Managing Hypertension Among People Living with HIV: an Integrated Model (MAP-IT)

这项提案是阿布贾大学、FHI 360、纽约大学和圣路易斯大学共同提出的 大学。获得抗逆转录病毒药物提高了艾滋病毒携带者(PLWH)的存活率，世卫组织 现在经历了比普通人群更高的心血管疾病死亡率，主要是由于HTN负担增加。全球 疾病负担报告说，从1990年到2015年，尼日利亚与HTN相关的死亡率增加了95%。因此， 迫切需要控制PLWH中HTN的策略。医生短缺和缺乏机会限制了尼日利亚的发展 在初级卫生中心(PHCS)控制HTN的能力，大多数PLWH都在那里接受护理。获得护理和 将任务转移到护士身上可能会减轻这些障碍。2011年，FHI 360发起了一个由美国国际开发署资助的项目， 加强艾滋病毒/艾滋病综合服务(SIDHAS)，提供普及艾滋病毒的机会 为尼日利亚超过190,000名妇女和儿童提供服务。在加纳32个卫生中心的随机对照试验中，我们发现 根据世界卫生组织心血管疾病风险包，护士领导的HTN控制任务转移策略(TASSH)导致34% 与仅覆盖医疗保险相比，收缩压下降幅度更大(U01HL114198；PI：Ogedesbe)。塔什 包括简历风险评估、药物滴定和患者生活方式咨询。存在一种有效的 HIV慢性弧菌平台(SIDHAS)和行之有效的循证干预措施控制HTN(TASSH) 为实施TASSH作为HTN控制的综合非传染性疾病-艾滋病毒模式提供了独特的机会 PLWH。然而，尼日利亚的PHCS[由于其薄弱的医疗体系]缺乏协调所需的专业知识 多层次的制度变革。克服这一障碍的实施战略是通过提供外部 应对实施循证护理方面的挑战的专业知识和支持。尽管PF一直是 在高收入国家被广泛使用，它在将EBI转化为非洲常规实践方面的作用尚未得到 测试过。FHI360‘S SIDHAS计划及其在Akwa Ibom[艾滋病毒最高的州]支持的47个PHC 在尼日利亚的负担]-提供一个可行的艾滋病毒慢性护理平台，将TASSH作为综合模式实施 用于PLWH的HTN控制。我们将使用混合方法设计分两个阶段进行这项研究：1)UG3 规划阶段，将利用促进卫生服务研究行动(PARiHS)来制定背景- 实施和促进将TASSH整合到艾滋病毒慢性护理平台(SIDHAS)的具体PF战略 用于PLWH中HTN的管理；以及2)将使用REACH、有效性、 采用、实施和维护(RE-AIM)在由30个PHC组成的阶梯楔形群组中进行评估 在960例合并无控制HTN的PLWH患者中，PF对TASSH采用水平的影响(主要结果)；血压控制 (共同主要结果)；以及18个月的TASSH维持水平(次要结果)。我们还将 审查TASSH的采用和实施保真度，以此作为可能解释影响的机制 PF对血压控制的影响。爱国阵线战略包括：(A)一个咨询委员会，将为以下方面提供领导支助 实施TASSH；和(B)训练有素的护士(实习促进者)，他们将担任教练，提供支持， 向将在PHCS实施TASSH的护士进行知识交流和绩效反馈。

This proposal is a collaboration between University of Abuja, FHI 360, New York University and Saint Louis University. Access to antiretroviral drugs has led to increased survival of people living with HIV (PLWH), who now experience higher CVD-mortality than the general population, largely due to increased HTN burden. Global Burden of Disease reported a 95% increase in HTN-related mortality in Nigeria from 1990 to 2015. Thus, strategies to control HTN in PLWH are sorely needed. Physician shortage and poor access limit Nigeria’s capacity to control HTN in primary health centers (PHCs), where most PLWH receive care. Access to care and task-shifting of duties to nurses may mitigate these barriers. In 2011, FHI 360 initiated a USAID-funded program, Strengthening Integrated Delivery of HIV-AIDS Services (SIDHAS), which provides universal access to HIV services for over 190,000 PLWH in Nigeria . In a cluster RCT of 32 health centers in Ghana, we showed that a nurse-led task-shifting strategy for HTN control (TASSH), based on the WHO CVD Risk Package, led to a 34% greater systolic BP reduction than health insurance coverage alone (U01HL114198; PI: Ogedegbe). TASSH includes CV risk assessment; medication titration; and patient lifestyle counseling. The existence of an effective HIV chronic are platform (SIDHAS) and a well-proven evidence-based intervention for HTN control (TASSH) provides a unique opportunity for implementation of TASSH as an integrated NCD-HIV model for HTN control in PLWH. However, PHCs in Nigeria [with its weak healthcare system] lack the expertise needed to coordinate multilevel system changes. An implementation strategy to overcome this barrier is PF via provision of external expertise and support for addressing challenges in implementing evidence-based care. Although PF has been widely utilized in high income countries, its role in translating EBIs into routine practice in Africa has not been tested. FHI 360’s SIDHAS program and the 47 PHCs it supports in Akwa Ibom – [the state with the highest HIV burden in Nigeria] - provide a viable HIV chronic care platform for implementing TASSH as an integrated model for HTN control in PLWH. We will conduct this study in two phases using a mixed-methods design: 1) a UG3 planning phase that will use Promoting Action on Research in Health Services (PARiHS) to develop a context- specific PF strategy to implement, and facilitate integration of TASSH into an HIV chronic care platform (SIDHAS) for management of HTN in PLWH; and 2) a UH3 implementation phase that will use Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) to evaluate, in a stepped-wedge cluster RCT of 30 PHCs in 960 PLWH with uncontrolled HTN, the effect of PF on levels of TASSH adoption (primary outcome); BP control (co-primary outcome); and levels of TASSH sustainment (secondary outcome) at 18 months. We will also examine adoption and implementation fidelity of TASSH as potential mechanisms that may explain the impact of PF on BP control. The PF strategy comprises: (a) an advisory board that will provide leadership support for TASSH implementation; and (b) trained nurses (practice facilitators) who will serve as coaches, provide support, knowledge exchange and performance feedback to the nurses who will deliver TASSH at the PHCs.