Integration of Hypertension Management into HIV Care in Nigeria: A Task Strengthening Strategy

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Project Abstract Access to highly active antiretroviral treatment led to increased survival of people living with HIV (PLWH) in Africa, which in turn increased their CVD burden. PLWH now experience high CVD-mortality probably due to uncontrolled hypertension (HTN). Based on Global Burden of Disease data, Nigeria had 95% increased HTN- related mortality from 1990 to 2015. Such high mortality could reverse the gains in survival among PLWH. In order to prevent such reversal, strategies to control HTN in PLWH are sorely needed. However acute shortage of healthcare workforce limits effective reduction of HTN-related morbidity. Task shifting of duties from physicians to nurses may mitigate this systems-level barrier to HTN control. 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 reduction in systolic BP than health insurance coverage (U01HL114198; PI: Ogedegbe). TASSH includes CV risk assessment; medication titration; and patient lifestyle counseling. Effective strategies for implementing evidence-based interventions (EBIs) like TASSH are typically multi-level. However, HIV clinics in Nigeria lack the expertise needed to coordinate practice changes without assistance. An implementation strategy to overcome this barrier is practice facilitation (PF) via provision of external expertise on practice redesign, and a tailored approach to provision of evidence-based care. PF provides expertise through an external coach, who provides support for implementing the EBI. Although PF has been widely utilized in high income countries, it role in translating EBIs into routine practice in Africa has not been tested. Thus, we will evaluate the effect of PF on implementing TASSH in HIV clinics. The Lagos State Primary Healthcare Board and its network of 67 HIV clinics provide a viable HIV chronic care platform for implementing TASSH as an integrated model for HTN control in PLWH. Using a hybrid clinical-effectiveness implementation design, we will conduct this study in 3 phases: 1) A pre-implementation phase using the Consolidated Framework for Implementation Research to tailor PF intervention for integrating TASSH into HIV clinics; 2) An implementation phase using RE- AIM to compare in a cluster RCT of 30 HIV clinics, the effect of PF vs. a self-directed condition (i.e. receipt of information on TASSH without PF) on BP reduction among 960 PLWH patients with HTN; and 3) A post- implementation phase to evaluate the effect of PF vs. self-directed condition on adoption and sustainability of TASSH. The PF intervention 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 HIV clinics. Primary outcome is change in systolic BP from baseline to 12 months. Secondary outcomes are adoption [proportion of patients that adopted TASSH]; sustainability [maintenance of TASSH adoption at 24 mos]; and mediators of adoption and sustainability at 12 and 24 mos.