Costs of Integrating Hypertension Care into HIV Care in Rural East African Clinics

Background: Sub-Saharan Africa faces twin epidemics of HIV and non-communicable diseases including hypertension. While integration of hypertension care into the chronic HIV-focused healthcare infrastructure is a key global priority, cost estimates for integration are largely unavailable. In the SEARCH Study, we performed population-based testing for HIV and hypertension and offered integrated streamlined chronic care. Here, we estimate costs for hypertension care integrated with HIV care for HIV-positive individuals, and the cost for hypertension care for HIV-negative people concomitantly in the same clinics. Methods: SEARCH (NCT:01864603) conducted community health campaigns for diagnosis and linkage to care for both HIV and hypertension. HIV-positive patients received hypertension/HIV care jointly including blood pressure monitoring and medications; HIV-negative patients received hypertension care alone at the same clinics. Within 10 Ugandan study communities during 2015-2016, we estimated incremental annual per-patient costs for hypertension care using standard micro-costing techniques, time-and-motion personnel studies, and administrative/clinical records review. Findings: Overall, 70 HIV-positive and 2355 HIV-negative participants received hypertension care. For HIV-positive participants, average incremental cost of hypertension care was $6.29/person/year, representing a 2.1% marginal increased cost over previously published estimates for HIV care alone. For HIV-negative persons, hypertension care cost $11.39/person/year, a 3.8% marginal increase over HIV care costs. Key costs for HIV-positive patients included hypertension medications ($6.19/patient/year; 98% of total) and laboratory testing ($0.10/ patient/year;2%). Key costs for HIV-negative patients included medications ($5.09/patient/year;45%) and clinic staff salaries ($3.66/patient/year;32%), while minor costs included laboratory testing ($0.10/patient/year;1%), fixed costs ($1.98/patient/year;17%) and other recurring costs ($0.56/patient/year;5%). Interpretation: For only 2-4% estimated additional costs, hypertension care was added to HIV care, and also expanded to all HIV-negative patients in prototypic Ugandan clinics, demonstrating substantial synergy. Our results should encourage accelerated scale-up of hypertension care into existing clinics to address the growing hypertension epidemic, secondarily reduce HIV care-related stigma, and improve community health. Funding: Research reported in this manuscript was supported by Division of AIDS, NIAID, of the National Institutes of Health under award number U01AI099959 and in part by the President’s Emergency Plan for AIDS Relief (PEPFAR), and Gilead Sciences. Declaration of Interest: Related to work in this manuscript, all authors declare no conflicts of interests. Ethical Approval: The SEARCH Study was approved by institutional review boards at Makerere University College of Health Sciences (Kampala, Uganda), the Kenya Medical Research Institute (Nairobi, Kenya), and the University of California, San Francisco, as well as by the Uganda National Council for Science and Technology.