Written by April Houston, MPH, MSW
About one-third of adults between the ages of 30-79 globally have hypertension, a dangerous medical condition the WHO recently called a “silent killer”.
It is true that many people with hypertension do not realize they have it until they experience a severe medical event. Hypertension brings with it an increased risk for stroke, heart attack, and kidney failure as the pressure in arteries is higher than it should be, causing the heart to work harder than necessary to circulate blood throughout the body. Hypertension is one of the top causes of death worldwide and its prevalence continues to grow.
A population of increasing concern for hypertension and cardiovascular disease are people living with HIV (PLHIV). Thanks to substantial financial and scientific investment in understanding and combatting HIV in recent decades and the invention and widespread availability of antiretroviral therapy (ART), many people with HIV are surviving into their senior years; and like most older adults, they are developing chronic health issues. PLHIV are actually more likely than the HIV-negative population to have hypertension, more likely to have a cardiovascular event, and have a higher risk of mortality overall.
In sub-Saharan Africa, home to two-thirds of the global population of PLHIV, most HIV health care services are delivered in specialized clinics. Although these HIV clinics are great resources for regular exams and ART medication distribution, clinicians there may not have the ability nor resources to screen for and treat other medical conditions, requiring people with multiple comorbidities to visit several different health facilities to get all the services they need (assuming, of course, they know they have other conditions in need of treatment).
New research, including the INTE-AFRICA trial, is increasingly touting the benefits of integrated healthcare services as an alternative to the standard vertical approach to HIV and chronic disease management. While the appeal of this approach is obvious from the patient perspective (who wouldn’t want to have fewer medical appointments?), the feasibility of it from a clinician and health system perspective is less well understood.
Imagine that you run an HIV clinic in Zambia, and you decide to change your model to one of integrated care. How do you go about it? What equipment and procedures must be in place to enable your clinic to offer care for hypertension and other chronic diseases on top of existing services? Do the clinicians have the right training and expertise? How will these additional services affect staff workloads? Are medications to manage chronic diseases available and affordable in these settings? What type of recordkeeping upgrades are needed? How much will these new services cost and who will pay for them?
These are important questions, and the HLB-SIMPLe Alliance, with funding from the National Heart, Lung, and Blood Institute (NHLBI), is trying to answer them with implementation science. Through six different large-scale trials in Botswana, Mozambique, Nigeria, South Africa, Uganda, and Zambia, our researchers are testing different strategies designed to improve screening for and management of hypertension and other cardio-metabolic diseases in health facilities that routinely treat PLHIV. Each trial is structured differently, but many of the strategies being tested are similar: training health providers and educating patients on chronic disease management, shifting certain tasks from physicians to other health workers, introducing electronic health records, providing diagnostic equipment and antihypertensive drugs, among others.
These studies are being led by researchers at African universities in partnership with American universities, civil society organizations, and relevant Ministries of Health to ensure these groups are aware of what we are learning and understand how our findings affect them . HLB-SIMPLE’s Research Coordinating Center (RCC) is providing organizational, administrative, and communications, and technical support to all the trials and will be offering regular updates through our website and various social media platforms.
These trials have already uncovered some important lessons in their pilot phases, and we look forward to sharing them with you in the months to come! Visit our website often to learn more about our work and follow us on X for photos and updates from our research teams and partners.
HLB-SIMPLe is funded by the Center for Translation Research and Implementation Science at the National Heart, Lung, and Blood Institute (NHLBI), a division of the US National Institutes of Health (NIH), through the following grants: U24-HL-154426, UH3-HL154499, UH3-HL-156390, UH3-HL-154498, UH3-HL-156388, UH3-HL-154501, UH3-HL156389.
For the iHEART-SA study team, community-engaged research (CEnR) and community-based primary healthcare are integral approaches for integrating hypertension and diabetes care into HIV care. By combining these approaches with stakeholder engagement and a community advisory board, the hope is to integrate health services across South Africa. With this in mind, community and research partnerships are crucial for effective implementation.
In order to continue improving community/research partnerships, Claudia Ordóñez, an adjunct assistant professor at Emory Univerity’s Rollins School of Public Health and the lead for the implementation of CEnR strategies for the iHEART-SA team, conducted a process improvement evaluation of iHEART-SA’s community advisory board (CAB) in late 2022.
Goals of the evaluation included quality improvement and capacity building for the community advisory board and research project implementation, dissemination of CEnR lessons learned to improve stakeholder engagement, and development of a process evaluation template to use for CAB and stakeholder activities.
The evaluation utilized a mixed methods approach with a short survey related to the implementation of the CAB and key informant interviews (KII) to measure the bi-directionality in CEnR. KII participants included patients, health activists, ministry of health leadership, and community liaisons. Preliminary results included seven KII’s that were transcribed, coded, and categorized into three dimensions. These dimensions and specific strategies recommended by CAB members to improve community and CAB/researcher partnerships are below.
- Values for trust building in partnerships: Specific strategies included bridging the gap between project and community-based stakeholders, cultivation of interpersonal relationships, and mitigation of assumption by researchers.
- Key elements for CAB & project outreach towards community-based stakeholders: Constant bi-directional communication through project liaisons, identifying effective communication technologies such as WhatsApp, and awareness campaigns.
- CAB meeting logistics: Identifying key agenda items for each meeting, the frequency and length of meetings should be established early on, and preparing for CAB meeting in advice.
Keep an eye out for the full evaluation results, along with details of iHEART-SA’s CEnR activities, coming soon!
It has been a busy few weeks for the HLB-SIMPLe Community Engagement Subcommittee (CESC)! The leadership transitioned from Mighty Ernest Mosimanegape Moseki (of InterCARE) to Claudia E. Ordóñez (of iHEART-SA) as the new chair, and Nabila Youssouf (of InterCARE) as vice-chair. A huge thank you to Ernest for taking on this position over the last year!
The CESC primary objectives are to: a) Operationalize community-engaged research in the context of implementation science; and b) Facilitate sharing of best practices and lessons learned for community-engaged research among and beyond the HLB-SIMPLe Alliance.
Subcommittee members were able to meet in person for the first time during the HLB-SIMPLe Annual Meeting in Uganda in May and reviewed activities and their progress to date, which include:
- Development and implementation of a baseline survey to assess community engagement understanding and approaches among each of the six Alliance projects, with the purpose of disseminating best practices and future benchmarking. Thanks again to all the sites’ teams for your time in the completion of the survey! Results will be disseminated later this year.
- “Check-ins” with Alliance projects sharing relevant information for best practices and gathering feedback for support needs regarding CE in implementation science.
The vision for the year ahead centers around more and on-going engagement with a wide range of stakeholders from each of the Alliance projects to foster relations and build a network on HIV and hypertension care. The CESC also wants to hear from all sites and disseminate their important work regarding stakeholder engagement. We plan to publish the community engagement activities and stories from each Alliance site every quarter. Please do not hesitate to reach out to us if you have any ideas, questions, or requests!