# Integrated Hypertension-HIV Care in Botswana: Mixed-Methods Evaluation of Determinants of Success in an Implementation Trial

## TL;DR

This study evaluates how integrating hypertension care into HIV treatment in Botswana affects patient outcomes and identifies factors that help or hinder success.

## Contribution

The study provides insights into the implementation of integrated care for HIV and hypertension in resource-limited settings using mixed methods.

## Key findings

- Integration improved patient experiences by increasing efficiency of care and medication adherence.
- Barriers included stigma, workload, and insufficient resources.
- Positive perceptions of integrated care strategies were reported despite challenges.

## Abstract

Due to the success of HIV treatment, people living with HIV (PWH) have aged to develop chronic conditions. InterCARE is evaluating the integration of hypertension treatment into HIV care in Botswana. This involves adapting the Electronic Health Records [EHR], health care workers training, and the use of treatment partners. A pilot hybrid type 2 effectiveness implementation trial in two public HIV clinics found high effectiveness, adoption, and fidelity overall but low adoption of EHR. This mixed-methods research aimed to explain mean variation in these outcomes to inform future scale-up. Guided by the Consolidated Framework for Implementation Research, we recruited community members, healthcare workers, patients, and treatment partners to complete surveys (n = 100), and semi-structured interviews in-person (n = 10), 12 months after InterCARE implementation. Descriptive statistics and Fischer’s exact tests were calculated for surveys, and a deductive analysis was completed for interviews (Cohen’s Kappa = 0.86). Qualitative analysis found high acceptability of InterCARE compared to standard of care for HIV and hypertension. Integration improved patient experiences by increasing efficiency of care (e.g., reduced visit frequency, less time spent accessing care, reduced out-of-pocket costs). Integration of care and use of treatment partners increased medication adherence. Barriers included insufficient resources, HIV-related stigma (both internalized and perceived), high healthcare workers workload, and need for HIV providers’ training in hypertension. To improve implementation, suggestions included increasing client awareness and understanding of services through education, using various dissemination strategies (e.g., social media, community meetings, handouts), and enhancing provider buy-in. Overall, results showed positive perceptions of the strategies and overall integration. This research provides valuable insight into factors that affect outcomes from bundled implementation strategies supporting integration among chronic diseases and HIV in resource-limited settings.