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Exploring barriers and facilitators to integrated hypertension-HIV management in Ugandan HIV clinics using the
Martin Muddu1,2,3, Andrew K Tusubira2, Brenda Nakirya2
1Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
Insights
Integrating hypertension care into HIV clinics faces barriers like resource shortages and provider workload. However, the benefits of one-stop services and compatibility with existing HIV care facilitate this crucial integration for people living with HIV.
Area of Science:
- Public Health
- Implementation Science
- Cardiovascular Disease Research
Background:
- Individuals with HIV (PLHIV) on antiretroviral therapy face elevated cardiovascular disease (CVD) risk.
- Hypertension (HTN) is a primary CVD risk factor, necessitating integrated care within HIV services in Uganda.
- Previous research identified significant implementation gaps in co-managing HTN and HIV.
Purpose of the Study:
- To explore barriers and facilitators to integrating hypertension screening and treatment into HIV clinics in Eastern Uganda.
- To understand the perspectives of healthcare managers, providers, and PLHIV on integrated HTN/HIV care.
Main Methods:
- A qualitative study was conducted in three HIV clinics with varying HTN care performance.
- Semi-structured interviews and focus group discussions were held with 83 participants (managers, providers, PLHIV).
- The Consolidated Framework for Implementation Research (CFIR) guided data analysis to identify influencing factors.
Main Results:
- Key barriers included lack of functional BP machines, insufficient anti-hypertensive medications, increased provider workload, and inadequate patient/provider knowledge and skills.
- Facilitators comprised the relative advantage of one-stop services, simplicity, adaptability, and compatibility of integrated care.
- Organizational incentives, resources, knowledge access, intervention beliefs, self-efficacy, and planning were significant CFIR constructs influencing integration.
Conclusions:
- Despite modifiable barriers, integrating HTN/HIV care is desired by patients, providers, and managers.
- Overcoming barriers and leveraging facilitators through health system strengthening is essential for improving HTN access in PLHIV.
- Findings provide a basis for developing context-specific interventions for HTN/HIV integration in low- and middle-income countries.
Background:
Persons living with HIV (PLHIV) receiving antiretroviral therapy have increased risk of cardiovascular disease (CVD). Integration of services for hypertension (HTN), the primary CVD risk factor, into HIV clinics is recommended in Uganda. Our prior work demonstrated multiple gaps in implementation of integrated HTN care along the HIV treatment cascade. In this study, we sought to explore barriers to and facilitators of integrating HTN screening and treatment into HIV clinics in Eastern Uganda.
Methods:
We conducted a qualitative study at three HIV clinics with low, intermediate, and high HTN care cascade performance, which we classified based on our prior work. Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured interviews and focus group discussions with health services managers, healthcare providers, and hypertensive PLHIV (n = 83). Interviews were transcribed verbatim. Three qualitative researchers used the deductive (CFIR-driven) method to develop relevant codes and themes. Ratings were performed to determine valence and strengths of each CFIR construct regarding influencing HTN/HIV integration.
Results:
Barriers to HTN/HIV integration arose from six CFIR constructs: organizational incentives and rewards, available resources, access to knowledge and information, knowledge and beliefs about the intervention, self-efficacy, and planning. The barriers include lack of functional BP machines, inadequate supply of anti-hypertensive medicines, additional workload to providers for HTN services, PLHIV's inadequate knowledge about HTN care, sub-optimal knowledge, skills and self-efficacy of healthcare providers to screen and treat HTN, and inadequate planning for integrated HTN/HIV services.Relative advantage of offering HTN and HIV services in a one-stop centre, simplicity (non-complex nature) of HTN/HIV integrated care, adaptability, and compatibility of HTN care with existing HIV services are the facilitators for HTN/HIV integration. The remaining CFIR constructs were non-significant regarding influencing HTN/HIV integration.
Conclusion:
Using the CFIR, we have shown that while there are modifiable barriers to HTN/HIV integration, HTN/HIV integration is of interest to patients, healthcare providers, and managers. Improving access to HTN care among PLHIV will require overcoming barriers and capitalizing on facilitators using a health system strengthening approach. These findings are a springboard for designing contextually appropriate interventions for HTN/HIV integration in low- and middle-income countries.
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