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Amutuhaire W, Semitala FC, Kimera ID, Namugenyi C, Mulindwa F, Ssenyonjo R, Katwesigye R, Mugabe F, Mutungi G, Ssinabulya I, Schwartz JI, Katahoire AR, Musoke LS, Yendewa GA, Longenecker CT, Muddu M. 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. J Hum Hypertens 2024; 38:452-459. [PMID: 38302611 PMCID: PMC11076202 DOI: 10.1038/s41371-024-00897-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 10/01/2023] [Accepted: 01/18/2024] [Indexed: 02/03/2024]
Abstract
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.
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Affiliation(s)
- Willington Amutuhaire
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | | | | | | | - Frank Mulindwa
- Makerere University Infectious Diseases Institute, Kampala, Uganda
| | | | | | - Frank Mugabe
- Department of non-communicable diseases, Uganda Ministry of Health, Kampala, Uganda
| | - Gerald Mutungi
- Department of non-communicable diseases, Uganda Ministry of Health, Kampala, Uganda
| | | | - Jeremy I Schwartz
- Yale School of Medicine, Section of General Internal Medicine, Connecticut, CT, USA
| | - Anne R Katahoire
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lewis S Musoke
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - George A Yendewa
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Chris T Longenecker
- Department of Global Health and Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Martin Muddu
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
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Wamuti B, Sambai B, Magambo C, Ndegwa M, Macharia P, M Temu T, Farquhar C, Bukusi D. HIV assisted partner services (aPS) to support integrated HIV and hypertension screening in Kenya: a pre-post intervention study. BMC Public Health 2023; 23:2391. [PMID: 38041061 PMCID: PMC10693028 DOI: 10.1186/s12889-023-17205-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 11/10/2023] [Indexed: 12/03/2023] Open
Abstract
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.
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Affiliation(s)
- Beatrice Wamuti
- Harvard T. H. Chan School of Public Health, Harvard University, 677 Huntington Avenue, Boston, MA, 02115, USA.
| | - Betsy Sambai
- University of Washington - Kenya, Nairobi, Kenya
| | - Christine Magambo
- Voluntary Counselling and Testing (VCT) and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Paul Macharia
- Research and Programs Department, Kenyatta National Hospital, Nairobi, Kenya
| | - Tecla M Temu
- Department of Global Health, University of Washington, Seattle, USA
| | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - David Bukusi
- Voluntary Counselling and Testing (VCT) and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya
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Goldstein D, Salvatore M, Ferris R, Phelps BR, Minior T. Integrating global HIV services with primary health care: a key step in sustainable HIV epidemic control. Lancet Glob Health 2023; 11:e1120-e1124. [PMID: 37349037 DOI: 10.1016/s2214-109x(23)00156-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/27/2023] [Accepted: 03/06/2023] [Indexed: 06/24/2023]
Abstract
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.
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Affiliation(s)
- Deborah Goldstein
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA.
| | | | - Robert Ferris
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Benjamin Ryan Phelps
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Thomas Minior
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
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Wali S, Ssinabulya I, Muhangi CN, Kamarembo J, Atala J, Nabadda M, Odong F, Akiteng AR, Ross H, Mashford-Pringle A, Cafazzo JA, Schwartz JI. Bridging community and clinic through digital health: Community-based adaptation of a mobile phone-based heart failure program for remote communities in Uganda. BMC DIGITAL HEALTH 2023; 1:20. [PMID: 38800672 PMCID: PMC11116269 DOI: 10.1186/s44247-023-00020-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/11/2023] [Indexed: 05/29/2024]
Abstract
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.
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Affiliation(s)
- Sahr Wali
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
- Centre for Digital Therapeutics, Toronto General Hospital, University Health Network, R. Fraser Elliott Building, 4th floor, 190 Elizabeth St, Toronto, ON M5G 2C4 Canada
| | - Isaac Ssinabulya
- Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Uganda Heart Institute, MulagoNational Referral Hospital, Kampala, Uganda
| | | | | | | | - Martha Nabadda
- Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
| | | | - Ann R. Akiteng
- Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Uganda Heart Institute, MulagoNational Referral Hospital, Kampala, Uganda
| | - Heather Ross
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, ON Canada
- Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON Canada
| | - Angela Mashford-Pringle
- Dalla Lana School of Public Health, Waakebiness-Bryce Institute for Indigenous Health, University of Toronto, Toronto, ON Canada
| | - Joseph A. Cafazzo
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
- Centre for Digital Therapeutics, Toronto General Hospital, University Health Network, R. Fraser Elliott Building, 4th floor, 190 Elizabeth St, Toronto, ON M5G 2C4 Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON Canada
- Department of Computer Science, University of Toronto, Toronto, ON Canada
| | - Jeremy I. Schwartz
- Initiative for Integrated Management of Non-Communicable Diseases, Kampala, Uganda
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, USA
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Isaac Derick K, Khan Z. 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. Cureus 2023; 15:e37422. [PMID: 37182060 PMCID: PMC10173023 DOI: 10.7759/cureus.37422] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 05/16/2023] Open
Abstract
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.
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Affiliation(s)
| | - Zahid Khan
- Acute Medicine, Mid and South Essex NHS Foundation Trust, Southend on Sea, GBR
- Cardiology, Bart's Heart Centre UK, London, GBR
- Cardiology and General Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, GBR
- Cardiology, Royal Free Hospital, London, GBR
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Moor SE, Tusubira AK, Wood D, Akiteng AR, Galusha D, Tessier-Sherman B, Donroe EH, Ngaruiya C, Rabin TL, Hawley NL, Armstrong-Hough M, Nakirya BD, Nugent R, Kalyesubula R, Nalwadda C, Ssinabulya I, Schwartz JI. Patient preferences for facility-based management of hypertension and diabetes in rural Uganda: a discrete choice experiment. BMJ Open 2022; 12:e059949. [PMID: 35863829 PMCID: PMC9310153 DOI: 10.1136/bmjopen-2021-059949] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Sarah Eg Moor
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew K Tusubira
- Uganda Initiative for Integrated Management of Non-communicable Diseases, Kampala, Uganda
| | - Dallas Wood
- Center for Applied Economics and Strategy, RTI International, Research Triangle Park, North Carolina, USA
| | - Ann R Akiteng
- Uganda Initiative for Integrated Management of Non-communicable Diseases, Kampala, Uganda
| | - Deron Galusha
- Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Baylah Tessier-Sherman
- Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Evelyn Hsieh Donroe
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Network for Global Non-communicable Diseases, Yale University, New Haven, Connecticut, USA
| | - Christine Ngaruiya
- Yale Network for Global Non-communicable Diseases, Yale University, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Tracy L Rabin
- Uganda Initiative for Integrated Management of Non-communicable Diseases, Kampala, Uganda
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Network for Global Non-communicable Diseases, Yale University, New Haven, Connecticut, USA
| | - Nicola L Hawley
- Yale Network for Global Non-communicable Diseases, Yale University, New Haven, Connecticut, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Mari Armstrong-Hough
- Department of Social and Behavioral Sciences and Department of Epidemiology, School of Global Public Health, New York University, New York, New York, USA
| | | | - Rachel Nugent
- Global Non-Communicable Diseases, RTI International, Seattle, Washington, USA
| | - Robert Kalyesubula
- African Community for Social Sustainability, Nakaseke, Uganda
- Department of Internal Medicine, Makerere University School of Medicine, Kampala, Uganda
| | - Christine Nalwadda
- Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda
| | - Isaac Ssinabulya
- Uganda Initiative for Integrated Management of Non-communicable Diseases, Kampala, Uganda
- Department of Internal Medicine, Makerere University School of Medicine, Kampala, Uganda
| | - Jeremy I Schwartz
- Uganda Initiative for Integrated Management of Non-communicable Diseases, Kampala, Uganda
- Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Network for Global Non-communicable Diseases, Yale University, New Haven, Connecticut, USA
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