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.

Keywords: Process evaluation of integrated hypertension-HIV management.

Fig. 1

Components of the HEARTS-based intervention for integrated management of HIV and hypertension. A Ccounseling and support on adherence to both hypertension and HIV medicines, side effects of medicines, implementation of physical exercise, healthy diet, salt reduction, weight reduction, and smoking cessation. B Simple, stepwise approach to titrate amlodipine, valsartan, and hydrochlorothiazide as the first-, second-, and third-line therapies, respectively. C Procured amlodipine, valsartan, and hydrochlorothiazide from a private not-for-profit access program and we gave medicines to patients at no cost. D Blood pressure (BP) measured by a peer educator using a validated Omron M6 BP machine. Clinicians repeated the BP measurement for patients with initial BP > 140/90 mmHg. E In addition to the aforementioned task shifting of measuring BP, we trained and mentored clinical officers and nurses to prescribe hypertension medications to reduce the burden on doctors. F Developed and shared quarterly targets on hypertension care indicators with healthcare providers. We adapted the HEARTS hypertension register and CVD patient cards and utilized them to record patient data. Conducted quarterly performance review meetings

Fig. 2

Percentage of patients enrolled in integrated hypertension-HIV care with controlled BP and suppressed HIV viral load (N = 1133). This is longitudinal patient-level data