Accelerating Delivery of rheumatic heart disease preventive iNterventions in Uganda (ADUNU)

Abstract:

Rheumatic heart disease (RHD) is the most commonly acquired heart disease among children and young adults worldwide. Continuous antibiotic prophylaxis (secondary prevention) with monthly intramuscular benzathine penicillin G (BPG) is a cornerstone of RHD control programs and has been used successfully for decades in wealthy countries. Unfortunately, because of neglect in the global and national health agendas, most RHD- endemic countries (like Uganda) have no RHD programs, so most of the estimated 40 million people living with RHD worldwide remain undiagnosed and unprotected from further valvular damage. Considering these challenges, our objective is to partner with the Ugandan government to test a novel community-based program, ADUNU (Acholi for “heart”) that aims to find individuals with RHD and provide secondary prevention close to where they live.

The program will be tested in two districts (one demonstration, one replication), building a foundation for national scale-up beyond the proposed research. ADUNU is based on two core, evidence-based technologies, (1) RHD testing using handheld echocardiography in community settings and (2) nurse-led, registry-based delivery of secondary prevention. ADUNU is a non-randomized experiment that will set up a new system in settings where RHD-related healthcare currently does not exist, with the goal of finding new cases and enrolling them in local registries that provide secondary prevention. ADUNU will be integrated with general primary healthcare and track outcomes over time, key factors in sustainability and scalability.

In Aim 1, we will evaluate ADUNU using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, mapped to the RHD Care Cascade (an adaptation of the cascade used for HIV). Primary quantitative outcomes in each of RE-AIM’s five dimensions will be supplemented with qualitative data from in-depth interviews and administrative data. In Aim 2, we will evaluate the cost-effectiveness and budget impact of ADUNU in these two districts in order to justify investment and plan for scale-up of the program nationally in Uganda, beyond the proposed study.

ADUNU will provide much-needed evidence to government stakeholders in RHD-endemic countries, demonstrating how a pragmatic, community-based strategy can deliver guideline-based care to people living with RHD. It will also provide critical, and currently absent, evidence on the cost-effectiveness, affordability, and sustainability of RHD programs in resource-limited settings.