Integrated Community-based Treatment of HIV and Hypertension in Zambia

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ABSTRACT An estimated 10-30% of the 21.8 million HIV-infected adults in sub-Saharan Africa have hypertension, the single largest risk factor for cardiovascular disease (CVD). The consequences of untreated hypertension are magnified in HIV-infected individuals who are at 50% greater risk of experiencing a CVD event than HIV- uninfected persons, even after controlling for traditional CVD risk factors. Although the scale up of HIV treatment means that millions of patients are now in contact with the health system, poor uptake of hypertension treatment in these same populations persists. As a result, fewer than 10% of hypertensive patients on HIV treatment have controlled blood pressure. Because HIV and hypertension management share many barriers (e.g., opportunity costs of accessing care), emerging solutions for HIV treatment also represent critical opportunities to improve access to, and sustainability of, treatment for other chronic conditions in Africa. The proposed K23 study seeks to understand the implementability and effects of adding hypertension treatment into the “community adherence group” (CAG) model for HIV treatment in Zambia. In Aim 1, we will evaluate the implementation of the hypertension care into this model by measuring adoption, fidelity of implementation, and sustainability of access to hypertension medications over time. In Aim 2, we will use a before-and-after design to evaluate the effectiveness of introduced practices on blood pressure. In Aim 3, we will use in-depth interviews and focus groups among both health care workers and patients to understand how to optimize the acceptability, fit, and reach of the model for future dissemination and eventual extension into HIV-uninfected populations with hypertension. I am currently immersed in a project supported by the Bill and Melinda Gates Foundation that seeks to implement and scale up the CAG model for HIV treatment in Zambia. My hands-on knowledge of CAG implementation will make the addition of a hypertension component into the CAG model immediately feasible. Findings from the scientific aims proposed will inform an R01 evaluating the dissemination of an integrated HIV and hypertension treatment CAG model and an R21 to expand the model to HIV-uninfected patients. The overarching goal of this proposed mentored career development award is to support my development into an independent implementation science researcher with a focus on health systems innovations for chronic diseases in resource-limited settings. The career development aims for this K23 are to obtain expertise in (1) the application of implementation science theory to research design and evaluation; (2) analytic methods for correlated and longitudinal data; (3) the use of qualitative methods in implementation research and (4) positioning research questions and findings to optimize influence on practice and policy. This plan will be carried out with coursework and guidance of an international team of mentors with expertise in HIV & cardiovascular disease epidemiology, implementation science, biostatistics, and mixed methods research.