Participants and setting

A purposive sample of key stakeholders, including PLWH patient advocates, community nurses, chief medical officers, and policymakers from HIV services in Akwa Ibom, Nigeria, were identified and recruited through face to face method by the research team to participate in in-depth interviews. Akwa Ibom is a southern state in Nigeria with one of the highest prevalences of HIV in Nigeria [45]. It is one of four states in the South-South and South-East region of Nigeria with a relatively high HIV prevalence of 2% or above [45]. It is also among key priority states that account for over 50% of PLWH in Nigeria, new HIV infections, and death from HIV [45].

Twenty-four key stakeholders were interviewed and included: six PLWH who also served as patient advocates, ten health care providers consisting of six nurses and four medical officers, and five policymakers and three directors of primary health care clinics in Akwa Ibom. Participants were between 34 to 60 years of age and the majority (71%) were female (Table 1).

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Table 1. Sociodemographic characteristics of respondents.

https://doi.org/10.1371/journal.pone.0294595.t001

Study design

This study is part of a larger implementation trial aiming to investigate the integration of an evidence-based task-sharing strategy for the management of hypertension (TASSH) within HIV clinics in Nigeria. In the larger implementation trial we adapted TASSH to include treatment of uncomplicated hypertension by Community Nurses using the Nigeria Hypertension Treatment Protocol [46]. The present study used semi-structured in-depth interviews with key stakeholders involved with HIV service delivery at clinics in Akwa Ibom State of Nigeria. This approach was chosen because it offers a deeper understanding of stakeholder perspectives, including lived experiences with providing health care services for PLWH that may impact the integration of evidence-based task-sharing strategies for hypertension within existing HIV services [44].

Data collection

We developed an interview topic guide that focused on factors likely to influence the integration and adoption of TASSH within HIV clinics in Akwa Ibom, Nigeria such as the relative advantage of TASSH, alignment with existing clinic structures, patient support, and alignment with national guidelines, the perceived complexity of TASSH, and limited resources [1]. We piloted the draft interview guide for comprehensibility, flow, and meaning, with two individuals who met all inclusion criteria and were not participating in the study. The interview guide was modified based on feedback prior to use in the field. 2 experienced researchers who both public health professionals conducted the interviews with key stakeholders. Data collection took place from May 31^st to June 11^th 2021. Only the interviewer and interviewee were present during the interviews. Specifically, they asked participants to first describe their perceptions of the TASSH project, its potential impact on the workflow of staff as well as current patient experience and clinical encounters within HIV clinics. Ethical approval was obtained from The University of Abuja, Nigeria institutional review board (Approval number UATH/HREC/PR/2020/006). Written consent was obtained from all participants consistent with the procedures approved by the University of Abuja, Nigeria institutional review board prior to the interviews. Interviews were carried out until saturation. The Interviews lasted for one hour and were audio recorded. Not identifiable information was obtained from participants.

Data analysis

The interviews were transcribed verbatim and uploaded into Microsoft Excel for coding and thematic analysis by 2 trained research assistants. We applied a two-prong approach: categorizing coded data using the PEN-3 cultural model and analyzing the interviews using the Framework Approach for qualitative analysis [47]. The Framework Approach is a systematic process in which case-level data (rows) are summarized along thematic categories (columns) in a matrix. It involves five steps that include: 1) familiarization with the data: 2) identifying a thematic framework: 3) indexing; 4) charting, and 5) mapping and interpreting the data [47]. We structured the coding process using the PEN-3 cultural empowerment domain of positive, existential, and negative factors as well as the relationship and expectation domain of perceptions, enablers, and nurturers like to impact the integration of TASSH within existing HIV serves in Akwa Ibom [43]. Coding began with an independent reading of the transcripts by the 2 research assistants to compare coding, codes and discuss emergent themes. Following agreement on definitions and interpretation of codes, a coding strategy was developed and used to code the remainder of the interviews. Coded data were initially categorized using the PEN-3 domains, then, data were summarized, compared, and contrasted, until identifying patterns and themes emerged. To ensure rigor with the coding process, an audit trail of coding decisions were recorded and reviewed during meetings with the research team [48]. Key stakeholder quotes were also collected to provide thick description of their perspectives. To foster credibility, we linked data to categories in the PEN-3 cultural model to flesh out our understanding of the essential contextual and/or culturally compelling factors that may influence the integration of TASSH within HIV clinics in Nigeria. Standards for reporting qualitative research were used to guide the reporting of the data.

Extending continuity of care for PLWH in familiar or comprehensive settings (patient advocates)

Some patient advocates believed that the implementation of TASSH would promote continuity of care for PLWH. Some suggested that it would make communication easier between patients and their providers. They also felt that it would be more helpful to have the same healthcare worker who is managing their HIV treatment also manage them if they have other illnesses, such as hypertension. One patient advocate stated the following:

"I think it will be cool. Because from there, the people have already known your history, and they know the kind of drugs, they know the type of ART you are taking, and whether you are faced with high blood pressure and you will feel very free, because someone that you have been meeting, you have been meeting over years, and you will feel free to, actually say, this is what is happening to me, this is how it is, and the person knows your history already. So, he will know how to address other related issues." PA06

Another patient advocate noted that vital signs, including blood pressure readings, are ongoing as part of HIV service delivery in many clinics. However, having dedicated support would enhance the care being provided to PLWH, particularly with referrals to additional care. They noted the following:

“Once the vital signs are being conducted when you arrive and your blood pressure is continually higher than a hundred and twenty, definitely that’s an indication that hypertension is around the corner, so, they (nurses at the health center) will refer you to further care in comprehensive sites.” PA-04

Another stated that extending the continuity of care for PLWH within existing HIV services helps to address issues related to stigma. They shared the following:

“It also helps to control stigma and is more confidential to the client if they continue to access their care in one place, because leaving here and going to another place, people will ask questions. They can say things like, “this one is having double chronic diseases”. Stigma will set in.” PA-05

One stated it furthers ongoing interactions and communications between PLWH and their provider. They shared the following:

“You will feel very free, because someone that you have been meeting, over the years, is the same person that you can actually say, this is what is happening to me, this is how it is, and the person knows your history already. So, they will know how to address other related health issues.” PA-06

However, in cases when care is complex, one patient advocate stated that trained nurses often refer cases to comprehensive sites given the persistent problem of hypertension. They stated the following:

“We (patient advocate) make a referral also from the primary health to comprehensive site, because they (nurses at the site) have been trained and have the ability to carry out new care given the ongoing hypertension problem in the state.” PA-04

Empowering health care workers (health care providers)

One of the key roles of healthcare workers is to meet PLWH needs across different chronic care contexts. As a result, some healthcare workers suggested there were more benefits than barriers to integrating hypertension care within existing HIV services. One shared the following:

“I’m seeing much benefits than barriers or challenges. Benefit number one, the nurses in the community, they are the people that have a good rapport with PLWH. Thus, they are close to the patient and we have the techniques of ensuring that each visits the hospital… We are the one to check on them when they visit… I’m believing that when the workers will be trained from all cadres of nursing and the equipment made available, the job (TASSH) will be successful." HCP04

Additionally, healthcare workers stated that the measurement of patients’ blood pressure was a routine practice at most departments at their facilities and was convinced that the focus on strengthening the use of this practice will help in the integration of hypertension within routine HIV services at the clinics. One participant shared the following:

"My primary health clinic is able to implement task-sharing because it is something we already do with the issue of blood pressure…we already measure this. It is a practice that has already been on the ground in several units, like the Maternity Unit, the Family Planning, and even the outpatient department. Now, incorporating it into the system will not be a problem.” HCP04

One healthcare provider noted that task-sharing strategies for hypertension will enhance patient care, particularly in cases where patients need referrals or further treatment, rather than sending them home with no additional care. They stated the following:

"we’ll gain much from it because instead of sending patients home, at least people will be there to take care of them. If the doctors are not there, at least the nurses or other workers can try to provide care." HCP03

Another who worked in a primary health clinic stated that these services (hypertension care) were not currently part of their duties to monitor overtime in their patients. However, because the cases are growing, such a program would empower them to provide routine screening and management among PLWH. They stated the following:

“The benefits of task-sharing strategies are to prevent hypertension and also to build the capacity of the nurses and the CHEWs involved in the care. It will also help in the early diagnosis and, the early detection and diagnosis of hypertension as well as prevent complications with hypertension like stroke, kidney disease, heart failure, and sudden death. Currently, it is not the duty of nurses (at primary health centers) to provide hypertension care, however, we now have the opportunity (through such programs like TASSH) of being trained to manage PLWH with hypertension.” HCP06

However in settings where these services are currently being provided, another health care worker noted that it would help to reduce the challenge of shortage of staff, but ensuring that other cadres of health care workers provide hypertension care, thus fostering teamwork between staff. They stated the following:

“At this facility, the nurses are very few, very few nurses; and we divide them into shifts. By the time you put them into shifts, some shifts may result in no nurse at all…Because of that, we also try to shift some duties to the Community Health Extension Workers (CHEWs) that are with us, and I think that is the aspect of the task-sharing strategies that would be beneficial to us, so that they (CHEWs) can also be able to take blood, measure blood pressure and then record accordingly…because we don’t have enough nurses to do the work. But we have few nurses here, we have CHEWs here, we have health attendants, and all other workers. And I think in the issue of task shifting and sharing, everyone should be involved because it’s a team work.” HCP07

Similarly, training and re-training of staff were recommended as one of the key strategies necessary to enhance the integration of hypertension care within routine HIV services in the country. One participant shared the following:

“what will enhance the implementation of task-sharing strategies for hypertension care is having more staff that are trained and have the capacity to handle the program… when patients appear before them, and the card of these patients is before them, and since they are being incorporated in the TASSH program, they will now see the question on patient’s care, “Has this person’s blood pressure been checked?” If it’s not checked, okay, let me know the patient’s blood pressure. So, it will help. And if they discover the patient is hypertensive, they will make sure that the patient gets immediate care… as a result, there should be proper training and re-training of staff.” HCP06

Access and availability of resources, including blood pressure monitoring equipment and the supportive monitoring of these resources, was suggested as another strategy necessary to address the leaky cascade of hypertension care among PLWH. These resources help to optimize the hypertension cascade for PLWH by ensuring they get proper care with screening, diagnosis, management, and control of their hypertension. One healthcare provider shared the following:

“The first important thing is we must have a good blood pressure monitor. Because without having a monitor, you would not know when the blood pressure is high…Given the necessary equipment…; the necessary tools, and the necessary update of knowledge, they (staff) would be able to carry out the components of the TASSH program.” HCP07

Alongside resources, is the need for collaboration and open communication among all focal persons within the existing HIV services. Participants believed that meetings with focal persons, held monthly in some settings or every two months in other settings were pivotal for adopting and sustaining new programs within their health systems.

“Like in this facility, we have heads of units’ meeting; the focal persons would meet and, because we work as a team, you cannot just say I am doing family planning, and then, you-, you-, family planning cannot stand alone, immunization cannot stand. So, all the focal persons, we meet, and then we interact and make sure the team moves together. And, if you don’t do that, you know, somebody will stand alone and the program will not work…We have open dialog during these meetings…Because you know, without communication, you cannot succeed.”

Enhancing existing workflow, staff motivation, and stakeholder engagement (policymakers)

Among some policymakers, task-sharing strategies which are in alignment with existing policies will improve the efficiency of services at the primary healthcare level. Due to the shortage of doctors at this level of care, it is important that the few doctors available are managing the critical patients and some tasks such as hypertension screening can be handled by other healthcare workers thus promoting efficiency.

“It (task shifting) will lessen burdens on the professional physicians and it will also make them more efficient. They will also have time to concentrate on very critical cases. It will also reduce the time patients will spend in the hospital”. PM03

The implementation of TASSH was identified as a means of improving the capacity of healthcare workers in the primary healthcare system. Some policymakers believed that this will motivate healthcare workers to promote the uptake of TASSH in their facilities because it will be helpful in their skill development

“One, because it will empower the nurses and other health workers on how to manage the hypertensive cases, how to prevent other diseases such as the cardiovascular diseases” PM02

Staff motivation was identified by some policymakers as a way to facilitate the uptake of TASSH. They highlighted that it could be financial or non-financial, and could be as simple as the continuous appreciation of the effort of these healthcare providers involved in the TASSH process which will, in turn, encourage the healthcare providers to continue to implement TASH leading to the success of the program.

“You need to also factor in how to motivate them. When we’re talking about motivating them, it might not just be financial motivation. No. From time to time, appreciate them and tell them, “O, you are useful. You are relevant. You’re contributing to the success of these things. Everybody, I think at that level, people want to be appreciated”. PM03

Some policymakers also mentioned that in their facilities they had a culture of collaboration between all cadres of healthcare workers and a culture of open communication. They stated that this culture would be vital in promoting the implementation of task-sharing strategies for hypertension care. They explained that they had a routine team meeting where they discussed the best practices and how things can be done to benefit their patients. Such meetings are important for sharing updates on new programs.

“Well, we collaborate actions, because we have monthly meetings where we review our activities. Once a month, we pick a particular case, discuss it among ourselves and we suggest the way forward, and what should be done. That is how we collaborate within ourselves”.PM01

One policymaker noted that due to the high number of patients attending the primary care centers, limited staff, and other pertinent issues such as providing COVID-19 vaccinations and routine immunization services, limited attention is given to the identification and management of hypertension in patients within existing HIV services. These competing priorities should be considered when implementing new programs like TASSH as noted below:

“We have a shortfall in the number of healthcare workers in the state, and so many programs are coming in at the same time. We are doing COVID-19 vaccination right now. Then, immunization plus days are also coming in. Net replacement campaign is also coming in. A lot of things” PM02

Another policymaker noted that service provision was fragmented in some primary health centers with limited infrastructure, staff strength, and staff capacity across the region. As a result, all the PHCs may not be able to implement TASSH as intended. The context in which the TASSH program will be implemented should be taken into consideration. They shared the following:

"The operational base, that controls the other smaller PHCs under them, might have better facilities, might have well-trained nurses, and some of those cases. So, you need to carefully select, you know, the facilities, you need to carefully select based on where you have the right infrastructure for you to work with." PM03

Finally, one policymaker shared that to facilitate the uptake of TASSH program, advocacy with all key stakeholders was important. They emphasized that this should include the health workers expected to implement the program, managers, and directors at the PHC facilities, service users, the community, the government, and policymakers. Also that the government and policymakers should ensure that there is an enabling environment for this program to be successfully integrated at the PHC level and a strategic health plan that includes this program.

“The stakeholders would definitely have to include all people expected to be involved. So that’s the level of the government, from the community, people that are running the program. The state government provides the enabling environment, allowing this program to be fully incorporated formally as part of the things that are offered on a routine basis. Okay, So they advocate that level. Policy making level can be incorporated cause of this, just so that they provide the enabling environments and a Strategic health Plan will be needed for reflecting to what extent this program fits with priorities.” PM04