Integrating Hypertension and Cardiovascular Disease Care into Existing HIV Service Package in Botswana (InterCARE)

项目摘要 据估计，博茨瓦纳26%的艾滋病毒感染者患有高血压。不受控 高血压将增加该人群中已经增加的心血管（CVD）疾病的风险。一 高血压研究嵌套在艾滋病毒预防试验（博茨瓦纳联合预防项目- BCPP），高血压连续护理在PLWHIV中是次优的; 46%的人知道他们的 高血压，42%的人在服药，44%的人在服药达到推荐的血压目标， 总体高血压控制率为19%。这些数据突出了我们环境中的多个实施差距 艾滋病病毒感染者的高血压控制和错过的机会，以解决心血管疾病的危险因素， 高血压患者。尽管有国家指导方针的建议， 医疗保健、所需药物的可获得性以及可以提高质量的方法，包括培训， 指导，以及使用电子健康记录（EHR）提醒。实施研究迫在眉睫 需要制定更有效的策略，以提高已建立的有效高血压的吸收， 和CVDRF管理干预措施在博茨瓦纳和其他低收入和中等收入 中低收入国家。我们建议调整和测试策略，以有效地整合证据- 基于干预措施（EBI）的艾滋病毒护理，以改善高血压级联护理（认识，诊断， 治疗，对照）和一般CVD危险因素知识，诊断和治疗使用晚期T4 实施研究混合型2研究设计。首先，我们将制定一套实施方案， 在现有艾滋病毒护理平台内为艾滋病毒感染者提供艾滋病毒-高血压/心血管综合护理的战略 和高血压和试点测试（2个艾滋病毒诊所），以探索使用RE-AIM的实施结果 为更广泛的测试提供适应信息的框架。我们将利用从 制定和试行实施战略，然后使用第2类混合设计来衡量 多组成部分战略在提高EBI采用率方面的实施成果， 在双重诊断为艾滋病毒和艾滋病的成年人中，HTN级联的改善成功率 高血压为了实现这第二个目标，我们提出了一个类型2混合有效性-实现 一项10组随机试验（在设施水平1：1随机化），每组300名成人，年龄在20 - 30岁之间， 75岁，双重诊断为HIV和高血压（> 140/90mmHg，如果与HIV感染者一起生活，则> 130/80mmHg） 糖尿病/慢性肾病）。我们的主要定量实施 实现基于RE-AIM框架实施的成果（接受治疗的艾滋病毒感染者比例 在达到降压药物阈值的人群中），有效性（ 控制血压），加上采用（筛查高血压的PLWHIV提供者的比例 压力加上开抗高血压药物的供应商的比例）。我们的合作伙伴 定性实施成果将包括对忠诚度的评估（干预措施审计 按照设计实施）和维护（提供者和患者对维护能力的感知， 血压控制从第一次控制到试验结束的变化）。我们的次要实现 结果，我们将包括可行性评估（实施综合艾滋病毒/HTN护理的能力， HIV/HTN/CVD护理、临床病毒抑制等）和可接受性（患者和提供者调查， （三）实施战略。

PROJECT SUMMARY An estimated 26% of people living with HIV (PLWHIV) in Botswana have hypertension. Uncontrolled hypertension will add to the already increased risk for cardiovascular (CVD) disease in this population. A hypertension study nested within an HIV prevention trial (Botswana Combination Prevention Project- BCPP), the hypertension continuum of care was suboptimal among PLWHIV; 46% aware of their hypertension, 42% on medication, 44% of those on medication at recommended blood pressure target, with an overall hypertension control of 19%. These data highlight multiple implementation gaps in our setting among PLWHIV for hypertension control and the missed opportunity to address CVD risk factors among those with hypertension. These gaps occur despite national guidelines recommendations, free universal healthcare, availability of needed medications and approaches which can improve quality including training, coaching, and the use of electronic health records (EHR) reminders. Implementation research is urgently needed to develop more effective strategies to improve the uptake of established effective hypertension and CVDRF management interventions among PLWHIV in Botswana and other low- and middle-income countries (LMICs). We propose the adaptation and testing of strategies to effectively integrate evidence- based interventions (EBI) into HIV care to improve hypertension cascade of care (awareness, diagnosis, treatment, control) and general CVD risk factor knowledge, diagnosis and treatment using a late-stage T4 implementation research hybrid type 2 study design. First, we will develop a set of implementation strategies for integrated HIV-HTN/CVD care within an existing HIV care platform for adults with HIV and hypertension and pilot test (2 HIV Clinics) to explore implementation outcomes using RE-AIM framework to inform adaptation for broader testing. We will use the knowledge gained from the development and piloting of the implementation strategy to then use a type 2 hybrid design to measure the implementation outcomes of multi-component strategy in improving EBI uptake and improvement success rates in the HTN cascade among adults with a dual diagnosis of HIV and Hypertension. To achieve this second aim, we are proposing a type 2 hybrid effectiveness-implementation of a 10-cluster randomized trial (1:1 randomization at the facility level) of 300 adults per cluster between 20- 75 years old with a dual diagnosis of HIV and hypertension (>140/90mmHg, >130/80mmHg if living with Diabetes mellitus/Chronic Kidney Disease) in Botswana. Our primary quantitative implementation outcomes based on the RE-AIM framework implementation are reach (proportion of PLWHIV on treatment among those who meet threshold for anti-hypertensive medication), effectiveness (proportion with controlled blood pressure), plus adoption (proportion of providers who screen PLWHIV for high blood pressure plus proportion of providers who prescribe anti-hypertensive medications). Our co-primary qualitative implementation outcomes will include assessment of fidelity (audit of intervention implementation as designed) and maintenance (provider and patient perceptions of ability to maintain plus change in blood pressure control from first control to end of the trial). Our secondary implementation outcomes, we will include assessment of feasibility (ability to implement integrated HIV/HTN care, HIV/HTN/CVD care, clinic viral suppression, etc.) and acceptability (patient and provider survey and interviews) of the implementation strategy.