1
|
Amutuhaire W, Semitala FC, Kimera ID, Namugenyi C, Mulindwa F, Ssenyonjo R, Katwesigye R, Mugabe F, Mutungi G, Ssinabulya I, Schwartz JI, Katahoire AR, Musoke LS, Yendewa GA, Longenecker CT, Muddu M. Time to blood pressure control and predictors among patients receiving integrated treatment for hypertension and HIV based on an adapted WHO HEARTS implementation strategy at a large urban HIV clinic in Uganda. J Hum Hypertens 2024; 38:452-459. [PMID: 38302611 PMCID: PMC11076202 DOI: 10.1038/s41371-024-00897-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 10/01/2023] [Accepted: 01/18/2024] [Indexed: 02/03/2024]
Abstract
In this cohort study, we determined time to blood pressure (BP) control and its predictors among hypertensive PLHIV enrolled in integrated hypertension-HIV care based on the World Health Organization (WHO) HEARTS strategy at Mulago Immunosuppression Clinic in Uganda. From August 2019 to March 2020, we enrolled hypertensive PLHIV aged ≥ 18 years and initiated Amlodipine 5 mg mono-therapy for BP (140-159)/(90-99) mmHg or Amlodipine 5 mg/Valsartan 80 mg duo-therapy for BP ≥ 160/90 mmHg. Patients were followed with a treatment escalation plan until BP control, defined as BP < 140/90 mmHg. We used Cox proportional hazards models to identify predictors of time to BP control. Of 877 PLHIV enrolled (mean age 50.4 years, 62.1% female), 30% received mono-therapy and 70% received duo-therapy. In the monotherapy group, 66%, 88% and 96% attained BP control in the first, second and third months, respectively. For patients on duo-therapy, 56%, 83%, 88% and 90% achieved BP control in the first, second, third, and fourth months, respectively. In adjusted Cox proportional hazard analysis, higher systolic BP (aHR 0.995, 95% CI 0.989-0.999) and baseline ART tenofovir/lamivudine/efavirenz (aHR 0.764, 95% CI 0.637-0.917) were associated with longer time to BP control, while being on ART for >10 years was associated with a shorter time to BP control (aHR 1.456, 95% CI 1.126-1.883). The WHO HEARTS strategy was effective at achieving timely BP control among PLHIV. Additionally, monotherapy anti-hypertensive treatment for stage I hypertension is a viable option to achieve BP control and limit pill burden in resource limited HIV care settings.
Collapse
Affiliation(s)
- Willington Amutuhaire
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | | | | | | | - Frank Mulindwa
- Makerere University Infectious Diseases Institute, Kampala, Uganda
| | | | | | - Frank Mugabe
- Department of non-communicable diseases, Uganda Ministry of Health, Kampala, Uganda
| | - Gerald Mutungi
- Department of non-communicable diseases, Uganda Ministry of Health, Kampala, Uganda
| | | | - Jeremy I Schwartz
- Yale School of Medicine, Section of General Internal Medicine, Connecticut, CT, USA
| | - Anne R Katahoire
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lewis S Musoke
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - George A Yendewa
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Chris T Longenecker
- Department of Global Health and Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Martin Muddu
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| |
Collapse
|
2
|
Musimbaggo DJ, Kimera ID, Namugenyi C, Schwartz JI, Ssenyonjo R, Ambangira F, Kizza L, Mbuliro M, Katwesigye R, Ssinabulya I, Muddu M, Neupane D, Olsen MH, Pareek M, Semitala FC. Factors associated with blood pressure control in patients with hypertension and HIV at a large urban HIV clinic in Uganda. J Hum Hypertens 2024; 38:345-351. [PMID: 36476778 PMCID: PMC11001571 DOI: 10.1038/s41371-022-00786-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/20/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
Globally, people living with HIV on antiretroviral therapy have an increased risk of cardiovascular disease. Hypertension is the most important preventable risk factor for cardiovascular disease and is associated with increased morbidity. We conducted an exploratory survey with hypertensive persons living with HIV who received integrated HIV and hypertension care in a large clinic in Uganda between August 2019 and March 2020 to determine factors associated with blood pressure control at six months. Controlled blood pressure was defined as <140/90 mmHg. Multivariable logistic regression was used to determine baseline factors associated with blood pressure control after 6 months of antihypertensive treatment. Of the 1061 participants, 644 (62.6%) were female. The mean age (SD) was 51.1 (9.4) years. Most participants were overweight (n = 411, 38.7%) or obese (n = 276, 25.9%), and 98 (8.9%) had diabetes mellitus. Blood pressure control improved from 14.4% at baseline to 66.1% at 6 months. Comorbid diabetes mellitus (odds ratio (OR) = 0.41, 95% confidence interval (CI) = 0.26-0.64, p < 0.001) and HIV status disclosure (OR = 0.73, 95% CI = 0.55-0.98, p = 0.037) were associated with the absence of controlled blood pressure at 6 months. In conclusion, comorbid diabetes mellitus and the disclosure of an individual's HIV status to a close person were associated with poor blood pressure control among persons living with HIV who had hypertension. Therefore, subpopulations of persons living with HIV with hypertension and comorbid diabetes mellitus may require more thorough assessments and intensive antihypertensive management approaches to achieve blood pressure targets.
Collapse
Affiliation(s)
| | | | | | - Jeremy I Schwartz
- Department of Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | | | | | - Lubega Kizza
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Mary Mbuliro
- Makerere University Joint AIDS Program, Kampala, Uganda
| | | | - Isaac Ssinabulya
- Department of Medicine, Makerere University College of Health Science, Kampala, Uganda
- Uganda Heart Institute, Kampala, Uganda
| | - Martin Muddu
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Dinesh Neupane
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michael Hecht Olsen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Cardiology Section, Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark
| | - Manan Pareek
- Department of Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Fred C Semitala
- Makerere University Joint AIDS Program, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Science, Kampala, Uganda
| |
Collapse
|
3
|
Ambangira F, Sharman JE, Muddu M, Kimera ID, Namara D, Musimbaggo DJ, Namugenyi C, Ssenyonjo R, Mbuliro M, Katwesigye R, Schwartz JI, Semitala FC, Ssinabulya I. Diabetes mellitus care cascade among a cohort of persons living with HIV and hypertension in Uganda: A retrospective cohort study. Int J STD AIDS 2023; 34:728-734. [PMID: 37269360 DOI: 10.1177/09564624231179497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND In Uganda, it is recommended that persons with HIV receive integrated care to address both hypertension and diabetes. However, the extent to which appropriate diabetes care is delivered remains unknown and was the aim of this study. METHODS We conducted a retrospective study among participants receiving integrated care for HIV and hypertension for at least 1 year at a large urban HIV clinic in Mulago, Uganda to determine the diabetes care cascade. RESULTS Of the 1115 participants, the majority were female (n = 697, 62.5%) with a median age of 50 years (Inter Quartile Range: 43, 56). Six hundred twenty-seven participants (56%) were screened for diabetes mellitus, 100 (16%) were diagnosed and almost all that were diagnosed (n = 94, 94%) were initiated on treatment. Eighty-five patients (90%) were retained and all were monitored (100%) in care. Thirty-two patients (32/85, 38%) had glycaemic control. Patients on a Dolutegravir-based regimen (OR = 0.31, 95% CI = 0.22-0.46, p < 0.001) and those with a non-suppressed viral load (OR = 0.24, 95% CI = 0.07-0.83, p = 0.02) were less likely to be screened for diabetes mellitus. CONCLUSIONS In very successful HIV care programs, large gaps still linger for the management of non-communicable diseases necessitating uniquely designed intervention by local authorities and implementing partners addressing the dual HIV and non-communicable diseases burden.
Collapse
Affiliation(s)
| | - James E Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Martin Muddu
- Makerere University, Joint AIDS Program (MJAP), Kampala, Uganda
| | | | - Daphine Namara
- University of California Berkeley, School of Public Health, Berkeley, CA, USA
| | | | | | | | - Mary Mbuliro
- Makerere University, Joint AIDS Program (MJAP), Kampala, Uganda
| | | | - Jeremy I Schwartz
- Yale School of Medicine, Section of General Internal Medicine, New Haven, CT, USA
| | | | | |
Collapse
|
4
|
Muddu M, Semitala FC, Kimera ID, Musimbaggo DJ, Mbuliro M, Ssennyonjo R, Kigozi SP, Katwesigye R, Ayebare F, Namugenyi C, Mugabe F, Mutungi G, Longenecker CT, Katahoire AR, Schwartz JI, Ssinabulya I. Using the RE-AIM framework to evaluate the implementation and effectiveness of a WHO HEARTS-based intervention to integrate the management of hypertension into HIV care in Uganda: a process evaluation. Implement Sci Commun 2023; 4:102. [PMID: 37626415 PMCID: PMC10463385 DOI: 10.1186/s43058-023-00488-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND World Health Organization (WHO) HEARTS packages are increasingly used to control hypertension. However, their feasibility in persons living with HIV (PLHIV) is unknown. We studied the effectiveness and implementation of a WHO HEARTS intervention to integrate the management of hypertension into HIV care. METHODS This was a mixed methods study at Uganda's largest HIV clinic. Components of the adapted WHO HEARTS intervention were lifestyle counseling, free hypertension medications, hypertension treatment protocol, task shifting, and monitoring tools. We determined the effectiveness of the intervention among PLHIV by comparing hypertension and HIV outcomes at baseline and 21 months. The RE-AIM framework was used to evaluate the implementation outcomes of the intervention at 21 months. We conducted four focus group discussions with PLHIV (n = 42), in-depth interviews with PLHIV (n = 9), healthcare providers (n = 15), and Ministry of Health (MoH) policymakers (n = 2). RESULTS Reach: Among the 15,953 adult PLHIV in the clinic, of whom 3892 (24%) had been diagnosed with hypertension, 1133(29%) initiated integrated hypertension-HIV treatment compared to 39 (1%) at baseline. Among the enrolled patients, the mean age was 51.5 ± 9.7 years and 679 (62.6%) were female. EFFECTIVENESS Among the treated patients, hypertension control improved from 9 to 72% (p < 0.001), mean systolic blood pressure (BP) from 153.2 ± 21.4 to 129.2 ± 15.2 mmHg (p < 0.001), and mean diastolic BP from 98.5 ± 13.5 to 85.1 ± 9.7 mmHg (p < 0.001). Overall, 1087 (95.9%) of patients were retained by month 21. HIV viral suppression remained high, 99.3 to 99.5% (p = 0.694). Patients who received integrated hypertension-HIV care felt healthy and saved more money. Adoption: All 48 (100%) healthcare providers in the clinic were trained and adopted the intervention. Training healthcare providers on WHO HEARTS, task shifting, and synchronizing clinic appointments for hypertension and HIV promoted adoption. IMPLEMENTATION WHO HEARTS intervention was feasible and implemented with fidelity. Maintenance: Leveraging HIV program resources and adopting WHO HEARTS protocols into national guidelines will promote sustainability. CONCLUSIONS The WHO HEARTS intervention promoted the integration of hypertension management into HIV care in the real-world setting. It was acceptable, feasible, and effective in controlling hypertension and maintaining optimal viral suppression among PLHIV. Integrating this intervention into national guidelines will promote sustainability.
Collapse
Affiliation(s)
- Martin Muddu
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda.
| | - Fred Collins Semitala
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Isaac Derick Kimera
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | | | - Mary Mbuliro
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Rebecca Ssennyonjo
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | | | - Rodgers Katwesigye
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | | | | | | | | | | | | | - Jeremy I Schwartz
- Section of General Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA
| | - Isaac Ssinabulya
- Mulago Hospital Complex, Uganda Heart Institute, Kampala, Uganda
| |
Collapse
|
5
|
Muddu M, Semitala FC, Kimera I, Mbuliro M, Ssennyonjo R, Kigozi SP, Katwesigye R, Ayebare F, Namugenyi C, Mugabe F, Mutungi G, Longenecker CT, Katahoire AR, Ssinabulya I, Schwartz JI. Improved hypertension control at six months using an adapted WHO HEARTS-based implementation strategy at a large urban HIV clinic in Uganda. BMC Health Serv Res 2022; 22:699. [PMID: 35610717 PMCID: PMC9131679 DOI: 10.1186/s12913-022-08045-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 05/05/2022] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To adapt a World Health Organization HEARTS-based implementation strategy for hypertension (HTN) control at a large urban HIV clinic in Uganda and determine six-month HTN and HIV outcomes among a cohort of adult persons living with HIV (PLHIV). METHODS Our implementation strategy included six elements: health education, medication adherence, and lifestyle counseling; routine HTN screening; task shifting of HTN treatment; evidence-based HTN treatment protocol; consistent supply of HTN medicines free to patients; and inclusion of HTN-specific monitoring and evaluation tools. We conducted a pre-post study from October 2019 to March 2020 to determine the effect of this strategy on HTN and HIV outcomes at baseline and six months. Our cohort comprised adult PLHIV diagnosed with HTN who made at least one clinic visit within two months prior to study onset. FINDINGS We enrolled 1,015 hypertensive PLHIV. The mean age was 50.1 ± 9.5 years and 62.6% were female. HTN outcomes improved between baseline and six months: mean systolic BP (154.3 ± 20.0 to 132.3 ± 13.8 mmHg, p < 0.001); mean diastolic BP (97.7 ± 13.1 to 85.3 ± 9.5 mmHg, p < 0.001) and proportion of patients with controlled HTN (9.3% to 74.1%, p < 0.001). The HTN care cascade also improved: treatment initiation (13.4% to 100%), retention in care (16.2% to 98.5%), monitoring (16.2% to 98.5%), and BP control among those initiated on HTN treatment (2.2% to 75.2%). HIV cascade steps remained high (> 95% at baseline and six months) and viral suppression was unchanged (98.7% to 99.2%, p = 0.712). Taking ART for more than two years and HIV viral suppression were independent predictors of HTN control at six months. CONCLUSIONS A HEARTS-based implementation strategy at a large, urban HIV center facilitates integration of HTN and HIV care and improves HTN outcomes while sustaining HIV control. Further implementation research is needed to study HTN/HIV integration in varied clinical settings among diverse populations.
Collapse
Affiliation(s)
- Martin Muddu
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Fred C. Semitala
- grid.11194.3c0000 0004 0620 0548Makerere University College of Health Sciences, Kampala, Uganda
| | - Isaac Kimera
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Mary Mbuliro
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Rebecca Ssennyonjo
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Simon P. Kigozi
- grid.463352.50000 0004 8340 3103Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Rodgers Katwesigye
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Florence Ayebare
- grid.11194.3c0000 0004 0620 0548Makerere University College of Health Sciences, Kampala, Uganda
| | - Christabellah Namugenyi
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Frank Mugabe
- grid.415705.2Ministry of Health, Kampala, Uganda
| | | | - Chris T. Longenecker
- grid.67105.350000 0001 2164 3847Case Western Reserve University School of Medicine, Cleveland, OH USA
| | - Anne R. Katahoire
- grid.11194.3c0000 0004 0620 0548Makerere University College of Health Sciences, Kampala, Uganda
| | - Isaac Ssinabulya
- grid.416252.60000 0000 9634 2734Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Jeremy I. Schwartz
- grid.47100.320000000419368710Yale School of Medicine, 333 Cedar Street, New Haven, CT 06511 USA
| |
Collapse
|