Addressing gaps in healthcare providers’ knowledge, attitudes, and practices to establish a sustainable model for integrated HIV- hypertension care in Uganda

doi:10.21203/rs.3.rs-4819337/v1

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Research Article

Addressing gaps in healthcare providers’ knowledge, attitudes, and practices to establish a sustainable model for integrated HIV- hypertension care in Uganda

https://doi.org/10.21203/rs.3.rs-4819337/v1

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Background

Despite the available guidelines to integrate HIV and hypertension (HTN) care in Uganda, access to quality HTN care is still limited to a few tertiary HIV clinics. We explored the current state of HTN care in HIV settings, understand healthcare providers’ (HCP) knowledge, attitudes and practices regarding HTN care, as well as the perceptions of HCPs, healthcare managers and policymakers about integrated HIV-HTN care. The goal was to use this formative research to inform the design of a sustainable, robust model for integrating HIV-HTN care in primary health care (PHC) HIV clinics in urban and peri-urban areas of Uganda

Methods

We conducted a parallel convergent mixed methods study at ten HIV clinics in Kampala and Wakiso districts. We consecutively surveyed 89 HCPs involved in the provision of routine HIV care to assess their knowledge, attitudes and practices towards HTN care. We purposively selected 40 HCPs and 6 healthcare managers to participate in semi-structured key informant interviews (KII). Interviews were audio recorded and later transcribed. Through an iterative process, the data was deductively coded and the final codes were mapped onto the domains of the updated Consolidated Framework for Implementation Research (CFIR). Quantitative data was analysed in Stata 14. Categorical data were summarized using proportions and frequencies, while median and interquartile ranges were used for continuous data. The data was stratified by district.

Results

Between June 2021 and November 2021, 89 HCPs (45-Kampala, 44-Wakiso) median age of 35 (IQR, 29–45) years, and 62% of them were female participated in the survey. HCPs reported no in-service training on HTN, had insufficient knowledge on HTN, limited access to simplified protocols for the treatment of HTN, and reported varying levels of HIV-HTN integration across the ten clinics. HCPs reported a lack of sufficient numbers of functional blood pressure (BP) devices, anti-hypertensive medicines, lack of reporting tools and feedback regarding HTN care metrics as the major hindrances to provision of integrated HIV-HTN care. Despite these hindrances, HCP expressed willingness to integrate HIV-HTN care to reduce client waiting time, costs, and HCP workload.

Conclusions

This formative assessment identified gaps in current HTN care in HIV clinics in urban and peri-urban Uganda. This provided a context to inform the design of a sustainable, robust and sustainable model for integrating HTN and HIV-HTN care in PHC HIV clinics in urban and peri-urban areas of Uganda.

Sub-Saharan Africa (SSA) region has the highest burden of HIV globally and has demonstrated remarkable efforts and successes in combating the HIV/AIDS epidemic over the past four decades. For example, AIDS-associated mortality decreased significantly by more than two-thirds between 2004 and 2022 [1]. As a result of this decline in HIV/AIDS-associated mortality, people living with HIV (PLHIV) are ageing with it. Consequently, PLHIV face a heightened risk of developing non-communicable diseases (NCDs) including cardiovascular diseases and diabetes, among others. SSA region also has a growing proportion of people living with hypertension (HTN), which is the greatest risk factor for cardiovascular diseases[2].

In Uganda, 20–30% of PLHIV aged 18 years and older have comorbid HTN, a prevalence higher than that observed in their HIV-negative counterparts. [3, 4]. While Uganda has made significant strides towards UNAIDS 95-95-95 targets to end the HIV pandemic, the quality of care for HTN has not kept pace[5]. For instance, recent studies show that less than half of PLHIV receive blood pressure (BP) measurements during clinic visits, and less than a quarter of those with HTN achieve their BP targets[6, 7]

The successful expansion of antiretroviral therapy (ART ) services across Uganda has significantly reduced HIV-associated morbidity and mortality. As a result, PLHIV are living longer into older age. However, in addition to the traditional risk factors for HTN, PLHIV are exposed to HIV-induced chronic inflammation and adverse effects of ART, all of which amplify the risk for NCDs. HTN is a significant risk factor for cardiovascular diseases (CVD) and is responsible for a fourfold increase in estimated CVD disability-adjusted life years (DALYs) compared to high LDL cholesterol[8].

Owing to the high burden of HTN and the need to preserve the gains from the successful but verticalised HIV programs, the World Health Organization (WHO) and Uganda Ministry of Health (MoH) recommend integration of HIV and HTN (HIV-HTN) care[9, 10]. Integration of services is defined as ‘the organization and management of the health services so that people get the care they need, when they need it in ways that are user friendly, achieve the desired results and provide value for money’. Integration of HIV and HTN can be defined and applied in this context as providing health education, BP measurement, anti-hypertensive treatment initiation and monitoring, cardiovascular risk assessment and anti-hypertensive refill by the same HIV HCP in the same spaces where PLHIV receive HIV services. Despite available guidance, the integration of HIV-HTN care remains limited in its reach, often confined to select academic institutions or specialized HIV clinics in Uganda. Previous implementation studies have identified numerous barriers hampering the integration of these services, including limited knowledge, inconsistent BP measurement, and poor access to medications and lack of standardized treatment protocol for HTN [4, 11, 12].

In an effort to design a robust and sustainable model for integrating HIV-HTN care in PHC HIV clinics in urban and peri-urban areas of Uganda, we conducted a mixed-method formative study to explore the current practices of HTN care in HIV clinic settings, understand healthcare providers’ (HCP) knowledge, attitudes and practices regarding HTN care as well as the perceptions of HCPs, healthcare managers and policymakers about integrated HIV-HTN care. In this paper, we present HCPs’ knowledge and attitudes about HTN care, their perception of integrated HIV-HTN care, and policy maker’s perceived need for integration of HIV-HTN care in PHC HIV clinics. We also describe how the findings from this formative study have shaped the design of a multi-component implementation strategy.

Conceptual Approach: The Consolidated Framework for Implementation Research

We utilized the Consolidated Framework for Implementation Research (CFIR) as our conceptual framework. CFIR is a comprehensive framework that includes constructs associated with effective implementation. CFIR comprises 39 constructs organized into five domains: Intervention Characteristic, Outer Setting, Inner Setting, Characteristics of Individuals, and Process[13]. CIFR enabled us to identify factors that could potentially promote or inhibit adoption, implementation, and maintenance of tailored interventions during the planning phase. We utilized the CFIR to guide the assessment of factors that could impact the implementation of integrated HIV and HTN care. Examining the presence or absence of CFIR constructs helped us understand why the implementation might succeed or fail. As such we assessed HCPs' knowledge, attitudes, and practices related to HTN care and their perception of an integrated delivery model for HTN and HIV care. Using the CFIR framework, we identified areas where we could improve HTN care within the HIV program. We analyzed the intervention characteristics, outer and inner settings, characteristics of individuals, and the implementation process. This enabled us to develop strategies to integrate HTN care into HIV care and address the identified gaps. [14]

Study Design

The formative used a parallel convergent mixed methods design to collect, analyze, and interpret qualitative and quantitative data.

Study Setting

We conducted the research at ten HIV clinics in Kampala (5) and Wakiso (5) districts in the central region of Uganda. These two districts have over 122 HIV clinic centers and provide HIV care and treatment services to about 210,745 PLHIVs. The ten clinics were purposively selected based on geographical location (urban vs. peri-urban), type of health facility [private not for profit (PNFP) vs. public], level of health facility (hospitals, health center IV, or health center III) as well as the number of PLHIV who accessed care at these clinics (≥ 2000 or < 2000). Table 1. HIV services at the selected facilities receive support from local comprehensive HIV/AIDS implementing partners funded by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) program through the Centers for Disease Control and Prevention.

Table 1

Showing Study Sites, number of PLHIV receiving HIV care and treatment and number of HCPs who participated in this study.
Site	Health facility type	Geographical location	KAP Survey	KII
Kampala
A	Public	Urban	08	4
B	Public	Urban	12	4
C	Public	Urban	09	4
D	Public	Urban	05	4
E	PNFP	Urban	11	4
Wakiso
F	Public	Peri-urban	09	4
G	Public	Peri-urban	06	4
I	PNFP	Peri-urban	12	4
H	Public	Peri-urban	07	4
K	Public	Peri-urban	10	4
TOTAL			89	40
KAP- Knowledge, attitudes and practice, KII- Key informant interviews, PNFP – Private not for Profit

Study procedures

Quantitative

We contacted and enrolled eligible HCPs (medical doctors, clinical officers [clinical officers hold a diploma in clinical medicine], nurses, pharmacists or pharmacy technicians, laboratory personnel, or clinic administrators) who provided HIV care at the selected ten HIV clinics in Kampala and Wakiso districts. All participants provided informed consent to participate in this study. Four research assistants with training in social sciences consecutively administered pretested surveys to 89 HCPs involved in providing HIV care. Since the study aimed to enroll all providers involved in providing HIV care at study clinics, there was no predetermined sample size.

Using a survey questionnaire, we collected data on sociodemographic characteristics (age, sex, years of clinical practice, and cadreship), knowledge about diagnosis, risk factors for HTN, blood pressure (BP) control targets, and complications of HTN. We also included questions on how often HCPs attended to PLHIV with HTN, the desirability for task shifting in providing HTN care, and perceived barriers to integrated HIV-HTN care. The questions on practice assessed scheduling appointments for PLHIV who had HTN, the HCP’s role in the provision of HTN care, lifestyle changes, and pharmacologic recommendations made by the provider to PLHIV and HTN. We also assessed if HIV-HTN services were provided in the same space, and by the same HCP. The surveys were conducted in English. Additionally, we used an observation checklist to document the availability of guidelines and simplified protocols for HTN treatment, availability of resources (medications, BP devices), and observed clinic processes regarding HTN care cascades at the ten HIV clinics

Qualitative study

A total of 40 HCPs were purposefully selected from the 89 to participate in semi-structured key informant interviews (KII) to explore their perceptions of HTN-HTN care and perceived barriers to and facilitators of integrated HTN-HIV care at the HIV clinics. We aimed to achieve a balance among the various professional cadres (medical officers, clinical officers, and nurses) as well as their levels of professional experience. Table 2. Interviews were also conducted with healthcare managers and policymakers purposively sampled based on their roles as healthcare managers and policy and decision makers (n = 6); Kampala capital City authority (n = 3), Wakiso District (n = 1), and Uganda MoH (n = 2-one from the national AIDS control program and another from the Department of NCDs). Similar to the KII conducted with the HCPs, those conducted with healthcare managers and policymakers were conducted by a female social scientist with a good understanding of the subject using semi-structured interview guides. All interviews were recorded with the participants' consent. The interviews for 30–60 minutes. The audio files were transferred to a password-protected computer and de-identified to protect the participants' identity and ensure confidentiality. The de-identified audio files were then transcribed verbatim in Microsoft Word in preparation for data analysis.

Table 2

**Data sources and approaches for data collection and analysis used in this formative study**
Study objective	Method	Study Population	Data Analysis
Assess HCPs’ knowledge attitudes and practices of HTN diagnosis, treatment and monitoring at HIV clinics in Kampala and Wakiso districts.	Quantitative KAP Survey questionnaire	HCP	Descriptive analysis
Assess HCPs’ and policy makers’ perceptions of current HTN care and perceived barriers to and facilitators of integrated HIV-HTN in HIV clinics in Kampala and Wakiso Districts	Qualitative Semi-structured interviews	Healthcare managers and policymakers HCP	Inductive and deductive, findings mapped onto CFIR
*HTN- Hypertension, KAP- Knowledge Attitudes and Practices, PLHIV- people living with HIV.

Data analysis

Quantitative

The survey data was collected and managed using the Research Electronic Data Capture (REDCap) system hosted at the Infectious Diseases Research Collaboration [15, 16]. After collection, the data were exported and analyzed in STATA version 14.1 (StataCorp, Texas, USA). Categorical data were summarized using proportions and frequencies, while median and interquartile ranges were used for continuous data. The data was stratified per district. Comparisons between districts were made using chi-squared tests and Mann-Whitney tests for categorical and continuous variables, respectively.

Qualitative

We used an inductive approach to analyze the data, starting with open coding guided by the data to identify emerging themes. The study team (FA, CK, and JS) reviewed a sample of the transcripts to identify emerging patterns, which helped us develop a codebook. We then had weekly meetings to discuss the coding framework and ensure intercoder reliability and consistency. After finalizing the coding framework, we divided the transcripts equally among the three coders (FA, CK, and JS) and applied the coding framework to all the transcripts. Once the initial coding was completed, we held a meeting to discuss the coding outputs for consensus building. The second level of coding was deductive, where we mapped the initial coded work onto the domains and constructs of the 2022 Update of the Consolidated Framework for Implementation Research (CFIR)[13].

Study Participants characteristics

Between June 2021 and November 2021, 89 HCPs participated in the survey. The median age of the participants was 35 years (interquartile range (IQR) 29- to 45), and 62% of them were female. The majority of the HCPs were nurses (37%) or clinical officers (27%), with a median clinical practice duration of 9 years (IQR, 5–16).(Table 3).

Table 3

Key characteristics of HCPs participating in the formative study at selected HIV clinics in Kampala and Wakiso districts.
Variable	n(%)
	Overall (n = 89)	Kampala (n = 45)	Wakiso (n = 44)
Sex
Female	54 (61.8)	22 (48.9)	33 (75)	0.01
Male	34 (38.2)	23 (51.1)	11 (25)
Median age (IQR)^a	35 (29, 45)	35 (30, 45)	34.5 (28, 43)	0.43
Profession
Medical Doctor	12 (13.5)	11 (24.4)	1 (2.3)	0.02
Nurse	33 (37.1)	13 (28.9)	20 (45.5)
Clinical officer	24 (27)	10 (22.2)	14 (31.8)
HIV counsellor	7 (7.9)	3(6.7)	4 (9.1)
Other*	13 (14.6)	8 (17.8)	5(11.4)
Years of clinical practice (IQR)^a	9 (5, 16)	10 (5, 17)	8.5 (5, 15.5)	0.35
^aWilcoxon rank sum test, Categorical variables – χ² *Other include; laboratory technicians(7) pharmacy technicians(3), nurse assistants (3)

Among forty HCPs who took part in the KII, the median age was 35 (range 29.5–43.5), with 23 (58%) being female. The median years of practice were 10 (interquartile range 5–17).

Knowledge about risk factors for HTN, diagnosis, treatment, and complications

The study showed that most HCPs had not received training on HTN care, with 60.7% stating that they had never received any training throughout their careers. Only 20% of clinics had received relevant training in HTN in the past two years. Despite this, 64% of HCPs reported using guidelines for HTN care, with the Uganda Clinical guidelines being the most commonly used reference. However, only 44.9% and 60.7% of HCPs correctly identified the diagnostic thresholds for HTN (140 mmHg systolic and 90 mmHg diastolic), while 76% and 48% correctly identified the control targets (< 140 mmHg systolic and < 90 mmHg diastolic) for adults being treated for HTN (Table 4).

Table 4

HCP knowledge about HTN diagnosis, treatment, monitoring and complications
Variable	n(%)			p value
Variable	Overall (n = 89)	Kampala (n = 45)	Wakiso (n = 44)
HCP refers to HTN guidelines	57 (64)	26 (57.8)	31 (70.5)	0.21
Guidelines used (n = 57)
Uganda clinical guidelines (UCG)	37 (64.9)	13 (50)	24(77.4)	0.01
Consolidated HIV guidelines	10 (17.5)	5 (19.2)	5 (16.1)
Others	6 (10.5)	6 (23.1)	0
Do not know	4 (7.1)	2 (7.7)	2 (6.5)
HTN training outside formal medical training
Received no training	54 (60.7)	26 (57.8)	28 (63.6)	0.44
Within the last 12 months	17 (19.1)	10 (22.2)	7 (15.9)
Between 1 and 2 years	7 (7.9)	3 (6.7)	4 (9.1)
Between 2–5 years	9 (10.1)	6 (13.3)	3(6.8)
Over 5 years	2 (1.3)	0	2 (4.5)
Knows SBP Cut off for diagnosis of HTN
140 mmHg	40 (44.9)	22 (48.9)	18 (40.9)	0.44
Do not know	49 (55.1)	23 (51.1)	26 (59.1)
Knows DBP Cut off for diagnosis of HTN
90 mmHg	54 (60.7)	29 (64.4)	25 (56.8)	0.46
Do not know	35 (39.3)	16 (35.6)	19 (43.2)
Knows SBP goal in most adult clients
< 140 mmHg	68 (76.4)	34 (75.6)	34 (77.3)	0.84
Does not know	21 (23.6)	11 (24.4)	10 (22.7)
Knows DBP goal in most adult clients
< 90 mmHg	43 (48.3)	23 (51.1)	20 (45.5)	0.59
Does not know	46 (48.3)	22 (48.9)	24 (54.5
Knows circumstances when a lower BP goal is desired
Yes	58 (65.2)	35 (77.8)	23 (52.3)	0.012
Conditions with lower BP goal (n = 58)
Diabetes	17 (29.3)	9 (20)	8 (18.2)	0.478
Ischemic heart disease	10 (17.2)	4 (8.9)	6 (13.6)	0.798
Chronic kidney disease	10 (17.2)	8 (17.8)	2 (4.5)	0.048
Prior heart attack	13 (22.4)	7 (13.6)	6 (15.6)	0.798
Cardiovascular risk > 20%	8 (13.8)	5 (11.1)	3 (6.8)	0.479
Prior stroke	11 (19)	5 (11.1)	6 (13.6)	0.717
Stoppage of medication if BP is controlled
Yes	14 (15.7)	8 (13.6)	8 (17.8)	0.592
Risk factors for HTN
Genetics/ family related	65 (73)	31 (68.9)	34 (77.3)	0.373
Eating excessive salt	25 (28.1)	8 (17.8)	17 (38.6)	0.029
Excessive consumption of alcohol	41 (46.1)	24 (53.3)	17 (38.6)	0.164
Physical inactivity	52 (58.4)	29 (64.4)	23 (52.3)	0.244
Obesity /overweight	46 (51.7)	25 (55.6)	21 (47.7)	0.460

HCP Knowledge of hypertension diagnosis and treatment.

HCPs reported that they had insufficient knowledge about the care and treatment of HTN. They believed that receiving in-service training on HTN would be beneficial for them to provide optimal HTN care. HCPs also mentioned that their current practices in HTN care were based on what they had learned during pre-graduation medical training. As a result, they relied on this knowledge to make clinical decisions regarding HTN care.

“For most of us [HCP], the knowledge we are using to manage HTN is what we acquired during our medical training. We receive mentorship and refresher training on other disease conditions but we have never received one on HTN care.” (Nurse, Clinic H)

“We need some kind of training to address the knowledge gaps that we have. I’m very sure the knowledge gaps are quite many because we are clinicians of different training backgrounds, with different experiences and we are all interacting with these clients independently without being supervised and there’s no clear guideline addressing HTN as a whole”( HIV clinic head, Clinic A)

BP measurement, HTN treatment and monitoring practices

Most of the HCPs reported that they would synchronize HIV and HTN clinic visits, only 64% provided both HIV-HTN care within the HIV clinics and only 42% attended to HTN clients on most days of the week (Table 5).

Table 5

HCPs’ practices regarding HTN treatment, monitoring and complications.
Variable	n(%)			p value
	Overall (n = 89)	Kampala (n = 45)	Wakiso (n = 44)
Frequency of managing HTN
Most of the days	37 (41.6)	18 (40)	19 (43.2)	0.66
At least weekly	31 (34.8)	16 (35.6)	15 (34.1)
At least monthly	4 (4.5)	1 (2.2)	3 (6.8)
Less than monthly	17 (19.1)	10 (22.2)	7 (15.9)
Management of HIV-HTN comorbidities
Provide HIV clinical assessment only	3 (3.4)	0	3 (6.8)	0.1
Provide clinical assessment for HIV and HTN	57 (64)	30 (66.7)	27 (61.4)
Provide care for HIV and refer to HTN clinic	16 (18)	6 (13.3)	10 (22.7)
Provide HIV care and refer to another facility	6 (6.7)	3 (6.7)	3 (6.8)
Others*	7 (7.9)	6 (13.3)	1 (2.3)
Synchronization of HIV and HTN clinic visits
No	27 (30.3)	9 (20)	18 (40.9)
Yes	61 (68.5)	35 (77.8)	26 (59.1)	0.07
HCPs responsible for BP measurement
Doctor	43 (48.3)	30 (66.7)	13 (29.5)	< 0.01
Nurse	69 (77.5)	33 (73.3)	36 (81.8)	0.34
Clinical officer	68 (76.4)	32 (71.1)	36 (81.8)	0.23
HIV counsellors	17 (19.1)	5 (11.1)	12 (27.3)	0.05
Other**	27 (30.3)	19 (42.2)	8 (18.2)	0.01
Others client education and lifestyle counselling, referral for further management and encouraging self-monitoring * Expert clients, peer educators, pharmacy technicians.

BP measurement and monitoring

More than a third of the available BP machines at these health facilities were non-functional (Fig. 1).

Figure 1: Availability of BP monitoring devices at the selected HIV clinics in the Kampala and Wakiso districts

HCPs reported inconsistent practices related to BP measurement and these varied across the 10 HIV clinics. For example, in public health facility-based HIV clinics, HCPs mentioned that not all clients had a BP measurement taken during clinic visits. Instead, measurements were selectively performed for individuals who self-advocated, presented with symptoms suggestive of HTN (such as headache, swollen feet, chest pain), or were otherwise deemed by HCPs to be at high risk. Additionally, HCPs reported that BP measurements were mostly taken on less busy clinic days and were often not done when the clinics were busier.

“We measure BP, especially for elderly clients and others who also have symptoms [suggestive of HTN], you have to go ahead and take their BP” (Clinical officer, Clinic I )

“If a client complains about some of the signs and symptoms like persistent headache, palpitations abnormal tiredness that is when the BP is taken. If someone doesn’t complain given that the clinic has long queues, we do not usually go the extra mile to take BP. [We] do not usually screen everyone… (Nurse, Clinic G )

HCPs mentioned lack of BP devices and batteries as barriers to BP screening for all clients attending a given clinic. One HCP noted that he often uses his personal BP device in the clinic.

“The first challenge is lack of equipment such as BP machines because I personally use mine [BP machine] and not for the clinic - my personal one. So that is one of the most challenges we have faced” (Clinical officer, Clinic F)

“The triage area could be missing the BP machines, if the BP machines are available, the batteries are not available…” (Clinical Officer, Clinic F)

Availability of anti-hypertensive medication

Thiazides (typically bendroflumethiazide) and calcium channel blockers (typically nifedipine) tended to be more available at the HIV clinics compared to other medication classes (Table 6). Nine out of 10 clinics did not have any medication in the class of angiotensin-converting enzyme inhibitors (ACE) or angiotensin receptor blockers (ARB).

Table 6

Anti-hypertensive medication availability at selected HIV clinics
	Some medications within the medication class are always available	At least one medication within the class is always available, but not always the same medication	At least one medication within the medication class is sometimes available	No medications in the medication class are available at all	Stockout in the medication class in the last 3 months
Thiazide diuretic	4	2	0	3	1
CCB	5	1	2	2	0
Beta-blocker	2	1	0	7	0
ACEIs	0	0	1	9	0
ARB	0	0	1	9	0
Other medications	0	0	3	7	0
CCB – Calcium channel blocker, ACEIs -Angiotensin-converting enzyme inhibitors, ARB- Angiotensin receptor blockers, Other medications include methyldopa and hydralazine

HCPs at public HIV clinics reported frequent stock out and unavailability of anti-hypertensive medications. PLHIV with HTN received a prescription for HTN medications and were referred for refills to either other clinic points within the same health facility or encouraged to purchase medications at private pharmacies or clinics. HCPs at PNFP at HIV clinics reported that anti-hypertensive medications were available at the main hospital pharmacies, but clients could only access them at a cost.

“The HIV clinic does not have anti-hypertensive medications…. when anti-hypertensive treatment is prescribed, clients have to pay for it at the main pharmacy within the hospital or purchase them from a private facility” (Clinical Officer, Clinic I)

“Some of the medications are not available here and these clients don’t have money to buy them. So you find they can spend some time when they are off HTN treatment and by the time they come back, their BP is high” (Nurse, Clinic A)

Prioritization of HTN care in HIV clinics

Most HCPs mentioned that HTN care were deemed of lower priority compared to other services provided in the clinic. Consequently, HTN services received less attention, as they were not a core component of the HIV care package. Furthermore, HCPs highlighted the lack of support received from the MoH to facilitate the integration of HIV and HTN services, as elucidated in the following excerpts:

I would say priority for HTN care was low in the HIV program overall. The Uganda MoH guidelines encourage [HIV-HTN] integration, however, no practical support is given to clinics to integrate HTN care.(Medical officer, Clinic E )

And even when you’re reporting, no one is even interested. You’re not even putting it in the report, you’re not, no one is interested in knowing, how many high blood pressure clients do you have in the clinic, how many received treatment, you know, whereas other things we actually report on them very specifically but here it’s like said in passing. (Medical officer, Clinic C)

Perceived benefits of integrated HIV -HTN care

HCPs believed that provision of integrated HTN-HIV would address several challenges experienced in the HIV clinics including improving HCP knowledge on the management of HTN and their ability to provide holistic care to clients. Additionally, they believed clients would greatly benefit from integrated HIV-HTN care through reduced clinic visit-associated travel costs and would receive holistic care by the same HCP as shown below.

“The clients will be able to receive one service at the same place without having to be referred to other departments like general out-patient to get their medications or see a clinician. [HIV-HTN] Integration is good because the client gets holistic services and it also reduces transport costs. When somebody comes for HIV and then you give another appointment for HTN, it increases the burden” (Clinical Officer, Clinic K)

“We will benefit in that our clients will be managed well and will also be able when we get knowledge to manage it [HTN] will make it easier for us to work on our clients” (Clinical officer, Clinic K)

Similarly, reduction of time clients often spend at facilities was perceived to be an anticipated benefit under the integrated HIV-HTN service approach. A HCP describes how integration of HTN and HIV services may redeem client time.

[HIV -HTN ]Integration is good because it will reduce on the time that a client spends at the facility. So when someone is screened and is found to be hypertensive, he is managed in the same clinic without the need to refer them to another service point within the health facility (Nurse, Clinic K)

“I believe it is very important for us to integrate these services into the HIV setting so that we can save on clients’ time and even not frustrate them because when they go to many different service points, the clients get frustrated. I think [HIV-HTN] integration is very important and it's worth trying” (Clinical Officer, Clinic C)

A nurse explained how client management is expected to improve when clients are equipped with knowledge on how to manage HTN and how this could make HCPs’ work easier as expressed in the excerpt below.

Our clients will be managed well and will also be able when we get knowledge to manage [HTN], it will make it easier for us to work on our clients (Nurse, Clinic K)

“ [HIV-HTN] integration is good because the client gets holistic services and it also reduces transport costs. When somebody comes for HIV and then you give another appointment for HTN, it increases the burden of coming back. So this [HIV-HTN] integration will reduce the costs of the client to keep moving up and down. (Clinical Officer, Clinic D)

Perceived barriers to integrated HIV-HTN care

From quantitative data, insufficient training on HTN care and treatment, inadequate number of functional BP devices, inconsistent supply of anti-hypertensive medications as well as perception that PLHIV could not afford HTN treatment were identified as major impediments to the integration of HIV and HTN. Despite these challenges, HCP noted that HTN care in HIV settings is important and did not believe that it would result in an excessive workload (Fig. 2). Table 7: summarizes the different barriers and facilitators to integrated HIV-HTN care.

Table 7

Mapping barriers to and facilitators of integrated HIV-HTN care using the CFIR framework
	Description	Barriers (B)/ facilitators (F)
Outer Setting Domain
B. Local	Sociocultural values (e.g., shared responsibility in helping recipients) and beliefs (e.g., convictions about the worthiness of recipients) encourage the Outer Setting to support implementation and/or delivery of the innovation.	Desire to provide holistic and patient-centred care (F) Perceived belief that integrated HIV-HTN care will reduce client waiting time and reduce transportation costs incurred during multiple and fragmented appointments (F)
C. Local conditions	Economic, environmental, political, and/or technological conditions enable the Outer Setting to support implementation and/or delivery of the innovation.	Inadequate technical support from the policy and program officials regarding the integration of HIV-HTN in primary healthcare clinics (B). Low priority is given to hypertension care by the HIV program implementing partners and programs (B)
D. Partnerships and connections	The Inner Setting is networked with external entities, including referral networks, academic affiliations, and professional organization networks.	No clear and streamlined referral patterns for clients with hypertension (B). No clear guidelines for blood pressure measurement at the clinics (B).
G3. Performance-Measurement Pressure	Quality or benchmarking metrics or established service goals drive implementation and/or delivery of the innovation.	No clear metrics for monitoring the integration of HIV-HTN care (B) Existing monitoring and evaluation reports for HIV programs do not include NCD care (B)
Inner Setting Domain
A2. Information Technology Infrastructure	Technological systems for tele-communication, electronic documentation, and data storage, management, reporting, and analysis support functional performance of the Inner Setting.	HTN care metrics are not included in the available registries and other source documents (B). Existing electronic systems do not capture hypertension-related indicators
E. Tension for Change	The current situation is intolerable and needs to change.	Desire to provide patient-centred care (F)
E3. Materials & Equipment	Supplies are available to implement and deliver the innovation.	Unavailability of antihypertensive medications (B). Inadequate BP monitoring devices (B)
K. Access to Knowledge & Information	Guidance and/or training is accessible to implement and deliver the innovation.	Unavailability of standardized and easy-to-use protocol for HTN treatment (B). Low knowledge about hypertension care among healthcare providers (B) Inadequate training on hypertension care for healthcare providers involved in HIV care (B)

Figure 3: Perceived barriers to HTN screening, treatment, and monitoring among HCPs

HCPs reported that perceived benefits outweighed perceived barriers to successful integrated HIV-HTN care. An anticipated increased workload and added responsibility were identified as a key potential barrier to implementing integrated HTN-HIV services, however, HCPs believed they would be able to manage the integrated activities.

“Of course, the [HIV-HTN] integration will be good although it may cost us time. It is going to affect our time to attend to the client - what we call the turnaround time. The duration of time you take to attend to one client will be affected but I think that can be silent. For HIV, there are things you are supposed to do for the client and HTN should be one of them. I think we can still integrate those [HIV-HTN] services. But the turnaround time for seeing one client will be increased” (H13009, Senior Nurse, Clinic C)

It [HIV-HTN integration] also reduces on workload for the staff because HTN cases will be managed at one place….” (Clinical Officer, Clinic D)

Policy and decision makers’ perspectives on HTN integration into HIV services

Policymakers at the MoH and healthcare managers from the two districts shared their perceptions regarding current HTN practices and their views on the integration of HIV and HTN care. They pointed out the need for training and capacity building of HCPs on HTN if successful integration of these services is to be realised.

“The critical gaps that need to be addressed are the capacity building of the HCPs themselves (20003, Policy Maker, MOH)

Alignment of integrated HIV-HTN care with differentiated service delivery models was highlighted as a key consideration to allow for dispensing of anti-hypertensive medications to clients who typically accessed their ART medications in a differentiated manner. This would facilitate the development of a one-stop shop where clients would receive both ART and anti-hypertensive medications an integrated manner. This was highlighted especially for public HIV clinics within the KCCA jurisdiction.

“I request that if this project [HTN-HIV integration] is to come in, we need extra support. For example, if someone is on anti-hypertensives and we need to go into the community to look for them even if it is not their clinic day, this differentiated model should be included in this project.” (HIV Program lead, Clinic I)

The practice of multi-month dispensing of anti-hypertensive medications, which is already done for ART, was also seen as a crucial factor that could influence the successful integration of HIV and hypertension care. There was a perception among some policy and decision-makers that BP monitoring for PLHIV with HTN would require more frequent visits to the health facility.

“My view is that the health practice is inadequate because if you look at the provision of HIV or ART services especially for those clients getting their refills, quantities that may last them 2–3 months which is too much of a time for someone who is on hypertensive care and need regular frequent monitoring to assess whether the medications are working or not. So due to the large number of client s in the ART clinic it is difficult to change the schedule. The best that can be done currently is to advise the ART HCP to follow-up on their clients in the clinic or the general out- patients’ clinic. So the schedule cannot allow us to reschedule the number of the outpatient clients to the regular routine for more frequent follow up” (Policy maker, MOH)

Integration would reportedly address time constraints faced by HCPs especially with clients frequently visiting the HIV clinics to access different services.

“On the side of health workers, it reduces time. If today you are in the HIV clinic, tomorrow you come back to the DM clinic it doesn’t make sense but if you have all the medications on one side, see this client once, tomorrow you do other things. I think it also improves client care because now we are talking about holistic approach to care on HIV and NCDs, so you are able to interact with this person more because you are dealing with more than one ailment…leading to better management of this condition(Policy Maker, MOH)

…..So if you are talking about integration, it means you would lift HTN control to the level HIV is at. With the same answer I have given; - the training of health workers and avail them, provide equipment, infrastructure, provide medication, provide monitoring tools and review performance. If you don’t do that, then you can’t talk about integration (Policy maker, MoH, NCD)

HCP satisfaction from providing comprehensive services was perceived to be a benefit of integrated HIV-HTN services. A policymaker describes this perceived benefit in the excerpt below;

“HCPs will draw satisfaction from a comprehensive care intervention that improves the outcome for the clients without having to send the client to another clinic” (Health Manager, KCCA)

Holistic client management was mentioned as a potential advantage to integrated HIV-HTN services with clients being managed in one place.

“It is actually advantageous because you get to manage the client in one place and all these people who have been falling through the cracks suppressed but have may be died due to heart attacks….all those you can manage because you are managing their illnesses in one place” (Policy maker, MoH, NCD)

This formative study sought to understand the current practices of HTN care in HIV clinic settings, and understand HCP’s knowledge, attitudes and practices regarding HTN care. Additionally, we explored the perceptions of HCPs and policymakers regarding integrated HTN-HIV care and how these insights could be incorporated into designing an intervention for integrated HIV-HTN care. The findings would inform the design of a robust and sustainable model for integrating HTN and HIV care in HIV clinics in urban and peri-urban areas of Uganda.

The study revealed varying levels of integration of HIV-HTN care across the ten study clinics. HCPs expressed inadequate knowledge and training on HTN care, insufficient amounts of antihypertensive medications, inadequate number of functional BP monitoring devices and low priority of HTN services as major barriers to integrated HIV-HTN care. Despite these hindrances, HCPs expressed the desire to provide integrated and holistic HIV-HTN care if adequately trained and provided with appropriate resources.

The findings show that most HIV clinics in Wakiso and Kampala districts have only partially integrated HIV-HTN services. However, this could have changed with the recent developments by the national AIDS control program to expand the integration of HTN and HIV care, notably with the pilot of integrated HIV-HTN care by the MoH following our remarkable findings from a pilot project[17]. One of the major hindrances to the integration of HIV-HTN care was HCPs’ insufficient knowledge and inadequate in-service training on HTN. For example, many HCPs were unaware of the systolic and diastolic BP thresholds for diagnosis of HTN. These findings are consistent with previous research[4, 11]. Strategies aimed at enhancing the uptake of integrated

HIV-HTN care will necessitate cadre-specific training on HTN care. Fulfilling HCPs' enthusiasm for knowledge on HTN could lead to enhanced client care, improved client understanding of HTN and increased client engagement in self-care practices related to HTN care. Additionally, incorporating routine training for HCPs in the HIV clinics on HTN care will have ripple effects on the management of HTN beyond the HIV clinic settings. Providing standardized protocols for blood pressure measurement and treatment that are easy to use could facilitate task shifting, particularly in clinics where there are limited human resources and predominantly staffed by lower cadre personnel[17].

While HCPs indicated they provide clinical assessment for HTN, a greater number of HCPs referred clients to other in-facility and out-facility clinics for further management of HTN. The inadequacy of functional BP devices and anti-HTN medications at the HIV clinics limited implementation of a “one-stop shop” for HIV and HTN care, a consistent finding in other studies in Uganda and South Africa[18, 19]. Integrating HTN care into HIV care requires addressing these barriers and ensuring consistent and sustained access to BP monitors and medications. Additionally, a sustainable approach to integrating HIV care should consider mirroring the relatively advanced and client-centered ART differentiated delivery models[20]. For instance, there is a need to consider providing HTN care in the same settings as HIV care whether in the community or facility, and aligning HIV and HTN clinic appointments regardless of the level of clinical status of the comorbid condition. This would reduce clinic visits and subsequent client time and transportation costs, ultimately leading to a better client experience. Although the HCPs’s workload may increase due to additional tasks such as BP measurement, documentation of HTN status, clinical assessment and monitoring of HTN, the integration of HIV and HTN care is likely to result in less fragmentation, efficient utilization of HCP time, and freeing up time to attend to other medical care. The cohort of HCPs who participanted in this interveiew are relatively experienced with median duration of 9 years in clinical practice. Enhancing their knowledge about HTN care as well as motivating them with the needed supplies could facilitate integration of these care.

HCPs and policymakers highlighted the deprioritisation of HTN care in the HIV clinics. This stemmed from the fact that HTN care indicators are not part of the routine performance metrics and targets for HIV clinics and HCPs are often unaware of the burden of HTN and other measures of quality of care. This was also coupled with the lack of feedback on HIV-HTN integration from the district and national levels about clinics’ performance regarding the incorporation of HTN care within HIV clinics. To establish a sustainable model for the integration of HIV and HTN care, it is imperative to align HIV registers and other health information tools to incorporate HTN care metrics. Coordinated and integrated reporting, supplemented by feedback from district and regional levels, is essential for sustaining improvements in HTN care within HIV clinics.

Limitations

This formative research had several limitations. Firstly, participants were recruited from clinics in urban (Kampala) and peri-urban (Wakiso) districts, which may not accurately represent the general composition and perspectives of HCPs in rural communities, who might be less qualified and more constrained by resource limitations. However, results generated by our team form from the same settings have been found to be more generalizeable[21, 22]. Secondly, social desirability bias could have influenced participants to provide responses they perceived as favourable, thereby concealing their true opinions and perceptions.

This formative assessment identified gaps in current HTN care in HIV clinics in urban and peri-urban Uganda as well as enthusiasm from the HCPs to integrate HIV-HTN care. Barriers to integration of HIV-HTN were insufficient training, insufficient level of knowledge about HTN care, inadequate number of functional BP devices as well as lack of reporting and feedback on HTN care. In order to leverage the HIV program to integrate HTN, there’s a need to address the identified barriers as well as strengthen enablers of integrated HIV-HTN care.

AIDS

Acquired immunodeficiency syndrome

ART

Antiretroviral therapy

Blood Pressure

CFIR

Consolidated Framework for Implementation Research

CVD

Cardiovascular diseases

DALYs

disability-adjusted life years

HCP

Healthcare provider

HIV

human immunodeficiency virus

IEC

Information, Education and Communication

KCCA

Kampala Capital City Authority

KII

Key informant interviews

LDL

low-density lipoproteins

MoH

Ministry of Health

NCD

Non-Communicable Diseases

PEPFAR

U.S. President's Emergency Plan for AIDS Relief

PHC

Primary Health Care

PLHIV

People Living with HIV

PNFP

Private not for profit

REDCap

Research Electronic Data Capture

SSA

Sub-Saharan Africa

UNAIDS

The Joint United Nations Programme on HIV/AIDS

WHO

World Health Organization

Ethics approval and consent to participate

This research received ethical approval from the Makerere University School of Medicine Research and Ethics Committee (Reference #: Mak-SOMREC-2021-58) and the Uganda National Council for Science and Technology (Reference #: SS808ES). Additionally, administrative clearance was obtained from the Uganda Ministry of Health, Kampala Capital City Authority, and Wakiso District Local Government. All participants provided written informed consent before taking part in the study.

Consent for Publication

Not applicable

Competing interests

No competing interests to declare.

Author Affiliations

Infectious Diseases Research Collaboration, Kampala, Uganda

Funding

The research reported in this publication was funded by the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health (USA) under Award number 1UG3HL154501. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute, the National Institutes of Health, or the U.S. Department of Health and Human Services.

Author Contribution

FCS, CTL, ARK, JIS, MM, IS, JK, and DS secured the funding for this research: JBK, FCS, CTL, ARK, and AF conceptualized, drafted and reviewed the manuscript. JBK, FA, JS, and CK participated in data collection. JBK analysed quantitative data and FA, CK, JS and ARK analysed qualitative data. All authors reviewed and contributed to the final manuscript.

Acknowledgement

We would like to express our appreciation to the research participants and the managers of health facilities and clinics who agreed to take part in this study. We also acknowledge the support of the Uganda Ministry of Health, the Wakiso District Local Government Health Directorate, and the Kampala Capital City Authority Directorate of Public Health and Environment officials, as well as the HIV comprehensive partners in the two districts. Finally, we thank the National Heart, Lung, and Blood Institute and the Fogarty International Center of the U.S. National Institutes of Health (https://www.nih.gov/about-nih/contact-us) for funding this trial and supporting our work. We also extend our gratitude to the Makerere University School of Medicine Implementation Science Training Program for providing the first author with foundational training in implementation science.

Data Availability

The datasets used during this study are available from the corresponding author upon reasonable request.

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No competing interests reported.

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Addressing gaps in healthcare providers’ knowledge, attitudes, and practices to establish a sustainable model for integrated HIV- hypertension care in Uganda

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Abstract

Background

Methods

Results

Conclusions

Figures

BACKGROUND

Conceptual Approach: The Consolidated Framework for Implementation Research

METHODS

Study Design

Study Setting

Study procedures

Quantitative

Qualitative study

Data analysis

Quantitative

Qualitative

RESULTS

Study Participants characteristics

Knowledge about risk factors for HTN, diagnosis, treatment, and complications

BP measurement, HTN treatment and monitoring practices

BP measurement and monitoring

Availability of anti-hypertensive medication

Prioritization of HTN care in HIV clinics

Perceived benefits of integrated HIV -HTN care

Perceived barriers to integrated HIV-HTN care

Policy and decision makers’ perspectives on HTN integration into HIV services

DISCUSSION

Limitations

CONCLUSION

Abbreviations

Declarations

Competing interests

Author Affiliations

Funding

Author Contribution

Acknowledgement

Data Availability

References

Additional Declarations

Supplementary Files

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