Integration of COVID-19 and TB screening in Kampala, Uganda: healthcare provider perspectives

Abstract Background Following the first wave of the COVID-19 outbreak, Uganda experienced a 40% drop in tuberculosis (TB) screening by June 2020. We sought to identify barriers to and facilitators of integrated COVID-19 and TB screening from the perspective of healthcare providers (HCPs) at a National Referral Hospital in Kampala, Uganda. Design/methods We conducted a cross-sectional study using in-depth interviews with 12 HCPs involved in TB activities in the outpatient and emergency departments at Kiruddu National Referral Hospital, Kampala, Uganda. We explored the HCP experiences at work in the setting of COVID-19, HCP perceived effect of COVID-19 on TB screening activities at the hospital, and perceptions about social and contextual factors that might influence the willingness of HCP to integrate screening of COVID-19 and TB. We analyzed the data using an inductive thematic approach and we denoted the emergent themes as barriers to and facilitators of COVID-19/TB integrated screening. We then mapped the themes to the Capability, Opportunity, Motivation, and Behavior (COM-B) model. Results The facilitators to integrated COVID-19 and TB screening included the availability of TB focal persons and already existing training forums at the hospital that could be utilized to strengthen the capacity of HCP to integrate COVID-19 and TB screening. The barriers included HCP’s inadequate knowledge on how to integrate screening of COVID-19 and TB, the absence of simple easy-to-use standard operating procedures and data collection tools for integrated screening, inconsistent supply of personal protective equipment (PPE), understaffing, and fear of contracting COVID-19 infection. The identified intervention functions to address the facilitators or barriers included education, persuasion, enablement, and training. Conclusions These findings provided a basis for designing contextually appropriate interventions targeting factors that are likely to influence HCP decisions and willingness to conduct TB screening in the context of COVID-19. Future studies should evaluate the effect of addressing these barriers to the integration of COVID-19 and TB as well as the effect of this on TB case finding in high-burden TB settings

Integrated multi-month dispensing of antihypertensive and antiretroviral therapy to sustain hypertension and HIV control

Multi-month dispensing (MMD) is a patient-centered approach in which stable patients receive medicine refills of three months or more. In this pre-post longitudinal study, we determined hypertension and HIV treatment outcomes in a cohort of hypertensive PLHIV at baseline and 12 months of receiving integrated MMD. At each clinical encounter, one healthcare provider attended to both hypertension and HIV needs of each patient in an HIV clinic. Among the 1,082 patients who received MMD, the mean age was 51 (SD = 9) years and 677 (63%) were female. At the start of MMD, 1,071(98.9%) patients had achieved HIV viral suppression, and 767 (73.5%) had achieved hypertension control. Mean blood pressure reduced from 135/87 (SD = 15.6/15.2) mmHg at the start of MMD to 132/86 (SD = 15.2/10.5) mmHg at 12 months (p < 0.0001). Hypertension control improved from 73.5% to 78.5% (p = 0.01) without a significant difference in the proportion of patients with HIV viral suppression at baseline and at 12 months, 98.9% vs 99.0% (p = 0.65). Patients who received MMD with elevated systolic blood pressure at baseline were less likely to have controlled blood pressure at 12 months (OR-0.9, 95% CI, 0.90,0.92). Overall, 1,043 (96.4%) patients were retained at 12 months. Integrated MMD for stable hypertensive PLHIV improved hypertension control and sustained optimal HIV viral suppression and retention of patients in care. Therefore, it is feasible to provide integrated MMD for both hypertension and HIV treatment and achieve dual control in the setting of sub-Saharan Africa

Using the RE-AIM framework to evaluate the implementation and effectiveness of a WHO HEARTS-based intervention to integrate the management of hypertension into HIV care in Uganda: a process evaluation

Abstract Background World Health Organization (WHO) HEARTS packages are increasingly used to control hypertension. However, their feasibility in persons living with HIV (PLHIV) is unknown. We studied the effectiveness and implementation of a WHO HEARTS intervention to integrate the management of hypertension into HIV care. Methods This was a mixed methods study at Uganda’s largest HIV clinic. Components of the adapted WHO HEARTS intervention were lifestyle counseling, free hypertension medications, hypertension treatment protocol, task shifting, and monitoring tools. We determined the effectiveness of the intervention among PLHIV by comparing hypertension and HIV outcomes at baseline and 21 months. The RE-AIM framework was used to evaluate the implementation outcomes of the intervention at 21 months. We conducted four focus group discussions with PLHIV (n = 42), in-depth interviews with PLHIV (n = 9), healthcare providers (n = 15), and Ministry of Health (MoH) policymakers (n = 2). Results Reach: Among the 15,953 adult PLHIV in the clinic, of whom 3892 (24%) had been diagnosed with hypertension, 1133(29%) initiated integrated hypertension-HIV treatment compared to 39 (1%) at baseline. Among the enrolled patients, the mean age was 51.5 ± 9.7 years and 679 (62.6%) were female. Effectiveness: Among the treated patients, hypertension control improved from 9 to 72% (p < 0.001), mean systolic blood pressure (BP) from 153.2 ± 21.4 to 129.2 ± 15.2 mmHg (p < 0.001), and mean diastolic BP from 98.5 ± 13.5 to 85.1 ± 9.7 mmHg (p < 0.001). Overall, 1087 (95.9%) of patients were retained by month 21. HIV viral suppression remained high, 99.3 to 99.5% (p = 0.694). Patients who received integrated hypertension-HIV care felt healthy and saved more money. Adoption: All 48 (100%) healthcare providers in the clinic were trained and adopted the intervention. Training healthcare providers on WHO HEARTS, task shifting, and synchronizing clinic appointments for hypertension and HIV promoted adoption. Implementation: WHO HEARTS intervention was feasible and implemented with fidelity. Maintenance: Leveraging HIV program resources and adopting WHO HEARTS protocols into national guidelines will promote sustainability. Conclusions The WHO HEARTS intervention promoted the integration of hypertension management into HIV care in the real-world setting. It was acceptable, feasible, and effective in controlling hypertension and maintaining optimal viral suppression among PLHIV. Integrating this intervention into national guidelines will promote sustainability