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2007 Bull Who Chron Dis Clinics Cambodia
2007 Bull Who Chron Dis Clinics Cambodia
2007 Bull Who Chron Dis Clinics Cambodia
2007 Bull Who Chron Dis Clinics Cambodia
2007 Bull Who Chron Dis Clinics Cambodia
2007 Bull Who Chron Dis Clinics Cambodia
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2007 Bull Who Chron Dis Clinics Cambodia

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  • 1. Offering integrated care for HIV/AIDS, diabetes and hypertension within chronic disease clinics in Cambodia B Janssens,a W Van Damme,b B Raleigh,a J Gupta,a S Khem,a K Soy Ty,a MC Vun,c N Ford d & R Zachariah e Problem In Cambodia, care for people with HIV/AIDS (prevalence 1.9%) is expanding, but care for people with type II diabetes (prevalence 5–10%), arterial hypertension and other treatable chronic diseases remains very limited. Approach We describe the experience and outcomes of offering integrated care for HIV/AIDS, diabetes and hypertension within the setting of chronic disease clinics. Local setting Chronic disease clinics were set up in the provincial referral hospitals of Siem Reap and Takeo, 2 provincial capitals in Cambodia. Relevant changes At 24 months of care, 87.7% of all HIV/AIDS patients were alive and in active follow–up. For diabetes patients, this proportion was 71%. Of the HIV/AIDS patients, 9.3% had died and 3% were lost to follow-up, while for diabetes this included 3 (0.1%) deaths and 28.9% lost to follow-up. Of all diabetes patients who stayed more than 3 months in the cohort, 90% were still in follow-up at 24 months. Lessons learned Over the first three years, the chronic disease clinics have demonstrated the feasibility of integrating care for HIV/AIDS with non-communicable chronic diseases in Cambodia. Adherence support strategies proved to be complementary, resulting in good outcomes. Services were well accepted by patients, and this has had a positive effect on HIV/AIDS-related stigma. This experience shows how care for HIV/AIDS patients can act as an impetus to tackle other common chronic diseases. Bulletin of the World Health Organization 2007;85:880–885. Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. .‫الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة‬ Introduction In 2002, Médecins Sans Frontières HAART began to be provided in Cambodia in 2001. By the end of (MSF) and the Cambodian Ministry At the end of 2004, there were an esti- 2005, 12 355 people were on treatment of Health established chronic disease mated 100 000 people living with HIV/ through programmes run jointly by the clinics to integrate HIV/AIDS care AIDS in Cambodia, of whom ap- Ministry of Health and nongovernmen- with the management of diabetes and proximately 25 000 were estimated to tal organizations (NGOs). hypertension in two provincial capitals, urgently require care and treatment Chronic diseases are largely ne- Takeo and Siem Reap. This paper de- with highly active antiretroviral therapy glected in developing countries. 6 In scribes the approach and outcomes of (HAART).1,2 Cambodia, medical care for diseases this strategy. Cambodia is struggling with a grow- such as diabetes, arterial hypertension ing burden of chronic diseases. A survey and epilepsy was not generally included Context done in 2005 estimated that between in the reconstruction of the health care 5% and 11% of all adults had type II Siem Reap and Takeo are both predomi- system over the past 15 years. Most dia- diabetes and the prevalence of impaired nantly rural provinces, although the betics receive only limited medication glucose intolerance was between 10% urban population of Siem Reap town at referral hospital outpatient depart- and 15%. The same survey showed that is increasing rapidly due to growing ments or when they arrive with severe between 12% and 25% of the popula- tourism around the Angkor Wat temple hyperglycaemia at emergency wards; tion screened could be classified as being complex. Both locations were selected they are rarely referred to long-term care hypertensive.3 These results are consis- for this pilot programme because they once they are discharged. Some drugs tent with growing evidence that diabetes are large provincial centres with referral to treat arterial hypertension are avail- and other non-communicable diseases hospital capacity to expand activities. able at hospitals and health centres, but represent a significant and growing part Furthermore, adequate care for the tar- these are usually provided for only two of the disease burden in low-income countries.4,5 get diseases at these sites was lacking. weeks. Médecins Sans Frontières, KH1, House # 72, Street 592, Sang Kat Boengkok 2, Khan Tuol Kork, Phnom Penh, Cambodia. Correspondence to B Janssens (e-mail: a b.janssens@bigfoot.com). Institute of Tropical Medicine, Antwerp, Belgium. b National Centre of HIV/AIDS, Dermatology and STDs, Ministry of Health, Phnom Penh, Cambodia. c Médecins Sans Frontières, Bangkok, Thailand. d Médecins Sans Frontières operational centre, Brussels, Belgium. e doi: 10.2471/BLT.06.036574 (Submitted: 11 September 2006 – Revised version received: 10 April 2007 – Accepted: 16 April 2007) Bulletin of the World Health Organization | November 2007, 85 (11) 880
  • 2. Lessons from the field B Janssens et al. Offering integrated care in Cambodian chronic disease clinics Rationale for the chronic disease principles of chronic disease manage- diabetics and other patients, a routine ment and a patient-centred approach. questionnaire is used to assess income clinics Counsellors were also recruited, al- and eligibility for exemption from these The rationale to combine care of HIV/ though when the clinics started counsel- user fees. AIDS, diabetes and hypertension was lors were not yet a recognized part of the All new HIV/AIDS patients were based on three assumptions. Cambodian health system and trained staged at their first visits by WHO clini- First, the availability of antiretrovi- psychologists were and still are rare. cal staging and a CD4 count. Treatment ral treatment in developing countries is Counsellors were either nurses or staff for opportunistic infections, mainly transforming HIV/AIDS into a chronic members recruited after an evaluation of tuberculosis and cryptococcus menin- disease, as has been the experience else- appropriate personal skills. A continu- gitis, was provided where needed and where.7 It was anticipated that in this ous training programme was organized prophylaxis for PCP (cotrimoxazole) resource-poor context, efficiency gains by MSF for all staff to deal with newly and cryptococcal meningitis (flucon- could be attained through the estab- appearing needs and problems, and to azol) was started according to national lishment of a multidisciplinary chronic introduce new tools and guidelines. guidelines. For all patients requiring disease care team that would use a com- Most of the training was organized as antiretroviral treatment (CD4 count mon approach to respond to the needs on-the-job training, with theoretical < 200 cells/mm³ or WHO stage IV), a of chronic disease patients, especially in training sessions organized around spe- standardized medical and psychosocial providing continuity of care, long-term cific topics every three months. treatment preparedness plan was fol- adherence support and social support. The complex needs of chronic pa- lowed. Almost all patients were started Second, in Cambodian society as tients relied on a functional collabora- on a standard first-line regimen of elsewhere, the stigma attached to HIV/ tion with several other hospital depart- stavudine, lamivudine and nevirapine; AIDS presents a barrier to care. By pro- ments, particularly for severely ill AIDS zidovudine and efavirenz were used as viding care for seropositive clients and patients. A separate infectious diseases alternatives in case of intolerance to the patients with other chronic diseases inpatient ward with appropriate staff first-line regimen. Most regimens were within the same facility, it was hoped resources and equipment was set up given as generic fixed-dose combina- that facility-related stigma could be in each hospital. Efforts were made to tions. Once on HAART, patients were reduced. integrate services for tuberculosis and followed up on a monthly basis and a Third, it was considered important HIV for efficient care of co-infected routine laboratory protocol of alanine that the care delivery model should re- patients. aminotransferase, and haemoglobin at flect epidemiological realities. Although Staffing in both clinics was gradu- months 1, 2, 3, 6 and 12 was used to at the clinics’ inception reliable epide- ally increased to meet the increasing monitor for drug side-effects. Treatment miological data on diabetes and other patient load, from 8 staff members in success was monitored by CD4 lympho- chronic diseases was lacking, these ill- 2003 to a total of 20 full-time staff cyte count every 6 months. nesses were recognized to contribute members (8 medical doctors, 8 counsel- Diabetes patients were all type 2 an increasing share of the total burden lors and 4 nurses) in 2005. Of this total, and treatment was based on two oral of disease in Cambodia. Diabetes was 10 were engaged from other hospital hypoglycaemic drugs: metformin and given a specific priority, since it was seen departments, and the rest were engaged glibenclamide. For a limited number of by many health workers as a frequent with MSF funds. MSF also provided patients insulin therapy was commenced problem. The provision of systematic financial support for the new clinic func- using slow-release insulin (Insulatard, and continuous care for chronic diseases tions, mainly the purchase of medicines Novo Nordisk, Denmark) at two doses was encouraged by both the Ministry of that were not routinely available from every 24 hours. Priority was given to Health and local WHO representatives, the Ministry of Health (initially includ- the stabilization of blood glucose levels, who were involved in the final design of ing antiretrovirals and all medicines for control of blood pressure and diagnosis this pilot health care delivery model. opportunistic infections) and incentives and care of foot sores. Prior to 2006, for staff members who had to cope with routine monitoring of glycosolated hae- Development of services ever-increasing workloads. Investments moglobin (HbA1c) was not possible due As in the rest of the country’s public were also made to improve the struc- to high cost, but this has since become a hospitals, no structured care for HIV tures and medical equipment of the routine monitoring test. or diabetes existed before the chronic clinics, hospitals and laboratories. All Patients with arterial hypertension disease programmes. These began with operating costs – medicines and staff were treated according to a protocol a strong emphasis on outpatient consul- salaries – were gradually taken over by based on standard guidelines, using a tations, with services actively promoted the Ministry of Health. stepwise approach with hydrochloro- as clinics for treatment of diabetes, hy- thiazide, atenolol and captopril as the pertension and HIV/AIDS. Regarding Description of services main antihypertensive drugs. The objec- other chronic diseases, mental health Every new patient was given a unique tive was to control arterial blood pres- patients were not included, as mental identification code and an individual sure below 160/90 mmHg. health clinics existed in both provinces, medical file. All HIV services were In both clinics, a team of coun- while some other patients, such as epi- provided free of charge according to sellors provided a series of activities leptics and those with thyroid disorders, national policy. Diabetes patients pay complementary to the medical con- were accepted but were few in number. a fixed fee per consultation of approxi- sultations, for both HIV/AIDS and All consultations were carried out mately US$ 0.50, which also covers diabetes patients. The principal objec- by doctors who received training on the the costs of drugs and diagnostics. For tive of the counselling activities was to Bulletin of the World Health Organization | November 2007, 85 (11) 881
  • 3. Lessons from the field B Janssens et al. Offering integrated care in Cambodian chronic disease clinics encourage drug adherence and lifestyle Fig. 1. Inflow of new patients in chronic disease clinics, Cambodia changes with information and psycho- social support, with the long-term aim 300 of providing patients with the means Number of patients 250 HIV/AIDS patients (knowledge and confidence) to assume Diabetic patients 200 more responsibility in the management 150 of their disease.8 Peer-support groups 100 were established for antiretroviral users 50 and diabetics; these groups provide an 0 essential continuation of the work of the Start HAART Start Takeo Jun. 2002 Jun. 2004 Jun. 2003 Sep. 2003 Mar. 2004 Mar. 2005 Dec. 2002 Dec. 2003 Sep. 2004 Dec. 2004 Jun. 2005 Sep. 2005 Dec. 2005 Mar. 2002 counsellors and doctors. Patients and outcomes Time Data on patient history and progression on treatment were obtained at every consultation. For HIV patients, data months. Towards the end of the third at 24 months or more. In the cohort of were entered into routine monitoring quarter, the number of new HIV/AIDS hypertension patients, 32% were lost to software (Fuchia, Epicentre, Paris); for patients exceeded the number of new follow-up. Here again, most of the pa- other chronic disease patients, a tailored diabetes patients and continued to in- tients who discontinued care did so early database was established. crease in both centres, while the num- in treatment. Of all patients who stayed Between March 2002 and Decem- ber of new diabetics remained stable at longer than two months in follow-up, ber 2005, a total of 9149 chronic disease an average of 52 patients per month in 81% were still in regular follow-up at patients attended one of the clinics at both clinics combined. 12 months. least once (5273 in Siem Reap and 3876 A cohort analysis of all patients at The median CD4 count of HIV in Takeo); 4793 of these were HIV- 24 months of treatment shows that 87.7% patients on HAART rose from 53 cells/ positive, 2638 had diabetes, 1419 were of HIV patients who started HAART and mm³ at baseline to 218 cells/mm³ at hypertensive and 299 were diagnosed 71% of the diabetics were still alive and month 12 and 316 cells/ mm³ at month with another chronic disease. in active follow-up (Table 1). Only 3% 24 of treatment. Between June 2006 and Among HIV patients, median CD4 of HIV patients on HAART were lost to February 2007, HbA1c results became at baseline was 53 cells/mm³; 72% were follow-up; 9.3% had died, with mortality available for 451 diabetes patients with in need of HAART at first consultation highest in the first 3 months, reflecting more than 6 months of regular treat- and a total of 2497 people living with the fact that most patients sought care ment, which is 27% of the active cohort. HIV/AIDS started HAART. Among at a very late stage in their disease. In The median value was 8.6%; 57% of the diabetics, doctors registered one or more contrast, of the 29% losses in the diabetes patients had an HbA1c below or equal complications (peripheral neuropathy, cohort, only 3 (0.1%) patients had died, to 9%. Of all hypertension patients who nephropathy, retinopathy or coronary and the rest were lost to follow–up, with were on regular drug therapy for more heart disease) in 15.2% of these pa- 64% lost to follow-up in the first three than 6 months in December 2006, 68% tients. In both centres, new diabetic pa- months. Of the patients who remained in had reached blood pressures equal to or tients outnumbered new HIV patients (Fig. 1) during the programme’s early care at 3 months, 90% were still in care below the target of 160/90 mmHg. Table 1. Survival and cohort retention of HIV/AIDS patients who started HAART and diabetes patients who started treatment in chronic disease clinics, Takeo and Siem Reap Months on treatment 0–3 3–6 6–12 12–18 12–24 24+ HIV patients 2 497 a N 2 317 1 906 1 288 691 300 289 Deaths (cumulative) 110 37 (147) 34 (181) 16 (197) 4 (201) 0 (201) Lost to follow-up (cumulative) 36 19 (55) 15 (70) 7 (77) 1 (78) 2 (80) Transfer out to other service (cumulative) 25 48 (73) 80 (153) 58 (211) 13 (224) 3 (227) Median CD4 count (cells/mm³) 53 154 180 218 269 309 344 % remaining in care b 94.1 91.7 89.3 88 87.7 87.6 Diabetes patients 2 638 a N 2 484 1 795 1 321 801 457 25 Deaths (cumulative) 0 0 2 0 0 1 (3) Lost to follow-up (cumulative) 487 91 (578) 116 (694) 52 (746) 15 (761) 9 (770) Transfer out to other service (cumulative) 1 0 1 1 0 0 % remaining in care b 81.5 78.1 73.6 71.6 71 70.7 All patients who started HAART or diabetes treatment in the chronic disease clinics of Siem Reap or Takeo. a Kaplan–Meier survival estimate. b Bulletin of the World Health Organization | November 2007, 85 (11) 882
  • 4. Lessons from the field B Janssens et al. Offering integrated care in Cambodian chronic disease clinics Discussion At 24 months on HAART, only group, see the added value of this model 3% of HIV patients were lost to care, of care. The experience of these two chronic while this was true for almost 30% for The burden of chronic diseases diseases in Cambodia shows that inte- the diabetics. A more detailed analysis in developing countries has received grating care for HIV/AIDS with care for of the diabetic cohort shows that most increasing attention recently. WHO other chronic diseases is feasible, result- of the losses to follow-up appear in the has called for innovative action in this ing in satisfactory outcomes for patients first 3 months; after that, almost 90% regard,12 and it has been argued that and efficiency gains for the services. of diabetics remained part of the cohort NGOs should address these huge un- Over three years, the two centres at 24 months of follow-up. Many rea- met needs 13 and that chronic diseases demonstrated that staff could effectively sons could explain the early dropouts: should figure more prominently on the assume a multidisciplinary role and that diabetes is not seen as life-threatening, international development agenda.14 skills to manage patients who need to alternative care through private provid- The justifiable increase in atten- start a lifelong treatment were relevant ers exists and some patients might be tion to HIV/AIDS in recent years has to and effective for both HIV/AIDS uncomfortable sharing premises with highlighted the fact that other chronic and diabetic care. Doctors adapted to HIV patients. This needs to be evalu- diseases remain neglected. The chronic the role of chronic diseases specialists ated more fully. disease clinics approach has demon- and gradually adopted a patient-centred Outcomes of patients who started strated an ability to respond to these approach. Adherence support counsel- HAART compare favourably or equally epidemiological realities, and provides lors, a new function in the health-care to other described cohorts, both in an example of how the considerable system that was created with expanding western settings and in other developing attention to and funding of HIV/AIDS HIV/AIDS care, have been shown to be countries.9,10 The results of the diabetes care can offer an opportunity to im- valuable in supporting adherence and patients are measured by HbA1c, and prove care for non-communicable dis- lifestyle changes for diabetics. at this stage the interpretation of these eases like diabetes and hypertension, The rapid expansion of patient results is limited because no baseline which are increasingly seen as high- inflow is a good indicator that these values are available for the patients of priority public health challenges for the services were well accepted by both the diabetic cohort; results are only avail- developing world.15 diabetics and HIV patients. The latter able for 27% of all patients and these do Now that HAART is becoming arrived in very small numbers in the not represent a randomized sample. The progressively more available in the de- first months after the clinics opened mean HbA1c value measured is 0.7% veloping world, HIV care is a matter but numbers increased significantly higher than was found in a 24-month of chronic disease management. There after this initial period. We believe this western cohort;11 no comparable data is an important opportunity for HIV is partly because they could mingle with from a resource-limited context were programmes to both learn from and other patients with less stigma-associated found in the literature. reinforce other chronic disease pro- diseases. Nevertheless, the high early Attention to diabetes care at the grammes. In Cambodia, the experience mortality and low median CD4 reflects Cambodian health ministry is still lim- of the chronic disease clinics has shown the fact that large number of patients ited, reflecting scarce funding for non- that care can be integrated. Because staff had no access to HAART earlier. The communicable disease control. This and services are complementary, patient fact that the inflow of new diabetes has clearly limited the extent to which outcomes are good and there are indica- patients never slowed, even with clinic these programmes could be replicated, tions that the integration has reduced waiting rooms often crowded with very although gradually more stakeholders, HIV-related stigma. ■ ill HIV patients, is another indicator like the ministry’s newly established Competing interests: None declared. that the services were well accepted. non-communicable diseases working Résumé Offre de soins intégrée à l’intention des personnes vivant avec le VIH/sida, un diabète ou de l’hypertension par les dispensaires cambodgiens spécialisés dans les maladies chroniques Problématique Au Cambodge, l’offre de soins à l’intention des Modifications pertinentes Au bout de 24 mois de soins, sur personnes vivant avec le VIH/sida (prévalence : 1,9 %) est en l’ensemble des patients vivant avec le VIH/sida, 87,7 % étaient développement, mais pour les personnes atteintes de diabètes encore vivants et faisaient l’objet d’un suivi actif. S’agissant des de type II (prévalence 5 à 10 %), d’une hypertension artérielle patients diabétiques, cette proportion était de 71 %. Parmi les ou d’une autre maladie chronique pouvant être traitée, elle reste patients contaminés par le VIH, 9,3 % étaient morts et 3 % très limitée. étaient perdus de vue, tandis que parmi les diabétiques, on Démarche Nous décrivons l’expérience et les résultats obtenus enregistrait 3 décès (0,1 %) et une proportion de 28,9 % de avec une offre de soins intégrée à l’intention des personnes vivant perdus de vue. Parmi l’ensemble des patients diabétiques restés avec le VIH/sida, un diabète ou une hypertension, dans le cadre plus de 3 mois dans la cohorte, 90 % étaient encore suivis au de dispensaires spécialisés dans les maladies chroniques. bout de 24 mois. Contexte local Des dispensaires spécialisés dans les maladies Enseignements tirés Sur les trois premières années, les chroniques ont été mis en place dans les hôpitaux spécialisés de dispensaires spécialisés dans les maladies chroniques ont prouvé Siem Reap et Takeo, deux capitales provinciales du Cambodge. la faisabilité d’une offre de soins intégrée pour les personnes Bulletin of the World Health Organization | November 2007, 85 (11) 883
  • 5. Lessons from the field B Janssens et al. Offering integrated care in Cambodian chronic disease clinics vivant avec le VIH/sida et atteintes d’une maladie chronique non ce qui a un effet positif sur la stigmatisation dont ils souffrent. Cette transmissible au Cambodge. La complémentarité des stratégies expérience montre à quel point la prise en charge des personnes d’aide à l’observance a également été démontrée, d’où l’obtention vivant avec le VIH/sida peuvent donner une impulsion à celle de bons résultats. Ces services sont bien acceptés par ces patients, d’autres maladies chroniques courantes. Resumen Atención integrada contra el VIH/SIDA, la diabetes y la hipertensión en dispensarios de enfermedades crónicas de Camboya Problema En Camboya se está extendiendo masivamente la se habían perdido en el seguimiento, mientras que las cifras atención a las personas con infección por VIH/SIDA (prevalencia para la diabetes fueron de 3 (0,1%) defunciones y un 28,9% del 1,9%), pero la atención a las personas con diabetes de perdidos en el seguimiento. De todos los pacientes con diabetes tipo 2 (prevalencia: 5%–10%), hipertensión arterial y otras que permanecieron más de 3 meses en la cohorte, el 90% se enfermedades crónicas tratables sigue siendo muy limitada. encontraban aún sometidos a seguimiento a los 24 meses. Enfoque Describimos la experiencia y los resultados de la Enseñanzas extraídas Durante los tres primeros años, los oferta de atención integrada para la infección por VIH/SIDA, la dispensarios de enfermedades crónicas han demostrado la diabetes y la hipertensión en el entorno de los dispensarios de viabilidad de la integración de la atención contra el VIH/SIDA y la enfermedades crónicas. proporcionada contra las enfermedades crónicas no transmisibles Contexto local Se establecieron dispensarios de enfermedades en Camboya. Las estrategias de apoyo a la observancia tuvieron un efecto complementario, lo que se tradujo en buenos resultados. crónicas en los hospitales de referencia provinciales de Siem Reap Los servicios fueron bien aceptados por los pacientes, y eso tuvo y Takeo, dos capitales de provincia de Camboya. un efecto positivo en la estigmatización relacionada con el VIH/ Cambios destacables Tras 24 meses de aplicación de ese SIDA. Esta experiencia demuestra que la atención a los pacientes régimen de atención, el 87,7% de todos los pacientes con VIH/ con VIH/SIDA puede ser un estímulo para hacer frente a otras SIDA permanecían con vida y sometidos a seguimiento activo. enfermedades crónicas comunes. Entre los pacientes con diabetes esa proporción era del 71%. De los pacientes con VIH/SIDA, el 9,3% habían muerto y un 3% ‫ملخص‬ َّ ‫إيتاء الرعاية املتكاملة لإليدز والعدوى بفريوسه والسكري وارتفاع ضغط الدم‬ ‫ضمن عيادات األمراض املزمنة يف كمبوديا‬ ُ ‫املصابني باإليدز والعدوى بفريوسه مات 3.9% منهم فيام فقدت متابعة‬ ‫املشكلة: يتَّسع نطاق الرعاية التي تقدَّم يف كمبوديا للمصابني باإليدز أو‬ ‫3%، ومن السكريـني مات 3 (1%) وفقدت متابعة 9.82% منهم. ومن بني‬ ‫بالعدوى بفريوسه (ومعدل انتشاره 9.1%)، إال أن الرعاية التزال محدودة‬ َّ ‫جداً ملرىض النمط الثاين من السكري (ومعدل انتشاره 5-01%)، وارتفاع‬ ‫جميع السكريـني الذين بقوا ملدة تزيد عىل 3 شهور ضمن األتراب، ظل‬ .ً‫09% يتلقون املتابعة حتى 42 شهرا‬ .‫ضغط الدم وغري ذلك من األمراض املزمنة التي تربأ باملعالجة‬ ‫األسلوب: قدَّم الباحثون وصفاً للخربات والحصائل التي تنتج عن إيتاء الرعاية‬ ‫الدروس املستفادة: خالل السنوات الثالثة األوىل، أثبتت عيادة األمراض‬ َّ ‫املزمنة إمكانية إدماج رعاية مرض اإليدز والعدوى بفريوسه ضمن األمراض‬ ‫املتكاملة لإليدز والعدوى بفريوسه والسكري وارتفاع ضغط الدم ضمن مرافق‬ ‫املزمنة غري السارية يف كمبوديا. وقد أثبتت استـراتيجية دعم االمتثال أنها‬ .‫عيادات األمراض املزمنة‬ ،‫مكملة، وذات حصائل جيدة. وقد كانت الخدمات مقبولة جداً لدى املرىض‬ ‫املرفق املحيل: لقد أسـست عيادات األمراض املزمنة يف مستشفيات اإلحالة يف‬ ِّ َّ ‫مام أعطى تأثريات إيجابية يف ما يتعلق بالوصمة الناجمة عن اإلصابة مبرض‬ .‫واليتَي سيم ريب وتاكيو، وهام عاصمتان لواليتَني كمبود َّيتَني‬ ْ‫ن‬ ْ‫ن‬ ْ‫ن‬ ‫التغريات ذات الصلة: بعد 42 شهراً من تلقي الرعاية كان 7.78% من مجمل‬ ِّ ‫اإليدز والعدوى بفريوسه. وتظهر هذه التجربة كيف ميكن للرعاية املقدَّمة‬ ُّ‫ر‬ ‫ملرىض اإليدز والعدوى بفريوسه أن تكون دافعاً ملعالجة أمراض مزمنة أخرى‬ ‫مرىض اإليدز والعدوى بفريوسه عىل قيد الحياة ويخضعون ملتابعة فعالة. أما‬ َّ .‫شائعة‬ ‫بالنسبة للسكريـني فقد كان من بقي منهم عىل قيد الحياة 17%، ومن بني‬ References 1. 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