An estimated 26% of people living with HIV (PLWHIV) in Botswana have hypertension. Uncontrolled hypertension will add to the already increased risk for cardiovascular (CVD) disease in this population. A hypertension study nested within an HIV prevention trial (Botswana Combination Prevention Project- BCPP), the hypertension continuum of care was suboptimal among PLWHIV; 46% aware of their hypertension, 42% on medication, 44% of those on medication at recommended blood pressure target, with an overall hypertension control of 19%. These data highlight multiple implementation gaps in our setting among PLWHIV for hypertension control and the missed opportunity to address CVD risk factors among those with hypertension. These gaps occur despite national guidelines recommendations, free universal healthcare, availability of needed medications and approaches which can improve quality including training, coaching, and the use of electronic health records (EHR) reminders. Implementation research is urgently needed to develop more effective strategies to improve the uptake of established effective hypertension and CVDRF management interventions among PLWHIV in Botswana and other low- and middle-income countries (LMICs). We propose the adaptation and testing of strategies to effectively integrate evidence- based interventions (EBI) into HIV care to improve hypertension cascade of care (awareness, diagnosis, treatment, control) and general CVD risk factor knowledge, diagnosis and treatment using a late-stage T4 implementation research hybrid type 2 study design. First, we will develop a set of implementation strategies for integrated HIV-HTN/CVD care within an existing HIV care platform for adults with HIV and hypertension and pilot test (2 HIV Clinics) to explore implementation outcomes using RE-AIM framework to inform adaptation for broader testing. We will use the knowledge gained from the development and piloting of the implementation strategy to then use a type 2 hybrid design to measure the implementation outcomes of multi-component strategy in improving EBI uptake and improvement success rates in the HTN cascade among adults with a dual diagnosis of HIV and Hypertension. To achieve this second aim, we are proposing a type 2 hybrid effectiveness-implementation of a 10-cluster randomized trial (1:1 randomization at the facility level) of 300 adults per cluster between 20- 75 years old with a dual diagnosis of HIV and hypertension (>140/90mmHg, >130/80mmHg if living with Diabetes mellitus/Chronic Kidney Disease) in Botswana. Our primary quantitative implementation outcomes based on the RE-AIM framework implementation are reach (proportion of PLWHIV on treatment among those who meet threshold for anti-hypertensive medication), effectiveness (proportion with controlled blood pressure), plus adoption (proportion of providers who screen PLWHIV for high blood pressure plus proportion of providers who prescribe anti-hypertensive medications). Our co-primary qualitative implementation outcomes will include assessment of fidelity (audit of intervention implementation as designed) and maintenance (provider and patient perceptions of ability to maintain plus change in blood pressure control from first control to end of the trial). Our secondary implementation outcomes, we will include assessment of feasibility (ability to implement integrated HIV/HTN care, HIV/HTN/CVD care, clinic viral suppression, etc.) and acceptability (patient and provider survey and interviews) of the implementation strategy.

Public Health Relevance

Hypertension is one of the leading contributors of excess risk of heart attacks and strokes among the 36 million people living with HIV (PLWHIV) globally. The hypertension care cascade among PLWHIV has major deficits when compared to the HIV care cascade of 90:90:90. Our proposed study, to be conducted Botswana, will leverage a successful national ART program and infrastructure of a recently completed CDC/NIH funded HIV prevention trial to first develop an implementation strategy, and then use the new implementation strategy to conduct a type 2 hybrid multi-component cluster randomized trial to optimize evidence based implementation (EBI) uptake and improvement in the hypertension cascade among adults with dual diagnosis of HIV and Hypertension.

Agency
National Institute of Health (NIH)
Institute
National Heart, Lung, and Blood Institute (NHLBI)
Project #
1UG3HL154499-01
Application #
10069492
Study Section
Special Emphasis Panel (ZHL1)
Program Officer
Price, Leshawndra Nyrae
Project Start
2020-09-15
Project End
2022-08-31
Budget Start
2020-09-15
Budget End
2021-08-31
Support Year
1
Fiscal Year
2020
Total Cost
Indirect Cost
Name
University of Botswana
Department
Type
DUNS #
568321843
City
Gaborone
State
Country
Botswana
Zip Code
0000