World AIDS Day 2024: Multi-level perspectives on factors that impact hypertension screening, treatment, and management among people with HIV in South Africa

Most people with HIV live in low- and middle-income countries, where less than half with high blood pressure are diagnosed, and many go untreated. Understanding the barriers and facilitators to hypertension care in these settings can help create strategies to integrate hypertension and HIV care.
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Understanding barriers and facilitators to integrated HIV and hypertension care in South Africa - Implementation Science Communications

Background The burden of hypertension among people with HIV is high, particularly in low-and middle-income countries, yet gaps in hypertension screening and care in these settings persist. This study aimed to identify facilitators of and barriers to hypertension screening, treatment, and management among people with HIV in primary care clinics in Johannesburg, South Africa. Additionally, different stakeholder groups were included to identify discordant perceptions. Methods Using a cross-sectional study design, data were collected via interviews (n = 53) with people with HIV and hypertension and clinic managers and focus group discussions (n = 9) with clinic staff. A qualitative framework analysis approach guided by COM-B and the Theoretical Domains Framework were used to identify and compare determinants of hypertension care across stakeholder groups. Results Data from clinic staff and managers generated three themes characterizing facilitators of and barriers to the adoption and implementation of hypertension screening and treatment: 1) clinics have limited structural and operational capacity to support the implementation of integrated care models, 2) education and training on chronic care guidelines is inconsistent and often lacking across clinics, and 3) clinicians have the goal of enhancing chronic care within their clinics but first need to advocate for health system characteristics that will sustainably support integrated care. Patient data generated three themes characterizing existing facilitators of and barriers to clinic attendance and chronic disease self-management: 1) the threat of hypertension-related morbidity and mortality as a motivator for lifestyle change, 2) the emotional toll of clinic’s logistical, staff, and resource challenges, and 3) hypertension self-management as a patchwork of informational and support sources. The main barriers to hypertension screening, treatment, and management were related to environmental resources and context (i.e., lack of enabling resources and siloed flow of clinic operations) and patients’ knowledge and emotions (i.e., lack of awareness about hypertension risk, fear, and frustration). Clinical actors and patients differed in perceived need to prioritize HIV versus hypertension care. Conclusions The convergence of multi-stakeholder data highlight key areas for improvement, where tailored implementation strategies targeting motivations of clinic staff and capacity of patients may address challenges to hypertension screening, treatment, and management recognized across groups.

Cardiovascular disease is the leading cause of death worldwide, and people living with HIV are at a higher risk. One major risk for cardiovascular disease is high blood pressure (i.e., hypertension), but many people with HIV, especially in South Africa, don't get the care they need for it. While there are guidelines for diagnosing and treating hypertension, routine blood pressure checks are often lacking. Since many people with HIV are already receiving care, combining hypertension treatment with HIV care could help improve health outcomes for this population.

What led to this study?

Our team interviewed and held group discussions with clinic staff and patients to understand the challenges and needs for better managing hypertension alongside HIV care. This study reports key factors that affect the way hypertension care is delivered, such as knowledge, support, and social and environmental influences that impact patients’ engagement with care. The findings will help develop better strategies to improve care by addressing the barriers and leveraging strengths identified in the healthcare system and community.

Why is this study important?

Despite hypertension being a major risk factor for cardiovascular disease, most people with HIV do not receive the recommended screening and treatment. Addressing hypertension alongside HIV care could significantly reduce the risk of cardiovascular disease and improve overall health outcomes, but there is not enough theory-driven research to create feasible and effective strategies for combining hypertension and HIV care in resource limited settings in a way that fits the specific needs of different clinical actors and people affected by these conditions. The findings from this study will help guide the design of more effective healthcare strategies and interventions, ensuring better care for people with HIV while optimizing the use of available healthcare resources.

Did this study find any differences between perspectives of different stakeholders?

One unexpected difference between the two groups was their view on the seriousness of the diseases. Patients seemed to think hypertension was more urgent, while clinic staff felt that treating HIV should be the main focus for people dealing with both conditions. Overall, the study emphasizes the need for better education for both patients and healthcare workers about hypertension and highlights the importance of improving healthcare systems to better manage both conditions.

What is the wider significance of the study findings?

Both patients and clinic staff pointed out that a lack of proper facility resources and clinic organization made it difficult to regularly check and treat high blood pressure. Many staff members also felt they didn’t have enough training on how to care for chronic conditions like high blood pressure. Despite these challenges, there was strong support among clinical actors for combining HIV and hypertension care. Staff suggested incorporating a stronger focus on chronic disease care in regularly held clinical trainings, providing additional resources, and offering rewards to motivate staff. However, they stressed that for this to work long-term, bigger changes are needed in the healthcare system. Interviews with people living with HIV and hypertension revealed key insights into their experiences with managing their condition. Many patients were motivated to change their lifestyle because they feared serious health problems, like strokes, caused by uncontrolled hypertension. However, they often found clinics difficult to navigate due to long wait times and lack of organization. Additionally, patients managed their condition with the help of family and community groups, but most expressed a need for more guidance and tools, like blood pressure machines, to help them monitor their health at home.

How were these findings used to inform future work?

A broader stakeholder group provided input on these data, allowing for a comprehensive understanding of how hypertension care could be improved in the South African context. Participatory research methods were then used to inform the design of implementation strategies aimed at promoting the adoption and implementation of guideline-recommended hypertension screening and management practices in local primary care settings. By centering the design of those strategies on data collected in this study, our team aims to overcome challenges at the patient, provider, and clinic-level that may hinder improved cardiovascular disease control in this high-risk population.

Geldsetzer P, Manne-Goehler J, Marcus ME, et al. The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults. Lancet. 2019, 394(10199):652-662. doi: 10.1016/S0140-6736(19)30955-9.

Wollum, A, Gabert R, McNellan CR, et al. Identifying gaps in the continuum of care for cardiovascular disease and diabetes in two communities in South Africa: Baseline findings from the HealthRise project. PLOS ONE. 2018; 13(3): e0192603.

Johnson LCM, Khan SH, Ali MK, et al. Understanding barriers and facilitators to integrated HIV and hypertension care in South Africa. Implement Sci Commun. 2024;5(1):87. doi: 10.1186/s43058-024-00625-5.

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HIV infections
Life Sciences > Health Sciences > Biomedical Research > Pathogenesis > Infection > Infectious Diseases > HIV infections
Public Health
Life Sciences > Health Sciences > Public Health
Hypertension
Life Sciences > Health Sciences > Clinical Medicine > Diseases > Cardiovascular Diseases > Hypertension

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Implementation science both emphasizes the primacy of context but also seeks — as a scientific endeavor — generalizable or transferable insights and inferences that apply or inform across those settings. Implementing contexts are highly variable social, organizational, and community systems. Similarly, the nature of influence, power, and positionality varies across the relationships in these specific systems. Across such environments, singular insights about the effects of strategies, their barriers, facilitators, or even mechanisms cannot be expected to be invariant. Yet accepting the premise in implementation science that every context is unique seemingly precludes one of the central features of the discipline itself, which is to seek insights that apply widely and are useful for prediction. How does implementation science reconcile its pursuit of scientific legitimacy and generalizing while maintaining its commitment to understanding what works, for whom, and under what circumstances — when these circumstances vary?

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This Collection supports and amplifies research related to SDG 3, Good Health and Well-Being, SDG 4, Quality Education, SDG 10, Reduced Inequalities, and SDG 17, Partnerships for the Goals.

This collection is open for submissions from all authors on the condition that the manuscript falls within the scope of the collection and the journal it is submitted to.

All submissions in this collection undergo the relevant journal’s standard peer review process. Similarly, all manuscripts authored by a Guest Editor(s) will be handled by the Editor-in-Chief of the relevant journal. As an open access publication, participating journals levy an article processing fee (Implementation Science fees, and Implementation Science Communications fees). We recognize that many key stakeholders may not have access to such resources and are committed to supporting participation in this issue wherever resources are a barrier. For more information about what support may be available, please visit OA funding and support, or email OAfundingpolicy@springernature.com or the Editor-in-Chief of the journal where the article is being submitted.

Publishing Model: Open Access

Deadline: Mar 01, 2025