Integrating hypertension and HIV care in Namibia: A quality improvement collaborative approach.

BACKGROUND: Hypertension (HTN) is highly prevalent among people with HIV (PWH) in Namibia, but screening and treatment for HTN are not routinely offered as part of HIV care delivery. We report the implementation of a quality improvement collaborative (QIC) to accelerate integration of HTN and HIV care within public-sector health facilities in Namibia.
METHODS: Twenty-four facilities participated in the QIC with the aim of increasing HTN screening and treatment among adult PWH (>15 years). HTN was defined according to national treatment guidelines (i.e., systolic blood pressure >140 and/or diastolic blood pressure >90 across three measurements and at least two occasions), and decisions regarding initiation of treatment were made by physicians only. Teams from participating hospitals used quality improvement methods, monthly measurement of performance indicators, and small-scale tests of change to implement contextually tailored interventions. Coaching of sites was performed on a monthly basis by clinical officers with expertise in QI and HIV, and sites were convened as part of learning sessions to facilitate diffusion of effective interventions.
RESULTS: Between March 2017 and March 2018, hypertension screening occurred as part of 183,043 (86%) clinical encounters at participating facilities. Among 1,759 PWH newly diagnosed with HTN, 992 (56%) were initiated on first-line treatment. Rates of treatment initiation were higher in facilities with an on-site physician (61%) compared to those without one (51%). During the QIC, facility teams identified fourteen interventions to improve HTN screening and treatment. Among barriers to implementation, teams pointed to malfunctions of blood pressure machines and stock outs of antihypertensive medications as common challenges.
CONCLUSIONS: Implementation of a QIC provided a structured approach for integrating HTN and HIV services across 24 high-volume facilities in Namibia. As rates of HTN treatment remained low despite ongoing facility-level changes, policy-level interventions-such as task sharing and supply chain strengthening-should be pursued to further improve delivery of HTN care among PWH beyond initial screening.

Introduction

The scale up of antiretroviral therapy (ART) in sub-Saharan Africa (SSA) has led to steep declines in HIV-related mortality. In Namibia, a sparsely populated, middle-income country in SSA where an estimated 12% of the adult population is living with HIV, deaths from HIV have fallen by 22% since 2010 [1]. Although communicable diseases, including HIV, still comprise the leading causes of morbidity and mortality in Namibia [2], the prevalence of non-communicable diseases (NCD) such as cardiovascular disease, diabetes, and cancer has risen sharply, contributing to nearly 41% of all yearly deaths. Among preventable risk factors for NCDs, elevated blood pressure (i.e., hypertension) has been identified as the greatest contributor to NCD-related death and disability in Namibia [3]. Hypertension (HTN) affects an estimated one in five adults in Namibia [4, 5], yet remains underdiagnosed and undertreated, with only 47% reporting awareness of their condition and less than 20% achieving adequate control [5]. This gap has particular relevance to the care of PWH, who bear a disproportionate burden of HTN [6], and whose risk of cardiovascular disease exceeds that of the general population by a factor of two [7].

Over the past two decades, primary healthcare systems in Namibia and other countries in SSA with high burdens of HIV have evolved to support the engagement of people with HIV (PWH) in life-long care [8]. As decentralized platforms of longitudinal service delivery, these systems are uniquely suited to provide integrated care for the growing number of PWH with HTN [9]. Indeed, a cohort study in South Africa has observed an “ART advantage,” showing that individuals engaged in HIV care were more likely to receive HTN screening and treatment than the general population [10]. Notably, integrated care has been previously implemented to address sexual and reproductive health in Namibia [11]. However, despite a clear opportunity for synergy and cost saving [12], implementation of integrated models of care for HIV and HTN in LMICs has been discouragingly slow. Several factors have been identified as barriers to implementation, including limited human resource capacity, fragile supply chains for diagnostic equipment and medication, weak health information systems, and ambiguous or nonexistent guidance on implementation [13]. In these settings, new interventions, models, and approaches to integrate HIV and HTN services at scale are needed, with specific attention to how context may influence their implementation and scalability [14-16].

Quality improvement collaboratives (QIC) have been promoted as an effective strategy for improving the quality of healthcare delivery across diverse contexts [17, 18]. Specifically, QICs seek to bridge the “know-do” gap—the gulf between clinical guidelines and their implementation—through capacity building, group problem-solving, shared leadership, and normative pressure [19]. In HIV service delivery [20], QICs have been implemented to address performance gaps in areas as varied as mother-to-child transmission [21, 22], provider-initiated testing and counseling [23, 24], ART initiation [25], tuberculosis preventive therapy coverage [26], viral load monitoring [27], and stigma reduction [28]. However, no work to date has investigated how QICs may be applied to address gaps in scale up of integrated service delivery. In this work, we report the implementation of a QIC—the Namibia Project for Retention of Patients on ART (NAMPROPA)—whose objective was to improve uptake of HTN screening and treatment in routine HIV care in Namibia.

Methods

Implementation context

NAMPROPA was launched in November 2016 by Namibia’s Ministry of Health and Social Services (MHSS) with the aim of improving care engagement, viral monitoring, viral suppression, and HTN screening and treatment in 24 ART facilities across three regions with high burdens of HIV—Khomas, Ohangwena, and Zambezi (Table 1). These sites were purposively selected based on their high relative patient volumes. All participating facilities are publicly funded and provide health services free-of-charge to over 50,000 PWH—nearly one third of all PWH receiving ART in Namibia’s public sector. Although all facilities dispense ART on site, only a minority stock anti-HTN medications recommended as “first-line” by Namibia’s Standard Treatment Guidelines. All facilities have a nurse on site, but only 33% have an on-site physician. In line with MHSS’s approach to task sharing and decentralized HIV care delivery [29-31], facilities without an on-site physician remain in frequent contact with a regional medical officer. Importantly, nurses in Namibia can initiate ART in patients with a new HIV diagnosis, but only physicians can provide an initial prescription for anti-HTN therapy. Prior to the implementation of NAMPROPA, HTN screening and treatment were not routinely conducted as part of HIV service delivery in participating sites. Technical support for implementation of the QIC was provided by the University of California, San Francisco (UCSF), the Health Resources and Service Administration, and the U.S. Centers for Disease Control and Prevention.

Table 1

Site characteristics, by region.

	Khomas	Ohangwena	Zambezi
Adult HIV prevalence (%)	8.3%	17.9%	22.3%
Participating facilities, n	7	10	7
ART caseloads, n
0–999	1	5	6
1000–4999	5	4	1
5000+	1	1	0
Number of HCWs, n
0–10	0	1	1
11–20	5	2	2
>20	2	7	5
On-site physician?, n
Yes	6	3	2
No	1	7	5

ART–antiretroviral therapy; HCW–healthcare worker.

QIC approach

The design of NAMPROPA was adapted from the Institute for Healthcare Improvement’s Breakthrough Series Model, an improvement science methodology in which participating sites are convened to apply quality improvement (QI) methods (e.g., Plan-Do-Study-Act cycles, cascade analysis, process mapping, root cause analysis) to the identification and improvement of gaps in a specific area of healthcare delivery [32]. QICs are complex, quasi-experimental interventions that collect repeated cross-sectional data to track implementation success [19]. Fig 1 presents specific QIC activities. In contrast to traditional QI approaches in which projects are implemented and evaluated at individual sites over a period of months, QICs feature more frequent performance measurement and smaller-scale tests of changes, enabling sites to test multiple interventions and share experiences with other participating facilities over an accelerated period of time. The accumulation of evidence-informed [33] interventions and performance improvements are significantly accelerated through QICs, leading to the compilation of a “change package” for use in scale-up activities. Since an overarching aim of NAMPROPA was to promote QI capacity-building, no facilities were assigned to serve as controls. MHSS had significant prior experience implementing QI programming [34-36], but no QIC had been implemented in Namibia prior to NAMPROPA.

Fig 1

NAMPROPA structure and activities.

QI–quality improvement; QIC–quality improvement collaborative.

Coaching and support

Participating sites received coaching and support from regional and district clinical mentors, an existing cadre of physicians and nurses employed by MHSS with special expertise in HIV clinical care [29]. These mentors had been formally trained in QI principles, methods, and coaching through national MHSS-led QI seminars [34, 35]. As part of NAMPROPA activities, clinical mentors visited sites at a minimum of a monthly basis, integrating QI coaching into their routine activities to build capacity for HIV care and treatment with specific activities including review of sites’ performance data, communication of NAMPROPA updates, and assistance with design, execution, and evaluation of Plan-Do-Study-Act cycles. Between coaching visits, sites convened QI meetings to plan and track implementation. Technical support for regional mentors in QI methods and coaching was provided by MHSS and UCSF with monthly check-in calls to monitor implementation and discuss challenges.

Peer-to-peer exchange

Over 12 months, teams of three staff members from the 24 participating facilities, clinical mentors, and MHSS stakeholders were convened on three occasions as part of three-day, in-person learning sessions (LS). The objectives of LS were to gain proficiency in QI tools and methods, share examples of QI interventions, develop action plans, and prioritize future improvement activities. These LS also featured presentations from MHSS on current HTN treatment guidelines and protocols for referring patients with newly diagnosed HTN for treatment initiation. Between LS, ongoing peer-to-peer exchange was facilitated through participation in WhatsApp groups, email, and regional meetings.

Data collection

Rates of HTN screening and treatment were reported by participating sites to MHSS on a monthly basis using a pre-programmed electronic workbook (Microsoft Excel 2013, Microsoft Corporation, Redmond, WA) equipped to produce automated run charts. These data were subsequently aggregated to reflect collaborative-wide and region-specific performance and presented to sites for benchmarking. Measures were defined in alignment with Namibia’s Standard Treatment Guidelines for adults (>15 years) [37]. These guidelines define HTN as a blood pressure that consistently exceeds 140/90 mm Hg across three measurements and at least two occasions. In cases of mild HTN (<160/100 mm Hg), guidelines recommend provision of health education on mitigation of risk factors and monthly monitoring. Among patients with severe HTN (≥160/100 mm Hg) or mild HTN that is resistant to initial intervention, monotherapy with a thiazide diuretic (i.e., amiloride/hydrochlorothiazide) is recommended as first-line treatment. To capture “change ideas” and site-reported implementation barriers, we conducted semi-structured interviews of 138 health workers (i.e., physicians, nurses, pharmacists, data clerks, health assistants, and field officers) as part of site visits and undertook a content analysis of these interviews and facility presentations as part of LS. The number of coaching visits and QI meetings were tracked by MHSS on a monthly basis. As part of the QIC’s final learning session, participating facility teams compiled a “change package” of improvement interventions. During this process, participants from each region were convened to rank changes according to effectiveness (i.e., the magnitude of improvement on the basis of Plan-Do-Study-Act cycles) and perceived sustainability (i.e., how likely a change might be sustained in the long-term). Selected changes from each region were then presented to the large group, and a final list of changes was determined by group discussion and majority vote. Changes were subsequently collated according to domains of the Chronic Care Model—a heuristic for organizing changes that improve care for chronic conditions [38], including HIV [39].

Ethical considerations

Implementation of NAMPROPA activities, including data collection and analysis, was approved by MHSS and the institutional review board of UCSF, receiving a determination of non-research. As no patient-level data were collected, the need for informed consent was waived. We used SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines to structure reporting of NAMPROPA implementation and results [40].

Results

At baseline, no participating facilities were conducting screening for HTN. Prior to initiation of QIC activities, all sites were provided with blood pressure machines. Fig 2 reports the number of monthly patient encounters during which HTN screening was provided. Of 213,714 clinical encounters at participating sites that occurred between March 2017 and March 2018, HTN screening was conducted as part of 183,043 (86%). Between LS 1 and 2, HTN screening occurred as a part of 80% of encounters, compared to 89% between LS 2 and 3. Barriers to HTN screening cited by facility teams included challenges recording and analyzing QIC measures; malfunctions of blood pressure machines; and difficulties following up with patients for multiple blood pressure readings.

Fig 2

HTN screening rate and number of adult patients on ART, March 2017–March 2018.

ART–antiretroviral therapy; HTN–hypertension.

Collection and reporting of data on HTN treatment did not begin until September 2017. Fig 3 displays the rate of treatment initiation among patients newly diagnosed with HTN each month. During the 7 months in which data on HTN treatment were collected, 1,759 patients on ART were newly diagnosed with HTN, and 992 (56%) were successfully initiated on treatment. Among sites with an on-site physician, treatment rates were 61%, compared to 51% among sites without an on-site physician. Several barriers to HTN treatment were noted by sites, including limited physician availability to initiate anti-HTN treatment; stock outs of medications; and difficulties tracking patient referrals to tertiary facilities for treatment initiation. Reassuringly, analyses of HIV-specific measures from NAMPROPA demonstrated no detrimental impact of HTN screening and treatment on care engagement, viral load monitoring or viral suppression [41].

Fig 3

HTN treatment rate and number of adult patients on ART newly diagnosed with HTN, September 2017–March 2018.

ART–antiretroviral therapy; HTN–hypertension.

During NAMPROPA, participating sites convened 204 QI meetings, and 100% received coaching visits at least monthly. As part of the QIC’s third and final learning session, participating facility teams compiled a “change package” of improvement interventions that were assessed, on the basis of findings from PDSA cycles, to be both effective and feasible to sustainably implement. During NAMPROPA implementation, fourteen interventions were adopted to address HTN screening and treatment. Table 2 presents these interventions by Chronic Care Model domain. Overall, interventions in the domains of delivery system design and clinical information systems were most common, with sites implementing, respectively, four and three interventions in each of these domains.

Table 2

Implemented change ideas by Chronic Care Model domain.

Chronic Care Model domain and definition	Intervention
Organization of health care	• Involve clinic leadership in development and monitoring of QI interventions
	• Review monthly performance data in QIC indicators of HTN screening and treatment during QI team meetings on a weekly basis
Self-management support	• Include reminders in patient health passports to follow up for repeat BP screening if indicated
Community linkages	• Offer HTN screening during medication pick-ups at community-based ART delivery sites
Delivery system redesign	• Nurses provide training to health assistants on use of automated BP machines and protocol for recording BP in registers
	• Re-design clinic flow to incorporate HTN screening as part of initial registration rather than during visit with nurse or physician
	• Streamline clinic flow to allow patients with need for follow-up BP reading, but no additional care, to present to registration for screening rather than waiting in queue for nurse or physician
	• Stock anti-HTN medication in HIV clinic pharmacy to streamline medication pickups
Decision support	• Mentors provide refresher training to nurses on national guidelines for HTN treatment, including indication for counseling on behavior modification
	• Mentors provide refresher training on national guidelines for referring patients to outside facilities for HTN treatment initiation
Clinical information systems	• Develop a blood pressure monitoring register with columns for medical record number, SBP, DBP, and whether patient is currently on HTN treatment
	• Record patients’ BP readings in health passports and paper-based charts
	• Pharmacists and pharmacy assistants track stock outs of first-line anti-HTN medications
	• Include HTN screening data from community-based ART delivery sites in facilities’ performance data

ART–antiretroviral therapy; BP–blood pressure; DBP–diastolic blood pressure; HTN–hypertension; SBP–systolic blood pressure; QI–quality improvement; QIC–quality improvement collaborative.

Discussion

In this work, we have reported the implementation of a QIC to improve uptake of HTN screening and treatment as part of HIV care delivery. Over 12 months of implementation, HTN screening became routine in NAMPROPA sites, with coverage rates nearing 90% of all clinical encounters. Through these efforts, over 1,700 PWH were newly diagnosed with HTN, and nearly 1,000 were initiated on treatment. These results build on findings from previous work conducted in Ghana [42] and South Africa [25] that demonstrated the utility of a QIC approach in accelerating translation of clinical guidelines into practice. To our knowledge, the current work represents the first attempt to apply QIC methodology to the integration of HIV and HTN care in SSA.

Successful integration of services is a complex endeavor that requires extensive coordination, planning, and adaptation to local care contexts and resources constraints [43]. Among the challenges of integration lies the emergence of unintended, negative consequences, including increased clinic wait times [44, 45], stigma associated with care seeking for HIV and certain NCDs [46], and compromises to the effectiveness of care for existing disease-specific services. A notable strength of NAMPROPA was its concurrent collection, reporting, and continuous improvement of both HTN- and HIV-specific quality measures—a recommended approach for mitigating the impacts of unintended consequences in the context of scale up [47]. As Namibia’s national electronic health system for HIV care does not contain HTN-related fields, sites implemented several interventions to enable collection and management of HTN-specific data, including development of paper-based HTN registers and documentation of blood pressure readings in patient health passports. These interventions, while effective in the short run of the QIC, have notable limitations compared to electronic systems. Apart from enabling QI activities [48] and improving supply chain management [49], an integrated health information system can promote continuity of care across facilities—a crucial, albeit underappreciated determinant of quality [50]. Further efforts to integrate HTN and HIV care may benefit from incorporation of HTN-related fields and pharmacy dispending data into Namibia’s existing health information system.

As in other countries in SSA with shortages of healthcare workers, task sharing is essential to the success of HIV service delivery in Namibia [30]. However, in the absence of policies that enable task sharing for conditions beyond HIV, these shortages stand as a formidable hindrance to the scale up of integrated care in SSA [51]. In NAMPROPA, interventions to advance task sharing task sharing included capacity building of medical assistants to measure blood pressure and nurse-physician co-management of patients with an existing HTN diagnosis. Notably, however, while clinical guidelines in Namibia allow nurses to autonomously provide the full spectrum of HIV care, only physicians can initiate HTN treatment. Particularly in the two thirds of NAMPROPA sites without an on-site physician, PWH with a new diagnosis of HTN faced significant delays in treatment initiation, with many receiving referrals to other facilities. Policy changes to enable nurse-led HTN treatment in SSA have been considered [51], and several pilot studies have explored the feasibility of nurse-led delivery models with encouraging results [52-55]. Should nurse-led models find broad acceptance, steady attention to quality of care remains paramount [51, 56]. A structured approach, such as a QIC, may be especially useful in these settings, not only as a way to monitor the quality of scale up, but additionally as a way to promote “communities of practice” [57] through capacity-building, mentorship, and peer learning. Like all complex interventions, however, QICs require evidence-informed adaptation to be successfully implemented in new settings [58]. As numerous factors—including leadership, staff readiness, patient volume, and provider workload—can influence implementation, attention to context is crucial, and insights from implementation science may be particularly useful as implementers seek to apply a QIC approach to integrated service delivery in other settings [59].

A key finding of NAMPROPA was the consistently low rates of linkage to HTN care, with monthly rates averaging less than 60%. Low rates of linkage to HTN treatment have been reported elsewhere [60], and underscore a need to support PWH along the full “cascade” of HTN care—from screening and diagnosis to treatment and adequate control [61]. Among system-level determinants of linkage, challenges with execution and documentation of referrals for HTN treatment were most prominent. Although sites have a standardized mechanism for placing referrals—and further streamlined this process as part of the QIC—many PWH with new HTN were nevertheless deterred by the prospect of travel to an outside facility, long wait times at outpatient departments, and stock outs of anti-HTN medications. Notably, control of HTN among those on treatment was not tracked as part of NAMPROPA, although a recent cross-sectional study from Namibia suggests an unmet need to improve engagement after linkage, finding that only 43% reported “acceptable” levels of adherence (i.e., ≥ 80%) [62]. Like HIV, delivery of effective HTN care requires attention to a full “cascade” of essential processes, from initial screening to long-term control [61]. With insights gained through NAMPROPA, system-level interventions such as supply chain strengthening, task shifting policy reform, differentiated care models, and community awareness campaigns, stand to further improve outcomes along the HTN treatment cascade.

Limitations

The present work has limitations. First, as data on HTN screening and treatment were not routinely collected prior to implementation of NAMPROPA, we were not able to estimate a precise baseline of performance from which to compare sites’ performance. Second, as the study did not include control facilities, we cannot assess the extent to which the Hawthorne effect may have contributed to observed improvements in participating facilities. Third, as sites were purposively selected, generalizability of selected interventions to other settings may be limited without further adaptation. Fourth, although the integration of HTN screening and treatment did not adversely affect clinical HIV outcomes, we were not able to assess the QIC’s effects on patient-centered outcomes such as satisfaction, wait times, and health literacy. Attention to these outcomes is an important consideration in efforts to scale up of integrated service delivery. Future work that incorporates insights from time-motion studies [44], patient-pathway analyses [63], and assessments of patient experience [64] should be pursued to better understand the effects of integration efforts on patient experience and care-seeking behaviors.

Conclusion

As the burden of HTN grows in SSA, new, large-scale approaches are needed to sustainably offer HTN screening and treatment to all PWH. In this work, we have reported the implementation of a QIC to incorporate HTN screening and treatment into routine HIV care across 24-high volume facilities in Namibia. Bold policies and interventions to address system-level barriers such as brittle supply chains and limited human resources will be needed to ensure the success and sustainability of integrated service delivery in SSA. As linkage to initiation of HTN treatment remained a challenge despite focused QI activities, findings of this work suggest that the uptake of HTN screening and treatment is likely to benefit from further decentralization of integrated care.

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[The authors thank QI teams from participating sites for their dedication to continuous improvement as part of NAMPROPA. The authors also acknowledge the support of Harold Phillips, Tracey Gantt, Katie O’Connor, Simon Agolory, Sodzi Sodzi-Tettey, and Ernest Kanyoke. The project described in this article was funded by the U.S. Department of Health and Human Services, Health Resources and Services Administration under cooperative agreement #U1NHA08599. The views expressed in this publication are solely the opinions of the authors and do not necessarily reflect the official policies of the U.S. Department of Health and Human Services, the Health Resources and Services Administration, nor does mention of the department or agency name imply endorsement by the U.S. Government. Portions of data from this manuscript were previously presented as part of the 35th Conference of the International Society for Quality in Healthcare, September 23-26, 2018, Kuala Lumpur, Malaysia.]

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Reviewer #1: Thank you the authors for reporting important services, integrating hypertension and HIV care in Namibia.

Following recommendations I would propose to improve the manuscript:

Line 53: Authors write "Implementation of a QIC enabled the integration of HTN and HIV services in Namibia". Would you please describe how did authors reach the conclusion that the QIC enabled the integration of HTN and HIV services?

Line 109: Authors shared sites were purposely selected based on the site's relative patient volumes. How do authors think purposely selection is the best way to reach the objectives of this paper? Why do you select only sites with high volumes of patients? Sites which has low performance can also provide more valuable information about uptake and also barriers authors identified.

Line 109-110: Authors shared "These sites were purposively selected based on their high relative patient volumes". As the sites purposely and better functional sites, how you can the barriers you find out will be generalizable to whole Namibia. There is a recommendation was made written in lines 300-302 based on barriers authors identified. Please share how it will work for the whole SSA.

Line 302-304: Authors should also define how findings of this work suggest that the uptake of HTN screening and treatment is likely to benefit from further decentralization of integrated care.

Reviewer #2: Integrating hypertension and HIV care in Namibia: a quality improvement collaborative approach

PONE-D-22-03989

In general, it is a little difficult to understand the processes of how to provide a quality improvement collaborative approach and how to reach the intervention package. The objective is not clear about the main outcomes to present.

Abstract

Page 2, Line 41: the term using routine measurement is not clear and could not find in the main method session.

Methods

Page 7, line 175: To capture “change ideas” and site-reported implementation barriers, who were interviewed? Is there no implementation facilitators that can share as “Change ideas”?

Page 7 line 176: how many persons interviewed?

Page 7, line 180: How did all participating teams perform Plan-Do-Study-Act (PDSA) cycles? How did you get agreement for prioritizing for the intervention?

Page 7, line 181: If there is any change package that is out of domains of the Chronic Care

Model? If yes, how it handle?

Page 6, line 153: When was final decision approved to include as the intervention? Was the final decision to approve as the intervention was after peer to peer exchange or during coaching and support?

In the regular logistic supply system, HTN drugs is already supplied for HIV clinic?

Initiate anti-HTN treatment mean it is only for first visit? Does treatment rate count the follow up visit?

It would be better to explain a little bit more about Figure 1.

It would be better to explain how interview data was recorded and analyzed it throughlly?

Results

Page 7, Line 195, what is challenges documenting for?

I think intervention that has to perform should be clearly mentioned:

Table 2: In organization of health care, what are the performance data to review?

Table 2: What is paper based reminder? How it works? It may need to explain about it.

Table 2: In community linages , offer HTN screening at community based ART delivery sites. How data of HTN screening will be included in the data at HIV clinic site?

Table 2: Whom will Mentor be provided refresher training?

Health education on HTN is not included in the intervention? Why cannot it be included?

Figure 3 2nd Y axis should be HTN treatment rate.

page 8, line 209: Reference is included in the result session?

Discussion

It would be better to discuss also about strengths and limitations of using a quality improvement collaborative approach that can affect complying the intervention package?

The purpose of integrating program is not clear. Is it for initial screening and providing initial treatment or long-term support of HIV patients with HTN?

In limitation, feasibility of health care provider to provide the services and to follow the intervention should be discussed, too.

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Reviewer #1: No

Reviewer #2: Yes: Kyaw Ko Ko Htet

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Integrating hypertension and HIV care in Namibia.docx

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22 May 2022

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As requested, we have completed the PLOS questionnaire on Inclusivity in Global Research and have included it as Supporting Information in our resubmission.

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In line 192, we have added language to specify that the need for informed consent was waived as no patient-level data were collected.

4. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary table should remain/be uploaded as separate “supporting information” files.

As requested, we have included our tables as part of the main manuscript.

5. We note that you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 2 in your text. If accepted, production will need this reference to link the reader to Table 2.

In response to this error, we have changed the reference in line 334 to indicate Table 2 rather than Table 3.

6. Please include a copy of Table 3 which you refer to in your text on page 8.

“Table 2” was erroneously referred to as “Table 3” in the text. There is no Table 3 as part of this submission.

Additional Editor Comments:

1. Specifically mention your study design that is not currently clear whether it is a mixed-methods or a purely qualitative study.

We thank the editor for highlighting this omission. We have added language in the “QIC approach” section, specifically lines 127-128, to specify that the QIC is a quasi-experimental study without controls. We have also added a reference that examines approaches to QIC evaluation and highlights the inherent complexity associated with evaluating QICs.

2. Add a discussion on how the Hawthorne effect could impact the study’s findings and what the authors did (could do) to minimize this bias.

As our study did not use control facilities—a detail we have emphasized in the “QIC approach” section—we have added mention of the Hawthorne effect as an additional limitation of the work in lines 300-302.

3. Add a “Authors contributions” section before the references.

As requested, we have added a “Authors contributions” section before the references.

4. Submit a STROBE report as well since this paper reports an observational study.

As our work describes a quality improvement intervention, our strong preference would be to structure our reporting according to the Standards for Quality Improvement Reporting Excellence (SQUIRE), as reference to these standards stands to enhance searchability and scrutiny of our work by the healthcare quality improvement field.

Review Comments to the Author:

Reviewer #1: Thank you the authors for reporting important services, integrating hypertension and HIV care in Namibia. The following recommendations I would propose to improve the manuscript:

Line 53: The authors write “Implementation of a QIC enabled the integration of HTN and HIV services in Namibia.” Would you please describe how the authors reached the conclusion that the QIC enabled the integration of HTN and HIV services?

In line 53, we have changed the language to specify that the QIC “provided a structured approach for integrating HTN and HIV services.” As we discuss in lines 81-88, a notable shortcoming of prior integration efforts has been a lack of attention to how a structured approach, such as a QIC, may be useful in addressing a challenge (like integration) that requires changes across multiple levels of the health system.

Line 109: The authors share that sites were purposively selected based on the sites’ relative patient volumes. How do the authors think purposive selection is the best way to reach the objectives of this paper? Why select only sites with high volumes of patients? Sites which have low performance can also provide valuable information about uptake and barriers the authors identified.

We agree with the reviewer that barriers and enablers to uptake of interventions in health systems are highly heterogeneous—and may vary according to patient volume. As a time-limited, donor-funded initiative, however, site selection was undertaken with the explicit aim of producing the greatest impact in the shortest period of time. To acknowledge the reviewer’s criticism, we have added the issue of spread (i.e., implementation of the QIC intervention in other sites) as an area in need of further investigation in lines 272-277.

Lines 109-110: The authors share that “These sites were purposively selected based on their high relative patient volumes.” As the sites were purposively selected and better functional sites, how might the barriers you cite be generalizable to the rest of Namibia? There is a recommendation made in lines 300-302 based on the barriers the authors identified, please share how it will apply to SSA.

As above, we agree with the reviewer that heterogeneity of participating sites—in factors as diverse as leadership support, staff readiness, and patient volume—can impact site performance and may similarly impact generalizability. In lines 272-277, we further acknowledge this point by emphasizing the importance of adopting a rigorous implementation science approach when considering spread of the QIC intervention to settings outside Namibia.

Lines 302-304: The authors should also define how findings of this work suggest that the uptake of HTN screening and treatment is likely to benefit from further decentralization of integrated care.

In response to the reviewer’s suggestion, we have added language in lines 318-319 to clarify that further decentralization may be indicated based on our finding that linkage to HTN treatment remains a challenge, even despite improvements in HTN screening coverage.

Reviewer #2: In general, it is a little difficult to understand the processes of how to provide a quality improvement collaborative approach and how to reach the intervention package. The objective is not clear about the main outcomes to present.

To address the reviewer’s concern, in lines 180-185 we have added additional language to provide a more detailed description of how the “change package” of interventions was constructed. In addition, we have also added a more thorough description of the QIC approach—and specifically the activities that were implemented during NAMPROPA. We hope that these changes will improve clarity regarding the main objective and outcomes of the current work.

Page 2, Line 41: The term “routine measurement” is not clear and could not be found in the main methods section.

In line 41 we have amended the language to specify that “routine measurement” refers to “monthly measurement of performance indicators.”

Page 6, Line 153: When was the final decision to include a change as an intervention? Was the final decision to approve an intervention made during peer-to-peer exchange or during coaching and support?

To address the reviewer’ question, we have included additional language in lines 180-185 of the Methods section to specify that the interventions were chosen as part of the QIC’s final learning session.

Page 7, Line 175: To capture “change ideas” and site-reported implementation barriers, who was interviewed?

We have added language in lines 176-177 to specify that 138 individuals from all participating sites were interviewed, including physicians, nurses, pharmacists, data clerks, health assistants and field officers.

Page 7, Line 176: How many persons interviewed?

As above, we have added language in lines 176-177 to specify the number of individuals who were interviewed.

Page 7, Line 180: How did all participating teams perform Plan-Do-Study-Act (PDSA) cycles? How did you get agreement for prioritizing the interventions?

To address the reviewers’ questions, we have language in lines 180-185 to describe the process of prioritizing interventions in more detail.

Page 7, Line 181: Are there any changes that are outside the domains of the Chronic Care Model? If so, how were they handled?

No changes were outside the domains of the Chronic Care Model.

In the regular logistic supply system, are HTN drugs already supplied for HIV clinics?

In the supply chain system, anti-hypertensive medications are stocked in only select HIV clinics. We refer the reviewer to the section “Implementation context” where we report this in detail.

Is initiation defined as the first visit? Or does treatment rate count follow up visits?

In response to the reviewer’s question, we refer the reviewer to the section “Data collection” were we specify that treatment initiation is defined as receipt of health education for mild hypertension and prescription of first-line monotherapy for severe hypertension.

It would be better to explain a little bit more about Figure 1.

In response to the reviewer’s suggestion, in line 129 we have included explanation of Figure 1.

It would be better to explain how interview data were recorded and analyzed.

To respond to the reviewer’s suggestion, in lines 177-178 we have added details regarding how interview data were recorded and analyzed.

Page 7, Line 195, what is challenges documenting for? I think intervention that has to perform should be clearly mentioned.

In line 203, we have changed the wording from “documenting” to “recording” to make the language clearer.

Table 2: In organization of health care, what are the performance data to review?

To response to the reviewer’s question, we have amended the language in Table 2 to specify that “the performance data” specifically refer to monthly rates of HTN screening and treatment.

Table 2: What is paper based reminder? How it works? It may need to explain about it.

In response to the reviewer’s question, we have revised the language in Table 2 to specify that the “paper-based reminders” refer to reminders placed in the patients’ health passport—a document that they carry on their person to each visit.

Table 2: In community linkages, offer HTN screening at community-based ART delivery sites. How data of HTN screening be included in the data at HIV clinic site?

In Namibia, community-based ART delivery sites are part of a hub-and-spoke model in which health facilities represent “hubs” and community-based sites represent “spokes.” Each day, healthcare workers stationed at community-based sites return to the “hubs” to report data. Thus, performance in community-based sites is included in the corresponding hub’s performance. To address this detail, we have included an additional change in Table 2 under the category of “clinical information systems.”

Table 2: Who will mentor be providing refresher training?

We have added language in Table 2 to indicate that mentors provided refresher trainings specifically to nurses.

Health education on HTN is not included in the intervention? Why cannot it be included?

As the definition of HTN treatment includes health education for those with mild hypertension, health education was not included as an intervention.

Figure 2 2nd Y Axis should be HTN treatment rate.

We have amended the 2nd Y axis to correct this error.

It would be better to discuss also about strengths and limitations of using a quality improvement collaborative approach that can affect compiling the intervention package.

To address the reviewer’s suggestion, in lines 305-309 under the heading “Limitations” we have added further limitations to the QIC approach.

The purpose of integrating program is not clear. Is it for initial screening and providing initial treatment or long-term support of HIV patients with HTN?

In response to the reviewer’s question, we would argue that the answer is both to promote initial screening AND to provide long-term support to those with an existing dual diagnosis. However, as the QIC did not include indicators that capture long-term support, such as engagement and treatment success, we cannot make any conclusions about the QIC’s effect on long-term support and have described this limitation as an opportunity for future work in lines 290-295.

In limitations, the feasibility of health care providers to provide the services and to follow the intervention should be discussed too.

We agree with the reviewer that provider workload is a central concern, particularly when considering the sustainability of QI initiatives. We have added this concern as a limitation in lines 274-277.

Submitted filename: RESPONSE TO REVIEWERS - Basenero et al. .docx

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5 Jul 2022

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Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for hard work to improve the manuscript.

Authors selected study sites from only sites with high volume patients. The QIC approach may not be work in the areas with low volume patients.

About this comment, authors response was “We agree with the reviewer that barriers and enablers to uptake of interventions in health systems are highly heterogeneous—and may vary according to patient volume. As a time-limited, donor-funded initiative, however, site selection was undertaken with the explicit aim of producing the greatest impact in the shortest period of time.” This limitation reduced the strength of the findings. I still believe that the finding of this study can not be generalizable to whole Namibia. Authors should remove all statements about integration HTN and HIV services in Namibia. Policymakers and reader will misinterpret this findings. Authors should mention this limitation in the limitation section as well.

Reviewer #2: PONE-D-22-03989R1: Integrating hypertension and HIV care in Namibia: a quality improvement collaborative

Approach

I agree with the previous responses. I only have ONE minor comment.

(1) In abstract, although task sharing was recommended in the conclusion, the information of onsite physician did not mention in the abstract methods or result.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: KYAW KO KO HTET

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: PONE.docx

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5 Jul 2022

Review Comments to the Author:

Reviewer #1: Thank you for the hard work to improve the manuscript.

The authors selected study sites from only sites with high volume patients. The QIC approach may not work in areas with low volumes of patients. About this comment, the authors respond: “We agree with the reviewer that barriers and enablers to uptake of interventions in health systems are highly heterogeneous—and may vary according to patient volume. As a time-limited, donor-funded initiative, however, site selection was undertaken with the explicit aim of producing the greatest impact in the shortest period of time.” This limitation reduced the strength of the findings. I still believe that the finding of this study cannot be generalized to all of Namibia. The authors should remove all statements about integration of HTN and HIV services in Namibia. Policymakers and readers will misinterpret these findings. The authors should mention this limitation in the limitation section as well.

We agree with the reviewer that scale up of the QIC to other sites in Namibia would require further adaptation, with explicit attention to how facilities with lower patient volumes might perform. In response to the reviewer’s comment, we have amended language in the Abstract (line 53) and Conclusion (line 322) to specify that integration of HTN and HIV services was promoted in the 24 sites participating in the QIC—and not Namibia as a whole. We have also amended language in the Limitations section (lines 308-310) to emphasize that the generalizability of the study’s results may be limited—particularly when considering patient volumes as the reviewer mentions.

Reviewer #2: I agree with the previous responses. I only have ONE minor comment.

In the abstract, although task sharing was recommended in the conclusion, the information on on-site physicians was not mentioned in the abstract methods or results.

In response to the reviewer’s comment, we have added language in the methods (lines 38-39) and results (lines 46-47) sections of the Abstract to report additional information regarding on-site physicians.

Submitted filename: Response to Reviewers2 - Basenero et al..docx

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26 Jul 2022

Integrating hypertension and HIV care in Namibia: a quality improvement collaborative approach

PONE-D-22-03989R2

Dear Dr. Agins,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Thomas Tischer

Staff Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: PONE-D-22-03989R2: Integrating hypertension and HIV care in Namibia: a quality improvement collaborative approach

Thanks authors. I agree with your responses on previous comments. I do not have any comment on it.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Kyaw Ko Ko Htet

**********

Submitted filename: PONE_R2.docx

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3 Aug 2022

PONE-D-22-03989R2

Integrating hypertension and HIV care in Namibia: a quality improvement collaborative approach

Dear Dr. Agins:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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on behalf of

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PLOS ONE