Effectiveness of an Integrated Approach to HIV and Hypertension Care in Rural South Africa: Controlled Interrupted Time-Series Analysis

Ameh, Soter; Klipstein‐Grobusch, Kerstin; Musenge, Eustasius; Kahn, Kathleen; Tollman, Stephen; Gómez‐Olivé, Francesc Xavier

doi:10.1097/qai.0000000000001437

Cited by 43 publications

(54 citation statements)

References 29 publications

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“…Approaches to optimize care cascades are needed to maximize the benefits of hypertension screening and management for PLHIV [28]. Barriers to hypertension diagnosis and management for PLHIV exist on the individual (patient and/or caregiver) [26,29], interpersonal (provider) [30,31], health systems [32], and policy levels [33]. Existing research emphasizes individual and interpersonal-level barriers; however, health systems barriers receive less attention [34], presenting an opportunity to improve patient health by optimizing the complex hypertension cascade.…”

Section: Introductionmentioning

confidence: 99%

Systems analysis and improvement approach to optimize the hypertension diagnosis and care cascade for PLHIV individuals (SAIA-HTN): a hybrid type III cluster randomized trial

et al. 2020

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Background: Across sub-Saharan Africa, evidence-based clinical guidelines to screen and manage hypertension exist; however, country level application is low due to lack of service readiness, uneven health worker motivation, weak accountability of health worker performance, and poor integration of hypertension screening and management with chronic care services. The systems analysis and improvement approach (SAIA) is an evidence-based implementation strategy that combines systems engineering tools into a five-step, facility-level package to improve understanding of gaps (cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and iteratively test and redesign these modifications (continuous quality improvement). As hypertension screening and management are integrated into chronic care services in sub-Saharan Africa, an opportunity exists to test whether SAIA interventions shown to be effective in improving efficiency and coverage of HIV services can be effective when applied to the non-communicable disease services that leverage the same platform. We hypothesize that SAIA-hypertension (SAIA-HTN) will be effective as an adaptable, scalable model for broad implementation. Methods: We will deploy a hybrid type III cluster randomized trial to evaluate the impact of SAIA-HTN on hypertension management in eight intervention and eight control facilities in central Mozambique. Effectiveness outcomes include hypertension cascade flow measures (screening, diagnosis, management, control), as well as hypertension and HIV clinical outcomes among people living with HIV. Cost-effectiveness will be estimated as the incremental costs per additional patient passing through the hypertension cascade steps and the cost per additional disability-adjusted life year averted, from the payer perspective (Ministry of Health). SAIA-HTN implementation fidelity will be measured, and the Consolidated Framework for Implementation Research will guide qualitative evaluation of the implementation process in high-and low-performing facilities to identify determinants of intervention success and failure, and define core and adaptable components of the SAIA-HTN intervention. The Organizational Readiness for Implementing Change scale will measure facility-level readiness for adopting SAIA-HTN.

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Section: Introductionmentioning

confidence: 99%

Systems analysis and improvement approach to optimize the hypertension diagnosis and care cascade for PLHIV individuals (SAIA-HTN): a hybrid type III cluster randomized trial

et al. 2020

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“…More research is needed about how to effectively, efficiently and equitably manage the double burden of disease, including the potential of integrated care approaches 38 39. The evaluation of an integrated HIV-NCD model in South Africa, which found only very small clinical improvements, identified implementation challenges related to health systems and processes 40 41. There have been demonstration projects for integrated HIV-NCD care in Malawi,42 43 including incorporating hypertension care into services at high-volume HIV treatment sites in Lilongwe; but with reported implementation challenges, including the need to develop treatment guidelines, establish a referral network and train health workers—and, after 6 months of integrated care, rates of blood pressure control remained under 40% for these patients 42.…”

Section: Discussionmentioning

confidence: 99%

Integrated care experiences and out-of-pocket expenditures: a cross-sectional survey of adults receiving treatment for HIV and hypertension in Malawi

Moucheraud

Hing

Seleman³

et al. 2020

BMJ Open

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ObjectivesAs HIV-positive individuals’ life expectancy extends, there is an urgent need to manage other chronic conditions during HIV care. We assessed the care-seeking experiences and costs of adults receiving treatment for both HIV and hypertension in Malawi.Design, setting and participantsA cross-sectional survey was conducted with HIV-positive adults with hypertension at a health facility in Lilongwe that offers free HIV care and free hypertension screening, with antihypertensives available for purchase (n=199). Questions included locations and costs of all medication refills and preferences for these refill locations. Respondents were classified as using ‘integrated care’ if they refilled HIV and antihypertensive medications simultaneously. Data were collected between June and December 2017.ResultsOnly half of respondents reported using the integrated care offered at the study site. Among individuals using different locations for antihypertensive medication refills, the most frequent locations were drug stores and public sector health facilities which were commonly selected due to greater convenience and lower medication costs. Although the number of antihypertensive medications was equivalent between the integrated and non-integrated care groups, the annual total cost of care differed substantially (approximately US$21 in integrated care vs US$90 for non-integrated care)—mainly attributable to differences in other visit costs for non-integrated care (transportation, lost wages, childcare). One-third of those in the non-integrated care group reported no expenditure for antihypertensive medication, and six people in each group reported no annual hypertension care-seeking costs at all.ConclusionsIndividuals using integrated care saw efficiencies because, although they were more likely to pay for antihypertensive medications, they did not incur additional costs. These results suggest that preferences and experiences must be better understood to design effective policies and programmes for integrated care among adults on antiretroviral therapy.

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“…This method of analysis is used for estimating the effects of longitudinal intervention in interrupted time-series data [20,22]. The purpose of this analysis was to model the monthly average data over time using the autoregressive moving average (ARMA) models to account for autocorrelation inherent in the time-series data [23]. Two time periods were specified: (1) pre-intervention period from January to June 2011 -6 months before the integrated model was rolled-out, including the month of June 2011 when the model was initiated; and (2) post-intervention period from July 2011 to June 2013-24 months of implementation of the model.…”

Section: Theme 2: Changes In Patients' Health Outcomes Attributable Tmentioning

confidence: 99%

Evaluation of an integrated HIV and hypertension management model in rural South Africa: a mixed methods approach

Ameh

2020

Global Health Action

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Background: A summary of Soter Ameh's PhD thesis titled, 'An integrated HIV and hypertension management model in rural South Africa: A mixed methods approach' is presented here. In responding to the dual high burden of non-communicable diseases (NCDs) and HIV in South Africa, the national government initiated an integrated chronic disease management (ICDM) model in health facilities as a pilot programme. The aim of the ICDM model is to leverage the successes of the innovative HIV treatment programme for NCDs to improve the quality of care and health outcomes of adult patients. Objectives: The specific objectives of this study were to: (1) determine the quality of care provided in the integrated model in 2013, (2) describe patients' and operational managers' perceptions of quality of care in the integrated model in 2013, and (3) assess effectiveness of the integrated model in controlling CD4 counts (>350 cells/mm3) and blood pressure (<140/ 90 mmHg) of patients from 2011 to 2013. Methods: A combination of quantitative and qualitative methods was used to assess and describe the quality of care in the model. Effectiveness of the model in controlling patients' blood pressure (BP) and CD4 counts was assessed in selected PHC facilities in the Bushbuckridge municipality in Mpumalanga province, South Africa. Results: The findings showed the suboptimal quality of care in five of the eight priority dimensions of care used as leverage for the NCD programme. The ICDM model had a small but significant effect on BP control for hypertension patients receiving treatment. Conclusions: The HIV programme needs to be more extensively leveraged for hypertension treatment to achieve an optimal BP control in the study area. These findings could have policy relevance for low-and middle-income countries currently undertaking proof of concept studies to demonstrate the feasibility of implementing an integrated chronic disease care model.

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Effectiveness of an Integrated Approach to HIV and Hypertension Care in Rural South Africa: Controlled Interrupted Time-Series Analysis

Abstract: Supplemental Digital Content is Available in the Text.

Cited by 43 publications

References 29 publications

Systems analysis and improvement approach to optimize the hypertension diagnosis and care cascade for PLHIV individuals (SAIA-HTN): a hybrid type III cluster randomized trial

Systems analysis and improvement approach to optimize the hypertension diagnosis and care cascade for PLHIV individuals (SAIA-HTN): a hybrid type III cluster randomized trial

Integrated care experiences and out-of-pocket expenditures: a cross-sectional survey of adults receiving treatment for HIV and hypertension in Malawi

Evaluation of an integrated HIV and hypertension management model in rural South Africa: a mixed methods approach

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