Integrated multi-month dispensing of antihypertensive and antiretroviral therapy to sustain hypertension and HIV control

Viral load suppression and retention in care among children and adolescents receiving multi-month anti-retroviral therapy refills: a program data review in Uganda

BACKGROUND

In July 2022, Uganda's Ministry of Health extended the 2021 WHO guidelines that recommended 3-6 monthly dispensing of antiretroviral therapy (ART) to include all children and adolescents living with HIV (CALHIV). Treatment outcomes following this recommendation have not yet been documented. We compared viral load (VL) suppression and retention in HIV care rates among CALHIV receiving 1, 2-5, and >  = 6 monthly ART dispensation in Uganda.

METHODS

A cross-sectional study of electronic medical records in 118 health facilities was conducted. Data for CALHIV 10-19 years captured at their most recent five clinic visits as of 15th May 2023 were analysed. Most recent two VL < 1000 copies/ml were used as measures for VL suppression and sustained VL suppression. A client was considered retained in care if they visited the clinic within 28 days from their expected return visit date. We used margins plots and a modified poisson model adjusting for facility level clustering to assess VL suppression and retention across multi-month ART categories.

RESULTS

A total of 2864 CALHIV, 1609 (56.2%) being females and with a median age of 12 years (inter quartile range, iqr = 7) were included. Overall suppression and retention rates were 80.4% (2133/2654) and 87.8% (2514/2864) respectively. A significant number had been dispensed ART for ≥ 2 months (50%, 2-5 months and 43.5%, ≥ 6 months). Probability of having a suppressed VL was higher among CALHIV that had received ≥ 6 months and 2-5 months of ART compared to those of 1 month i.e., 83% vs 79% vs 41% respectively. Probability of being retained in care didn't differ across multi-month ART categories. CALHIV who received ART for 2-5 months and ≥ 6 months compared to 1 month were more likely to have a suppressed VL; (adj.PR = 1.98; 95%CI:1.41, 2.80) and (adj.PR = 2.21; 95% CI:1.59, 3.05) respectively. CALHIV with a Tuberculosis diagnosis history were less likely to have a suppressed VL (adj.PR = 0.73; 95%CI:0.65,0.81), however this was not statistically significantly different between multi-month categories.

CONCLUSION

CALHIV receiving multi-month ART including 6 months dispensation had better VL suppression rates. Retention rates however didn't differ by multi-month dispensing categories as observed among adults in the interval trial. We recommend multi-month ART dispensation including more than 6 months among CALHIV irrespective of their age, clinical stage, and history of prior co-morbidities.

Current out of pocket care costs among HIV and hypertension co-morbid patients in urban and peri-urban Uganda

BACKGROUND

Despite improvements to the cascade of HIV care in East Africa, access to care for non-communicable disease co-morbidities like hypertension (HTN) remains a persistent problem. The integration of care for these conditions presents an opportunity to achieve efficiencies in delivery as well as decrease overall costs for patients. This study aims to build evidence on the burden of current out-of-pocket costs of care among HIV-HTN co-morbid patients.

METHODS

We administered a pre-tested, cross-sectional, out-of-pocket cost survey to 94 co-morbid patients receiving HIV care from 10 clinics in the Wakiso and Kampala districts of Uganda from June to November 2021. The survey assessed socio-demographic characteristics, direct medical costs (e.g., medications, consultations), indirect costs (e.g., transport, food, caregiving), and economic costs (i.e., foregone income) associated with seeking HIV and HTN care, as well as possible predictors of monthly care costs. Patients were sampled both during a government-imposed nation-wide full COVID-19 lockdown (n = 30) and after it was partially lifted (n = 64).

RESULTS

Median HIV care costs constitute between 2.7 and 4.0% of median monthly household income, while HTN care costs are between 7.1 to 7.9%. For just under half of our sample, the median monthly cost of HTN care is more than 10% of household income, and more than a quarter of patients report borrowing money or selling assets to cover costs. We observe uniformly lower reported costs of care for both conditions under full COVID-19 lockdown, suggesting that access to care was limited. The main predictors of monthly HIV and HTN care costs varied by disease and costing perspective.

CONCLUSIONS

Patient out of pocket costs of care for HIV and HTN were substantial, but significantly lower during the 2021 full COVID-19 lockdown in Uganda. New strategies such as service integration need to be explored to reduce these costs.

High rate of uncontrolled hypertension among adults receiving integrated HIV and hypertension care with aligned multi-month dispensing in Malawi: results from a cross-sectional survey and retrospective chart review

INTRODUCTION

People living with HIV have high rates of hypertension. Integrated HIV and hypertension care with aligned multi-month dispensing of medications (MMD) could decrease the burden of care for individuals and health systems. We sought to describe hypertension control and evaluate its association with different durations of MMD among Malawian adults receiving integrated care with aligned dispensing of antiretroviral therapy (ART) and antihypertensive medication.

METHODS

We conducted a cross-sectional survey and retrospective chart review of adults (≥18 years) receiving integrated HIV and hypertension care on medications for both conditions for at least 1 year, with aligned MMD at seven clinics in Malawi. Data were collected from July 2021 to April 2022 and included socio-demographics, clinical characteristics, antihypertensive medications and up to the three most recent blood pressure measurements. Bivariate analyses were used to characterize associations with hypertension control. Uncontrolled hypertension was defined as ≥2 measurements ≥140 and/or ≥90 mmHg. Chart reviews were conducted for a random subset of participants with uncontrolled hypertension to describe antihypertensive medication adjustments in the prior year.

RESULTS

We surveyed 459 adults receiving integrated care with aligned dispensing (58% female; median age 54 years). Individuals most commonly received a 3-month aligned dispensing of ART and antihypertensive medications (63%), followed by every 6 months (16%) and every 4 months (15%). Hypertension control was assessed in 359 respondents, of whom only 23% had controlled hypertension; 90% of individuals in this group reported high adherence to blood pressure medications (0-1 missed days/week). Control was more common among those with longer aligned medication dispensing intervals (20% among those with 1- to 3-month dispensing vs. 28% with 4-month dispensing vs. 40% with 6-month dispensing, p = 0.011). Chart reviews were conducted for 147 individuals with uncontrolled hypertension. Most had high self-reported adherence to blood pressure medications (89% missing 0-1 days/week); however, only 10% had their antihypertensive medication regimen changed in the prior year.

CONCLUSIONS

Uncontrolled hypertension was common among Malawian adults receiving integrated care with aligned MMD and was associated with shorter refill intervals and few antihypertensive medication escalations. Integrated care with aligned MMD is promising, but further work is needed to understand how to optimize hypertension outcomes.

Time to blood pressure control and predictors among patients receiving integrated treatment for hypertension and HIV based on an adapted WHO HEARTS implementation strategy at a large urban HIV clinic in Uganda

In this cohort study, we determined time to blood pressure (BP) control and its predictors among hypertensive PLHIV enrolled in integrated hypertension-HIV care based on the World Health Organization (WHO) HEARTS strategy at Mulago Immunosuppression Clinic in Uganda. From August 2019 to March 2020, we enrolled hypertensive PLHIV aged ≥ 18 years and initiated Amlodipine 5 mg mono-therapy for BP (140-159)/(90-99) mmHg or Amlodipine 5 mg/Valsartan 80 mg duo-therapy for BP ≥ 160/90 mmHg. Patients were followed with a treatment escalation plan until BP control, defined as BP < 140/90 mmHg. We used Cox proportional hazards models to identify predictors of time to BP control. Of 877 PLHIV enrolled (mean age 50.4 years, 62.1% female), 30% received mono-therapy and 70% received duo-therapy. In the monotherapy group, 66%, 88% and 96% attained BP control in the first, second and third months, respectively. For patients on duo-therapy, 56%, 83%, 88% and 90% achieved BP control in the first, second, third, and fourth months, respectively. In adjusted Cox proportional hazard analysis, higher systolic BP (aHR 0.995, 95% CI 0.989-0.999) and baseline ART tenofovir/lamivudine/efavirenz (aHR 0.764, 95% CI 0.637-0.917) were associated with longer time to BP control, while being on ART for >10 years was associated with a shorter time to BP control (aHR 1.456, 95% CI 1.126-1.883). The WHO HEARTS strategy was effective at achieving timely BP control among PLHIV. Additionally, monotherapy anti-hypertensive treatment for stage I hypertension is a viable option to achieve BP control and limit pill burden in resource limited HIV care settings.

HIV assisted partner services (aPS) to support integrated HIV and hypertension screening in Kenya: a pre-post intervention study

BACKGROUND

People living with HIV (PLWH) have a higher risk of developing hypertension compared to HIV uninfected individuals. HIV assisted partner services (aPS), where PLWH are assisted by a healthcare provider to disclose their status to sexual and / or drug injecting partner(s), offers an opportunity for integrated HIV and hypertension screening. We evaluated the feasibility of the aPS model in supporting integrated HIV and hypertension screening at the Kenyatta National Hospital, Kenya.

METHODS

Between August 2019 and December 2020, we conducted a pre-post intervention study. We enrolled women receiving HIV testing services (HTS) with confirmed hypertension (female index clients) and traced their male relatives for HIV and hypertension screening and reviewed management at 3-months. Hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg, diastolic blood pressure (DBP) ≥ 90 mmHg, and/or use of antihypertensive medication.

RESULTS

One hundred female index clients (median age: 55 years; interquartile range (IQR): 47-65) mentioned 165 male relatives (median: 49 years; IQR: 40-59) of whom 35% (n = 58/165) were enrolled. Of the male relatives, 29% had hypertension (n = 17/58), 34% had pre-hypertension (n = 20/58), and none were HIV-positive (n = 0/58). Among the female index clients, there was a statistically significant decline in SBP (pre: 156 mmHg, post: 133 mmHg, p-value: < 0.0001) and DBP (pre: 97 mmHg, post: 80 mmHg, p-value: < 0.0001), and increase in antihypertensive medication uptake (pre: 91%, n = 84/92; post: 98%, n = 90/92; X2: 4.3931, p-value: 0.036) relative to baseline. Among the male relatives, there was a statistically significant increase in antihypertensive medication uptake among those with hypertension (pre: 13%, n = 6/46; post: 17%, n = 8/46; X2: 32.7750, p-value: < 0.0001) relative to baseline.

CONCLUSION

HIV aPS holds promise for integrated HIV and hypertension screening among at-risk clients and their families. Twenty-nine percent of the male relatives had hypertension, higher than the national prevalence (24%), while one-third had pre-hypertension. We observed relatively high participant retention, reductions in blood pressure, and increase in antihypertensive medication uptake among those with confirmed hypertension. Future research expanding the aPS model to other non-communicable diseases through larger studies with longer follow-ups is required to better assess causal relationships and optimize integrated service delivery.

Integrating global HIV services with primary health care: a key step in sustainable HIV epidemic control

Ending the HIV epidemic relies in part on integrating stand-alone HIV programming with primary health-care platforms to improve population-level health and ensure sustainability. Integration of HIV and primary health care services in sub-Saharan Africa improves both outcomes. Existing models support both integrating primary health care services into existing HIV services, and incorporating HIV services into primary health care platforms, with optimal programming based on local contexts and local epidemic factors. Person-centred differentiated service delivery, community-based interventions, and a well supported health workforce form the backbone of successful integration. Strategic financing to optimise HIV and primary health care integration requires well-coordinated partnerships with host governments, private sector companies, multilateral stakeholders, development banks, and non-government organisations. Programme success will require increased flexibility of international donors' implementation guidance as well as involvement of local communities and civil society organisations. As we seek to end the HIV epidemic by 2030 amidst a constrained global economic climate, integration of HIV programming with primary health care offers an avenue of opportunity and hope.

Bridging community and clinic through digital health: Community-based adaptation of a mobile phone-based heart failure program for remote communities in Uganda

Background

In Uganda, limited healthcare access has created a significant burden for patients living with heart failure. With the increasing use of mobile phones, digital health tools could offer an accessible platform for individualized care support. In 2016, our multi-national team adapted a mobile phone-based program for heart failure self-care to the Ugandan context and found that patients using the system showed improvements in their symptoms and quality of life. With approximately 84% of Ugandans residing in rural communities, the Medly Uganda program can provide greater benefit for communities in rural areas with limited access to care. To support the implementation of this program within rural communities, this study worked in partnership with two remote clinics in Northern Uganda to identify the cultural and service level requirements for the program.

Methods

Using the principles from community-based research and user-centered design, we conducted a mixed-methods study composed of 4 participatory consensus cycles, 60 semi-structured interviews (SSI) and 8 iterative co-design meetings at two remote cardiac clinics. Patient surveys were also completed during each SSI to collect data related to cell phone access, community support, and geographic barriers. Qualitative data was analyzed using inductive thematic analysis. The Indigenous method of two-eyed seeing was also embedded within the analysis to help promote local perspectives regarding community care.

Results

Five themes were identified. The burden of travel was recognized as the largest barrier for care, as patients were travelling up to 19 km by motorbike for clinic visits. Despite mixed views on traditional medicine, patients often turned to healers due to the cost of medication and transport. With most patients owning a non-smartphone (n = 29), all participants valued the use of a digital tool to improve equitable access to care. However, to sustain program usage, integrating the role of village health teams (VHTs) to support in-community follow-ups and medication delivery was recognized as pivotal.

Conclusion

The use of a mobile phone-based digital health program can help to reduce the barrier of geography, while empowering remote HF self-care. By leveraging the trusted role of VHTs within the delivery of the program, this will help enable more culturally informed care closer to home.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44247-023-00020-5.

Prevalence, Awareness, Treatment, Control of Hypertension, and Availability of Hypertension Services for Patients Living With Human Immunodeficiency Virus (HIV) in Sub-Saharan Africa (SSA): A Systematic Review and Meta-analysis

Sub-Saharan Africa (SSA) is faced with a dual burden of hypertension and human immunodeficiency virus (HIV). In this review we sought to determine the prevalence, awareness, and control of hypertension among persons living with HIV (PLHIV), and the availability of hypertension services at the HIV care points in SSA. We searched the PubMed, Embase, Scopus, Cochrane library, Global index Medicus, African Journal online, and WHO Institutional Repository for Information Sharing (IRIS) for studies on the epidemiology of hypertension, and hypertension services for PLHIV in SSA. Twenty-six articles were identified for the review, with 150,886 participants; weighted mean of age 37.5 years and female proportion of 62.6%. The pooled prevalence was 19.6% (95% confidence interval [CI], 16.6%, 22.5%); hypertension awareness was 28.4% (95% CI, 15.5%, 41.3%), and hypertension control was 13.4% (95% CI, 4.7%, 22.1%). HIV-related factors like CD4 count, viremia, and antiretroviral therapy regimen were not consistently associated with prevalent hypertension. However, high body mass index (BMI) above 25 kg/m² [odds ratio: 1.64, 95% CI (1.26, 2.02)] and age above 45 years [odds ratio: 1.44, 95% CI (1.08, 1.79)] were associated with prevalent hypertension. Even when PLHIV on ART were more likely to be screened for hypertension and monitored, there was infrequent screening and treatment of hypertension in most HIV clinics. Most studies recommended integrating of HIV and hypertension services. We report a high prevalence of hypertension in a relatively young population of PLHIV with suboptimal screening, treatment, and control of hypertension. We recommend strategies to integrate HIV and hypertension services.

Patient preferences for facility-based management of hypertension and diabetes in rural Uganda: a discrete choice experiment

OBJECTIVE

To explore how respondents with common chronic conditions-hypertension (HTN) and diabetes mellitus (DM)-make healthcare-seeking decisions.

SETTING

Three health facilities in Nakaseke District, Uganda.

DESIGN

Discrete choice experiment (DCE).

PARTICIPANTS

496 adults with HTN and/or DM.

MAIN OUTCOME MEASURES

Willingness to pay for changes in DCE attributes: getting to the facility, interactions with healthcare providers, availability of medicines for condition, patient peer-support groups; and education at the facility.

RESULTS

Respondents were willing to pay more to attend facilities that offer peer-support groups, friendly healthcare providers with low staff turnover and greater availabilities of medicines. Specifically, we found the average respondent was willing to pay an additional 77 121 Ugandan shillings (UGX) for facilities with peer-support groups over facilities with none; and 49 282 UGX for 1 month of medicine over none, all other things being equal. However, respondents would have to compensated to accept facilities that were further away or offered health education. Specifically, the average respondent would have to be paid 3929 UGX to be willing to accept each additional kilometre they would have to travel to the facilities, all other things being equal. Similarly, the average respondent would have to be paid 60 402 UGX to accept facilities with some health education, all other things being equal.

CONCLUSIONS

Our findings revealed significant preferences for health facilities based on the availability of medicines, costs of treatment and interactions with healthcare providers. Understanding patient preferences can inform intervention design to optimise healthcare service delivery for patients with HTN and DM in rural Uganda and other low-resource settings.