Cross-Cutting Implementation Strategies to Integrate Hypertension Care Into HIV Care in Africa: Results From Six Country Studies in the HLB-SIMPLe Alliance.

introductionThe National Heart, Lung and Blood Institute (NHLBI), in 2020, funded six implementation research trials in Africa (Botswana, Mozambique, Nigeria, South Africa, Uganda and Zambia) to test implementation strategies for integrating evidence-based cardiovascular disease (CVD) care into primary care for people living with HIV. We identified cross-site implementation strategies used by the six trials to integrate CVD care for people living with HIV in these diverse settings.

methodsBetween December 2022 and September 2023, we reviewed protocols for each trial and followed up with study teams from the six studies to identify implementation strategies targeting the individual (healthcare worker [HCW] and patient), facility and system levels. Guided by the Expert Recommendations for Implementing Change (ERIC) taxonomy of implementation strategies, we grouped and defined strategies used for each study. We then specified each strategy (i.e. actor, the action, action targets, temporality, dose, implementation outcomes addressed and theoretical justification) to understand similarities and differences in how cross-cutting implementation strategies were operationalized.

resultsTen implementation strategies were identified across the six trials for integrating hypertension (six studies) and diabetes (one study) care into existing HIV primary healthcare platforms. Three strategies, HCW training, audit and feedback, and practice facilitation or coaching, were implemented in all trials. Function and form synthesis showed that while these strategies shared the common goal of improving provider capacity and quality of care, their delivery varied across settings. HCW training was adapted in duration, frequency and trainer type; audit and feedback processes differed in how data were used and integrated with district quality improvement structures; and practice facilitation approaches ranged from study-led to health system-led models. These adaptations reflected contextual differences in health system capacity and available resources while maintaining a shared focus on strengthening HIV-CVD service integration.

conclusionsWith the increasing burden of CVD among people living with HIV, identifying implementation strategies for integrating CVD care into HIV primary healthcare is critical. Our study provides contextually relevant information on cross-site implementation strategies aimed at achieving this in six African countries. The findings underscore the necessity of strategies that extend beyond conventional training, highlighting coaching, facilitation and developing data systems as central to approaches to improve integrated CVD care for people living with HIV in low-resource settings.