Research Article: Capabilities, opportunities and motivations for integrating evidence-based strategy for hypertension control into HIV clinics in Southwest Nigeria

Date Published: June 6, 2019

Publisher: Public Library of Science

Author(s): Juliet Iwelunmor, Oliver Ezechi, Chisom Obiezu-Umeh, Titilola Gbajabiamila, Adesola Z. Musa, David Oladele, Ifeoma Idigbe, Aigbe Ohihoin, Joyce Gyamfi, Angela Aifah, Babatunde Salako, Olugbenga Ogedegbe, Kwasi Torpey.


Given the growing burden of cardiovascular diseases in sub-Saharan Africa, global donors and governments are exploring strategies for integrating evidence-based cardiovascular diseases prevention into HIV clinics. We assessed the capabilities, motivations and opportunities that exist for HIV clinics to apply evidence-based strategies for hypertension control among people living with HIV (PLHIV) in Nigeria.

We used a concurrent Quan-Qual- study approach (a quantitative first step using structured questionnaires followed by a qualitative approach using stakeholder meetings).We invited key stakeholders and representatives of HIV and non-communicable disease organizations in Lagos, Nigeria to 1) assess the capacity of HIV clinics (n = 29) to, and; 2) explore their attitudes and perceptions towards implementing evidence-based strategies for hypertension management in Lagos, Nigeria (n = 19)The quantitative data were analyzed using SPSS whereas responses from the stakeholders meeting were coded and analyzed using thematic approach and an implementation science framework, the COM-B (Capabilities, Opportunities, Motivations and Behavior) model, guided the mapping and interpretation of the data.

Out of the 29 HIV clinics that participated in the study, 28 clinics were public, government-owned facilities with 394 HIV patients per month with varying capabilities, opportunities and motivations for integrating evidence-based hypertension interventions within their services for PLHIV. Majority of the clinics (n = 26) rated medium-to-low on the psychological capability domains, while most of the clinics (n = 25) rated low on the physical capabilities of integrating evidence-based hypertension interventions within HIV clinics. There was high variability in the ratings for the opportunity domains, with physical opportunities rated high in only eight HIV clinics, two clinics with a medium rating and nineteen clinics with a low rating. Social opportunity domain tended to be rated low in majority of the HIV clinics (n = 21). Lastly, almost all the HIV clinics (n = 23) rated high on the reflective motivation domain although automatic motivations tended to be rated low across the HIV clinics.

In this study, we found that with the exception of motivations, the relative capabilities whether physical or psychological and the relative opportunities for integrating evidence-based hypertension intervention within HIV clinics in Nigeria were minimal. Thus, there is need to strengthen the HIV clinics in Lagos for the implementation of evidence-based hypertension interventions within HIV clinics to improve patient outcomes and service delivery in Southwest Nigeria.

Partial Text

Despite decreases in overall new infections globally, HIV remains a major public health threat in many parts of sub-Saharan Africa (SSA).[1] For example, nearly half of all new HIV infections are in Nigeria, South Africa, and Uganda where HIV/AIDS is the highest cause of life-years lost.[2] The successful and efficient dissemination of highly active antiretroviral treatment (HAART) in SSA has contributed to the increased survival of PLHIV, with dramatic reductions in the AIDS-related morbidity and mortality.[3] Consequently, many countries in SSA are now faced with the double burden of HIV and non-communicable diseases (NCDs), such that the prevalence of hypertension has increased among PLHIV in SSA.[4] For example, the prevalence of hypertension in Nigeria among HIV-positive patients under anti-retroviral therapy ranges between 27%-41%.[5, 6] Thus, there is a strong need to reduce the burden of hypertension among PLHIV in Nigeria which requires the implementation of proven evidence-based interventions (EBIs) targeted at hypertension control in the region.

This study examined the capabilities, opportunities, and motivations for integrating evidence-based hypertension interventions for people living with HIV within HIV clinics in Southwest Nigeria. Using the COM-B model (Capabilities, Opportunities, and Motivations) as a guide, we identified how factors such as education and training to reduce the knowledge-to-skill gap and boost the level of self-efficacy, task sharing of clinical duties to reduce the overburdened staff workload, limited availability and use of evidence-based guidelines, access to basic diagnostic tools and medications, and the availability of professional development opportunities may influence the implementation, delivery, and expansion of integrated hypertension services for PLHIV within HIV clinics. Although previous studies conducted in sub-Saharan Africa (SSA) have made mention of similar barriers to integrating NCD management, majority of the studies focused on other chronic diseases (i.e. cervical cancer, mental health, diabetes) but not hypertension, which is characterized as a silent killer and is currently the leading risk factor for CVD.[17–21] The identification of barriers or enablers by themselves are also not a new undertaking [22]; however, our approach to the assessment of these barriers across multiple clinical sites is unique and may potentially inform the development of interventions targeting the capabilities, opportunities, and motivations for successful service delivery of evidence-based hypertension interventions within HIV clinics.

Using the COM-B model, we have shown that while there are major modifiable capability and opportunity barriers to integrating hypertension control strategies within HIV clinics in Lagos, Nigeria, the motivation and willingness to integrate is apparent within the clinics. Taken together, the findings can inform decision makers on how to implement and ultimately scale-up and refine over time, integrated services for evidence-based hypertension interventions within HIV clinics.