Background:
Expanding the HIV care model to include HIV status-neutral hypertension treatment can improve cardiovascular disease outcomes; however, individuals with severe hypertension face additional barriers to care, including need for frequent clinic visits to titrate medications. We conducted a pilot study to test whether a clinician-driven, community health worker (CHW) facilitated telehealth intervention would improve hypertension control among adults with severe hypertension in rural Uganda and Kenya.
Methods:
We conducted a randomized controlled trial of hypertension treatment delivered via telehealth by a clinician (adherence assessment, counseling, decision-making) and facilitated by a CHW in the participant’s home, compared to clinic-based hypertension care (NCT04810650). We recruited adults ≥40 years with BP ≥160/100 mmHg at household screening by CHWs, with no restrictions by HIV status. After initial evaluation at the clinic, participants were randomized to telehealth or clinic-based hypertension follow-up. All participants were treated using standard country guideline-based antihypertensive drugs. The primary outcome was hypertension control at 24 weeks (BP <140/90); secondary outcomes included severe hypertension (BP ≥160/100) and retention in care (not late by ≥30 days at 24 weeks). We used TMLE to compare outcomes by arm, overall and among key subgroups.
Results:
We screened 2,965 adults ≥40 years, identifying 266 (9%) with severe hypertension and enrolling 200 (102 control, 98 intervention). Participants were 70% women, median age 62 (IQR 51-72); 14% were HIV-positive. Mean number of hypertension drugs prescribed at last visit was 1.6 in intervention and 1.7 in control. Week 24 hypertension control was 77% in intervention and 52% in control (RR 1.48, 95%CI 1.20-1.83); effect on hypertension control was greater among women (81% vs 53%; RR 1.53, 95%CI 1.21-1.94). Prevalence of severe hypertension at 24 weeks was 7% in intervention and 25% in control (RR 0.30, 95%CI 0.14-0.64), with similar effects among people with HIV (8% vs 21%, RR 0.39, 95%CI 0.04-3.82). Retention in care at 24 weeks was 91% in intervention and 61% in control (RR 1.49, 95%CI 1.26-1.76).
Conclusions:
Clinician-driven, CHW-facilitated telehealth for hypertension management improved hypertension control and reduced severe hypertension compared to clinic-based care. Telehealth focused on individuals with severe hypertension is a high-yield approach to improve outcomes among those with highest risk for CVD.