Exploring barriers and facilitators to integrated hypertension-HIV management in Ugandan HIV clinics using the Consolidated Framework for Implementation Research (CFIR)
Authors: Muddu Martin , Tusubira Andrew K. , Nakirya Brenda , Nalwoga Rita , Semitala Fred C. , Akiteng Ann R. , Schwartz Jeremy I , Ssinabulya Isaac 
Published: December 2019

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.

Contribution to the literature

We used the widely used and validated CFIR to assess the HIV program for HTN/HIV integration.

To our knowledge, this is the first study to explore barriers and facilitators to integrating hypertension screening and treatment into HIV clinics using the CFIR.

The barriers and facilitators identified are a basis for designing contextualized implementation interventions for HTN/HIV integration in Uganda and other LMIC using a health system strengthening approach.