Hypertension Diagnosis, Treatment, and Control among Older Chinese: Trends in the Hypertension Care Cascade

Hypertension is a major risk factor for cardiovascular disease, which is the leading cause of death in China. Older persons are at higher risk of elevated blood pressure and are more likely to have insufficient hypertension care, including delayed diagnosis and poor management. However, we know little about hypertension care among older Chinese at a population level. We use a nationally representative sample of older adults from the China Health and Retirement Longitudinal Study (CHARLS) in 2011 and 2015 (n = 9,083), to clarify the hypertension care cascade for the older population in China by specifying the level of diagnosis, treatment, and control of hypertension. We then examine the characteristics of those (1) who received appropriate hypertension care and (2) whose care improved over time. Diagnosis and care improved between 2011 and 2015. Among those with hypertension, 55% and 67% were diagnosed in 2011 and 2015 respectively; 46% and 60% were treated with modern medication; and 20% and 29% were effectively controlled. Those who had higher income (OR=1.52; P<0.01) or obese (OR=2.43; P<0.001) were relatively more likely to be diagnosed, while those living in the western region (OR=0.65; P<0.01) or living in urban areas with a rural hukou (OR=0.54; P<0.01) were less likely. Persons age 75+ (OR=0.55; P<0.05) were less likely to have their blood pressure controlled, while those who had higher income (OR=1.50; P<0.05) were more likely. The improvement from 2011 to 2015 in hypertension care was concentrated among those that are obese or living in the West.

Hypertension care cascade in the Ingwavuma rural community, uMkhanyakude District, KwaZulu-Natal province of South Africa

Background Treatment and control of hypertension are associated with a substantial reduction in adverse cardiovascular disease outcomes. Although South Africa aims to reduce the burden of cardiovascular diseases, there is limited evidence on the hypertension care cascade (HCC) performance in rural areas where stroke and hypertension are high. This study estimated HCC performance and identified predictors of hypertension screening among adults in the Ingwavuma community of KwaZulu-Natal, South Africa. Methods This was a cross-sectional study. Data were collected using the WHO STEPwise approach to surveillance (STEPS) questionnaire from 400 adult participants, excluding pregnant women and those with physical or cognitive impairments. Three hundred and ninety-three participants had complete data, and 131 had high blood pressure. We calculated progression rates for screening, diagnosis, treatment and control of hypertension from the sub-sample of participants with high blood pressure and assessed the bivariate association between HCC stages and participant characteristics and their effect sizes. We used binary and multivariable logistic regression to identify predictors of hypertension screening. Results Eighty-eight per cent of participants reported prior screening for hypertension. However, only 53.5% of patients under pharmacological treatment for hypertension had controlled blood pressure. In bivariate regression, employed participants were 80.3% (COR = 0.197, 95% CI [0.042–0.921]) more likely to be screened. In multivariable regression, the likelihood of hypertension screening was 82.4% (AOR = 0.176, 95% CI [0.047–0.655]) lower among participants in a cohabiting union than single participants. Similarly, employed participants were 87.4% (AOR = 0.129, 95% CI [0.017–0.952]) less likely to be screened than their unemployed counterparts. Conclusions The considerable attrition from the HCC across socio-demographic categories indicates a need for community-wide interventions. Empowering health care workers for community-based health promotion and hypertension management through point-of-care diagnostic tools could improve HCC performance. Efforts to improve the HCC should also focus on social determinants of health, notably gender and formal educational attainment.

Integrating HIV services and other health services: A systematic review and meta-analysis

Background Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness. Methods and findings We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41–1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16–1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20–1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05–2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03–1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response. Conclusions Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of ‘ending AIDS by 2030’, while simultaneously supporting progress towards universal health coverage.

904. Improving Infectious Disease Screening and Hepatitis C Care Cascade Outcomes Among Adults Receiving Medication Assisted Treatment

Background This initiative increased infectious disease (ID) screening in an adult medication assisted treatment (MAT) population at a Federally Qualified Health Center (FQHC) by implementing opt-out screening for HIV, viral hepatitis, and sexually transmitted infections (STIs), and assessed the success of a co-located hepatitis C (HCV) treatment program. Methods ID providers maintained a standing lab order for HIV, hepatitis A, hepatitis B, HCV, syphilis, chlamydia/gonorrhea (GC/CT), and trichomoniasis (trich), with reflex to confirmatory for HIV/HCV/syphilis. For all existing and new adult MAT patients, a MAT RN provided education, ensured lab draw on the day of MAT induction, and scheduled an ID follow-up visit. The patient then had an in-person or telemedicine visit with the ID provider to review results, discuss risk reduction, and initiate treatment (HIV PrEP or treatment for STI, HCV, or HIV) as indicated. Data was compiled and monitored by a Prevention RN. Plan, Do, Study, Act (PDSA) Model PDSA model demonstrating implementation approach Results The rate of testing among MAT patients increased over a one-year period. HCV treatment uptake in this setting exceeded that documented in published data for people who inject drugs (PWID). HCV Care Cascade Outcomes HCV screening and treatment outcomes within HCV Care Cascade model Screening Outcomes Screening rates among adult MAT population over a one-year measurement period Conclusion This study documents the successful implementation of an opt-out screening program among an adult substance use disorder (SUD) treatment population across urban, mixed, and designated rural environments. HCV treatment uptake in this setting exceeded that documented in published data for people who inject drugs (PWID). Barriers to implementation included acceptance among patients with long-term MAT participation, acceptance/adoption by behavioral health nursing and provider staff, and functional workflow development – establishment of protocol, lab availability, scheduling, and “tough sticks.” Modifications that increased effectiveness included an interdisciplinary approach and dedicated staff for monitoring results completion and patient outreach. Run chart: HIV screening rates over a one-year period HIV screening change among adult MAT patients over a one-year period Run chart: HCV screening rates over a one-year period HCV screening change among adult MAT patients over a one-year period HCV Care Cascade: HCV screening and treatment outcomes HCV screening and treatment outcomes presented in HCV Care Cascade for adult MAT population Disclosures All Authors: No reported disclosures

831. Hepatitis C Virus Micro-elimination Within a Human Immunodeficiency Virus Clinic: Challenges in the Home Stretch

Background Hepatitis c virus (HCV) eradication among persons with HIV (PWH) is alluring since DAAs efficacy is high regardless of HIV status and PWH in care are usually screened for HCV. Despite the potential, barriers to care have prevented many from achieving sustained virologic response (SVR). We performed a pharmacist-led campaign to reduce the proportion of PWH with active HCV and describe the barriers to care. Methods This retrospective review evaluated patients receiving care at a Ryan White-funded clinic from 07/2018 to 12/2020. Patients were eligible if HCV diagnosed ≥1 year and receiving HIV care. The primary endpoint was to compare the prevalence HCV before and after a pharmacy initiative to target the remaining patients at the clinic not treated during first 3 ½ year period of oral DAA therapy availability. Secondary analysis was to identify barriers to care, measure the proportion of patients in each step of the HCV care cascade, and determine predictors of SVR. Among barriers to care, inconsistent engagement was defined as patients with habitual missed appointments. Logistic regression and Chi-square tests were performed. Results 46 of 1,100 PWH had active HCV for ≥1 year. Median age, years since HIV and HCV diagnoses were 58.5 years of age, 17 years, and 11.5 years, respectively. Most patients were male (70%), Black (61%), Latinx (28%), HCV genotype 1 (90%), had an HIV RNA &lt; 200 copies/mL (72%), & had Medicaid (87%). 32/46 patients agreed to therapy, with all getting insurance approval and DAAs delivered. Glecaprevir/pibrentasvir (73%) was the preferred by payors, followed by sofosbuvir/velpatasvir (15%). Eight remained with active HCV and 19 achieved SVR. The prevalence rate dropped from 4.2% to 0.7% (P &lt; 0.0001). Active drug use, inconsistent engagement, mental health disorder and nonadherence were initial barriers to care. After multivariate analysis, patients with inconsistent engagement continued to be less likely achieve SVR compared to those we remained consistently in care (aOR: 0.062, 95 CI: 0.009-0.421). HCV care cascade in PWH within a Ryan White-funded clinic Active HCV includes 46 patients with chronic HCV infection receiving HIV in care at clinic, DAA approval process describes patients agreeing to HCV treatment along a continuum of pending laboratory results or pending prior authorization requests, DAA procurement depicts patients that have received approval and delivery of medications, DAA initiation describes patients who started treatment (27 patients), and SVR documented defines patients with an undetectable HCV RNA 12 weeks after therapy (19 patients). Conclusion Pharmacists can impact the burden of HCV among PWH receiving care. The HCV care cascade remains tied to the HIV continuum of care, with disengagement from care remaining an important rate-limiting step impeding micro-elimination. Disclosures All Authors: No reported disclosures

917. Accessible HCV Care for People Who Inject Drugs: Randomized Clinical Trial Comparing Low-Threshold Treatment at a Syringe Service Program Versus Facilitated Referral

Background To achieve hepatitis C virus (HCV) elimination, treatment programs need to be developed to engage, treat, and cure people who inject drugs (PWID). Methods We present final data from the Accessible Care Trial for curing HCV in PWID. The randomized clinical trial compared on-site, low-threshold HCV treatment with care-coordination at a NYC syringe service program (Accessible Care) with facilitated referral to local providers through a patient navigation program (Usual Care). Eligible participants were HCV RNA+ and had injected drugs in the past 90 days. Participants were randomized 1:1 to the Accessible Care or Usual Care arm. The primary endpoint was achievement of sustained virologic response (SVR12) within 12 months of enrollment. Secondary endpoints examined rates HCV care cascade step completion from referral to clinician, attending clinical visit, baseline lab testing, treatment initiation, and cure. Results Among the 572 participants screened, 167 met eligibility criteria and were enrolled, with two excluded post-randomization (N=165). Demographics were similar with a median age of 41 years; 22% women; 59% Hispanic and 5% non-Hispanic black. At baseline, 84% of participants had injected drugs in the past 30 days with those averaging 22 injections/month, 70% were receiving either methadone or buprenorphine, 57% were recently homeless, 7% were HIV+, and 11% were HCV treatment experienced. In the intention-to-treat analysis, 55/82 (67.1%) of the Accessible Care arm and 19/83 (22.9%) of the Usual Care arm achieved SVR12 (p&lt; 0.001). The SVR12 rates of those starting therapy were 55/64 (85.9%) and 19/22 (86.3%) in the two arms (p=0.96). Loss to follow-up (12.2% and 16.9%, p=0.51) was similar in the two arms. Significantly more participants in the Accessible Care arm achieved all steps in the care cascade with the greatest attrition in the Usual Care arm seen in referral to clinician and attending clinical visit. Conclusion Among HCV RNA+ PWID significantly higher rates of cure were achieved using the Accessible Care model focused on low-threshold, destigmatized, flexible HCV care compared to facilitated referral. To achieve HCV elimination, expansion of treatment programs specifically geared toward engaging PWID is paramount. Disclosures Benjamin Eckhardt, MD, MS, Gilead Sciences (Grant/Research Support) Shashi Kapadia, MD, Gilead Sciences Inc (Grant/Research Support) Kristen Marks, MD, Gilead Sciences (Grant/Research Support)

Hypertension care cascade at a large urban HIV clinic in Uganda: a mixed methods study using the Capability, Opportunity, Motivation for Behavior change (COM-B) model

Background Persons living with HIV (PLHIV) receiving antiretroviral therapy (ART) have a high prevalence of hypertension (HTN) and increased risk of mortality from cardiovascular diseases. HTN and HIV care integration is recommended in Uganda, though its implementation has lagged. In this study, we sought to analyze the HTN and HIV care cascades and explore barriers and facilitators of HTN/HIV integration within a large HIV clinic in urban Uganda. Methods We conducted an explanatory sequential mixed methods study at Mulago ISS clinic in Kampala, Uganda. We determined proportions of patients in HTN and HIV care cascade steps of screened, diagnosed, initiated on treatment, retained, and controlled. Guided by the Capability, Opportunity, Motivation and Behavior (COM-B) model, we then conducted semi-structured interviews and focus group discussions with healthcare providers (n = 13) and hypertensive PLHIV (n = 32). We coded the qualitative data deductively and analyzed the data thematically categorizing them as themes that influenced HTN care positively or negatively. These denoted barriers and facilitators, respectively. Results Of 15,953 adult PLHIV, 99.1% were initiated on ART, 89.5% were retained in care, and 98.0% achieved control (viral suppression) at 1 year. All 15,953 (100%) participants were screened for HTN, of whom 24.3% had HTN. HTN treatment initiation, 1-year retention, and control were low at 1.0%, 15.4%, and 5.0%, respectively. Barriers and facilitators of HTN/HIV integration appeared in all three COM-B domains. Barriers included low patient knowledge of HTN complications, less priority by patients for HTN treatment compared to ART, sub-optimal provider knowledge of HTN treatment, lack of HTN treatment protocols, inadequate supply of anti-hypertensive medicines, and lack of HTN care performance targets. Facilitators included patients’ and providers’ interest in HTN/HIV integration, patients’ interest in PLHIV peer support, providers’ knowledge and skills for HTN screening, optimal ART adherence counseling, and availability of automated BP machines. Conclusion The prevalence of HTN among PLHIV is high, but the HTN care cascade is sub-optimal in this successful HIV clinic. To close these gaps, models of integrated HTN/HIV care are urgently needed. These findings provide a basis for designing contextually appropriate interventions for HTN/HIV integration in Uganda and other low- and middle-income countries.