Barriers and facilitators to integrating home blood pressure monitoring into existing HIV community care in Nigeria

Abstract Background HIV/AIDS is a significant public health problem in sub-Saharan Africa (SSA), accounting for 70% of the global disease burden. HIV mortality in SSA has declined due to expanded access to anti-retroviral therapy (ART), often delivered through task sharing, which uses non-physician community health workers (CHWs), including Community Extension Workers (CHEWs), community pharmacists, and community nurses. Leveraging such non-physician CHW support for the monitoring of blood pressure in hypertensive persons living with HIV (PLHIV) is desirable, especially with the increasing burden of cardiovascular disease and its risk factors, especially hypertension, in this population. Given the success of community-based approaches for HIV treatment, integrating screening and monitoring of a non-communicable disease (NCD) like hypertension provides a quick win that is increasingly essential. Providing this add-on service in the comfort of the patient’s home environment has additional benefits, including greater reproducibility and increased patient involvement in their own care. This study explores integrating home blood pressure monitoring into community-based HIV treatment. Objective This study aimed to examine the facilitators and contextual barriers to implementing CHW support and home blood pressure (BP) monitoring among hypertensive PLHIV in HIV Clinics in Nigeria’s Federal Capital Territory (FCT) using the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Methods We purposively sampled 30 participants and conducted qualitative key informant interviews using a semi-structured interview guide, between 12th August 2022 and 20th February 2023. Participants included five each of hypertensive PLHIV, CHEWs, physicians, healthcare policymakers, community pharmacists, and community nurses. Interviews were tape-recorded, transcribed, and coded according to identified themes. Using Nvivo version 11, we conducted a framework analysis of our data to describe the facilitators and contextual barriers to implementing CHW support and home BP monitoring in hypertensive PLHIV. Ethical approval for this study was obtained from the Human Research and Ethics Committee of the University of Abuja Teaching Hospital, Gwagwalada. Results Overall contextual observations include existing donor-funded community ART refill mechanisms managed by volunteers. Proposed facilitators include providing a policy framework, advocating to stakeholders, providing government funding support, incentivising volunteers and patients, identifying champions for home BP monitoring among hypertensive PLHIV, training, supportive supervision, and patient involvement. Contextual barriers identified include financial constraints, a non-existent policy framework, lack of implementation guidelines, and a lack of dedicated human resources for home BP monitoring in hypertensive PLHIV, as well as provider, community, and patient resistance. Conclusion We identified facilitators and contextual barriers to CHW support and home BP monitoring among hypertensive PLHIV within the context of an existing donor-funded community ART refill program. The government’s leadership and funding are critical to overcoming barriers and successful implementation.