies and plans in East Africa. BMJ Global Health 2021; 6(5): e004669.

22.

Gonçalves

Mendes

Caldeira

, et al. Nurse-led care management models for patients with multimorbidity in hospital settings: a scoping review protocol. JBI Evid Synth 2021; 19(8): 1934–1940.

23.

Mkumba

Muiruri

Garg

, et al. Perspectives of chronic disease management among persons with HIV: a qualitative study. Patient Pref Adher 2021; 15: 49–55.

24.

Arksey

O’Malley

Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005; 8(1): 19–32.

25.

Levac

Colquhoun

O’Brien

KK.

Scoping studies: advancing the methodology. Implement Sci 2010; 5(1): 69.

26.

Tricco

Lillie

Zarin

, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Inter Med 2018; 169(7): 467–473.

27.

WHO. Global action plan for the prevention and control of noncommunicable diseases 2013–2020, https://www.google.com/search?q=9789241506236_eng.pdf+(who.int)&oq=9789241506236_eng.pdf+(who.int)&gs_lcrp=EgZjaHJvbWUyBggAEEUYOdIBBzMwM2owajmoAgCwAgE&sourceid=chrome&ie=UTF-8 (2013).

28.

Johnson

Phillips

Rayyan for systematic reviews. J Elect Res Libr 2018; 30(1): 46–48.

29.

Page

McKenzie

Bossuyt

, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71.

30.

Thomas

Harden

Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008; 8(1): 45.

31.

Michie

van Stralen

West

The behavior change wheel: a new method for characterizing and designing behavior change interventions. Implement Sci 2011; 6: 42.

32.

Michie

Atkins

West

The behavior change wheel: a guide to designing interventions. Surrey, UK: Silverback Publishing, 2014.

33.

Cane

O’Connor

Michie

Validation of the theoretical domains framework for use in behavior change and implementation research. Implement Sci 2012; 7: 37.

34.

Michie

Johnston

Abraham

, et al. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care 2005; 14(1): 26–33.

35.

Manavalan

Minja

Wanda

, et al. “It’s because I think too much”: perspectives and experiences of adults with hypertension engaged in HIV care in northern Tanzania. PLoS One 2020; 15(12): 1–15.

36.

Bauer

Wa Mwanza

Chilengi

, et al. Awareness and management of elevated blood pressure among human immunodeficiency virus–infected adults receiving antiretroviral therapy in urban Zambia: a call to action. Global Health Action 2017; 10(1): 1359923.

37.

Gonah

Moodley

Hlongwana

Prevalence of diabetes mellitus and hypertension in people living with human immunodeficiency virus on antiretroviral therapy in Gweru district, Zimbabwe. Afr J Primary Health Care Fam Med 2020; 12(1): 1–6.

38.

Manavalan

Madut

Hertz

, et al. Hypertension among adults enrolled in HIV care in northern Tanzania: comorbidities, cardiovascular risk, and knowledge, attitudes and practices. Pan Afr Med J 2022; 41: 285.

39.

Mutemwa

Peer

de Villiers

, et al. Prevalence, detection, treatment, and control of hypertension in human immunodeficiency virus (HIV)-infected patients attending HIV clinics in the Western Cape Province, South Africa. Medicine 2018; 97(35): e12121.

40.

Godongwana

De Wet-Billings

Milovanovic

The comorbidity of HIV, hypertension and diabetes: a qualitative study exploring the challenges faced by healthcare providers and patients in selected urban and rural health facilities where the ICDM model is implemented in South Africa. BMC Health Serv Res 2021; 21(1): 647.

41.

Buzaalirwa

Nambala

Banturaki

, et al. Implementing screening for hypertension in archetypal HIV primary care: a mixed-methods assessment. BMC Health Serv Res 2022; 22(1): 1–11.

42.

Ezeanolue

Iheanacho

Adedeji

, et al. Opportunities and challenges to integrating mental health into HIV programs in a low- and middle-income country: insights from the Nigeria implementation science Alliance. BMC Health Serv Res 2020; 20(1): 904.

43.

Leung

Aris

Mhalu

, et al. Preparedness of HIV care and treatment clinics for the management of concomitant non-communicable diseases: a cross- sectional survey. BMC Public Health 2016; 16(1): 1–8.

44.

Murudi-Manganye

Makhado

Sehularo

LA.

A conceptual model to strengthen integrated management of HIV and NCDs among NIMART-trained nurses in Limpopo Province, South Africa. Clin Pract 2023; 13(2): 410–421.

45.

Clouse

Motlhatlhedi

Bonnet

, et al. “I just wish that everything is in one place”: facilitators and barriers to continuity of care among HIV-positive, postpartum women with a non-communicable disease in South Africa. AIDS Care 2018; 30: 5–10.

46.

Gonah

Moodley

Hlongwana

Effects of HIV and non-communicable disease comorbidity on healthcare costs and health experiences in people living with HIV in Zimbabwe. South Afr J HIV Med 2020; 21(1): 1–8.

47.

Goldstein

Ford

Kisyeri

, et al. Person-centered, integrated non-communicable disease and HIV decentralized drug distribution in Eswatini and South Africa: outcomes and challenges. J Int AIDS Soc 2023; 26: e26113.

48.

Gonah

Moodley

Hlongwana

Capacity of antiretroviral therapy sites for managing NCDs in people living with HIV in Zimbabwe. South Afr J HIV Med 2020; 21(1): 1–7.

49.

Batte

Mukisa

Rykiel

, et al. Acceptability of patient-centered hypertension education delivered by community health workers among people living with HIV/AIDS in rural Uganda. BMC Public Health 2021; 21(1): 1343.

50.

Abas

Nyamayaro

Bere

, et al. Feasibility and acceptability of a task-shifted intervention to enhance adherence to HIV medication and improve depression in people living with HIV in Zimbabwe, a low income country in Sub-Saharan Africa. AIDS Behav 2018; 22(1): 86–101.

51.

Pfaff

Scott

Hoffman

, et al. You can treat my HIV—but can you treat my blood pressure? Availability of integrated HIV and non-communicable disease care in northern Malawi. Afr J Primary Health Care Fam Med 2017; 9(1): 1–8.

52.

Venables

Edwards

Baert

, et al. “They just come, pick and go” The acceptability of integrated medication adherence clubs for HIV and non communicable disease (NCD) patients in Kibera, Kenya. PLoS One 2016; 11(10): 1–12.

53.

Basenero

Neidel

Ikeda

, et al. Integrating hypertension and HIV care in Namibia: a quality improvement collaborative approach. PLoS One 2022; 17(8): 1–14.

54.

Kintu

Sando

Okello

, et al. Integrating care for non-communicable diseases into routine HIV services: key considerations for policy design in sub-Saharan Africa. J Int AIDS Soc 2020; 23: 1–5.

55.

Van Hout

Zalwango

Akugizibwe

, et al. Implementing integrated care clinics for HIV-infection, diabetes and hypertension in Uganda (INTE-AFRICA): process evaluation of a cluster randomized controlled trial. BMC Health Serv Res 2023; 23(1): 570.

56.

Gimbel

Mocumbi

Ásbjörnsdóttir

, et al. Systems analysis and improvement approach to optimize the hypertension diagnosis and care cascade for PLHIV individuals (SAIA-HTN): a hybrid type III cluster randomized trial. Implement Sci 2020; 15(1): 1–14.

57.

Hyle

Bekker

L-G

Martey

, et al. Cardiovascular risk factors among ART-experienced people with HIV in South Africa. J Int AIDS Soc 2019; 22(4): e25274.

58.

Gonah

Moodley

Hlongwana

Prevalence, healthcare costs and management of non-communicable diseases in people living with human immunodeficiency virus: a scoping review. Afr J Primary Health Care Fam Med 2020; 12(1): 1–8.

59.

Benzekri

Seydi

Doye

, et al. Increasing prevalence of hypertension among HIV-positive and negative adults in Senegal, West Africa, 1994–2015. PLoS One 2018; 13(12): e0208635.

60.

Gebrie

Hypertension among people living with human immunodeficiency virus receiving care at referral hospitals of Northwest Ethiopia: a cross-sectional study. PLoS One 2020; 15(8): 1–13.

61.

Kamkuemah

Gausi

Oni

Missed opportunities for NCD multimorbidity prevention in adolescents and youth living with HIV in urban South Africa. BMC Public Health 2020; 20(1): 821.

62.

Bernard

Dabis

de Rekeneire

Prevalence and factors associated with depression in people living with HIV in sub-Saharan Africa: a systematic review and meta-analysis. PLoS One 2017; 12(8): e0181960.

63.

Bernard

Seydi

Tanon

, et al. Barriers influencing task-shifting for the management of depression in people living with HIV: a study from West Africa IeDEA cohort collaboration. AIDS Care 2021; 33(3): 352–356.

64.

Kawiya

Davies

Lund

, et al. Missed opportunities to address common mental disorders and risky alcohol use among people living with HIV in Zomba, Malawi: a cross sectional clinic survey. PLoS One 2023; 17(2): 1–14.

65.

Chibanda

Cowan

Gibson

, et al. Prevalence and correlates of probable common mental disorders in a population with high prevalence of HIV in Zimbabwe. BMC Psychiatry 2016; 16: 55.

66.

Nakimuli-Mpungu

Musisi

Wamala

, et al. Effectiveness and cost-effectiveness of group support psychotherapy delivered by trained lay health workers for depression treatment among people with HIV in Uganda: a cluster-randomized trial. Lancet Global Health 2020; 8(3): e387–e398.

67.

Breuer

Stoloff

Myer

, et al. The validity of the Substance Abuse and Mental Illness Symptom Screener (SAMISS) in people living with HIV/AIDS in primary HIV care in Cape Town, South Africa. AIDS Behav 2014; 18(6): 1133–1141.

68.

Safren

O’Cleirigh

Andersen

, et al. Treating depression and improving adherence in HIV care with task-shared cognitive behavioral therapy in Khayelitsha, South Africa: a randomized controlled trial. J Int AIDS Soc 2021; 24(10): 1–10.

69.

Udedi

Stockton

Kulisewa

, et al. Integrating depression management into HIV primary care in central Malawi: the implementation of a pilot capacity building program. BMC Health Serv Res 2018; 18(1): 593.

70.

Kim

Mazenga

Devandra

, et al. Prevalence of depression and validation of the Beck Depression Inventory-II and the Children’s Depression Inventory-Short amongst HIV-positive adolescents in Malawi. J Int AIDS Soc 2014; 17: 18965.

71.

Bankole

Bakare

Edet

, et al. Psychological complications associated with HIV/AIDS infection among children in South-South Nigeria, sub-Saharan Africa. Cogent Med 2017; 4: 1372869.

72.

Dow

Mmbaga

Gallis

, et al. A group-based mental health intervention for young people living with HIV in Tanzania: results of a pilot individually randomized group treatment trial. BMC Public Health 2020; 20(1): 1358.

73.

Bhana

Rathod

Selohilwe

, et al. The validity of the Patient Health Questionnaire for screening depression in chronic care patients in primary health care in South Africa. BMC Psychiatry 2015; 15(1): 1–9.

74.

Devi

Kanitkar

Narendhar

, et al. A narrative review of the patient journey through the lens of non-communicable diseases in low- and middle-income countries. Adv Ther 2020; 37(12): 4808–4830.

75.

Irazola

Gutierrez

Bloomfield

, et al. Hypertension prevalence, awareness, treatment, and control in selected LMIC communities: results from the NHLBI/UHG network of centers of excellence for chronic diseases. Global Heart 2016; 11(1): 47–59.

76.

Banatvala

Rodwin

Zerayacob

, et al. Financing and allocating resources for NCD prevention and control. London, UK: Routledge, 2023, pp. 285–293.

77.

World Health Organization. Regional framework for integrating essential noncommunicable disease services in primary health care. Report of the Secretariat. Republic of Zimbabwe, 2017.

78.

Attaei

Khatib

McKee

, et al. Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet Public Health 2017; 2(9): e411–e419.

79.

Perone

Bausch

Boulle

, et al. Report of the WHO independent high-level commission on NCDs: where is the focus on addressing inequalities? BMJ Global Health 2020; 5(6): e002820.

80.

WHO. Health literacy development for the prevention and control of NCDs, https://www.who.int/groups/gcm/health-literacy-development-for-ncd-prevention-and-control (2023, accessed 10 December 2023).

81.

Jalali

Bikineh

Delavari

Strategies for reducing out of pocket payments in the health system: a scoping review. Cost Effect Res Alloc 2021; 19(1): 47.

82.

Alliance

Protecting populations, preserving futures: optimizing the health workforce to combat NCDs and achieve UHC. Geneva, Switzerland, 2019.

Mapping evidence on barriers to and facilitators of diagnosing noncommunicable diseases among people living with human immunodeficiency virus in low- and middle-income countries in Africa: A scoping review

Abstract

Objectives:

Introduction:

Methods:

Results:

Conclusion:

Keywords

Introduction

Methods

Step 2. Identifying relevant studies

Information sources

Step 3. Study selection

The eligibility criteria

Selection process

Step 4: Charting the data

Step 5: Organizing, summarizing, and reporting the findings

Step 6: Methodological quality appraisal

Results

Study characteristics

The theoretical framework used for the analysis of the findings

Barriers to the diagnosis of NCDs

Knowledge

Patient level barriers

Provider level barriers

Skills

Memory, attention, and decision processes

Behavioral regulation

Opportunity construct of COM-B

Physical opportunity

Environmental context and resources

Patient-level barriers

Transportation and long travel distance

Financial constraints and out-of-pocket payments

Provider-level barriers

Health-system-level barriers

Inadequate number of trained HCPs

Lack of NCD equipment and screening tools

NCD drug, medication, and supply chain problems

Lack of integrated NCDs and HIV care

Long waiting times

Lack of health system readiness

High out-of-pocket payments

Lack of NCD guidelines and guidance

Social opportunity

Motivation construct of COM-B

Beliefs about the capabilities

Intention

Beliefs about the consequences

Optimism

Goals

Social/professional role

Facilitators for diagnosing depression among PLWH

Environmental context and resource domain of TDF

Reinforcement

Discussion

Implication of the findings

Limitations of the study

Conclusion

Footnotes

Acknowledgements

Author contributions

Availability of data and materials

Declaration of conflicting interests

Funding

Ethics approval and consent to participate

Informed consent

Consent for publication

ORCID iD

References