This proposal is a collaboration between University of Abuja, FHI 360, New York University and Saint Louis University. Access to antiretroviral drugs has led to increased survival of people living with HIV (PLWH), who now experience higher CVD-mortality than the general population, largely due to increased HTN burden. Global Burden of Disease reported a 95% increase in HTN-related mortality in Nigeria from 1990 to 2015. Thus, strategies to control HTN in PLWH are sorely needed. Physician shortage and poor access limit Nigeria?s capacity to control HTN in primary health centers (PHCs), where most PLWH receive care. Access to care and task-shifting of duties to nurses may mitigate these barriers. In 2011, FHI 360 initiated a USAID-funded program, Strengthening Integrated Delivery of HIV-AIDS Services (SIDHAS), which provides universal access to HIV services for over 190,000 PLWH in Nigeria . In a cluster RCT of 32 health centers in Ghana, we showed that a nurse-led task-shifting strategy for HTN control (TASSH), based on the WHO CVD Risk Package, led to a 34% greater systolic BP reduction than health insurance coverage alone (U01HL114198; PI: Ogedegbe). TASSH includes CV risk assessment; medication titration; and patient lifestyle counseling. The existence of an effective HIV chronic are platform (SIDHAS) and a well-proven evidence-based intervention for HTN control (TASSH) provides a unique opportunity for implementation of TASSH as an integrated NCD-HIV model for HTN control in PLWH. However, PHCs in Nigeria [with its weak healthcare system] lack the expertise needed to coordinate multilevel system changes. An implementation strategy to overcome this barrier is PF via provision of external expertise and support for addressing challenges in implementing evidence-based care. Although PF has been widely utilized in high income countries, its role in translating EBIs into routine practice in Africa has not been tested. FHI 360?s SIDHAS program and the 47 PHCs it supports in Akwa Ibom ? [the state with the highest HIV burden in Nigeria] - provide a viable HIV chronic care platform for implementing TASSH as an integrated model for HTN control in PLWH. We will conduct this study in two phases using a mixed-methods design: 1) a UG3 planning phase that will use Promoting Action on Research in Health Services (PARiHS) to develop a context- specific PF strategy to implement, and facilitate integration of TASSH into an HIV chronic care platform (SIDHAS) for management of HTN in PLWH; and 2) a UH3 implementation phase that will use Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) to evaluate, in a stepped-wedge cluster RCT of 30 PHCs in 960 PLWH with uncontrolled HTN, the effect of PF on levels of TASSH adoption (primary outcome); BP control (co-primary outcome); and levels of TASSH sustainment (secondary outcome) at 18 months. We will also examine adoption and implementation fidelity of TASSH as potential mechanisms that may explain the impact of PF on BP control. The PF strategy comprises: (a) an advisory board that will provide leadership support for TASSH implementation; and (b) trained nurses (practice facilitators) who will serve as coaches, provide support, knowledge exchange and performance feedback to the nurses who will deliver TASSH at the PHCs.

Public Health Relevance

People Living With HIV (PLWH) are at increased risk for Non-Communicable Diseases (NCDs) including, cardiovascular diseases (CVD) with hypertension (HTN) as the most common. Integration of NCD management into HIV chronic care platforms may be a cost-effective strategy to mitigate the rising burden of NCDs in PLWH. The goal of the study is to evaluate the effectiveness of practice facilitation in the integration of a task-shifting strategy for hypertension control into Strengthening Integrated Delivery of HIV/AIDS Services (SIDHAS) HIV care platform for 960 PLWH across 30 PHCs in Akwa Ibom State. This Proposed study will occur in two phases: 1) UG3 Planning Phase using the PARiHS framework to explore factors and support systems required for successful implementation and integration of TASSH into existing HIV chronic care platform and development of a context-specific practice facilitation strategy. 2) UH3 Implementation Phase will use RE-AIM framework to evaluate in a stepped-wedge cluster RCT the effect of the practice facilitation strategy on the level of adoption of TASSH, BP control and level of sustainment of TASSH in management of HTN among 960 HIV+ patients across 30 PHCs. Findings will have public health impact and will contribute to improved efforts for management of HTN in PLWH in low- and middle-income countries.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
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Special Emphasis Panel (ZHL1)
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Price, Leshawndra Nyrae
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University of Abuja
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