PROJECT SUMMARY
An estimated 26% of people living with HIV (PLWHIV) in Botswana have hypertension. Uncontrolled
hypertension will add to the already increased risk for cardiovascular (CVD) disease in this population. A
hypertension study nested within an HIV prevention trial (Botswana Combination Prevention Project-
BCPP), the hypertension continuum of care was suboptimal among PLWHIV; 46% aware of their
hypertension, 42% on medication, 44% of those on medication at recommended blood pressure target, with
an overall hypertension control of 19%. These data highlight multiple implementation gaps in our setting
among PLWHIV for hypertension control and the missed opportunity to address CVD risk factors among
those with hypertension. These gaps occur despite national guidelines recommendations, free universal
healthcare, availability of needed medications and approaches which can improve quality including training,
coaching, and the use of electronic health records (EHR) reminders. Implementation research is urgently
needed to develop more effective strategies to improve the uptake of established effective hypertension
and CVDRF management interventions among PLWHIV in Botswana and other low- and middle-income
countries (LMICs). We propose the adaptation and testing of strategies to effectively integrate evidence-
based interventions (EBI) into HIV care to improve hypertension cascade of care (awareness, diagnosis,
treatment, control) and general CVD risk factor knowledge, diagnosis and treatment using a late-stage T4
implementation research hybrid type 2 study design. First, we will develop a set of implementation
strategies for integrated HIV-HTN/CVD care within an existing HIV care platform for adults with HIV
and hypertension and pilot test (2 HIV Clinics) to explore implementation outcomes using RE-AIM
framework to inform adaptation for broader testing. We will use the knowledge gained from the
development and piloting of the implementation strategy to then use a type 2 hybrid design to measure
the implementation outcomes of multi-component strategy in improving EBI uptake and
improvement success rates in the HTN cascade among adults with a dual diagnosis of HIV and
Hypertension. To achieve this second aim, we are proposing a type 2 hybrid effectiveness-implementation
of a 10-cluster randomized trial (1:1 randomization at the facility level) of 300 adults per cluster between 20-
75 years old with a dual diagnosis of HIV and hypertension (>140/90mmHg, >130/80mmHg if living with
Diabetes mellitus/Chronic Kidney Disease) in Botswana. Our primary quantitative implementation
outcomes based on the RE-AIM framework implementation are reach (proportion of PLWHIV on treatment
among those who meet threshold for anti-hypertensive medication), effectiveness (proportion with
controlled blood pressure), plus adoption (proportion of providers who screen PLWHIV for high blood
pressure plus proportion of providers who prescribe anti-hypertensive medications). Our co-primary
qualitative implementation outcomes will include assessment of fidelity (audit of intervention
implementation as designed) and maintenance (provider and patient perceptions of ability to maintain plus
change in blood pressure control from first control to end of the trial). Our secondary implementation
outcomes, we will include assessment of feasibility (ability to implement integrated HIV/HTN care,
HIV/HTN/CVD care, clinic viral suppression, etc.) and acceptability (patient and provider survey and
interviews) of the implementation strategy.
