PULESA-UGANDA-Strengthening the Blood Pressure Care and Treatment cascade for Ugandans living with HIV-ImpLEmentation Strategies to SAve lives

项目摘要 慢性艾滋病毒感染是心血管疾病的一个公认的危险因素。在撒哈拉以南非洲)--a 占全球可归因于艾滋病毒高血压的心血管疾病负担一半的地区是最多的 心血管疾病风险的重要驱动因素。有效的高血压管理存在深刻的障碍，包括有限的 知识，不一致的血压测量，以及难以获得药物治疗。艾滋病毒护理创新，如 获得免费抗逆转录病毒治疗、差异化服务提供以及在护理模式中使用PLHIV同龄人 可以改善对高血压等并存疾病的护理。PULESA-乌干达的首要目标 研究旨在改善城市和城市周边地区艾滋病毒携带者(PLHIV)的BP治疗级联 以可扩展和可持续的方式在乌干达开展工作。这种杂交是类型3研究建议首先探索的 HIV临床环境中循证BP护理的当前实践、常规、障碍和促进者 在坎帕拉和瓦基索地区(目标1)。然后，使用以人为中心的设计方法，一个设计团队 主要利益相关者将使用形成性评估中的数据来开发多组件 实施战略(HTN+)，以提高对循证BP的理解和遵守 治疗，适应乌干达这些艾滋病毒诊所的具体情况(次级目标1.1)。设计团队将适应 差异化服务交付模式，使用高血压PLHIV同行冠军，以及BP的方法 监测解决了BP护理的具体障碍和促进者。在随机化的阶梯形楔形簇中 对坎帕拉和瓦基索的16家诊所进行了试验，我们将确定实施的效果 改进BP级联指标的策略(目标2)。诊所将随机接受免费和 持续获得诊断设备和循证抗高血压药物(HTN-Basic) 没有次级目标1(HTN-PLUS)中制定的多组成部分实施战略。初级阶段 有效结果将是被诊断为高血压的患者中控制的百分比(&lt；140毫米汞柱 收缩压)。我们假设HTN-Basic干预将把控制率从基线的25%提高到35%， 而HTN-plus将进一步将控制权提高到40%。我们将进行广泛的混合方法过程 评估。我们将评估可伸缩性作为我们的主要实施成果，并将评估可接受性， 采用和实施环境。最后，我们将评估经济和金融的可持续性 从社会角度进行成本效益分析的综合护理战略将包括 家庭自付支出。这一目标的主要结果将是每BP的增量成本- 有控制力的病人。这项研究将为SSA政府利益相关者提供亟需的证据 通过预防心血管疾病造成的死亡和残疾来保护艾滋病毒治疗带来的健康收益的战略。 重要的是，它将为艾滋病毒模型的可扩展性、可持续性和公平性提供经济证据- 高血压管理一体化。

Project Summary Chronic HIV infection is a well-established risk factor for cardiovascular disease. In sub-Saharan Africa)—a region that may account for half of the global burden of CVD attributable to HIV—hypertension is the most important driver of CVD risk. Profound barriers to effective hypertension management exist, including limited knowledge, inconsistent BP measurement, and poor access to medications. HIV care innovations such as access to no-cost antiretroviral therapy, differentiated service delivery and use of PLHIV peers in care models may improve care of comorbid conditions such as hypertension. The overarching goal of PULESA-UGANDA study is to improve the BP treatment cascade for people living with HIV (PLHIV) in urban and peri-urban Uganda in a scalable and sustainable manner. This hybrid IS Type 3 study proposes to first explore current practice, routines, barriers, and facilitators of evidence–based BP care in HIV clinical settings in Kampala and Wakiso districts (Aim 1). Then, using a human-centered design approach, a design team of key stakeholders will use data from the formative assessment to develop a multi-component implementation strategy (HTN-PLUS) to improve uptake and adherence to evidence-based BP treatments, contextually adapted to these Ugandan HIV clinics (Sub-aim 1.1). The design team will adapt differentiated service delivery models, use of hypertensive PLHIV peer champions, and methods of BP monitoring that address specific barriers and facilitators of BP care. In a stepped-wedge cluster randomized trial of 16 clinics from Kampala and Wakiso, we will determine the effectiveness of implementation strategies to improve BP cascade metrics (Aim 2). Clinics will be randomized to receive free and consistent access to diagnostic equipment and evidence-based antihypertensive drugs (HTN-BASIC) with and without the multi-component implementation strategy developed in sub-aim 1 (HTN-PLUS). The primary effectiveness outcome will be % of patients with hypertension diagnosis who are controlled (<140mmHg systolic). We hypothesize that the HTN-BASIC intervention will increase control from 25% at baseline to 35%, and that HTN-PLUS will further increase control to 40%. We will conduct an extensive mixed-methods process evaluation. We will assess scalability as our main implementation outcome, and will also assess acceptability, adoption, and implementation climate. Finally, we will evaluate the economic and financial sustainability of the integrated care strategies in a cost-effectiveness analysis from a societal perspective that will include household out-of-pocket expenditures. The primary outcome of this aim will be incremental cost per BP- controlled patient. This study will provide much needed evidence to SSA government stakeholders for a strategy to preserve the health gains of HIV treatment by preventing death and disability from CVD. Importantly, it will offer economic evidence of the scalability, sustainability, and equity of a model of HIV- hypertension management integration.