Provider's and stakeholders' experiences with and perceptions of the benefits and challenges of delivering care for noncommunicable diseases within HIV care services in Rwanda

Provider's and stakeholders' experiences with and perceptions of the benefits and challenges of delivering care for noncommunicable diseases within HIV care services in Rwanda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Provider's and stakeholders' experiences with and perceptions of the benefits and challenges of delivering care for noncommunicable diseases within HIV care services in Rwanda Valentine Dushimiyimana, Ladislas Nshimiyimana, Yvonne Delphine Nsaba Uwera, and 15 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7150794/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The growing burden of noncommunicable diseases (NCDs) among people living with HIV (PLHIV) in sub-Saharan Africa, including Rwanda, presents a complex healthcare challenge. Delivering NCD care within HIV services is crucial for improving patient outcomes and requires a coordinated, multistakeholder approach, but evidence on implementation experiences remains limited. Methods This qualitative study explored healthcare providers' and stakeholders’ experiences and perceptions regarding the delivery of NCD care within HIV services in Rwanda. A total of 49 in-depth interviews were conducted with healthcare providers from 12 health facilities across five provinces as well as with stakeholders from HIV and NCD programs. The participants were purposefully selected on the basis of their roles in HIV and NCD care. The interviews were conducted in Kinyarwanda or English, transcribed verbatim, and analysed thematically via Dedoose software. Data triangulation was applied to ensure the validity and reliability of the findings. Results The study revealed that NCD care for PLHIV in Rwanda remains largely fragmented. Most participants reported that patients diagnosed with NCDs are referred to separate departments or facilities, leading to discontinuities in care. Despite the decentralisation of NCD services, significant challenges remain, including inadequately trained staff, a lack of integration, NCD management guidelines, weak referral and follow-up systems, and delays in diagnosis. Financial barriers, due to out-of-pocket costs for NCD medication, further impede access. High-risk groups are identified as older adults, obese people, and those with compromised immune function. The participants called for greater integration of NCD services with existing HIV care platforms. Conclusion Delivering NCD care within HIV services in Rwanda faces multiple systemic barriers, including fragmented service delivery, shortages and inadequate provider capacity in NCD management, and financial and referral constraints. To improve outcomes for PLHIV with NCDs, integrated care models, targeted provider capacity building, strengthened referral systems, and expanded financial protection mechanisms are urgently needed. Addressing these gaps will enhance patient care and strengthen the overall health system in Rwanda. HIV care noncommunicable diseases service delivery referral system healthcare providers Rwanda Introduction Noncommunicable diseases (NCDs) represent a significant burden on the health system globally ( 1 ) The rise in NCDs is mainly in sub-Saharan Africa, compounded by the remaining effects of the HIV epidemic ( 2 ). NCDs present a challenge for healthcare providers, especially when managing the complex needs of patients who are living with a double burden of HIV and NCDs. Rwanda has made remarkable progress in controlling the HIV epidemic. Rwanda has adopted a comprehensive approach to HIV care, which includes prevention, treatment, and care services. Rwanda efforts have been recognised globally as a model for successful HIV programs, especially in sub-Saharan Africa. By 2023, Rwanda had achieved significant milestones in terms of reducing the prevalence of HIV, with more than 97.5% of people living with HIV (PLHIV) accessing antiretroviral therapy (ART) and 95-95-95, with an estimated 95% of people living with HIV aware of their status, 97.5% receiving ART, and 98% achieving viral load suppression ( 3 ). These achievements demonstrate Rwanda's dedication to ending the HIV/AIDS epidemic and improving the quality of life for the infected and affected populations ( 3 ). With the success of ART, PLHIV are living longer and are increasingly at risk of developing NCDs, particularly those associated with ageing, lifestyle factors, and the side effects of ART use ( 4 ). NCDs such as hypertension, diabetes, cardiovascular diseases, and cancer have been shown to complicate HIV treatment and care ( 5 ). Moreover, the treatment for NCDs often requires long-term, complex management, which overlaps with the care needed for HIV. This complex challenge requires an integrated, coordinated, and multistakeholder approach to health care delivery. Understanding the experiences and perceptions of benefits and challenges in delivering care for noncommunicable diseases within HIV care services is crucial to improving the healthcare system's ability to manage the double burden of HIV and NCDs. By addressing these challenges and building benefits, Rwanda can continue to enhance its health system's capacity to provide effective, patient-centred care. This process requires active collaboration among all stakeholders, including healthcare providers, policymakers, and the communities they serve, to ensure the sustainability and success of incorporating NCD care models into HIV services. This study aims to explore providers' and stakeholders' experiences with NCD service delivery within HIV care services in Rwanda and identify providers' and stakeholders’ perceptions of challenges in NCD service delivery within HIV care services in Rwanda. Methods Study design We conducted a qualitative descriptive study to explore providers' experiences and perceptions regarding the benefits and challenges of delivering care for NCDs within HIV care services in Rwandan health facilities ( 6 ). This design was chosen to capture rich, contextual insights into experiences and challenges in delivering NCDs within HIV care services from the perspective of providers and stakeholders. Study Setting The study took place in 12 Rwandan health facilities providing HIV and NCD treatment and care services located in the five provinces and in the key stakeholder institutions located in Kigali city and Eastern Province. Study participant sampling Purposive sampling was used to select the participants who were directly involved or had significant experience in the delivery of NCD or HIV care services. Participants were selected on the basis of their roles and expertise in the management of HIV or NCDs at the selected research sites and the key collaborating institutions and development partners in the delivery of both services. Study participants The participants include healthcare providers (including doctors, nurses and social workers working in HIV and NCD care services) (HCPs) and stakeholders composed of central-level program implementers (Rwanda Biomedical Centre: an implementing agent of the Rwanda Ministry of Health) (CPIs) focused on HIV and NCDs at the central level, civil society organisations (CSOs) and development partners (DPs) working in NCD and HIV programs. Data collection We conducted face-to-face, in-depth interviews to gain a comprehensive understanding of the participants' experiences, insights, and perspectives. The interviews allowed for flexibility, ensuring that participants could discuss their unique experiences and perceptions. At the health facility, an introductory letter pointing out the research and requesting collaboration in the study implementation was sent, the principal investigator visited the sites to meet the facilities' leadership, and they introduced the health care provider in HIV and NCD services for more explanation. Health facility management nominated the health provider to work with on the basis of their role and responsibility related to the study. We scheduled the interviews on the basis of the availability of healthcare providers and conducted them in a private room to ensure confidentiality. For the stakeholders, we identified the key stakeholders of the HIV and NCD programs. After their identification, we sent invitations to the institutions for the nomination of two to three participants who work in or work closely with HIV or NCD services. The institution nominated the participants, after which we scheduled interviews according to their availability. The study team developed and validated an interview guide to obtain responses to the research question. The team of experienced research assistants conducted 49 in-depth interviews in participants' preferred language, either Kinyarwanda or English, and audio recordings were transcribed verbatim; transcripts in Kinyarwanda were then translated into English. Analysis We analysed the data via Dedoose software, version 9.0, and applied thematic analysis to identify patterns and insights within the data. The steps are as follows: Familiarisation with the data involved the research team reading and rereading the transcripts to immerse themselves in the information and identify emerging ideas and patterns. The research team systematically coded the transcripts via Dedoose. The coding employed both inductive (emerging from the data) and deductive (based on predefined themes such as challenges and NCD management) approaches. After coding, we grouped the data into broader themes on the basis of the research objectives. These themes reflected recurring patterns and significant insights across participants' narratives. Interpretation of findings: The identified themes were examined for their relevance and implications. The research team considered how these themes inform the understanding and improvement of healthcare practices and policies. Triangulation: We used data triangulation to ensure the validity and reliability of the findings. This is done by comparing the data across participant groups, including healthcare providers, central-level program implementers, civil society organisations, and development partners, to check consistency and identify any discrepancies in the findings. Divergent views across participant groups were not considered contradictions but were treated as meaningful variations that reflected differences in roles, perspectives, and experiences. Ethical consideration The Rwanda National Ethics Committee, No.84/RNEC/2021, granted ethical approval for the study, and we obtained informed consent from each participant prior to their participation. For confidentiality, we used codes for the identification of participants, audio recordings and transcriptions were securely stored, and all the data were anonymised to retain privacy. Results Participant characteristics A total of 49 participants, consisting of 27 men and 22 women, were included in the study. Most were health care providers (n = 23), followed by development partners (n = 10), central-level program implementers (n = 9), and civil society organisations (n = 7). Table 1 Participant characteristics Category Men (M) Women (W) Total Development Partner 7 3 10 Civil Society Organisations 5 2 7 Healthcare providers 8 15 23 Central-level program implementers 7 2 9 Total 27 22 49 We ascribed the data to two main themes to structure the results: ( 1 ) experience with the current status of NCD service delivery within HIV care programs for PLHIV and ( 2 ) challenges with the current NCD service delivery with HIV care services for PLHIV. Theme 1: Experience with the current status of NCD service delivery with HIV care services for PLHIV Transfer to specialist/orientation to NCD services Most participants articulated that the services for NCD care are not provided at the same place for HIV care and treatment, but if a PLHIV is diagnosed with NCDs, he/she is instead sent to another department for specialised management or to another health facility, such as a health centre. This implies a fragmented healthcare system where patients need to navigate different services to receive appropriate care, thus complicating the management of their health conditions, and the participants indicated that NCD services are not yet integrated into HIV patient care even if there are some achievements. HCPs, CPIs, and DPs expressed this concern most frequently. “Both services are not combined, which results in barriers to the patient; both patients with NCDs and patients with HIV have separate schedules for the service not only the services are being separated but also the healthcare providers are different, and the fact that patient has to be treated individually cannot be reached; therefore, we cannot reach the therapeutic goal that we wish for the patients.” CSO respondent. Proposed solution Some of the participants proposed integration as a solution to the existing challenges in service provision. ‘…..The remaining one is that the services are still working separately, one of the things which can be helpful is the integration.” CSO respondent In contrast to the general trend, a few respondents described efforts similar to partial integration. “…What we do is an integrated service in terms of screening and identifying the condition. However, in terms of managing the condition, we refer patients to the appropriate NCD services.” CSO respondent. “...otherwise, what we do is an integrated service, but it is a way of detecting or tracking down, but in terms of taking care, we leave it to other NCD services.” HCP respondent. Similarly, others explained that if a patient presents with symptoms suggestive of an NCD during a routine HIV visit, they are promptly referred to the designated NCD care department. When a patient presents with symptoms related to an NCD, we right away refer the patient to the given NCD focal person or department that deals with such conditions . Decentralisation A minority of respondents described NCD care services as being decentralised to the health centre level, primarily for screening activities. Some healthcare providers noted the implementation of task shifting in different hospitals and health centres where trained nurses have assumed NCD management responsibilities previously handled by physicians due to shortages of specialised providers. The respondents emphasised that screening for NCDs in HIV clinics facilitates early detection of risk factors, allowing clinicians to modify antiretroviral therapy (ART) regimens to mitigate these risks. However, they also expressed concern that despite these efforts, NCDs are frequently detected at advanced stages in some patients. “...the healthcare providers screen her, and when they find that she has started to get a risk, they change the treatment.” HCP respondent. Few of the respondents highlighted the progress made in expanding healthcare services for NCDs. They noted that NCD services are now available in some health facilities, have been decentralised, and expressed optimism that, in the future, these services will be distributed more widely, similar to how HIV care, treatment, and prevention services are available throughout the whole country. They compare the success in decentralising NCD services to the recognised network of HIV care services and hope that there will be broader access to NCD care. “We have reached a good milestone thus far because NCD services are already in some health facilities and have been decentralised. We think that in the future, it will be disseminated as it has been to services of HIV care, treatment, and prevention, which are available in the whole country.” CPI respondent. Most common NCDs in PLHIV and people at high risk of NCDs The narratives of the participants revealed that they were aware of the most common NCDs and their risk factors. Hypertension was highlighted as the most common NCD among PLHIV, followed by diabetes and cardiovascular diseases. Other conditions reported by participants included cancer, asthma, and renal failure. The participants identified PLHIV as a population at high risk for developing NCDs, with particular emphasis on those aged 50 and above. Some respondents also noted elevated risk among adults as young as 35 years. Additional high-risk groups identified by participants included individuals with obesity, those with compromised immune function, and smokers. “ Most people I have seen, people who are obese, people who are overweight, tend to have diabetes and high blood pressure…” HCP respondent. “NCDs, we know that are diseases that mostly affect adults aged 35 years and above but are the most common diseases in people with other illnesses and are easily affected.” HCP respondent “……people who are often in their fifties or older, but among those living with the HIV virus, there are also young people who get diabetes without considering the age.” HCP respondent. “…behaviours like taking a lot of alcohol, smoking or taking other drugs, living without doing sports in life, and more others.” HCP respondent. Theme 2: Experienced challenges with current NCD service delivery with HIV care services for PLHIV Shortage of staff and limited capacity for effective management of NCDs The respondents were most concerned with the need for knowledge and skills for NCD management for nurses providing HIV care services. They noted that as more PLHIV present with NCD comorbidities, healthcare providers require additional training to competently deliver both HIV and NCD care. This need for capacity building was further coupled with the absence of guidelines for NCD diagnosis and management among PLHIV. These concerns were consistently raised by HCPs, CPIs, and DPs. “HIV services can continue to operate independently, and then the healthcare professional in HIV services can be trained to obtain necessary skills related to the management of hypertension and cardiovascular diseases because telling a patient to go to another service can also pass through different channels we are preventing. If possible, it can be integrated. I can’t say that HIV services can be integrated with NCDs, can be too much; I advise that the profession in HIV services can obtain the capacity to manage detected NCDs.” CSO respondent. “...actually, we have a problem of not having trained professionals about NCDs.” HCP respondent “We still have the problem of human resources; staff where you find that the staff who are trained on HIV are not the ones who are trained for NCDs implies that healthcare providers who are providing HIV services have little knowledge of NCDs and those providing NCD services have little knowledge of HIV.” CSO respondent Most respondents emphasised that integrating NCD screening into existing HIV care services substantially increases the workload of healthcare providers beyond their current responsibilities related to HIV management. This concern was particularly evident among healthcare providers at health centres, who already tasked with delivering multiple service packages beyond HIV care. “It’s understandable, in some health facilities, you can find that health care providers have many responsibilities, they have heavy responsibilities, which lead them to focus on HIV care only, and then they do not check for other diseases the patients did not show or do not declare their presence, sometimes they do not care about them…….” CPI respondent. High Cost of NCD Care and Limited Availability of Essential Medicines at Health Facilities The respondents frequently highlighted that the cost of medication imposes a significant financial burden on patients, compounded by inconsistent availability of drugs at health facility pharmacies. When medications are out of stock, patients must purchase them from private pharmacies where costs are often not covered by community-based health insurance (CBHI) schemes, resulting in increased out-of-pocket expenditures. “... PLHIV with NCDs without health insurance or without the capacity to pay all fees, most of the people do not have financial capacity, and those diseases empty their pockets, which makes diagnosis complicated. When a person is capable of paying for consultation, medicines are expensive when available because are sometimes not available when the ordered packages do not yet arrive. That is also a challenge, but in general, their medicines are too expensive; it requires a person to have health insurance or be financially stable, but actually, it is not easy to take money from your pocket and pay medical fees.” CSO respondent “…It is clear that NCD services are not fully funded, meaning that some amount is paid by the patient, which is different from HIV services. This makes patients with NCDs pay for the services, and sometimes they are experiencing financial hardship, which may lead to poor adherence…” CSO respondent. Fragmented Referral Pathways for NCD Care among PLHIV The respondents described significant barriers within the referral system for PLHIV diagnosed with NCDs, particularly those who use the CBHI. Following diagnosis, patients are often required to return to their health centre to obtain a formal referral document for NCD services, which prevents same-day access to care. This fragmented process creates additional logistical burdens, contributes to delays in treatment, limits timely access to care, and results in lost productivity due to repeated visits to healthcare facilities. “There is a process where patients must go through the health centre to receive a transfer for treatment through the Rwanda Social Security Board's (RSSB) approved channels. However, once referred, there is no one to follow up with the patient, and they end up waiting with others. Sometimes, the patient is given an appointment due to the high number of patients, only to return the next day and report that they were not treated. This situation places a burden on the patient, leading to delays and a significant loss of time.” HCP respondent. Suboptimal Follow-up Systems The respondents reported significant challenges in ensuring effective follow-up care for PLHIV with NCD comorbidities. The lifelong nature of HIV treatment, combined with the added burden of chronic NCD medications, was described as contributing to patient fatigue, which in turn affects adherence and may lead to treatment discontinuation. One central program implementer noted that the prolonged management of multiple chronic conditions imposes a considerable burden on patients. Inadequate follow-up was also attributed to shortages in the healthcare workforce and the absence of community-level monitoring systems to support ongoing care between facility visits. “The second issue is the long-term follow-up required for NCDs. These are chronic diseases that patients live with for an extended period, often requiring lifelong medication. When combined with HIV treatment, this can lead to patient fatigue, which may result in poor adherence to medication or inadequate follow-up care.” CPI respondent Healthcare providers also highlighted systemic barriers to effective patient follow-up. Suboptimal follow-up was attributed to persistent workforce shortages within health facilities and the absence of community-based monitoring mechanisms to support patients between clinical visits. “The challenges are similar across the other services, but there is a shortage of trained staff and a lack of community follow-up. We had people who were used to making follow-ups on NCD cases in the community, but they have been suspended. The people living with HIV usually come to pick up their drugs, but there is no proper follow-up for NCD cases in the community.” HCP respondent Long Waiting Times A few respondents reported that patients frequently expressed dissatisfaction with delays in service delivery at health facilities. “…What we did not talk about is the amount of time people spend here. Because a person who has been done many different services sees that they take a lot of time at the hospital.” HCP respondent Information Sharing and Coordination Challenges Challenges related to coordination and information sharing across services were frequently highlighted by the respondents. In some cases, diagnostic tests were unnecessarily repeated, suggesting poor communication between service units and a lack of integrated patient records. These inefficiencies hinder effective follow-up and compromise the overall quality and efficiency of service provision. “We sometimes repeat the tests that have been done from another service. This is caused by the fact that these services work independently. Some tests, like creatinine and others, may be requested from another service, and when patients come to our service, we can repeat them because we are not aware if they have been collected, and most patients are not aware of the tests collected.” Nurse from NCD services. “…there is unkown information about other services they receive and other treatments, so that can be taken into consideration at an appropriate level.” CPI respondent. Discussion This qualitative study provides valuable insights into the experiences and challenges faced by healthcare providers and stakeholders in delivering NCD care within HIV service settings in Rwanda. Despite considerable progress in the provision of HIV care, persistent challenges, particularly the fragmentation of services and limited healthcare workforce capacity, continue to hinder the effective management of NCDs alongside HIV care, as consistently reported in recent studies. Status of NCD Service Delivery The findings of this study indicate that the delivery of NCD care for PLHIV in Rwanda is not integrated into existing HIV care and treatment services, resulting in significant fragmentation of care. Consistent with evidence from other African contexts, this fragmentation stemming from parallel health systems for HIV and chronic disease care poses a major barrier to providing comprehensive, patient-centred services. Achieving effective integration will require the development and implementation of evidence-based strategies tailored to the unique needs of PLHIV ( 7 , 8 ). Most healthcare providers and stakeholders reported that PLHIV diagnosed with NCDs are typically referred to separate departments or different healthcare facilities for specialised care. This finding aligns with literature that highlights similar patterns of care fragmentation, where PLHIV are transferred to other health facilities or services for the management of detected NCDs ( 9 – 11 ) While some participants acknowledged the decentralisation of NCD screening to health centres and the use of task shifting for trained nurses to manage NCDs, care delivery remains compartmentalised, resulting in fragmented patient pathways. The lack of integration was repeatedly highlighted as a barrier to delivering efficient and holistic care, as patients are required to navigate multiple health services, which could lead to delays and gaps in care. Experience with current NCD service delivery in HIV care One of the central findings of this study is the fragmentation of service delivery. While screening for NCDs such as hypertension is routinely incorporated into HIV care, actual NCD management is frequently transferred to specialised services or other health facilities. This separation of services results in a disjointed experience for patients, who must navigate multiple points of care. The same findings were highlighted in other studies, where the integrated care for NCDs for PLHIV remains a complex issue ( 10 , 11 ). This fragmentation is particularly apparent in the patient referral system, where PLHIV who are diagnosed with NCDs are often sent to another department or health facility. This is similar to the finding that patients face difficulties accessing comprehensive care, often having to navigate unconnected appointments and facilities for HIV and NCD management ( 12 ). This fragmentation complicates the care of PLHIV and leads to poor adherence to both HIV and NCD treatments, as they struggle with the logistical burdens of managing multiple appointments across different services or health facilities ( 12 – 14 ). Few respondents mentioned that the decentralisation of NCD services to health centres is a good step in the management of NCDs and recommended that it should be effectively integrated into the HIV care continuum model. The integration of NCD care within HIV services has been proposed by interviewees as a potential solution to overcome this fragmentation; this suggestion is similar to the finding that integrated care can improve both HIV and NCD outcomes by providing a more streamlined approach to patient management ( 15 – 17 ). Hypertension, diabetes, and cardiovascular diseases were identified as the most prevalent NCDs among PLHIV, and this finding is consistent with studies showing a greater burden of these diseases among PLHIV( 18 – 20 ). The increased risk of NCDs in elderly people and those with obesity or low immunity is also well established, aligning with global trends that recognise age and comorbidities as major risk factors for NCDs among PLHIV ( 18 – 20 ). Experienced challenges in NCD service delivery This study highlights several critical challenges in the implementation of NCD care within HIV service settings. The most significant challenge identified was the shortage of healthcare providers with adequate skills and knowledge to manage both HIV and NCDs. The respondents reported that healthcare providers working in HIV services often lack the necessary competencies to manage NCDs, whereas those based on NCD services have limited training and experience in delivering HIV care. This gap in expertise underscores the urgent need for targeted training initiatives to increase the capacity of HIV care providers in NCD management. Consistent with our findings, previous studies have identified the shortage of qualified healthcare workers as a persistent barrier to the effective integration of NCD management within HIV ( 21 – 24 ). However, this approach presents different challenges, especially the heavy workload faced by HIV healthcare providers, mainly nurses and social workers; this will add more tasks for them, as they are already responsible for delivering a range of HIV-related services. In terms of the abovementioned challenges, the delay in service delivery leading to the long waiting time mentioned in this research repeatedly comes from patients seeking services and is similar to a recent report from the Rwanda Ministry of Health indicating that the healthcare worker population density is one healthcare worker per 1,000 people ( 25 ). This figure falls behind the WHO-recommended healthcare worker density of 4.45 healthcare workers per 1,000 people ( 25 , 26 ). Task shifting, proposed as a solution involving the delegation of certain aspects of care from specialised providers to lower-level providers, has been described as a double-edged sword: although it might reduce the workload of specialised providers, it can also compromise the quality of care if the delegated providers are not adequately trained ( 27 – 29 ). Rwanda a success story in task shifting through trained nurses delivering HIV care, such as prescribing ART, supporting retention, improving patients' health outcomes, and working with community health workers to minimise the number of patients lost to follow-up ( 30 ). The cost of NCD treatment was also identified as a challenge, and financial barriers remain significant, with a focus on medications that are not covered by community-based health insurance. This was reported in other settings where out-of-pocket spending on NCDs can worsen the burden on that population ( 23 , 31 ). The financial constraints impact nonadherence to treatment, as PLHIV, rather than NCDs, require a budget that may prioritise HIV care, which is free for coverage. Another major challenge is the referral system, which requires patients to return to the health centre or another health facility to obtain NCD service referral documents before they can access NCD care. This process causes delays and adds logistical burdens for patients ( 20 – 23 ). This inadequate referral system has been identified as a barrier to timely care in other studies and requires improvements in health system coordination ( 24 , 25 ). There is a need for streamlining the referral process, and integrating NCD services into HIV care services could improve the PLHIV experience and reduce the time spent at health facilities ( 32 ). While participants described that patients presenting with symptoms suggestive of NCDs during routine HIV care follow-up were referred to designated NCD services, none of the participants mentioned any follow-up mechanism to track whether these referrals led to actual service uptake. This finding indicates that we did not provide insight into the outcomes of these referrals. This lack of follow-up information highlights uncertainties around the continuity and effectiveness of the referral process within integrated HIV and NCD care, particularly in resource-constrained settings. Similarly, weak referral and tracking systems can limit the effectiveness of integrated care efforts, particularly when health systems are understaffed and overburdened ( 8 ). Proposed solution to the identified challenges Given the challenges outlined, the participants presented several solutions. First and foremost, integrating NCD care into HIV services was viewed as a vital step toward better healthcare delivery. Integration can reduce fragmentation, streamline the patient experience, and potentially improve health outcomes. However, the integration of HIV and NCD services requires meticulous planning and strategic capacity building to address different care models, clinical workflows, and resource demands of both disease areas. Healthcare providers must be trained not only in managing the chronic nature of NCDs alongside HIV but also in using integrated clinical protocols, ensuring continuity of care, and navigating potential challenges such as increased patient load, overlapping medication regimens, and complex comorbidity management. These are in line with the key issues identified by the NCD program in Rwanda, highlighting the minimal integration of NCD prevention and control with public healthcare platforms such as HIV/AIDS ( 33 ) Another significant proposal was to train healthcare providers in the management of NCDs, particularly in HIV care settings. The proposal reflects the reform planned by the Rwanda MOH by 2028 to increase the healthcare workforce ( 25 ). While capacity-building initiatives, such as targeted training, are critical to improving healthcare providers’ ability to manage the dual burden of HIV and NCDs, their effectiveness depends on the concurrent resolution of systemic organisation constraints, particularly those related to workload, staffing shortages, and the integration of service delivery models. Furthermore, the availability of guidelines and treatment regimens specifically designed for managing NCDs in PLHIV should be ensured. Improving the financial accessibility of NCD care, ensuring the availability of necessary treatment in health facility pharmacies, and reducing patients' out-of-pocket payments were also emphasised. Expanding community-based health insurance coverage and ensuring that all NCD treatments are included in the package of services covered by insurance schemes would reduce patients' financial burdens and encourage improved treatment adherence. Finally, a more efficient and coordinated referral system, as well as improved community-level follow-up, was proposed to improve patient adherence and long-term health outcomes. Patients are more likely to adhere to their treatment plans if the time and effort required to obtain NCD services are reduced and follow-up care is consistently delivered. Implications for Policy and Practice The findings of this study underscore the need for systemic changes to improve the provision of NCDs within HIV care services. There is a critical need to incorporate structured NCD training into national HIV clinical guidelines to ensure that healthcare providers can manage both HIV and NCDs effectively. Prioritising task shifting from specialised providers to trained healthcare providers, training providers across the continuum of care, and ensuring that well-trained personnel deliver both NCD and HIV care are crucial. It is also recognised by the Rwanda Ministry of Health, stating that a reform is needed to resolve the challenge with the goal of quadrupling the number of healthcare workers by 2027 to bring Rwanda closer to the WHO recommendation ( 25 ). In addition, the integration of certain NCD services into HIV care services could mitigate fragmentation, reduce referral delays, and improve adherence to treatment. Addressing the financial barriers to NCD care services is essential; policymakers could extend coverage under a community-based health insurance scheme to include all NCD treatments that are not included. Reducing the financial burden on patients would likely improve adherence and health outcomes. Improving the referral system for NCD cases that require advanced care and complicated cases requiring specialist management and ensuring better coordination of NCD care within HIV services are essential for providing more effective care. In addition, setting up a referral tracking system with feedback loops to providers could enhance the continuity of care and improve patients' outcomes when integrated services are provided. In the context where HIV and NCD services are colocated or linked, investment in simple, workable mechanisms for documenting and monitoring referral outcomes may help ensure that patients do not fall through the cracks ( 8 ). Finally, efforts to share patients’ information across services and avoid unnecessary duplication of tests could improve the efficiency of care and reduce the burden on patients. Limitations Although the study offers significant insights, many constraints should be recognised. This study did not include information on the follow-up of patients referred from HIV to NCD services. We did not know whether or how referred patients were tracked or whether they successfully accessed the recommended care. Therefore, we are unable to mention information on the effectiveness of the referral process. Future studies should consider incorporating specific prompts from patient records or service-level monitoring tools to better understand referral outcomes. The study relied on self-reported data, which, while valuable for capturing participants’ subjective perspectives, may be subject to social desirability bias. Given the professional roles of respondents within the health system, some may have felt constrained in expressing critical views, whether due to perceived expectations, fear of judgment, or concerns about potential implications for their job security. Future research could mitigate this limitation by incorporating independent observations, document reviews, or patient feedback to increase the validity and depth of the findings. Conclusion Delivering care for NCDs within HIV services in Rwanda presents a significant challenge but also a clear opportunity for improvement. Significant barriers remain challenges, particularly related to the fragmentation of care, the provider capacity, the financial burden of care, the medication shortage, and the fragmented referral system. Addressing these challenges through policy reform, strengthening healthcare infrastructure, increased provider training, resource allocation, and better coordination could lead to more effective, efficient, and comprehensive care for PLHIV with NCDs and ultimately improve health outcomes for this vulnerable population. These actions not only benefit PLHIV but also contribute to the broader health system and community in Rwanda and other countries with similar settings. Abbreviations 1. ART antiretroviral therapy 2. CSO Civil Society Organisation 3. CPI Central-level Program Implementers 4. DP Development Partners 5. HCPs healthcare providers 6. NCDs Noncommunicable diseases PLHIV people living with HIV Declarations Ethics approval and consent to participate The Rwanda National Ethics Committee approved the study (RNEC) No. 210/RNEC/2020 and No. 84/RNEC/2021. All participants provided informed consent before taking part in the study. The study keeps participants’ information confidential through the use of codes and a password-protected database. A unique research identification number was assigned to each participant and used across all study procedures. Consent for publication Not applicable Conflicts of interest The authors declare that they have no competing interests. Funding The study was implemented under funds from the Rwanda National Council for Science and Technology (NCST) under excellent research funding. The funder of the study had no role in the design, data collection, data analysis, data interpretation, or writing of the manuscript. Author Contribution VD, LN, YVNU, VNU, BAK, PK, JV, MFM,PM, LB,JCSN, CM, ER, MD,MT, NABN, GVH, SC: study inceptionVD, LD, YVNU, VNU: design and tool development, data collection VD, LN, YVNU, VNU, MMF: transcription, analysis, aMD, MT, NABN, GVH, SC: read the manuscript, provide input, and approve the version for submission.GVH, SC: study inception, study implementation, analysis, and manuscript writing supervision Acknowledgement We acknowledge all the participants of the study and all the technical assistance provided by the key stakeholder institutions and health facility leadership of the NCOHIRWA Cohort Study research sites, as well as those who were supported in transcription and translation, data coding, and proofreading of the manuscript. Availability of data and materials The datasets generated and/or analysed during the current study are available from the corresponding author upon reasonable request. References WHO. Noncommunicable diseases [Internet]. 2024 [cited 2025 Jun 5]. Available from: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases Moyo-Chilufya M, Maluleke K, Kgarosi K, Muyoyeta M, Hongoro C, Musekiwa A. The burden of noncommunicable diseases among people living with HIV in Sub-Saharan Africa: a systematic review and meta-analysis. EClinicalMedicine [Internet]. 2023 Nov 1 [cited 2025 Jun 5];65. Available from: https://www.thelancet.com/action/showFullText?pii=S2589537023004327 Rwanda, Biomedical Centre. HIV,STIs and Viral Hepatitis Program annual report 2022–2023 [Internet]. Kigali; 2023 [cited 2025 Mar 15]. Available from: https://www.rbc.gov.rw/fileadmin/user_upload/report23/HIV%20Annual%20report%202022%20-2023.pdf Coetzee L, Bogler L, De Neve J, Bärnighausen T, Geldsetzer P, Vollmer S. HIV, antiretroviral therapy and non-communicable diseases in sub‐Saharan Africa: empirical evidence from 44 countries over the period 2000 to 2016. 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Tropical Medicine & International Health [Internet]. 2017 Aug 1 [cited 2025 Mar 3];22(8):926–37. Available from: https://onlinelibrary.wiley.com/doi/full/ 10.1111/tmi.12901 Odayar J, Phillips TK, Hennessey C, Myer L. Guidelines for the transfer of people living with HIV attending primary healthcare facilities in South Africa: a scoping review. Int Health [Internet]. 2024 Oct 24 [cited 2025 Mar 3];0:1–8. Available from: https://dx.doi.org/10.1093/inthealth/ihae057 Kasango A, Daama A, Negesa L. Challenges in managing HIV and noncommunicable diseases and health workers’ perception regarding integrated management of noncommunicable diseases during routine HIV care in South Central Uganda: A qualitative study. PLoS ONE. 2024;19(8):e0302290. n der Mannen JS, Heine M, Lalla-Edward ST, Ojji DB, Mocumbi AO, Klipstein-Grobusch K. Lessons Learnt from HIV and Noncommunicable Disease Healthcare Integration in Sub-Saharan Africa. Glob Heart. 2024;19(1). Knight L, Schatz E, Mukumbang FC. I attend at Vanguard and I attend here as well: barriers to accessing healthcare services among older South Africans with HIV and noncommunicable diseases. Int J Equity Health. 2018;17(1):147. Chireshe R, Manyangadze T, Naidoo K. Integrated chronic care models for people with comorbid of HIV and noncommunicable diseases in Sub-Saharan Africa: A scoping review. PLoS One [Internet]. 2024 Mar 1 [cited 2025 Mar 8];19(3):e0299904. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0299904 McCombe G, Murtagh S, Lazarus JV, Van Hout MC, Bachmann M, Jaffar S et al. Integrating diabetes, hypertension and HIV care in sub-Saharan Africa: a Delphi consensus study on international best practice. BMC Health Serv Res [Internet]. 2021 Dec 15 [cited 2025 Mar 8];21(1):1235. Available from: https://bmchealthservres.biomedcentral.com/articles/ 10.1186/s12913-021-07073-0 McCombe G, Lim J, Van Hout MC, Lazarus JV, Bachmann M, Jaffar S et al. Integrating Care for Diabetes and Hypertension with HIV Care in Sub-Saharan Africa: A Scoping Review. Int J Integr Care. 2022;22(1). Gonah L, Moodley I, Hlongwana K. Prevalence, healthcare costs and management of noncommunicable diseases in people living with human immunodeficiency virus: A scoping review. Afr J Prim Health Care Fam Med [Internet]. 2020 Oct 19 [cited 2025 Mar 8];12(1):8. Available from: https://phcfm.org/index.php/phcfm/article/view/2474/4306 Achwoka D, Waruru A, Chen TH, Masamaro K, Ngugi E, Kimani M et al. Noncommunicable disease burden among HIV patients in care: a national retrospective longitudinal analysis of HIV-treatment outcomes in Kenya, 2003–2013. BMC Public Health [Internet]. 2019 Dec 3 [cited 2025 Mar 8];19(1):372. Available from: https://bmcpublichealth.biomedcentral.com/articles/ 10.1186/s12889-019-6716-2 Moyo-Chilufya M, Maluleke K, Kgarosi K, Muyoyeta M, Hongoro C, Musekiwa A. The burden of noncommunicable diseases among people living with HIV in Sub-Saharan Africa: a systematic review and meta-analysis. EClinicalMedicine [Internet]. 2023 [cited 2025 Mar 8];65:102255. Available from: www.thelancet.com. Kasango A, Daama A, Negesa L. Challenges in managing HIV and noncommunicable diseases and health workers’ perception regarding integrated management of noncommunicable diseases during routine HIV care in South Central Uganda: A qualitative study. PLoS One [Internet]. 2024 Aug 1 [cited 2025 Mar 9];19(8):e0302290. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0302290 Badacho AS, Woltamo DD, Demissie DB, Mahomed OH. 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. Volume 12. SAGE Open Medicine. SAGE Publications Ltd; 2024. Achwoka D, Mutave R, Oyugi JO, Achia T. Tackling an emerging epidemic: the burden of noncommunicable diseases among people living with HIV/AIDS in sub-Saharan Africa. PAMJ. 2020; 36:271 [Internet]. 2020 Aug 12 [cited 2025 Mar 9];36(271):1–9. Available from: https://www.panafrican-med-journal.com//content/article/36/271/full Patel P, Sabin K, Godfrey-Faussett P. Approaches to Improve the Surveillance, Monitoring, and Management of Noncommunicable Diseases in HIV-Infected Persons: Viewpoint. JMIR Public Health Surveill. 2018;4(4):e10989 https://publichealth.jmir.org/2018/4/e10989 [Internet]. 2018 Dec 20 [cited 2025 Mar 9];4(4):e10989. Available from: https://publichealth.jmir.org/2018/4. 4X4 Reform. Executive Summary Towards Quadrupling the current workforce in 4 years (4x4); Uplifting Quantity and Quality of care. 2024. Health workforce requirements for universal health coverage and the Sustainable Development Goals. (‎Human Resources for Health Observer, 17)‎ [Internet]. [cited 2025 Jun 5]. Available from: https://iris.who.int/handle/10665/250330 Joshi R, Thrift AG, Smith C, Praveen D, Vedanthan R, Gyamfi J et al. Task-shifting for cardiovascular risk factor management: lessons from the Global Alliance for Chronic Diseases Analysis. BMJ Glob Health [Internet]. 2018 [cited 2025 Mar 13];3:1092. Available from: https://gh.bmj.com Rabkin M, de Pinho H, Michaels-Strasser S, Naitore D, Rawat A, Topp SM. Strengthening the health workforce to support integration of HIV and noncommunicable disease services in sub-Saharan Africa. AIDS [Internet]. 2018 Jul 1 [cited 2025 Mar 13];32(Supplement 1):S47–54. Available from: https://journals.lww.com/00002030-201807011-00006 Leong SL, Teoh SL, Fun WH, Lee SWH. Task shifting in primary care to tackle healthcare worker shortages: An umbrella review. European Journal of General Practice [Internet]. 2021 [cited 2025 Mar 11];27(1):198–210. Available from: https://www.tandfonline.com/action/journalInformation?journalCode=igen20 Nsanzimana S, Prabhu K, McDermott H, Karita E, Forrest JI, Drobac P et al. Improving health outcomes through concurrent HIV program scale-up and health system development in Rwanda: 20years of experience. BMC Med [Internet]. 2015 Sep 9 [cited 2025 Jun 5];13(1):1–7. Available from: https://bmcmedicine.biomedcentral.com/articles/ 10.1186/s12916-015-0443-z Garrib A, Birungi J, Lesikari S, Namakoola I, Njim T, Cuevas L et al. Integrated care for human immunodeficiency virus, diabetes and hypertension in Africa. Trans R Soc Trop Med Hyg [Internet]. 2019 Dec 1 [cited 2025 Mar 13];113(12):809–12. Available from: https://dx.doi.org/10.1093/trstmh/try098 Adeyemi O, Lyons M, Njim T, Okebe J, Birungi J, Nana K, et al. Integration of noncommunicable disease and HIV/AIDS management: a review of healthcare policies and plans in East Africa. BMJ Glob Health. 2021;6(5):e004669. National Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda. 2020. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7150794","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":487330468,"identity":"ea827e0c-9037-4afc-9f61-0269d033292e","order_by":0,"name":"Valentine 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Montréal","correspondingAuthor":false,"prefix":"","firstName":"Madeleine","middleName":"","lastName":"Durand","suffix":""},{"id":487330492,"identity":"afe26f28-1865-455c-a9ed-5a1b7110baf3","order_by":14,"name":"Marc Twagirumukiza","email":"","orcid":"","institution":"University of Ghent","correspondingAuthor":false,"prefix":"","firstName":"Marc","middleName":"","lastName":"Twagirumukiza","suffix":""},{"id":487330494,"identity":"0da3396c-ae6a-42ce-895a-c756736d76a4","order_by":15,"name":"Ntobeko AB Ntusi","email":"","orcid":"","institution":"University of the Witwatersrand","correspondingAuthor":false,"prefix":"","firstName":"Ntobeko","middleName":"AB","lastName":"Ntusi","suffix":""},{"id":487330495,"identity":"737daf75-343b-4aba-ae76-263ab680f449","order_by":16,"name":"Geert Hove","email":"","orcid":"","institution":"University of Ghent","correspondingAuthor":false,"prefix":"","firstName":"Geert","middleName":"","lastName":"Hove","suffix":""},{"id":487330496,"identity":"35278760-183c-4035-8d47-42800cce7b29","order_by":17,"name":"Steven Callens","email":"","orcid":"","institution":"University of Ghent","correspondingAuthor":false,"prefix":"","firstName":"Steven","middleName":"","lastName":"Callens","suffix":""}],"badges":[],"createdAt":"2025-07-17 15:54:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7150794/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7150794/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87882854,"identity":"574147d6-5937-4d8e-81d1-ea955ced0386","added_by":"auto","created_at":"2025-07-30 04:46:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1069733,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7150794/v1/afbd67e2-3b5d-47df-bfcf-f823472efa12.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Provider's and stakeholders' experiences with and perceptions of the benefits and challenges of delivering care for noncommunicable diseases within HIV care services in Rwanda","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNoncommunicable diseases (NCDs) represent a significant burden on the health system globally (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) The rise in NCDs is mainly in sub-Saharan Africa, compounded by the remaining effects of the HIV epidemic (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). NCDs present a challenge for healthcare providers, especially when managing the complex needs of patients who are living with a double burden of HIV and NCDs. Rwanda has made remarkable progress in controlling the HIV epidemic. Rwanda has adopted a comprehensive approach to HIV care, which includes prevention, treatment, and care services. Rwanda efforts have been recognised globally as a model for successful HIV programs, especially in sub-Saharan Africa. By 2023, Rwanda had achieved significant milestones in terms of reducing the prevalence of HIV, with more than 97.5% of people living with HIV (PLHIV) accessing antiretroviral therapy (ART) and 95-95-95, with an estimated 95% of people living with HIV aware of their status, 97.5% receiving ART, and 98% achieving viral load suppression (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These achievements demonstrate Rwanda's dedication to ending the HIV/AIDS epidemic and improving the quality of life for the infected and affected populations (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWith the success of ART, PLHIV are living longer and are increasingly at risk of developing NCDs, particularly those associated with ageing, lifestyle factors, and the side effects of ART use (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). NCDs such as hypertension, diabetes, cardiovascular diseases, and cancer have been shown to complicate HIV treatment and care (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Moreover, the treatment for NCDs often requires long-term, complex management, which overlaps with the care needed for HIV. This complex challenge requires an integrated, coordinated, and multistakeholder approach to health care delivery. Understanding the experiences and perceptions of benefits and challenges in delivering care for noncommunicable diseases within HIV care services is crucial to improving the healthcare system's ability to manage the double burden of HIV and NCDs. By addressing these challenges and building benefits, Rwanda can continue to enhance its health system's capacity to provide effective, patient-centred care. This process requires active collaboration among all stakeholders, including healthcare providers, policymakers, and the communities they serve, to ensure the sustainability and success of incorporating NCD care models into HIV services. This study aims to explore providers' and stakeholders' experiences with NCD service delivery within HIV care services in Rwanda and identify providers' and stakeholders’ perceptions of challenges in NCD service delivery within HIV care services in Rwanda.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe conducted a qualitative descriptive study to explore providers' experiences and perceptions regarding the benefits and challenges of delivering care for NCDs within HIV care services in Rwandan health facilities (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This design was chosen to capture rich, contextual insights into experiences and challenges in delivering NCDs within HIV care services from the perspective of providers and stakeholders.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The study took place in 12 Rwandan health facilities providing HIV and NCD treatment and care services located in the five provinces and in the key stakeholder institutions located in Kigali city and Eastern Province.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy participant sampling\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePurposive sampling was used to select the participants who were directly involved or had significant experience in the delivery of NCD or HIV care services. Participants were selected on the basis of their roles and expertise in the management of HIV or NCDs at the selected research sites and the key collaborating institutions and development partners in the delivery of both services.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy participants\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The participants include healthcare providers (including doctors, nurses and social workers working in HIV and NCD care services) (HCPs) and stakeholders composed of central-level program implementers (Rwanda Biomedical Centre: an implementing agent of the Rwanda Ministry of Health) (CPIs) focused on HIV and NCDs at the central level, civil society organisations (CSOs) and development partners (DPs) working in NCD and HIV programs.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003e We conducted face-to-face, in-depth interviews to gain a comprehensive understanding of the participants' experiences, insights, and perspectives. The interviews allowed for flexibility, ensuring that participants could discuss their unique experiences and perceptions.\u003c/p\u003e\u003cp\u003e At the health facility, an introductory letter pointing out the research and requesting collaboration in the study implementation was sent, the principal investigator visited the sites to meet the facilities' leadership, and they introduced the health care provider in HIV and NCD services for more explanation. Health facility management nominated the health provider to work with on the basis of their role and responsibility related to the study. We scheduled the interviews on the basis of the availability of healthcare providers and conducted them in a private room to ensure confidentiality.\u003c/p\u003e\u003cp\u003eFor the stakeholders, we identified the key stakeholders of the HIV and NCD programs. After their identification, we sent invitations to the institutions for the nomination of two to three participants who work in or work closely with HIV or NCD services. The institution nominated the participants, after which we scheduled interviews according to their availability. The study team developed and validated an interview guide to obtain responses to the research question. The team of experienced research assistants conducted 49 in-depth interviews in participants' preferred language, either Kinyarwanda or English, and audio recordings were transcribed verbatim; transcripts in Kinyarwanda were then translated into English.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAnalysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe analysed the data via Dedoose software, version 9.0, and applied thematic analysis to identify patterns and insights within the data. The steps are as follows:\u003c/p\u003e\u003cp\u003eFamiliarisation with the data involved the research team reading and rereading the transcripts to immerse themselves in the information and identify emerging ideas and patterns.\u003c/p\u003e\u003cp\u003eThe research team systematically coded the transcripts via Dedoose. The coding employed both inductive (emerging from the data) and deductive (based on predefined themes such as challenges and NCD management) approaches.\u003c/p\u003e\u003cp\u003eAfter coding, we grouped the data into broader themes on the basis of the research objectives. These themes reflected recurring patterns and significant insights across participants' narratives.\u003c/p\u003e\u003cp\u003eInterpretation of findings: The identified themes were examined for their relevance and implications. The research team considered how these themes inform the understanding and improvement of healthcare practices and policies.\u003c/p\u003e\u003cp\u003eTriangulation: We used data triangulation to ensure the validity and reliability of the findings. This is done by comparing the data across participant groups, including healthcare providers, central-level program implementers, civil society organisations, and development partners, to check consistency and identify any discrepancies in the findings. Divergent views across participant groups were not considered contradictions but were treated as meaningful variations that reflected differences in roles, perspectives, and experiences.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical consideration\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The Rwanda National Ethics Committee, No.84/RNEC/2021, granted ethical approval for the study, and we obtained informed consent from each participant prior to their participation. For confidentiality, we used codes for the identification of participants, audio recordings and transcriptions were securely stored, and all the data were anonymised to retain privacy.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eParticipant characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA total of 49 participants, consisting of 27 men and 22 women, were included in the study. Most were health care providers (n\u0026thinsp;=\u0026thinsp;23), followed by development partners (n\u0026thinsp;=\u0026thinsp;10), central-level program implementers (n\u0026thinsp;=\u0026thinsp;9), and civil society organisations (n\u0026thinsp;=\u0026thinsp;7).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMen (M)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWomen (W)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDevelopment Partner\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCivil Society Organisations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthcare providers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCentral-level program implementers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWe ascribed the data to two main themes to structure the results: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) experience with the current status of NCD service delivery within HIV care programs for PLHIV and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) challenges with the current NCD service delivery with HIV care services for PLHIV.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 1: Experience with the current status of NCD service delivery with HIV care services for PLHIV\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTransfer to specialist/orientation to NCD services\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMost participants articulated that the services for NCD care are not provided at the same place for HIV care and treatment, but if a PLHIV is diagnosed with NCDs, he/she is instead sent to another department for specialised management or to another health facility, such as a health centre. This implies a fragmented healthcare system where patients need to navigate different services to receive appropriate care, thus complicating the management of their health conditions, and the participants indicated that NCD services are not yet integrated into HIV patient care even if there are some achievements. HCPs, CPIs, and DPs expressed this concern most frequently.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Both services are not combined, which results in barriers to the patient; both patients with NCDs and patients with HIV have separate schedules for the service not only the services are being separated but also the healthcare providers are different, and the fact that patient has to be treated individually cannot be reached; therefore, we cannot reach the therapeutic goal that we wish for the patients.\u0026rdquo; CSO respondent.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eProposed solution\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSome of the participants proposed integration as a solution to the existing challenges in service provision.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026hellip;..The remaining one is that the services are still working separately, one of the things which can be helpful is the integration.\u0026rdquo; CSO respondent\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn contrast to the general trend, a few respondents described efforts similar to partial integration.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;What we do is an integrated service in terms of screening and identifying the condition. However, in terms of managing the condition, we refer patients to the appropriate NCD services.\u0026rdquo; CSO respondent.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...otherwise, what we do is an integrated service, but it is a way of detecting or tracking down, but in terms of taking care, we leave it to other NCD services.\u0026rdquo; HCP respondent.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSimilarly, others explained that if a patient presents with symptoms suggestive of an NCD during a routine HIV visit, they are promptly referred to the designated NCD care department.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWhen a patient presents with symptoms related to an NCD, we right away refer the patient to the given NCD focal person or department that deals with such conditions\u003c/em\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eDecentralisation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA minority of respondents described NCD care services as being decentralised to the health centre level, primarily for screening activities. Some healthcare providers noted the implementation of task shifting in different hospitals and health centres where trained nurses have assumed NCD management responsibilities previously handled by physicians due to shortages of specialised providers. The respondents emphasised that screening for NCDs in HIV clinics facilitates early detection of risk factors, allowing clinicians to modify antiretroviral therapy (ART) regimens to mitigate these risks. However, they also expressed concern that despite these efforts, NCDs are frequently detected at advanced stages in some patients.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...the healthcare providers screen her, and when they find that she has started to get a risk, they change the treatment.\u0026rdquo; HCP respondent.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFew of the respondents highlighted the progress made in expanding healthcare services for NCDs. They noted that NCD services are now available in some health facilities, have been decentralised, and expressed optimism that, in the future, these services will be distributed more widely, similar to how HIV care, treatment, and prevention services are available throughout the whole country. They compare the success in decentralising NCD services to the recognised network of HIV care services and hope that there will be broader access to NCD care.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We have reached a good milestone thus far because NCD services are already in some health facilities and have been decentralised. We think that in the future, it will be disseminated as it has been to services of HIV care, treatment, and prevention, which are available in the whole country.\u0026rdquo; CPI respondent.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMost common NCDs in PLHIV and people at high risk of NCDs\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe narratives of the participants revealed that they were aware of the most common NCDs and their risk factors. Hypertension was highlighted as the most common NCD among PLHIV, followed by diabetes and cardiovascular diseases. Other conditions reported by participants included cancer, asthma, and renal failure.\u003c/p\u003e\u003cp\u003eThe participants identified PLHIV as a population at high risk for developing NCDs, with particular emphasis on those aged 50 and above. Some respondents also noted elevated risk among adults as young as 35 years. Additional high-risk groups identified by participants included individuals with obesity, those with compromised immune function, and smokers.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eMost people I have seen, people who are obese, people who are overweight, tend to have diabetes and high blood pressure\u0026hellip;\u0026rdquo; HCP respondent.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;NCDs, we know that are diseases that mostly affect adults aged 35 years and above but are the most common diseases in people with other illnesses and are easily affected.\u0026rdquo; HCP respondent\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;\u0026hellip;people who are often in their fifties or older, but among those living with the HIV virus, there are also young people who get diabetes without considering the age.\u0026rdquo; HCP respondent.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;behaviours like taking a lot of alcohol, smoking or taking other drugs, living without doing sports in life, and more others.\u0026rdquo; HCP respondent.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 2: Experienced challenges with current NCD service delivery with HIV care services for PLHIV\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eShortage of staff and limited capacity for effective management of NCDs\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe respondents were most concerned with the need for knowledge and skills for NCD management for nurses providing HIV care services. They noted that as more PLHIV present with NCD comorbidities, healthcare providers require additional training to competently deliver both HIV and NCD care. This need for capacity building was further coupled with the absence of guidelines for NCD diagnosis and management among PLHIV. These concerns were consistently raised by HCPs, CPIs, and DPs.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;HIV services can continue to operate independently, and then the healthcare professional in HIV services can be trained to obtain necessary skills related to the management of hypertension and cardiovascular diseases because telling a patient to go to another service can also pass through different channels we are preventing. If possible, it can be integrated. I can\u0026rsquo;t say that HIV services can be integrated with NCDs, can be too much; I advise that the profession in HIV services can obtain the capacity to manage detected NCDs.\u0026rdquo; CSO respondent.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...actually, we have a problem of not having trained professionals about NCDs.\u0026rdquo; HCP respondent\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We still have the problem of human resources; staff where you find that the staff who are trained on HIV are not the ones who are trained for NCDs implies that healthcare providers who are providing HIV services have little knowledge of NCDs and those providing NCD services have little knowledge of HIV.\u0026rdquo; CSO\u003c/em\u003e respondent\u003c/p\u003e\u003cp\u003eMost respondents emphasised that integrating NCD screening into existing HIV care services substantially increases the workload of healthcare providers beyond their current responsibilities related to HIV management. This concern was particularly evident among healthcare providers at health centres, who already tasked with delivering multiple service packages beyond HIV care.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s understandable, in some health facilities, you can find that health care providers have many responsibilities, they have heavy responsibilities, which lead them to focus on HIV care only, and then they do not check for other diseases the patients did not show or do not declare their presence, sometimes they do not care about them\u0026hellip;\u0026hellip;.\u0026rdquo; CPI respondent.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eHigh Cost of NCD Care and Limited Availability of Essential Medicines at Health Facilities\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe respondents frequently highlighted that the cost of medication imposes a significant financial burden on patients, compounded by inconsistent availability of drugs at health facility pharmacies. When medications are out of stock, patients must purchase them from private pharmacies where costs are often not covered by community-based health insurance (CBHI) schemes, resulting in increased out-of-pocket expenditures.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;... PLHIV with NCDs without health insurance or without the capacity to pay all fees, most of the people do not have financial capacity, and those diseases empty their pockets, which makes diagnosis complicated. When a person is capable of paying for consultation, medicines are expensive when available because are sometimes not available when the ordered packages do not yet arrive. That is also a challenge, but in general, their medicines are too expensive; it requires a person to have health insurance or be financially stable, but actually, it is not easy to take money from your pocket and pay medical fees.\u0026rdquo; CSO respondent\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;It is clear that NCD services are not fully funded, meaning that some amount is paid by the patient, which is different from HIV services. This makes patients with NCDs pay for the services, and sometimes they are experiencing financial hardship, which may lead to poor adherence\u0026hellip;\u0026rdquo; CSO respondent.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFragmented Referral Pathways for NCD Care among PLHIV\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe respondents described significant barriers within the referral system for PLHIV diagnosed with NCDs, particularly those who use the CBHI. Following diagnosis, patients are often required to return to their health centre to obtain a formal referral document for NCD services, which prevents same-day access to care. This fragmented process creates additional logistical burdens, contributes to delays in treatment, limits timely access to care, and results in lost productivity due to repeated visits to healthcare facilities.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There is a process where patients must go through the health centre to receive a transfer for treatment through the Rwanda Social Security Board's (RSSB) approved channels. However, once referred, there is no one to follow up with the patient, and they end up waiting with others. Sometimes, the patient is given an appointment due to the high number of patients, only to return the next day and report that they were not treated. This situation places a burden on the patient, leading to delays and a significant loss of time.\u0026rdquo;\u003c/em\u003e HCP respondent.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSuboptimal Follow-up Systems\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe respondents reported significant challenges in ensuring effective follow-up care for PLHIV with NCD comorbidities. The lifelong nature of HIV treatment, combined with the added burden of chronic NCD medications, was described as contributing to patient fatigue, which in turn affects adherence and may lead to treatment discontinuation. One central program implementer noted that the prolonged management of multiple chronic conditions imposes a considerable burden on patients. Inadequate follow-up was also attributed to shortages in the healthcare workforce and the absence of community-level monitoring systems to support ongoing care between facility visits.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The second issue is the long-term follow-up required for NCDs. These are chronic diseases that patients live with for an extended period, often requiring lifelong medication. When combined with HIV treatment, this can lead to patient fatigue, which may result in poor adherence to medication or inadequate follow-up care.\u0026rdquo;\u003c/em\u003e CPI respondent\u003c/p\u003e\u003cp\u003eHealthcare providers also highlighted systemic barriers to effective patient follow-up. Suboptimal follow-up was attributed to persistent workforce shortages within health facilities and the absence of community-based monitoring mechanisms to support patients between clinical visits.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The challenges are similar across the other services, but there is a shortage of trained staff and a lack of community follow-up. We had people who were used to making follow-ups on NCD cases in the community, but they have been suspended. The people living with HIV usually come to pick up their drugs, but there is no proper follow-up for NCD cases in the community.\u0026rdquo; HCP respondent\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eLong Waiting Times\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA few respondents reported that patients frequently expressed dissatisfaction with delays in service delivery at health facilities.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;What we did not talk about is the amount of time people spend here. Because a person who has been done many different services sees that they take a lot of time at the hospital.\u0026rdquo; HCP respondent\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eInformation Sharing and Coordination Challenges\u003c/b\u003e\u003c/p\u003e\u003cp\u003eChallenges related to coordination and information sharing across services were frequently highlighted by the respondents. In some cases, diagnostic tests were unnecessarily repeated, suggesting poor communication between service units and a lack of integrated patient records. These inefficiencies hinder effective follow-up and compromise the overall quality and efficiency of service provision.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We sometimes repeat the tests that have been done from another service. This is caused by the fact that these services work independently. Some tests, like creatinine and others, may be requested from another service, and when patients come to our service, we can repeat them because we are not aware if they have been collected, and most patients are not aware of the tests collected.\u0026rdquo;\u003c/em\u003e Nurse from NCD services.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;there is unkown information about other services they receive and other treatments, so that can be taken into consideration at an appropriate level.\u0026rdquo; CPI respondent.\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study provides valuable insights into the experiences and challenges faced by healthcare providers and stakeholders in delivering NCD care within HIV service settings in Rwanda. Despite considerable progress in the provision of HIV care, persistent challenges, particularly the fragmentation of services and limited healthcare workforce capacity, continue to hinder the effective management of NCDs alongside HIV care, as consistently reported in recent studies.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStatus of NCD Service Delivery\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe findings of this study indicate that the delivery of NCD care for PLHIV in Rwanda is not integrated into existing HIV care and treatment services, resulting in significant fragmentation of care. Consistent with evidence from other African contexts, this fragmentation stemming from parallel health systems for HIV and chronic disease care poses a major barrier to providing comprehensive, patient-centred services. Achieving effective integration will require the development and implementation of evidence-based strategies tailored to the unique needs of PLHIV (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMost healthcare providers and stakeholders reported that PLHIV diagnosed with NCDs are typically referred to separate departments or different healthcare facilities for specialised care. This finding aligns with literature that highlights similar patterns of care fragmentation, where PLHIV are transferred to other health facilities or services for the management of detected NCDs (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eWhile some participants acknowledged the decentralisation of NCD screening to health centres and the use of task shifting for trained nurses to manage NCDs, care delivery remains compartmentalised, resulting in fragmented patient pathways. The lack of integration was repeatedly highlighted as a barrier to delivering efficient and holistic care, as patients are required to navigate multiple health services, which could lead to delays and gaps in care.\u003c/p\u003e\u003cp\u003e\u003cb\u003eExperience with current NCD service delivery in HIV care\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOne of the central findings of this study is the fragmentation of service delivery. While screening for NCDs such as hypertension is routinely incorporated into HIV care, actual NCD management is frequently transferred to specialised services or other health facilities. This separation of services results in a disjointed experience for patients, who must navigate multiple points of care. The same findings were highlighted in other studies, where the integrated care for NCDs for PLHIV remains a complex issue (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This fragmentation is particularly apparent in the patient referral system, where PLHIV who are diagnosed with NCDs are often sent to another department or health facility. This is similar to the finding that patients face difficulties accessing comprehensive care, often having to navigate unconnected appointments and facilities for HIV and NCD management (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This fragmentation complicates the care of PLHIV and leads to poor adherence to both HIV and NCD treatments, as they struggle with the logistical burdens of managing multiple appointments across different services or health facilities (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFew respondents mentioned that the decentralisation of NCD services to health centres is a good step in the management of NCDs and recommended that it should be effectively integrated into the HIV care continuum model. The integration of NCD care within HIV services has been proposed by interviewees as a potential solution to overcome this fragmentation; this suggestion is similar to the finding that integrated care can improve both HIV and NCD outcomes by providing a more streamlined approach to patient management (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHypertension, diabetes, and cardiovascular diseases were identified as the most prevalent NCDs among PLHIV, and this finding is consistent with studies showing a greater burden of these diseases among PLHIV(\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The increased risk of NCDs in elderly people and those with obesity or low immunity is also well established, aligning with global trends that recognise age and comorbidities as major risk factors for NCDs among PLHIV (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eExperienced challenges in NCD service delivery\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study highlights several critical challenges in the implementation of NCD care within HIV service settings. The most significant challenge identified was the shortage of healthcare providers with adequate skills and knowledge to manage both HIV and NCDs. The respondents reported that healthcare providers working in HIV services often lack the necessary competencies to manage NCDs, whereas those based on NCD services have limited training and experience in delivering HIV care. This gap in expertise underscores the urgent need for targeted training initiatives to increase the capacity of HIV care providers in NCD management. Consistent with our findings, previous studies have identified the shortage of qualified healthcare workers as a persistent barrier to the effective integration of NCD management within HIV (\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, this approach presents different challenges, especially the heavy workload faced by HIV healthcare providers, mainly nurses and social workers; this will add more tasks for them, as they are already responsible for delivering a range of HIV-related services.\u003c/p\u003e\u003cp\u003eIn terms of the abovementioned challenges, the delay in service delivery leading to the long waiting time mentioned in this research repeatedly comes from patients seeking services and is similar to a recent report from the Rwanda Ministry of Health indicating that the healthcare worker population density is one healthcare worker per 1,000 people (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This figure falls behind the WHO-recommended healthcare worker density of 4.45 healthcare workers per 1,000 people (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTask shifting, proposed as a solution involving the delegation of certain aspects of care from specialised providers to lower-level providers, has been described as a double-edged sword: although it might reduce the workload of specialised providers, it can also compromise the quality of care if the delegated providers are not adequately trained (\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Rwanda a success story in task shifting through trained nurses delivering HIV care, such as prescribing ART, supporting retention, improving patients' health outcomes, and working with community health workers to minimise the number of patients lost to follow-up (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe cost of NCD treatment was also identified as a challenge, and financial barriers remain significant, with a focus on medications that are not covered by community-based health insurance. This was reported in other settings where out-of-pocket spending on NCDs can worsen the burden on that population (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The financial constraints impact nonadherence to treatment, as PLHIV, rather than NCDs, require a budget that may prioritise HIV care, which is free for coverage.\u003c/p\u003e\u003cp\u003eAnother major challenge is the referral system, which requires patients to return to the health centre or another health facility to obtain NCD service referral documents before they can access NCD care. This process causes delays and adds logistical burdens for patients (\u003cspan additionalcitationids=\"CR21 CR22\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This inadequate referral system has been identified as a barrier to timely care in other studies and requires improvements in health system coordination (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). There is a need for streamlining the referral process, and integrating NCD services into HIV care services could improve the PLHIV experience and reduce the time spent at health facilities (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e While participants described that patients presenting with symptoms suggestive of NCDs during routine HIV care follow-up were referred to designated NCD services, none of the participants mentioned any follow-up mechanism to track whether these referrals led to actual service uptake. This finding indicates that we did not provide insight into the outcomes of these referrals. This lack of follow-up information highlights uncertainties around the continuity and effectiveness of the referral process within integrated HIV and NCD care, particularly in resource-constrained settings. Similarly, weak referral and tracking systems can limit the effectiveness of integrated care efforts, particularly when health systems are understaffed and overburdened (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eProposed solution to the identified challenges\u003c/b\u003e\u003c/p\u003e\u003cp\u003eGiven the challenges outlined, the participants presented several solutions. First and foremost, integrating NCD care into HIV services was viewed as a vital step toward better healthcare delivery. Integration can reduce fragmentation, streamline the patient experience, and potentially improve health outcomes. However, the integration of HIV and NCD services requires meticulous planning and strategic capacity building to address different care models, clinical workflows, and resource demands of both disease areas. Healthcare providers must be trained not only in managing the chronic nature of NCDs alongside HIV but also in using integrated clinical protocols, ensuring continuity of care, and navigating potential challenges such as increased patient load, overlapping medication regimens, and complex comorbidity management. These are in line with the key issues identified by the NCD program in Rwanda, highlighting the minimal integration of NCD prevention and control with public healthcare platforms such as HIV/AIDS (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eAnother significant proposal was to train healthcare providers in the management of NCDs, particularly in HIV care settings. The proposal reflects the reform planned by the Rwanda MOH by 2028 to increase the healthcare workforce (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). While capacity-building initiatives, such as targeted training, are critical to improving healthcare providers\u0026rsquo; ability to manage the dual burden of HIV and NCDs, their effectiveness depends on the concurrent resolution of systemic organisation constraints, particularly those related to workload, staffing shortages, and the integration of service delivery models. Furthermore, the availability of guidelines and treatment regimens specifically designed for managing NCDs in PLHIV should be ensured.\u003c/p\u003e\u003cp\u003eImproving the financial accessibility of NCD care, ensuring the availability of necessary treatment in health facility pharmacies, and reducing patients' out-of-pocket payments were also emphasised. Expanding community-based health insurance coverage and ensuring that all NCD treatments are included in the package of services covered by insurance schemes would reduce patients' financial burdens and encourage improved treatment adherence. Finally, a more efficient and coordinated referral system, as well as improved community-level follow-up, was proposed to improve patient adherence and long-term health outcomes. Patients are more likely to adhere to their treatment plans if the time and effort required to obtain NCD services are reduced and follow-up care is consistently delivered.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplications for Policy and Practice\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe findings of this study underscore the need for systemic changes to improve the provision of NCDs within HIV care services. There is a critical need to incorporate structured NCD training into national HIV clinical guidelines to ensure that healthcare providers can manage both HIV and NCDs effectively. Prioritising task shifting from specialised providers to trained healthcare providers, training providers across the continuum of care, and ensuring that well-trained personnel deliver both NCD and HIV care are crucial. It is also recognised by the Rwanda Ministry of Health, stating that a reform is needed to resolve the challenge with the goal of quadrupling the number of healthcare workers by 2027 to bring Rwanda closer to the WHO recommendation (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition, the integration of certain NCD services into HIV care services could mitigate fragmentation, reduce referral delays, and improve adherence to treatment. Addressing the financial barriers to NCD care services is essential; policymakers could extend coverage under a community-based health insurance scheme to include all NCD treatments that are not included. Reducing the financial burden on patients would likely improve adherence and health outcomes. Improving the referral system for NCD cases that require advanced care and complicated cases requiring specialist management and ensuring better coordination of NCD care within HIV services are essential for providing more effective care. In addition, setting up a referral tracking system with feedback loops to providers could enhance the continuity of care and improve patients' outcomes when integrated services are provided. In the context where HIV and NCD services are colocated or linked, investment in simple, workable mechanisms for documenting and monitoring referral outcomes may help ensure that patients do not fall through the cracks (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Finally, efforts to share patients\u0026rsquo; information across services and avoid unnecessary duplication of tests could improve the efficiency of care and reduce the burden on patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAlthough the study offers significant insights, many constraints should be recognised. This study did not include information on the follow-up of patients referred from HIV to NCD services. We did not know whether or how referred patients were tracked or whether they successfully accessed the recommended care. Therefore, we are unable to mention information on the effectiveness of the referral process. Future studies should consider incorporating specific prompts from patient records or service-level monitoring tools to better understand referral outcomes.\u003c/p\u003e\u003cp\u003eThe study relied on self-reported data, which, while valuable for capturing participants\u0026rsquo; subjective perspectives, may be subject to social desirability bias. Given the professional roles of respondents within the health system, some may have felt constrained in expressing critical views, whether due to perceived expectations, fear of judgment, or concerns about potential implications for their job security. Future research could mitigate this limitation by incorporating independent observations, document reviews, or patient feedback to increase the validity and depth of the findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDelivering care for NCDs within HIV services in Rwanda presents a significant challenge but also a clear opportunity for improvement. Significant barriers remain challenges, particularly related to the fragmentation of care, the provider capacity, the financial burden of care, the medication shortage, and the fragmented referral system. Addressing these challenges through policy reform, strengthening healthcare infrastructure, increased provider training, resource allocation, and better coordination could lead to more effective, efficient, and comprehensive care for PLHIV with NCDs and ultimately improve health outcomes for this vulnerable population. These actions not only benefit PLHIV but also contribute to the broader health system and community in Rwanda and other countries with similar settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e1. ART\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eantiretroviral therapy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e2. CSO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCivil Society Organisation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e3. CPI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCentral-level Program Implementers\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e4. DP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDevelopment Partners\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e5. HCPs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ehealthcare providers\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e6. NCDs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNoncommunicable diseases\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePLHIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epeople living with HIV\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe Rwanda National Ethics Committee approved the study (RNEC) No. 210/RNEC/2020 and No. 84/RNEC/2021. All participants provided informed consent before taking part in the study. The study keeps participants\u0026rsquo; information confidential through the use of codes and a password-protected database. A unique research identification number was assigned to each participant and used across all study procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eConflicts of interest\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe study was implemented under funds from the Rwanda National Council for Science and Technology (NCST) under excellent research funding. The funder of the study had no role in the design, data collection, data analysis, data interpretation, or writing of the manuscript.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eVD, LN, YVNU, VNU, BAK, PK, JV, MFM,PM, LB,JCSN, CM, ER, MD,MT, NABN, GVH, SC: study inceptionVD, LD, YVNU, VNU: design and tool development, data collection VD, LN, YVNU, VNU, MMF: transcription, analysis, aMD, MT, NABN, GVH, SC: read the manuscript, provide input, and approve the version for submission.GVH, SC: study inception, study implementation, analysis, and manuscript writing supervision\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eWe acknowledge all the participants of the study and all the technical assistance provided by the key stakeholder institutions and health facility leadership of the NCOHIRWA Cohort Study research sites, as well as those who were supported in transcription and translation, data coding, and proofreading of the manuscript.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. 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BMJ Glob Health. 2021;6(5):e004669.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Strategy and Costed Action Plan for the Prevention and Control of Non-Communicable Diseases in Rwanda. 2020.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"HIV care, noncommunicable diseases, service delivery, referral system, healthcare providers, Rwanda","lastPublishedDoi":"10.21203/rs.3.rs-7150794/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7150794/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe growing burden of noncommunicable diseases (NCDs) among people living with HIV (PLHIV) in sub-Saharan Africa, including Rwanda, presents a complex healthcare challenge. Delivering NCD care within HIV services is crucial for improving patient outcomes and requires a coordinated, multistakeholder approach, but evidence on implementation experiences remains limited.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis qualitative study explored healthcare providers' and stakeholders\u0026rsquo; experiences and perceptions regarding the delivery of NCD care within HIV services in Rwanda. A total of 49 in-depth interviews were conducted with healthcare providers from 12 health facilities across five provinces as well as with stakeholders from HIV and NCD programs. The participants were purposefully selected on the basis of their roles in HIV and NCD care. The interviews were conducted in Kinyarwanda or English, transcribed verbatim, and analysed thematically via Dedoose software. Data triangulation was applied to ensure the validity and reliability of the findings.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe study revealed that NCD care for PLHIV in Rwanda remains largely fragmented. Most participants reported that patients diagnosed with NCDs are referred to separate departments or facilities, leading to discontinuities in care. Despite the decentralisation of NCD services, significant challenges remain, including inadequately trained staff, a lack of integration, NCD management guidelines, weak referral and follow-up systems, and delays in diagnosis. Financial barriers, due to out-of-pocket costs for NCD medication, further impede access. High-risk groups are identified as older adults, obese people, and those with compromised immune function. The participants called for greater integration of NCD services with existing HIV care platforms.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eDelivering NCD care within HIV services in Rwanda faces multiple systemic barriers, including fragmented service delivery, shortages and inadequate provider capacity in NCD management, and financial and referral constraints. To improve outcomes for PLHIV with NCDs, integrated care models, targeted provider capacity building, strengthened referral systems, and expanded financial protection mechanisms are urgently needed. Addressing these gaps will enhance patient care and strengthen the overall health system in Rwanda.\u003c/p\u003e","manuscriptTitle":"Provider's and stakeholders' experiences with and perceptions of the benefits and challenges of delivering care for noncommunicable diseases within HIV care services in Rwanda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 06:25:26","doi":"10.21203/rs.3.rs-7150794/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9e75911c-d477-442e-a519-c57ac4899538","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-25T20:53:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-23 06:25:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7150794","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7150794","identity":"rs-7150794","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}