A time‐motion study of cardiovascular disease risk factor screening integrated into HIV clinic visits in Swaziland

Abstract

IntroductionScreening of modifiable cardiovascular disease (CVD) risk factors is recommended but not routinely provided for HIV‐infected patients, especially in low‐resource settings. Potential concerns include limited staff time and low patient acceptability, but little empirical data exists. As part of a pilot study of screening in a large urban HIV clinic in Swaziland, we conducted a time‐motion study to assess the impact of screening on patient flow and HIV service delivery and exit interviews to assess patient acceptability.MethodsA convenience sample of patients ≥40 years of age attending routine HIV clinic visits was screened for hypertension, diabetes, hyperlipidemia and tobacco smoking. We observed HIV visits with and without screening and measured time spent on HIV and CVD risk factor screening activities. We compared screened and unscreened patients on total visit time and time spent receiving HIV services using Wilcoxon rank‐sum tests. A separate convenience sample of screened patients participated in exit interviews to assess their satisfaction with screening.ResultsWe observed 172 patient visits (122 with CVD risk factor screening and 50 without). Screening increased total visit time from a median (range) of 4 minutes (2 to 11) to 15 minutes (9 to 30) (p < 0.01). Time spent on HIV care was not affected: 4 (2 to 10) versus 4 (2 to 11) (p = 0.57). We recruited 126 patients for exit interviews, all of whom indicated that they would recommend screening to others.ConclusionProvision of CVD risk factor screening more than tripled the length of routine HIV clinic visits but did not reduce the time spent on HIV services. Programme managers need to take longer visit duration into account in order to effectively integrate CVD risk factor screening and counselling into HIV programmes.

Feasibility of integrated, multilevel care for cardiovascular diseases (CVD) and HIV in low- and middle-income countries (LMICs): A scoping review

“…Additionally, only 5% of selected studies (n = 1) was a randomized controlled trial (RCT)—a pragmatic cluster RCT [19]. Most studies were either descriptive, cross sectional studies (n = 8) [20, 21, 22, 23, 24, 25, 26, 27] or observational cohort studies (n = 6) [21, 28, 29, 30, 31] (See S1 Dataset )…”

“… 1 Reference numbers [22], [26], [38] 2 Reference numbers [22], [24], [25], [26], [27], [29], [30], [31], [32], [33], [34], [35], [37] 3 Reference numbers [27] 4 Reference numbers [22], [24], [30], [32], [33], [35] 5 Reference numbers [22], [26], [30], [32], [34] 6 Reference numbers [23], [30], [32], [33], [34], [39] 7 Reference numbers [19], [20], [21], [23], [25], [31], [33], [38] 8 Reference numbers [25], [26], [36], [37], [39] 9 Reference numbers [25], [26], [34], [36], [37], [39] 10 Reference numbers [34], [39]…”

“…Reporting of feasibility catered to the settings and/or scale-up of the interventions, helping identify unique facilitators and barriers to implementing integrated CVD-HIV care interventions (screening, referral/linkage to care and treatment) in LMIC settings. Barriers include lack of tracking of linkage to care after cases are referred (setting and scale-up specific) [22, 24, 29] loss to follow-up (setting-specific) [20], lacking time to make clinic visits during the weekdays (setting-specific) [30], using non-standard BP cutoffs (setting-specific) [33], insufficient funding (setting and scale-up specific) [28], cumbersome curriculum for training (scale-up specific) [19], and challenges in staffing and equipment (setting-specific) [37].…”

“…Facilitators include use of existing trained staff, training of healthcare personnel, use of local leaders (setting and scale-up specific) [22, 26, 28], free-of -charge care (setting-specific) [30], continuous medical supervision (setting-specific) [31], broad acceptability of intervention components (setting-specific) [29], having patient feedback (setting-specific) [29], enthusiastic buy-in, adoption, and acceptability from policy makers (scale-up specific) [19].…”

“… 11 Reference numbers [23] 12 Reference numbers [20], [24], [32], [34], [36], [37], [38], [39] 13 Reference numbers [19], [21], [22], [25], [26], [27], [28], [29], [30], [31], [32], [33], [35] 14 Reference numbers [28]…”