Discussion
This study provides client perspectives on an integrated HIV and hypertension screening model using aPS. Most participants felt that an integrated HIV and hypertension service model was viable and would greatly improve healthcare outcomes. Strong support systems at family and healthcare levels facilitated care and treatment for both conditions. However, key barriers to integration included limited public awareness of hypertension risk factors and treatment outcomes for those on lifelong HIV treatment, high cost of hypertension care despite free HIV care and healthcare system challenges, especially medication stockouts. Participants recommended improved public awareness through individual-level communication and mass media campaigns, decentralised screening services for both HIV and hypertension, and either free or subsidised hypertension care services delivered alongside HIV treatment services.
Strong support systems at the family and healthcare system levels were major facilitators to integrated care and management. Contrary to popular belief on separate gender roles at the family level, majority of the male FGD participants were comfortable supporting their spouses in household chores. Many felt that societal dogma against men contributing to domestic duties were outdated, and most were more than willing to support spousal care and treatment. While different integration formats are yet to be evaluated in SSA, participants in Tanzania felt that a peer support system supporting at-risk group members to change risky behaviours and maintain healthy lifestyle behaviours would help improve care and treatment, similar to feedback from our FGDs.15 At the healthcare system level, participants advocated for the modified aPS model as it offered a patient-centred approach to managing HIV and hypertension.16 17 The availability of a healthcare personnel familiar with the patient’s case was seen as a major advantage, and participants felt that it was easier to receive ongoing support for care retention.
Participants reported low awareness of the risk factors, signs and management of hypertension similar to other studies conducted in the region2–4 18 despite large public awareness on HIV. The existing HIV infrastructure can support increased public education for hypertension and other non-communicable diseases (NCDs) at the patient, family, community and healthcare system levels, for example, through interpersonal communication between the patient and provider, community screening engagements, mass media campaigns and training of healthcare providers on screening.16 Such platforms can potentially support screening for other NCDs, for example, diabetes mellitus and cancer.3 Surprisingly, participants were supportive of mandatory opt-out HIV and hypertension screening at each encounter with the healthcare system preferring it to the missed opportunities for early diagnosis and treatment of both conditions that have tragic long-term health and financial consequences. Policy makers may also consider instituting opt-out screening measures to promote early diagnosis and treatment, but this must consider three of the five Cs of HIV testing, that is, consent, counselling and confidentiality, to ensure clients are fully aware of the various care options should they screen positive.19
Despite high HIV awareness, stigma and fear of death persisted especially due to the decline of HIV awareness campaigns during the COVID-19 pandemic indicating the need to revamp and sustain mass education efforts. This ongoing stigma is similar to other SSA settings where PLWH saw the intersection between HIV and NCDs as a challenge due to the additional pill burden, clinician visits and mental distress.20 Such individuals will require multifaceted strategies to address structural and societal barriers to integrated HIV and hypertension management, for example, expedited clinic reviews, counselling support and multidisciplinary management at the individual level, clear implementation strategy with standardised care checklists and service coordinators at the healthcare system level, and proactive public awareness campaigns at the community level.16 17 21
High costs of hypertension care and treatment and supply chain challenges were major barriers to ongoing hypertension management. These stood against a backdrop of free HIV care and treatment services where service interruptions were infrequent. Participants proposed holistic healthcare system improvements to offset costs of hypertension services and promote patient-centred care models, for example, free or subsidised NCD care through the NHIF. Similar to a Tanzania study evaluating hypertension care for PLWH, providers noted system-related capacity limitations (staff, medications) and high costs of treatment as the underlying individual-level barriers and recommended prioritisation of resources and funding towards hypertension care.18 Ongoing NHIF reforms to expand care for NCDs signal hope to patients,22 and as policy makers consider integrated NCD management within and outside the existing HIV infrastructure, subsidies towards clinician consultation, diagnostics and medication will go a long way in improving the care cascade.
There were several strengths to this study. First, we evaluated an integrated HIV and hypertension aPS model contributing to literature on its feasibility in Kenya. Second, we conducted the study at KNH, the largest teaching and referral hospital in Kenya, to get a representative sample of the population and improve generalisability of study results. Third, we conducted the male and female FGDs separately to reduce potential for social desirability bias and obtain a better sense of societal norms and their influence on screening, care and treatment for both conditions. Among the limitations, we did not include provider or healthcare system-level perspectives due to budgetary constraints. These views would have given broader perspectives of integrating NCDs to existing HIV infrastructure. Also, by conducting FGDs, we were not able to get individual-level perspectives from interviewees. However, the findings from our study provide insight to suitable formats for integrated service delivery.