Exploring barriers and facilitators to integrated hypertension-HIV management in Ugandan HIV clinics using the Consolidated Framework for Implementation Research (CFIR)

Abstract

Background: Persons Living with HIV (PLHIV) receiving antiretroviral therapy have increased risk of cardiovascular disease (CVD). Integration of services for hypertension (HTN), the primary CVD risk factor, into HIV clinics is recommended in Uganda. Our prior work demonstrated multiple gaps in implementation of integrated HTN care along the HIV treatment cascade. In this study, we sought to explore barriers to, and facilitators of, integrating HTN screening and treatment into HIV clinics in Eastern Uganda. Methods: We conducted a qualitative study at three HIV clinics with low, intermediate, and high HTN care cascade performance, which we classified based on our prior work. Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured interviews with health services managers, health care providers and hypertensive PLHIV (n=83). Interviews were transcribed verbatim. Three qualitative researchers used both deductive (CFIR model-driven) and inductive (open coding) methods to develop relevant codes and themes. Ratings were performed to determine valence and strengths of each CFIR construct regarding influencing HTN/HIV integration. Results: Of the 39 CFIR constructs assessed, 17 were relevant to either barriers or facilitators to HTN/HIV integration. Six constructs strongly distinguished performance and were barriers, three of which were in the Inner setting (Organizational Incentives & Rewards, Available Resources, Access to Knowledge & Information); two in Characteristics of individuals (Knowledge & Beliefs about the Intervention and Self-efficacy) and one in Intervention characteristics (Design Quality & Packaging). Four additional constructs were weakly distinguishing and negatively influenced HTN/HIV integration. There were four facilitators for HTN/HIV integration related to the intervention (Relative advantage, Adaptability, Complexity and Compatibility). The remaining four constructs negatively influenced HTN/HIV integration but were non-distinguishing. Conclusion: Using the CFIR, we have shown that while there are modifiable barriers to HTN/HIV integration in the Inner setting, Outer setting, Characteristics of individuals and implementation Process, HTN/HIV integration is of interest to patients, health care providers and managers. Improving access to HTN care among PLHIV will require overcoming barriers and capitalizing on the facilitators using a health system strengthening approach. These findings are a springboard for designing contextually appropriate interventions for HTN/HIV integration in low- and middle-income countries.

Perspectives on preparing for long-acting injectable treatment for HIV among consumer, clinical and nonclinical stakeholders: A qualitative study exploring the anticipated challenges and opportunities for implementation in Los Angeles County

“…structural characteristics and capacity of the organization, the organizational implementation climate, capacity for change, readiness for implementation aided by availability of resources and access to knowledge, and overall perceived relative priority of LAI ART in the HIV treatment continuum), individual characteristics (e.g., knowledge and beliefs about the intervention and personal attributes such as motivation to use LAI), and also the implementation process (characterized by plans to ease implementation and engagement of key stakeholders with critical roles in the implementation process). The CFIR has been previously used to study the implementation of new technologies and clinic-based interventions for PWH and to explore the system-level challenges and facilitators to the implementation of these interventions [ 29 , 42 , 43 ]. See Table 1 for identified themes and representative quotes within each CFIR domain.…”

Hypertension Care Cascade at a Large Urban HIV Clinic in Uganda: A Mixed Methods Study Using the Capability, Opportunity, Motivation for Behavior change (COM-B) model

“…In Uganda, for example, high blood pressure contributes 4x higher estimated CVD disability adjusted life years (DALYs) compared to high LDL cholesterol [32]. Poor integration of HTN and HIV care has also been observed in rural clinics of Eastern Uganda and other parts of SSA [25,26].…”

Hypertension Care Cascade at a Large Urban HIV Clinic in Uganda: A Mixed Methods Study Using the Capability, Opportunity, Motivation for Behavior Change (COM-B) Model

“…In Uganda, for example, high blood pressure contributes 4x higher estimated CVD disability adjusted life years (DALYs) compared to high LDL cholesterol [32]. Poor integration of HTN and HIV care has also been observed in rural clinics of Eastern Uganda and other parts of SSA [25,26].…”

“…Key barriers to integrated HTN/HIV care include poor access to HTN medications, low provider knowledge of HTN care, inappropriate task shifting, lack of evidence based treatment protocols and weak systems for monitoring and evaluation [21,[23][24][25][26].…”