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Hypertension control in integrated HIV and chronic disease clinics in Uganda in the SEARCH study
Dalsone Kwarisiima1, Mucunguzi Atukunda1, Asiphas Owaraganise1
1Infectious Diseases Research Collaboration, Kampala, Uganda.
Insights
Integrated HIV and hypertension care improved blood pressure control in sub-Saharan Africa. However, visit frequency influenced by drug availability, not patient need, worsened hypertension control.
Area of Science:
- Public Health
- Infectious Disease Epidemiology
- Cardiovascular Disease Management
Background:
- Sub-Saharan Africa faces a growing hypertension burden alongside the world's highest HIV prevalence.
- Existing care models are insufficient for managing these co-occurring epidemics.
- Integrating HIV care infrastructure for hypertension management shows promise but requires further study.
Purpose of the Study:
- To evaluate the effectiveness of an integrated HIV and hypertension care delivery system on blood pressure control.
- To identify predictors of hypertension control within this integrated model.
Main Methods:
- Population screening for HIV and hypertension in rural Uganda (SEARCH study).
- Referral of individuals with HIV, hypertension, or both to an integrated chronic disease clinic.
- Follow-up visits scheduled based on blood pressure control and treatment guidelines, with analysis of predictors for hypertension control.
Main Results:
- Over 3 years, hypertension control improved from 15% at baseline to 46% at follow-up visits among 2038 participants.
- More frequent visits than clinically indicated for controlled hypertension were associated with poorer subsequent control.
- Hypertension control was slightly higher in HIV-infected patients (48%) compared to uninfected patients (46%).
Conclusions:
- An integrated HIV and chronic care model can improve hypertension control.
- Visit scheduling influenced by drug supply chain issues, rather than clinical necessity, negatively impacts hypertension management, mirroring challenges in HIV care.
Background:
There is an increasing burden of hypertension (HTN) across sub-Saharan Africa where HIV prevalence is the highest in the world, but current care models are inadequate to address the dual epidemics. HIV treatment infrastructure could be leveraged for the care of other chronic diseases, including HTN. However, little data exist on the effectiveness of integrated HIV and chronic disease care delivery systems on blood pressure control over time.
Methods:
Population screening for HIV and HTN, among other diseases, was conducted in ten communities in rural Uganda as part of the SEARCH study (NCT01864603). Individuals with either HIV, HTN, or both were referred to an integrated chronic disease clinic. Based on Uganda treatment guidelines, follow-up visits were scheduled every 4 weeks when blood pressure was uncontrolled, and either every 3 months, or in the case of drug stock-outs more frequently, when blood pressure was controlled. We describe demographic and clinical variables among all patients and used multilevel mixed-effects logistic regression to evaluate predictors of HTN control.
Results:
Following population screening (2013-2014) of 34,704 adults age ≥ 18 years, 4554 individuals with HTN alone or both HIV and HTN were referred to an integrated chronic disease clinic. Within 1 year 2038 participants with HTN linked to care and contributed 15,653 follow-up visits over 3 years. HTN was controlled at 15% of baseline visits and at 46% (95% CI: 44-48%) of post-baseline follow-up visits. Scheduled visit interval more frequent than clinical indication among patients with controlled HTN was associated with lower HTN control at the subsequent visit (aOR = 0.89; 95% CI 0.79-0.99). Hypertension control at follow-up visits was higher among HIV-infected patients than uninfected patients to have controlled blood pressure at follow-up visits (48% vs 46%; aOR 1.28; 95% CI 0.95-1.71).
Conclusions:
Improved HTN control was achieved in an integrated HIV and chronic care model. Similar to HIV care, visit frequency determined by drug supply chain rather than clinical indication is associated with worse HTN control.
Trial Registration:
The SEARCH Trial was prospectively registered with ClinicalTrials.gov : NCT01864603.
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