Practice assessment survey.

The practice assessment data were collected with two instruments. First, we assessed the capacity of HIV clinics to manage NCDs by use of an adapted version of the Service Availability and Readiness Assessment (SARA) tool[13], which was developed by the World Health Organization and used in a similar study conducted in Tanzania[14]. Capacity of the HIV clinics and clinical management practices related to HTN care were assessed as follows: 1) Demographics (provider’s age, educational level, nature of facility, years of experience in HIV care), 2) Organizational characteristics (proportion of HIV patients with diagnosis of HTN, availability of tools for diagnosis and treatment of hypertension, financing mechanism), 3) Healthcare provider characteristics (case diagnosis, treatment, referral and clinic follow-up patterns), 4) Patient characteristics (access to information related to hypertension management and lifestyle behaviors). Secondly, the HIV clinic representatives completed a self-reported scale to assess the organizational context for implementing evidence-based interventions [15]—using a 14-item measure that assesses the degree to which evidence-based practices for hypertension management are implemented within the HIV clinics. The scale was further divided into 5 subscales: three were developed to focus primarily on evidence-practice for hypertension treatment, three to focus on educational support for evidence-based practice, three to focus on recognition for evidence-based practice, two of the items on reward and the last three items focus on openness to implementation. The questions were stated in English. The practice assessment tools used were further adapted based on feedback from pilot testing within a sub-set of participants at two HIV clinics (including NIMR). The survey items and statements were mapped to the domain of the implementation science framework COM-B (see Table 1).

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Table 1. Mapping of survey questions and focus group discussion to the COM-B domains.

https://doi.org/10.1371/journal.pone.0217703.t001

Key stakeholder meeting.

In November 2017, we conducted a stakeholder meeting at NIMR with key stakeholders mentioned above. Participants were asked to describe the factors that will prompt the integration of HTN care into HIV clinics in Nigeria, as well as factors that will make it difficult to integrate HTN care within HIV clinics. They were asked to explain the reasoning for their suggestions, and to describe the best strategies to implement NCD care within the HIV program. The meeting, which lasted for two hours, was digitally recorded.

Capabilities for integrating hypertension management into HIV clinics.

Low capability on health education and training on provision of NCD care. While all stakeholders agreed that basic education and trainings are key enabling factors to increasing knowledge of the healthcare workers, a few explained that there were inadequate or intermittent training opportunities for the healthcare workers at the HIV clinics: “a lot of the clinics do not do refresher courses for their HIV practitioners…much less for hypertension care.” Nonetheless, about half of the clinic representatives surveyed (41% to 52%), reported that the potential for educational support for evidence-based practice for hypertension treatment exists and should also be provided through specific conferences, workshops or seminars, in-service training, journals and other educational resources that are often available at their HIV clinics. This observation indicative of a knowledge-to-skill-gap within some of the clinics. One of the stakeholders presented a scenario where bridging the knowledge-to-skill gap may occur via training. For example, the stakeholder shared that the training administered to the nurses presented them the opportunity to enhance their skills beyond their expectations: “We observed when we had an onsite training…it was an eye opener with the nurses saying “oh they didn't know that they could do this”. So maybe when we have training on these evidence-based hypertension interventions, it might be different.” One stakeholder also shared that providing the training may positively influence the self-efficacy and engagement of the healthcare workers with the inclusion of hypertension prevention and control for people living with HIV: “If we really train them well and show them the easy way to address the major issues people face…in hypertension care and also in HIV care…it will go a long way to improve their self-efficacy and how they engage with PLHIV coping with hypertension as well.”

Need for task shifting of clinical duties. Given the limited availability of skilled nurses and doctors, the primary care clinics are unable to cope with the growing number of HIV patients, as described below: “There are already human resources challenges that we are currently facing, now, we want to pull the same set of human resources [physicians] that we said is not adequate to provide this specialized hypertension services to the target group.” As a result, the stakeholders underscored the need to implement task shifting or task sharing within the primary healthcare centers which entails delegating clinical duties to non-physician healthcare workers. Another stakeholder suggested that other cadres of healthcare workers like community health workers (CHW) and junior community health workers (JCHW) should be utilized within the clinics in order to reduce the workload. In addition, the CHWs and JCHWs also connect well with community members. Nevertheless, progress is currently being made in the implementation of task sharing within the healthcare system, as mentioned below: “The new guideline (task-sharing) is trying to sensitize people to look at other health workers like CHW and the JCHW to come in to assist as we integrate these hypertension services because of work load for providing HIV care is already enormous.”

Opportunities for integrating hypertension interventions within HIV clinics.

Absence of evidence-based policies and guidelines on task-shifting of primary care duties. While “task shifting” or “task sharing” of clinical duties was highlighted by the majority of the stakeholders as a possible enabler for reducing the workload from the physicians, one of the stakeholders raised a concern that policies and guidelines have not been implemented at the clinics to regulate the shifted tasks to include workload, roles and responsibilities of the community health workers: “We are throwing so much at this people for them to manage so many people…The issue we have now is that we don't have a policy that says we can only have a health worker take care of 50 people max, and beyond 50 people no more”.

The lack of evidence-based guideline for task-shifting of primary care duties may result in staff overcrossing their boundaries due to role ambiguity, as described by a stakeholder: “Let us know what we are task shifting and let them know their limitations; if you train them and if you’re to support let them know where they stand, but when we are not allowed to monitor whatever we are task shifting, there is a tendency for us to go out of the way.”

Furthermore, a vast majority of the stakeholders denoted that although there is currently a draft national guideline for non-communicable disease management in Lagos state, it has not been implemented and is outdated. However, there is an existing guideline for HIV management.

High out-of-pocket payments as a barrier to management of HTN. A key barrier that emerged in the discussion was the high out-of-pocket payment that most patients are subjected to. Only 7% of the HIV clinic representatives surveyed indicated that the anti-hypertensive medications provided to patients at their clinic is free of charge. Eighty-six percent of the HIV clinic representatives reported that almost all HIV patients at their facility covers the cost of hypertension treatment or consultation fully out-of-pocket and none indicated that treatment was covered under health insurance.

In the light of this issue of out-of-pocket payment, one of the stakeholders revealed that there is progress currently being made to mitigate this barrier across Lagos State: “the Health Insurance scheme would be commencing soon and it would be mandatory for everyone in Lagos state to be part of the Scheme. The scheme would have short term, midterm and long term plans for HIV care as well as the identification of indigent patients.”

Limited availability of basic diagnostic equipment and medication. Based on responses from the practice assessment survey, basic diagnostic tools for NCDs, such as urinalysis, plasma creatinine, serum electrolytes, total cholesterol, serum lipoprotein, and echocardiogram, was reported to be present in 17%-79% of the HIV clinics. This suggests discordant beliefs regarding the availability of diagnostic tools at the clinics. One stakeholder revealed that although there are few clinics with adequate diagnostic tool, most the time, HIV clinics outsource or partner with better equipped primary healthcare centers across the local government areas to provide diagnostic testing. Another stakeholder reported that in Lagos State, there are “371 primary healthcare centers, and only 57 of the centers, which are called flagship primary health centers are fully functional, well stocked with drugs and equipment”.

Strengthening the referral network. In the context of task sharing, stakeholders raised a suggestion for strengthening the referral network. They identified the specific need for using the CHW to track patients because they provide home-based care. Furthermore, they expressed their beliefs that including CHWs within the referral network could potentially provide a comprehensive healthcare system that begins at home and extends to healthcare facilities: “These people should be involved because they are going to take some of the burden off the nurse’s work that he/she is complaining about and they will provide home-based care. As a result, we are going to be looking at a comprehensive system which starts right from the home down to the health system… which will further strengthen the referral network when you use the community health care workers.”

Compliance with existing national guidelines. Compliance with existing National Reporting guidelines was proposed by one of the stakeholders to ensure fidelity and sustainability of the intervention: “a guide, a scheme of service, an operational manual does not necessarily reflect operationality…the report coming from such systems may not be reflective of the actual activity on the field. Thus, it is important for the system of reporting now to be structured along with the national guidelines.”

Motivation for integrating hypertension interventions within HIV clinics.

Overburdening staff workload. Based on the practice assessment survey, more than 70% of the HIV clinic representatives indicated that the medical officers alone are responsible for identifying, treating, referring and the continuity of care for the HIV patients who are hypertensive. Thus, in-line with the commonly held concern of the stakeholders that doctor and nurses at the HIV clinic are overburdened with tasks: “We have a clinic where we might have 3 doctors running a shift and we have some nurses but not so much, and if you talk to all of them they will tell you that they are overwhelmed.” In addition, a few of the stakeholders cited their fear of the possibility of further straining the already overburdened workforce as a result of integrating NCD care into the HIV clinic: “so if someone has comorbid condition you’re now going to train the health workers to provide hypertension care in an HIV setting, this may overburden the health workers.” Particularly, a stakeholder reported that although health workers in the HIV clinics are willing to integrate, their current workload burden might make it difficult for them to adopt the intervention: “The health workers want to do it; the problem is that they are just overwhelmed.”

Lack of incentives for sustainability and enthusiasm. Reflecting on previous HIV funded programs, stakeholders recognized that one barrier to program sustainability and enthusiasm of health workers was the lack of incentives. Incentives were often discussed in relation to the provision of workshops, on-the job training, career advancement opportunities and monetary values. One stakeholder explained that: “The issue of incentives killed the HIV programs in Nigeria… because the money is not coming in the way it used to be in the past, most health care workers are not going into HIV services.” Thus, the discontinuation of supporting funds for HIV service delivery forces the clinicians at the HIV centers to explore other non-HIV care services. In addition, all the HIV clinic representatives surveyed were in total disagreement with the statement that ‘providers are financially incentivized to use evidence-based practices for hypertension treatment.’

Professional development. To address the issues of incentives, professional development opportunities were often cited by the stakeholders as a recommendation to be included in the intervention package: “They want a sense of personal development. That is if I leave this position today as a community health worker, will people still call me? …So if there is a sense of training such that they can also have refresher courses, that will be considered as an incentive.” Another stakeholder stressed the importance of issuing certification upon training completion as an example of valuable non-monetary incentive: “But another thing for incentive is the training, and more importantly the certificates that you give to them.”

Supportive supervision. As highlighted by one of the stakeholders, adequate staff supervision and support is necessary to boost the “confidence level” of the community healthcare workers to successfully engage in the evidence-based practices: “The only problem now we have is that people don't supervise people; for example, if we task shift and I am told to supervise, instead of me to support them, I will be looking for their mistakes to discredit their training; but if you do supportive supervision their confidence level will go up!”

Perceived benefit of the integration. The stakeholders believed that integrating NCDs into HIV care will reduce stigmatization and wait time by ensuring patients can walk into any General Out-Patients Department (GOPD), where all the patients’ complaint can be addressed in one location, without patients knowing each other’s diagnosis. Although, “not all the practices in the states have adopted integration of services right now”, however, some of the sub-facilities are currently undergoing integration. They also mentioned that all doctors will have the ability to provide any service anywhere within the facility at the primary and secondary care level if services are integrated: “We should look towards more of integration of HIV services into primary care… because aside from reducing stigma, it will reduce the waiting time…there would be a pool of Doctors in GOPD available to attend to the patients.”