Effect of a one-time financial incentive on linkage to chronic hypertension care in Kenya and Uganda: A randomized controlled trial.

BACKGROUND: Fewer than 10% of people with hypertension in sub-Saharan Africa are diagnosed, linked to care, and achieve hypertension control. We hypothesized that a one-time financial incentive and phone call reminder for missed appointments would increase linkage to hypertension care following community-based screening in rural Uganda and Kenya. METHODS: In a randomized controlled trial, we conducted community-based hypertension screening and enrolled adults ≥25 years with blood pressure ≥140/90 mmHg on three measures; we excluded participants with known hypertension or hypertensive emergency. The intervention was transportation reimbursement upon linkage (~$5 USD) and up to three reminder phone calls for those not linking within seven days. Control participants received a clinic referral only. Outcomes were linkage to hypertension care within 30 days (primary) and hypertension control <140/90 mmHg measured in all participants at 90 days (secondary). We used targeted minimum loss-based estimation to compute adjusted risk ratios (aRR). RESULTS: We screened 1,998 participants, identifying 370 (18.5%) with uncontrolled hypertension and enrolling 199 (100 control, 99 intervention). Reasons for non-enrollment included prior hypertension diagnosis (n = 108) and hypertensive emergency (n = 32). Participants were 60% female, median age 56 (range 27-99); 10% were HIV-positive and 42% had baseline blood pressure ≥160/100 mmHg. Linkage to care within 30 days was 96% in intervention and 66% in control (aRR 1.45, 95%CI 1.25-1.68). Hypertension control at 90 days was 51% intervention and 41% control (aRR 1.22, 95%CI 0.92-1.66). CONCLUSION: A one-time financial incentive and reminder call for missed visits resulted in a 30% absolute increase in linkage to hypertension care following community-based screening. Financial incentives can improve the critical step of linkage to care for people newly diagnosed with hypertension in the community.

Costs of integrating hypertension care into HIV care in rural East African clinics.

OBJECTIVE: Sub-Saharan Africa faces twin epidemics of HIV and noncommunicable diseases including hypertension. Integrating hypertension care into chronic HIV care is a global priority, but cost estimates are lacking. In the SEARCH Study, we performed population-level HIV/hypertension testing, and offered integrated streamlined chronic care. Here, we estimate costs for integrated hypertension/HIV care for HIV-positive individuals, and costs for hypertension care for HIV-negative individuals in the same clinics. DESIGN: Microcosting analysis of healthcare expenditures within Ugandan HIV clinics. METHODS: SEARCH (NCT: 01864603) conducted community health campaigns for diagnosis and linkage to care for both HIV and hypertension. HIV-positive patients received hypertension/HIV care jointly including blood pressure monitoring and medications; HIV-negative patients received hypertension care at the same clinics. Within 10 Ugandan study communities during 2015-2016, we estimated incremental annual per-patient hypertension care costs using micro-costing techniques, time-and-motion personnel studies, and administrative/clinical records review. RESULTS: Overall, 70 HIV-positive and 2355 HIV-negative participants received hypertension care. For HIV-positive participants, average incremental cost of hypertension care was $6.29 per person per year, a 2.1% marginal increase over prior estimates for HIV care alone. For HIV-negative participants, hypertension care cost $11.39 per person per year, a 3.8% marginal increase over HIV care costs. Key costs for HIV-positive patients included hypertension medications ($6.19 per patient per year; 98% of total) and laboratory testing ($0.10 per patient per year; 2%). Key costs for HIV-negative patients included medications ($5.09 per patient per year; 45%) and clinic staff salaries ($3.66 per patient per year; 32%). CONCLUSION: For only 2-4% estimated additional costs, hypertension care was added to HIV care, and also expanded to all HIV-negative patients in prototypic Ugandan clinics, demonstrating substantial synergy. Our results should encourage accelerated scale-up of hypertension care into existing clinics.

Costs of streamlined HIV care delivery in rural Ugandan and Kenyan clinics in the SEARCH Studys.

OBJECTIVES/DESIGN: As antiretroviral therapy (ART) rapidly expands in sub-Saharan Africa using new efficient care models, data on costs of these approaches are lacking. We examined costs of a streamlined HIV care delivery model within a large HIV test-and-treat study in Uganda and Kenya. METHODS: We calculated observed per-person-per-year (ppy) costs of streamlined care in 17 health facilities in SEARCH Study intervention communities (NCT: 01864603) via micro-costing techniques, time-and-motion studies, staff interviews, and administrative records. Cost categories included salaries, ART, viral load testing, recurring goods/services, and fixed capital/facility costs. We then modeled costs under three increasingly efficient scale-up scenarios: lowest-cost ART, centralized viral load testing, and governmental healthcare worker salaries. We assessed the relationship between community-specific ART delivery costs, retention in care, and viral suppression. RESULTS: Estimated streamlined HIV care delivery costs were $291/ppy. ART ($117/ppy for TDF/3TC/EFV [40%]) and viral load testing ($110/ppy for 2 tests/year [39%]) dominated costs versus salaries ($51/ppy), recurring costs ($5/ppy), and fixed costs ($7/ppy). Optimized ART scale-up with lowest-cost ART ($100/ppy), annual viral load testing ($24/ppy), and governmental healthcare salaries ($27/ppy), lowered streamlined care cost to $163/ppy. We found clinic-to-clinic heterogeneity in retention and viral suppression levels versus streamlined care delivery costs, but no correlation between cost and either retention or viral suppression. CONCLUSIONS: In the SEARCH Study, streamlined HIV care delivery costs were similar to or lower than prior estimates despite including viral load testing; further optimizations could substantially reduce costs further. These data can inform global strategies for financing ART expansion to achieve UNAIDS 90-90-90 targets.

High levels of retention in care with streamlined care and universal test and treat in East Africa.

OBJECTIVE: We sought to measure retention in care and identify predictors of nonretention among patients receiving antiretroviral therapy (ART) with streamlined delivery during the first year of the ongoing Sustainable East Africa Research on Community Health (SEARCH) 'test-and-treat' trial (NCT 01864603) in rural Uganda and Kenya. DESIGN: Prospective cohort of patients in the intervention arm of the SEARCH study. METHODS: We measured retention in care at 12 months among HIV-infected adults who linked to care and were offered ART regardless of CD4 cell count, following community-wide HIV-testing. Kaplan-Meier estimates and Cox proportional hazards modeling were used to calculate the probability of retention at 1 year and identify predictors of nonretention. RESULTS: Among 5683 adults (age ≥15) who linked to care, 95.5% [95% confidence interval (CI): 92.9-98.1%] were retained in care at 12 months. The overall probability of retention at 1 year was 89.3% (95% CI: 87.6-90.7%) among patients newly linking to care and 96.4% (95% CI: 95.8-97.0%) among patients previously in care. Younger age and pre-ART CD4 cell count below country treatment initiation guidelines were predictors of nonretention among all patients. Among those newly linking, taking more than 30 days to link to care after HIV diagnosis was additionally associated with nonretention at 1 year. HIV viral load suppression at 12 months was observed in 4227 of 4736 (89%) of patients retained with valid viral load results. CONCLUSION: High retention in care and viral suppression after 1 year were achieved in a streamlined HIV care delivery system in the context of a universal test-and-treat intervention.

Population-Based Assessment of Hypertension Epidemiology and Risk Factors among HIV-Positive and General Populations in Rural Uganda.

BACKGROUND: Antiretroviral therapy scale-up in Sub-Saharan Africa has created a growing, aging HIV-positive population at risk for non-communicable diseases such as hypertension. However, the prevalence and risk factors for hypertension in this population remain incompletely understood. METHODS: We measured blood pressure and collected demographic data on over 65,000 adults attending multi-disease community health campaigns in 20 rural Ugandan communities (SEARCH Study: NCT01864603). Our objectives were to determine (i) whether HIV is an independent risk factor for hypertension, and (ii) awareness and control of hypertension in HIV-positive adults and the overall population. RESULTS: Hypertension prevalence was 14% overall, and 11% among HIV-positive individuals. 79% of patients were previously undiagnosed, 85% were not taking medication, and 50% of patients on medication had uncontrolled blood pressure. Multivariate predictors of hypertension included older age, male gender, higher BMI, lack of education, alcohol use, and residence in Eastern Uganda. HIV-negative status was independently associated with higher odds of hypertension (OR 1.2, 95% CI: 1.1-1.4). Viral suppression of HIV did not significantly predict hypertension among HIV-positives. SIGNIFICANCE: The burden of hypertension is substantial and inadequately controlled, both in HIV-positive persons and overall. Universal HIV screening programs could provide counseling, testing, and treatment for hypertension in Sub-Saharan Africa.

Barriers and facilitators adolescent females living with HIV face in accessing contraceptive services: a qualitative assessment of providers' perceptions in western Kenya.

INTRODUCTION: Avoiding unintended pregnancies is important for the health of adolescents living with HIV and has the additional benefit of preventing potential vertical HIV transmission. Health facility providers represent an untapped resource in understanding the barriers and facilitators adolescents living with HIV face when accessing contraception. By understanding these barriers and facilitators to contraceptive use among adolescent females living with HIV, this study aimed to understand how best to promote contraception within this marginalized population. METHODS: We conducted structured in-depth interviews with 40 providers at 21 Family AIDS Care & Education Services - supported clinics in Homabay, Kisumu and Migori counties in western Kenya from July to August 2014. Our interview guide explored the providers' perspectives on contraceptive service provision to adolescent females living with HIV with the following specific domains: contraception screening and counselling, service provision, commodity security and clinic structure. Transcripts from the interviews were analyzed using inductive content analysis. RESULTS: According to providers, interpersonal factors dominated the barriers adolescent females living with HIV face in accessing contraception. Providers felt that adolescent females fear disclosing their sexual activity to parents, peers and providers, because of repercussions of perceived promiscuity. Furthermore, providers mentioned that adolescents find seeking contraceptive services without a male partner challenging, because some providers and community members view adolescents unaccompanied by their partners as not being serious about their relationships or having multiple concurrent relationships. On the other hand, providers noted that institutional factors best facilitated contraception for these adolescents. Integration of contraception and HIV care allows easier access to contraceptives by removing the stigma of coming to a clinic solely for contraceptive services. Youth-friendly services, including serving youth on days separate from adults, also create a more comfortable setting for adolescents seeking contraceptive services. CONCLUSIONS: Providers at these facilities identified attitudes of equating seeking contraceptive services with promiscuity by parents, peers and providers as barriers preventing adolescent females living with HIV from accessing contraceptive services. Health facilities should provide services for adolescent females in a youth-friendly manner and integrate HIV and contraceptive services.