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

项目总结 据估计，博茨瓦纳艾滋病毒携带者(PLWHIV)中有26%患有高血压。不受控制 高血压将增加这一人群本已增加的心血管(CVD)疾病风险。一个 高血压研究嵌套在艾滋病毒预防试验中(博茨瓦纳联合预防项目- BCPP)，在PLWHIV中，高血压连续护理是次优的；46%的人意识到他们的 高血压，42%在服药，44%在推荐血压目标下服药， 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 在控制高血压的PLWHIV和错失解决心血管疾病危险因素机会方面 有高血压的人。尽管国家指南建议，这些差距仍然存在，免费通用 医疗保健、所需药物的可获得性和可以提高质量的方法，包括培训， 指导，并使用电子健康记录(EHR)提醒。实施研究迫在眉睫 需要制定更有效的策略来改善对已确立的有效高血压的吸收 以及博茨瓦纳艾滋病毒感染者和其他中低收入者之间的CVDRF管理干预措施 国家(LMIC)。我们建议调整和测试战略，以有效地整合证据-- 以艾滋病毒护理为基础的干预(EBI)，以改善高血压护理的级联(意识、诊断、 治疗、控制)和使用晚期T4的一般心血管疾病危险因素知识、诊断和治疗 实施研究混合型二型研究设计。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成年艾滋病毒携带者提供艾滋病毒-HTN/心血管疾病综合护理的战略 以及高血压和试点测试(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 开发和试行实施策略，然后使用类型2混合设计来衡量 多组分战略在改善EBI吸纳和治疗方面的实施结果 在患有HIV和HIV双重诊断的成年人中HTN级联的改善成功率 高血压。为了实现这第二个目标，我们提出了一种第二类混合有效性--实施 一项10组随机试验(设施水平1：1随机化)，每组300名成年人，年龄在20- 75岁，有HIV和高血压双重诊断(&gt；140/90 mm Hg，如果与 糖尿病/慢性肾脏疾病)在博茨瓦纳。我们的主要量化实施 基于RE-AIM框架实施的成果是REACH(治疗中PLWHIV的比例 在达到降压药治疗门槛的患者中)、有效性( 控制血压)，外加收养(筛查PLWHIV高血压的提供者的比例 压力加上开抗高血压药物的提供者的比例)。我们的联合初选 质的执行结果将包括对忠诚度的评估(干预审计 按设计实施)和维护(提供商和患者对维护能力的看法 血压控制从第一次控制到试验结束)。我们的二次实施 结果，我们将包括对可行性的评估(实施HIV/HTN综合护理的能力， HIV/HTN/CVD护理、临床病毒抑制等)和可接受性(患者和提供者调查以及 访谈)对实施战略的评价。

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.