As HIV-infected persons live longer, common comorbidities shift from opportunistic infections to chronic conditions. The PEPFAR-supported clinic network in Malawi provides a unique opportunity to leverage the established clinic structure to incorporate screening and management of noncommunicable diseases (NCDs) such as hypertension (HTN) and provide enhanced HIV care. In addition, integrated services can facilitate testing among adult men, a hard-to-reach population for PEPFAR.
We integrated a HTN screening and management program using standardized HTN treatment protocols and cohort monitoring with HIV service delivery at two PEPFAR- supported clinics in Lilongwe, Malawi. Persons with at least three elevated blood pressures (SBP >140 or DBP>90) on each of two separate visits were diagnosed with HTN. The first elevated value was be rechecked during the same visit. Patients with HTN who had stable HIV were treated using a stepwise approach based on the Malawi Standard Treatment Guidelines with adaptation for HIV patients. We enhanced an electronic medical record system by developing a HTN module to monitor this subpopulation for outcomes of interest. Antiretroviral (ART) adherence was measured using pill counts.
From 2/15 to 7/16, 29,359 adults >20 years old [median age 38 (interquartile range: 32-45) and 61% female] were screened for HTN at two clinics. Of those screened, 3,448 (11%) were diagnosed with HTN, of whom 85% were given lifestyle modification advice or started on treatment. Severe disease (BP >180/110) requiring immediate treatment with ≥ 2 drugs was noted in 38%. Of all patients on antihypertensive treatment for 6 months, 26% had achieved controlled BP (Table). Of the 3,448 persons diagnosed with HTN, 53% were male, of whom 46% were 40-49 years of age; 200 men aged 40-49 received treatment for six months and 25% achieved BP control. ART adherence for hypertensive patients receiving HTN medications was similar with patients not on HTN medications (80% vs. 79%, respectively). The annual cost of treatment of the entire cohort with HTN was approximately $14,000 or $4/patient.
HTN screening and management can be successfully integrated into PEPFAR-funded HIV service delivery sites at low cost and with moderate blood pressure control rates. These findings support integration of NCD and HIV services to enhance HIV care as well as to target middle-aged men.