In 2019, the CREOLE trial addressed a practical question: which combinations of commonly used medicines lowered blood pressure most effectively in Black African patients with uncontrolled hypertension?
Conducted in six sub-Saharan African countries, the study found greater blood-pressure reductions at six months with two amlodipine-containing combinations than with perindopril plus hydrochlorothiazide. It did not establish differences in long-term cardiovascular outcomes. But it provided directly relevant evidence for a treatment decision clinicians make every day (1).
That is an important starting point for Africa’s noncommunicable-disease research agenda. The opportunity extends beyond testing new products. It includes resolving unanswered questions about existing treatments, understanding disease progression, and determining how effective care can be delivered consistently.
The strategic task is to build a research portfolio capable of answering those questions deliberately, rather than only when an individual funding opportunity appears.
A broader burden requires a deliberate response
An analysis published in 2025 using World Health Organization (WHO) data estimated that noncommunicable diseases (NCDs) accounted for 37.1% of deaths in the WHO African Region in 2019, up from 24.2% in 2000. Although age-standardized NCD mortality rates declined over that period, both the number of NCD deaths and their share of total mortality increased (2).
These conditions have not replaced infectious diseases. Health systems must address cardiovascular disease, diabetes, cancer and other chronic conditions while sustaining responses to HIV, tuberculosis, malaria and emerging infections. Research investment must accommodate that coexistence.
Recent evidence points to an imbalance in the research reaching influential journals. A review of randomized controlled trials published between 2019 and 2024 identified 83 Africa-only trials among 2,138 trials in five leading general medical journals. Of those 83, approximately three-quarters concerned infectious diseases, and only three addressed cardiovascular disease (3). Multicontinental trials involving African sites more frequently investigated NCDs.
This is not a census of all research conducted in Africa. It nevertheless sharpens the question facing institutions and funders: are they building sustained expertise in the conditions their health systems need to understand, or mainly responding to the studies available to them?
Choose the questions before the protocols
A credible NCD portfolio should begin with decisions that evidence could change.
For hypertension, the priority might be treatment combinations, earlier diagnosis or sustained blood-pressure control. For chronic kidney disease, it might be identifying progression sooner and evaluating interventions before advanced disease develops. For cancer, it could involve diagnostic pathways, treatment selection or reducing interruptions in care.
The appropriate priorities will differ between countries and institutions. Disease burden matters, but it is not sufficient on its own. Selection should also consider unmet clinical need, investigator expertise, existing services, scientific opportunity and a realistic route from research findings to patient benefit.
Commercial development pipelines belong in that assessment, but they should not determine the entire agenda. Studies of new medicines should sit alongside comparative treatment research, prevention, diagnostics and service-delivery research. Questions about affordable, established treatments deserve attention even when they offer limited commercial incentives.
Nor should every site attempt every therapeutic area. Networks can build complementary expertise across institutions, with some concentrating on cardiometabolic disease and others on oncology, sickle cell disease or chronic respiratory conditions. The objective is depth that supports a coherent sequence of studies, not breadth measured by a list of diseases.
African scientific leadership becomes concrete here: in choosing the questions, defining meaningful outcomes and deciding which evidence gaps merit sustained investment.
Build from existing strengths, without assuming they transfer automatically
Africa’s infectious-disease research experience provides a foundation for this expansion. Trial coordination, laboratory quality systems, participant follow-up and regulatory experience are valuable across disease areas. However, an experienced infectious-disease site is not automatically ready to conduct a heart-failure or cancer trial.
Different questions require different clinical capabilities. Depending on the protocol, cardiovascular research may need echocardiography and independent confirmation of clinical events. Kidney studies may require repeated, standardized measurements of kidney function. Cancer research may depend on reliable pathology, staging and specialist treatment pathways.
These requirements should shape investment before recruitment begins. Registries can help characterize patient populations and disease progression. Shared diagnostics can support research and clinical services. Follow-up systems should be designed to capture relevant outcomes beyond scheduled study visits, with appropriate consent and data safeguards.
The INTE-AFRICA trial offers a useful example of testing how existing services can support a broader clinical agenda. Across facilities in Uganda and Tanzania, it compared integrated management of HIV, diabetes and hypertension with separate services. Over 12 months, retention among participants with diabetes or hypertension was high in both groups, without a statistically significant improvement from integration (4). The primary analysis also found integrated care non-inferior for HIV viral suppression.
The lesson is not that integration invariably improves outcomes. It is that service redesign can be tested rigorously, including whether established HIV outcomes are preserved while other chronic conditions are managed.
Existing infrastructure is a starting point, not a substitute for evidence.
Fund the clinical pathway, not only the study visit
For many NCD studies, research quality depends on continuity: reliable diagnostics, medication availability, referral arrangements and follow-up over time. A portfolio strategy therefore needs to address the costs and responsibilities surrounding the protocol.
Sponsors and funders should distinguish study-specific expenses from capabilities that support several studies. Institutions and health-service partners should agree who maintains shared equipment, supports essential staff and sustains referral pathways between projects. Otherwise, temporary research provision risks being mistaken for durable clinical capability.
The same discipline applies to participants with multiple conditions. A cardiovascular study may encounter patients also living with diabetes, kidney disease or HIV. Eligibility criteria should reflect the scientific question and justified safety requirements, rather than exclude complexity by default. Where broader participation is appropriate, protocols need suitable monitoring, medication review and analysis plans.
Planning for use of the results should begin equally early. Evidence of efficacy alone does not resolve questions about affordability, diagnostic access or service delivery. Depending on the intervention, studies should generate information useful to regulators, guideline developers, procurers and clinicians, alongside the outcomes required for product development.
This is how therapeutic depth becomes relevant to health systems: a connected programme of research that informs what to use, for whom, and under what conditions.
What this means for ACRN
The Africa Clinical Research Network’s role in connecting investigators, institutions and sponsors provides a basis for this work (5). Its contribution should be to help translate priority clinical questions into credible research programmes, with transparent assessments of therapeutic expertise, patient pathways, diagnostic capability and follow-up performance.
That does not require claiming equal readiness across every NCD. It requires clarity about where expertise exists, where additional investment is needed and which collaborations can address specific gaps.
A balanced portfolio protects infectious-disease research while extending established strengths to a wider set of health priorities. Its success should be judged not simply by how many NCD protocols open, but by whether successive studies leave clinicians and health systems better able to make consequential decisions.
CREOLE began with a treatment question. Africa’s next research investments should be equally clear about the decisions they are intended to change.
References
- Ojji Dike B, Mayosi B, Francis V, Badri M, Cornelius V, Smythe W, et al. Comparison of Dual Therapies for Lowering Blood Pressure in Black Africans. New England Journal of Medicine. 2019;380(25):2429–39.
- Barry A, Impouma B, Wolfe CM, Campos A, Richards NC, Kalu A, et al. Non-communicable diseases in the WHO African region: analysis of risk factors, mortality, and responses based on WHO data. Scientific Reports. 2025;15(1):12288.
- Gaye B, Morsy MI, Kitara DL, Singh G, Shoaran M, Gurgone D, et al. African Representation in Randomized Controlled Trials Published in Leading Medical and Cardiovascular Journals, 2019-2024. J Am Coll Cardiol. 2026;87(15):1892–906.
- Kivuyo S, Birungi J, Okebe J, Wang D, Ramaiya K, Ainan S, et al. Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic cluster-randomised, controlled trial. The Lancet. 2023;402(10409):1241–50.
- Makadzange T. Africa Clinical Research Network (ACRN). 2025. Available from: https://acrnhealth.com/2025/04/14/why-african-leadership-in-science-matters-and-why-this-moment-is-pivotal/.