Out of the intended 1500, we identified 1,448 charts and 52 were missing (Figure 1). Of those identified, 1,426 were eligible for review while 22 were ineligible for various reasons (Figure 1). Majority of the charts were from Masaka (55%), a third from St. Balikudembe (30%) and the rest from Kalisizo (15%) (Table 1). Patients’ median age was 35 years (Interquartile range (IQR): 29 to 43) and two-thirds were women (65%). Patients had been on ART for a median of 4 years (IQR: 2 to 6) with a median duration in HIV care of 4 years (IQR: 1 to 7). Almost all (1269, (89%)) were still on a first-line ART with a few on second line regimens. In the previous year, patients had a median of 3 visits (IQR: 2 to 6) to the clinic. Using data available, 262 (18%) patients were classified as overweight or obese (body mass index (BMI) > 25 Kg/M2).
Period prevalence of screening
Of the 1426 patients, 783 had at least one BP measurement recorded at a clinic visit in 2017 or 2018. This represents a period prevalence of 55% (95% CI: 52% to 57%) (Table 2). Screening prevalence was highest in Masaka 67% (95 CI: 64% to 71%) and lowest in Kalisizo 4% (95% CI: 1.9% to 7.4%) (Table 2). Older adults (>55 years) had a higher screening prevalence at 55% (95% CI: 46% to 67%) compared to other age groups. Among the 783 patients with at least one BP measurement, 183 patients had reading in the pre-hypertensive range according to the Joint National Committee on Prevention, Treatment of High Blood Pressure (JNC 7) definition  corresponding to a period prevalence of 23% (95% CI; 21 to 26) (Table 2). Another 218 patients, had readings in the hypertensive range (28% (95% CI; 25 to 31)).
Determinants of hypertension screening
After adjusting for age, clinic site, duration on ART, duration in care, and ART regimen via modified Poisson regression; compared to women, men were less likely to be screened for hypertension with a PR of 0.85 (95% CI: 0.78 to 0.94; p=0.001) (Table 3). Also, for every 10-year increase in age, the prevalence of screening increased 1.07 times (95% CI:1.03 to 1.13; p=0.001) after adjusting for sex, clinic site, duration on ART, duration in care, and ART regimen. Further, patients were more likely to get screened if they attended more clinic visits since every 5 clinic visits attended increased likelihood of screening 1.84 fold (95% CI: 1.65 to 2.05); p<0.001), adjusting for sex, age, clinic site, duration on ART, duration in care, and ART. Screening prevalence also depended on clinical care site. Compared to Masaka, patients in Kalisizo (PR 0.06 (95% CI: 0.03 to 0.1; p<0.001)), and St Balikudembe (PR 0.85 (95%CI: 0.77, 0.93; p<0.001)) were less likely to be screened after adjusting for sex, age, duration on ART, duration in care, clinic visits, and ART regimen.
We performed 50 in-depth interviews among 33 patients and 17 health care workers (Table 4) across all sites. Of these, 21 were conducted at Masaka, 19 at St. Balikudembe and 10 in Kalisizo. Overall 69% (23) of patients and 65% (11) of providers were female.
Patients’ perception of Screening practice
Generally, patients reported inconsistent screening for hypertension as demonstrated by these quotes:
“…regarding hypertension whenever I come to the clinic, I am not screened for hypertension… but there is a season when all patients are screened for hypertension” (PM012)
“They are inconsistent, sometimes you come and they check but sometimes they don’t check.” (PSB008)
Screening depended on various influences, such as previously diagnosed hypertension as illustrated here:
“I have had hypertension for 13 years. Whenever I come to the clinic my blood pressure is measured. Sometimes when I come to the clinic I am not screened for hypertension but most of the times we are screened.” (PM012)
At St. Balikudembe clinic, another noted that screening has changed overtime with reduced frequency more recently.
“…They were checking sometime back but they have not been checking me these days” (PSB005)
While in Kalisizo another reported that screening only started recently.
“They have just started screening for hypertension when you visit the clinic… Sometimes they screen for blood pressure” (PK005)
Screening seemed more likely when patients came to clinic earlier in the day.
“Most of the time when I come to the clinic I must be screened for hypertension; this is why I come early so that I can be screened.” (PM008)
Notably, upon screening, patients reported insufficient provider communication regarding findings. Some patients perceived not communication, in some instances, as an indicator of normal BP status:
“They never told me. After screening he just told me move to this next point.” (PM003)
“If they have not told me anything, it means I don’t have [high blood] pressure.” (PSB006)
Patient’s perceived benefits of screening
Patients reported that routine screening is not only informative of one’s health status but is also the gateway to hypertension treatment.
“It is good [to screen] because when you know your health condition, you are better than a person who does not know” (PSB003)
Absence of anti-hypertensive medication at the HIV clinics, and medication cost were also noted as potential impediments to deriving full benefits of screening.
“…It would be better to get all the medication from this clinic also...” (PM008)
Providers’ perspectives on screening
Most providers recognized the importance of screening for hypertension among HIV-infected adults on ART.
“…We don’t have the statistics here but based on my own experience …. I think out of 10 patients I see in a day, 3 of them are hypertensive.” (HWSB002)
They reported however that screening was not necessarily emphasized across clinic facilities. For instance, the Masaka clinic allocated a day per week to screen older adults for hypertension among other issues.
“Right now, we are seeing many cases among the elderly. That’s why we have decided to allocate a day in the week on Wednesday which is for seniors… so that they don’t miss those routine services like BP, RBS [Random Blood Sugar] …” (HWM004)
Providers stated some challenges that imped regular screening, among them: the high patient numbers, limited staff and, few and/or defective BP machines. Providers stated:
“Some patients are not screened because we are busy, [and] we have to change, sometimes we divide ourselves.” (HWK004)
“…But then there are days that are actually very heavy [with many clients] and basing on the staffing, it makes it hard [to] screen everyone.” (HWK001)
“The challenge is once in a while, the [B.P] machine is down and the nurse is over whelmed so they say no… By the time we get the cells [batteries], more than 20 patients have gone [without screening]” (HWSB002)
Providers’ apathy was a reason for failing and inconsistent screening.
“I know what the ideal is, only that sometimes it is not done due to some laxity…sometimes they screen then next week they don’t.” (HWK002)
“Some health staff, feel like rushing clients and so they miss taking their blood pressure” (HWM004)
Providers also recounted that screening without access to anti-hypertensive medicines is a big challenge, suggesting that even just providing essential drugs would be a good start.
“…but the biggest challenge is we lack the essential hypertensive drugs… I think if you can give someone nifedipine they can buy the rest a few drugs not all drugs” (HWSB002)
Notably, BP measurements were documented for action by clinicians, even when the patient was not meant to see a clinician
“…For those who go through the “fast track”, we just write their [ART] drugs in the dispensing sheet. …we record the weight and the BP such that if there is anything wrong then that patient immediately goes back to the clinician” (HWM004)
We observed a lower likelihood of screening among men. Providers reported that most men requested many months’ worth of ART hence made fewer clinic visits
“… for men; they may ask for more than three months of drugs due to the nature of their work… but for women, if you tell them I want to see you after one month, they have no problem with that.” (HWM004)