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

项目摘要 获得高效抗逆转录病毒治疗导致艾滋病毒感染者（PLWH）的生存率提高， 非洲，这反过来又增加了他们的心血管疾病负担。PLWH现在经历高CVD死亡率，可能是由于 不受控制的高血压（HTN）。根据全球疾病负担数据，尼日利亚的HTN增加了95%， 从1990年到2015年的死亡率。如此高的死亡率可能会逆转艾滋病毒携带者存活率的提高。在 为了防止这种逆转，迫切需要控制艾滋病毒携带者中HTN的策略。然而， 卫生保健工作人员的缺乏限制了HTN相关发病率的有效降低。医生职责的任务转移 可能会减轻HTN控制的系统级障碍。在加纳32个健康中心的一个随机对照试验中， 我们发现，基于WHO CVD风险评估的护士主导的HTN控制任务转移策略（TASSH） 与健康保险覆盖相比，一揽子计划导致收缩压降低34%（U 01 HL 114198; PI： Ogedegbe）。TASSH包括CV风险评估;药物滴定;和患者生活方式咨询。有效 实施循证干预措施（EBI）（如TASSH）的策略通常是多层次的。然而，在这方面， 尼日利亚的艾滋病毒诊所缺乏在没有援助的情况下协调实践变化所需的专业知识。一个 克服这一障碍实施战略是通过提供外部专门知识促进实践 实践重新设计，以及提供循证护理的定制方法。PF通过以下方式提供专业知识 外部教练，为实施EBI提供支持。虽然PF已被广泛用于高 在收入国家中，它在非洲将预算外收入指数转化为日常做法方面的作用尚未得到检验。因此，我们将 评价PF在HIV门诊实施TASH的效果。拉各斯州初级保健委员会和 它的67个艾滋病毒诊所网络提供了一个可行的艾滋病毒慢性护理平台， PLWH中HTN控制模型。使用混合临床有效性实施设计，我们将进行 本研究分三个阶段进行：1）采用综合实施框架的实施前阶段 研究调整PF干预措施，将TASSH纳入艾滋病毒诊所; 2）使用RE的实施阶段- 目的在30个HIV诊所的随机对照试验中比较PF与自我导向条件（即接受 无PF的TASH信息）在960例PLWH伴HTN患者中降低血压;和3） 实施阶段，以评估PF与自我导向条件对采用和可持续性的影响 嘘。（a）一个咨询委员会，将为社会保障和安全行动提供领导支持 实施;和（B）受过训练的护士（实践促进者），他们将担任教练，提供支持， 向在艾滋病诊所提供TASSH的护士提供知识交流和绩效反馈。初级 结果是收缩压从基线到12个月的变化。次要结果是采用[ 采用TASSH的患者];可持续性[在24个月时维持TASSH采用];以及 12个月和24个月的采用率和可持续性。

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.