HIV assisted partner services (aPS) to support integrated HIV and hypertension screening in Kenya: a pre-post … – BMC Public Health

In this study utilizing the aPS model to support integrated HIV and hypertension screening, female index clients mentioned not only their husbands, but also their brothers, sons, and grandsons, widening the reach to men who may otherwise have never received HIV and hypertension screening services. Despite low enrolment among the male relatives, 29% of those enrolled had hypertension, 34% had pre-hypertension, and none were HIV-positive. At the 3 month follow-up visit, we observed relatively high retention among participants with statistically significant increase in antihypertensive medication uptake among those with hypertension. We also observed significant reductions in SBP and DBP among female index clients, though no significant changes in blood pressure were observed among enrolled male relatives.

To our knowledge, this is the first study in Kenya showing spousal and maternal associations in hypertension risk, highlighting the potential of the aPS model to support targeted hypertension screening among families with shared genetic and lifestyle related risk factors. In a longitudinal cohort study evaluating spousal metabolic risk factors and incident hypertension in Iran, there was increased risk of hypertension from having a spouse with diabetes mellitus [20]. Although they did not evaluate the children of such couples, the study highlighted the potential of using NCD health data from one family member to evaluate risk and guide the screening of the other. Interestingly, no fathers to the female index clients were mentioned in our study, either because they were deceased or resided outside of study catchment area, indicating a missed opportunity for screening. Fathers, as well as other older relatives, are at a higher risk for hypertension and other age-related morbidities. They, together with their families, may benefit from targeted screening for HIV and hypertension among other NCDs.

Overall, there was low enrolment of male relatives due to COVID-19 social distancing restrictions which was largely unavoidable [21]. However, a significant proportion of those not enrolled had inadequate locator information which was surprising as these were close relatives to the female index clients. Inadequate locator information e.g., wrong phone numbers, residential / workplace addresses, names, has been a challenge in previous aPS studies [22, 23]. Healthcare providers offering aPS will require training and support in creating rapport and building trust with index clients as they elicit contact information.

Twenty-nine percent of the enrolled male relatives had hypertension, higher than the national hypertension prevalence in Kenya (24%) [3], while 34% of them had pre-hypertension. This is quite alarming and indicates the value of targeted hypertension screening among family members to individuals known to have hypertension. A similar approach may be used for other NCDs that are common among families, e.g., diabetes mellitus - whose risk factors include central obesity which we observed among our participants. In Tanzania, the prevalence of diabetes mellitus and renal failure among hypertensive PLWH was 9% and 29%, respectively, while 53% had an intermediate to high 10-year risk of an atherosclerotic cardiovascular disease (ASCVD) event [24], flagging the risk for comorbidities in this population group. As PLWH grow older, policymakers will need to integrate NCD management into HIV programs to avert such complications. This is all the more important given Kenyas concerns over low HIV testing yields defined as proportion of individuals newly testing HIV-positive out of total individuals tested for HIV. Kenya has a low national HIV testing yield of approximately ~1% similar to our study where none of the participants were HIV-positive [25]. The available HIV infrastructure can, therefore, be more effectively utilized to support integrated service delivery for both communicable and NCDs.

There was relatively high participant retention and anti-hypertensive medication uptake at 3-months, potentially due to the family-centered approach to screening. In our qualitative study, participants preferred such hypertension screening models due to the inbuilt family support systems [26]. Policymakers may need to adopt integrated service delivery models to PLWH with NCD related comorbidities [27]. One such example is multimonth dispensing of ART and antihypertensive medications which was shown to improve hypertension control, viral suppression, and retention to care among hypertensive PLWH in Uganda [28]. We also observed changes in anthropometric measures at the 3-month visit with statistically significant declines in blood pressure among female index clients, though this was not observed among the male relatives. In a pilot study in Tanzania, researchers observed similar blood pressure declines over a 4-week period when utilizing a community healthcare worker delivered educational intervention to support integrated hypertension care engagement in HIV programs [29]. Such people-centered care models hold promise in improving care and management of hypertension, and potentially other NCDs, within HIV care programs.

Our study had several strengths. First, we evaluated the feasibility of the aPS model in supporting integrated HIV and hypertension screening services, contributing to literature on its potential. Second, this study was conducted at KNH, the largest teaching and referral hospital in Kenya that receives patients from the entire country, improving the generalizability of study results. Third, our study design included a pre-post intervention assessment of our outcomes of interest allowing us to assess changes over time.

Among the limitations, we had a small sample size due to COVID-19 social distancing restrictions that limited participant access. Second, we had a 3-month follow-up duration that may not be sufficient in evaluating long-term blood pressure control and lifestyle management. Third, our study design lacked both random assignment and a control group. It is, therefore, challenging to assess whether the direction and magnitude of the changes would have been different from a placebo group or if they were due to natural maturation. We, however, believe that the findings from our study provide insights to integrated HIV and hypertension screening services.

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HIV assisted partner services (aPS) to support integrated HIV and hypertension screening in Kenya: a pre-post ... - BMC Public Health