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Abstract Background Health-related stigma and its internalization among individuals with chronic health conditions contribute to impaired mental and physical health and quality of life. Research on health-related stigma has been siloed, with disease-specific measures that may not capture the experiences of individuals with multiple health conditions and that prevent comparisons across health conditions. The current study aimed to develop and test a transdiagnostic measure of internalized health-related stigma for use among adults with different physical health conditions. Methods An existing measure of internalized mental health stigma was adapted to assess stigma due to chronic physical health conditions following COSMIN procedures, with input from advisory boards of community members living with a range of stigmatized health conditions (obesity, type 1 and type 2 diabetes, skin diseases, HIV, chronic pain, and cancers) and of health professionals who specialized in these conditions. The new Internalized Health-Related Stigma (I-HEARTS) Scale was tested in an online sample of 300 adults with these health conditions, recruited from ResearchMatch. Additional psychosocial measures of mental health and quality of life were administered, and participants provided information about their health conditions and demographic characteristics. Exploratory factor analysis and tests of reliability and validity were conducted to determine the psychometric properties of the I-HEARTS Scale, and k-means clustering and receiver of characteristic curve analysis were used to determine a clinically meaningful cutoff score indicating high levels of internalized stigma. Results Factor analysis results yielded a 25-item scale with a 3-factor solution, with subscales of Perceived and Anticipated Stigma, Stereotype Application and Self-Devaluation, and Stigma Resistance. Psychometric properties for internal consistency, inter-item and item-total correlations, and test-retest reliability were strong. Certain demographics (e.g., younger age) and characteristics related to health conditions (e.g., greater symptom severity) were associated with higher levels of internalized stigma. I-HEARTS Scale scores correlated moderately to strongly with related but distinct psychosocial measures, and a cutoff score of 3.40 or higher on the 1–7 rating scale was determined to indicate clinically meaningful levels of internalized stigma. Conclusions The I-HEARTS Scale is a reliable and valid measure for the assessment of internalized health-related stigma among adults with varied stigmatized chronic health conditions. Study pre-registration https://osf.io/84c5d/?view_only=87238512f6d6475c87f8f64280a8a15f .

Community-based HIV testing offers an alternative approach to encourage HIV testing among men in sub-Saharan Africa. In this study, we evaluated a community-based HIV testing strategy targeting male bar patrons in northern Tanzania to assess factors predictive of prior HIV testing and factors predictive of accepting a real-time HIV test offer. Participants completed a detailed survey and were offered HIV testing upon survey completion. Poisson regression was used to identify prevalence ratios for the association between potential predictors and prior HIV testing or real-time testing uptake. Of 359 participants analyzed, the median age was 41 (range 19-82) years, 257 (71.6%) reported a previous HIV test, and 321 (89.4%) accepted the real-time testing offer. Factors associated with previous testing for HIV (adjusted prevalence ratio [aPR], 95% CI) were wealth scores in the upper-middle quartile (1.25, 1.03-1.52) or upper quartile (1.35, 1.12-1.62) and HIV knowledge (1.04, 1.01-1.07). Factors that predicted real-time testing uptake were lower scores on the Gender-Equitable Men scale (0.99, 0.98-0.99), never testing for HIV (1.16, 1.03-1.31), and testing for HIV > 12 months prior (1.18, 1.06-1.31). We show that individual-level factors that influence the testing-seeking behaviors of men are not likely to impact their acceptance of an HIV offer.

Objectives We aimed to prospectively describe incident cardiovascular events among people living with HIV (PLWH) in northern Tanzania. Secondary aims of this study were to understand non-communicable disease care-seeking behaviour and patient preferences for cardiovascular care and education.Design A prospective observational study.Setting This study was conducted at the Majengo HIV Care and Treatment Clinic, an outpatient government-funded clinic in Moshi, TanzaniaParticipants Adult patients presenting to an HIV clinic for routine care in northern Tanzania were enrolled from 1 September 2020 to 1 March 2021.Interventions At enrolment, participants completed a survey and a resting 12-lead ECG was obtained. At 6 month follow-up, a repeat survey regarding interim health events and repeat ECG was obtained.Primary and secondary outcome measures Interim major adverse cardiovascular events (MACE) were defined by: self-reported interim stroke, self-reported hospitalisation for heart failure, self-reported interim myocardial infarction, interim myocardial infarction by ECG criteria (new pathologic Q waves in two contiguous leads) or death due to cardiovascular disease (CVD).Results Of 500 enrolled participants, 477 (95.4%) completed 6 month follow-up and 3 (0.6%) died. Over the 6 month follow-up period, 11 MACE occurred (3 strokes, 6 myocardial infarctions, 1 heart failure hospitalisation and 1 cardiovascular death), resulting in an incidence rate of 4.58 MACE per 100 person-years. Of participants completing 6 month follow-up, 31 (6.5%) reported a new non-communicable disease diagnosis, including 23 (4.8%) with a new hypertension diagnosis.Conclusions The incidence of MACE among PLWH in Tanzania is high. These findings are an important preliminary step in understanding the landscape of CVD among PLWH in Tanzania and highlight the need for interventions to reduce cardiovascular risk in this population.

Abstract Current care models are inadequate to address the dual epidemic of hypertension and HIV in sub‐Saharan Africa. We developed a community health worker (CHW)‐delivered educational intervention, integrated into existing HIV care to address hypertension in persons living with HIV. A detailed educational curriculum was created with five sessions: three in‐person clinic sessions and two telephone sessions. The intervention was piloted among hypertensive adults at one HIV clinic in northern Tanzania over a 4‐week period. Primary outcomes were feasibility, fidelity, and acceptability of the intervention. Secondary outcomes included hypertension care engagement and systolic and diastolic blood pressure (SBP and DBP). Among 16 eligible participants, 14 (64% women, median age of 54.5 years) were recruited into the study, and 13 (92.9%) completed all five intervention sessions. The intervention was delivered with 98.8% fidelity to the curriculum content. Hypertension care engagement improved following the intervention. At baseline, two (15.4%) participants had seen a doctor previously for hypertension, compared to 11 (84.6%) participants post‐intervention (P = .0027). No participant was using antihypertensives at baseline, compared to 10 (76.9%) post‐intervention (P = .0016). Pre‐intervention median SBP was 164 (IQR 152–170) mmHg, compared to post‐intervention SBP of 146 (IQR 134–154) mmHg (P = .0029). Pre‐intervention median DBP was 102 (IQR 86–109) mmHg, compared to post‐intervention DBP of 89 (IQR 86–98) mmHg (P = .0023). A CHW‐delivered educational intervention, integrated into existing HIV care, is feasible and holds promise in improving hypertension care engagement and reducing blood pressure. Further research is needed to evaluate the efficacy and scale‐up of our intervention.

Data describing the incidence of hypertension and diabetes among people with HIV in sub-Saharan Africa remain sparse. In this study, adults with HIV were enrolled from a public clinic in Moshi, Tanzania (September 2020-March 2021). At enrollment, a survey was administered to collect information on comorbidities and medication use. Each participant's blood pressure and point-of-care glucose were measured. Baseline hypertension was defined by blood pressure ≥140/90 mmHg or self-reported hypertension at enrollment. Baseline diabetes was defined by self-reported diabetes or hyperglycemia (fasting glucose ≥126 mg/dl or random glucose ≥200 mg/dl) at enrollment. At 6-month follow-up, participants' blood pressure and point-of-care glucose were again measured. Incident hypertension was defined by self-report of new hypertension diagnosis or blood pressure ≥140/90 mmHg at follow-up in a participant without baseline hypertension. Incident diabetes was defined as self-report of new diabetes diagnosis or measured hyperglycemia at follow-up in a participant without baseline diabetes. During the study period, 477 participants were enrolled, of whom 310 did not have baseline hypertension and 457 did not have baseline diabetes. At six-month follow-up, 51 participants (95% CI: 38, 67) had new-onset hypertension, corresponding to an incidence of 33 new cases of hypertension per 100 person-years. Participants with incident hypertension at 6-month follow-up were more likely to have a history of alcohol use (90.2% vs. 73.7%, OR = 3.18, 95% CI:1.32-9.62, p = 0.008) and were older (mean age = 46.5 vs. 42.3, p = 0.027). At six-month follow-up, 8 participants (95% CI: 3, 16) had new-onset diabetes, corresponding to an incidence of 3 new cases of diabetes per 100 person-years. In conclusion, the incidence of elevated blood pressure and diabetes among Tanzanians with HIV is higher than what has been reported in high-income settings.

BackgroundSub-Saharan Africa has a high prevalence of hypertension with a low rate of awareness, treatment adherence, and control. The emergency department (ED) may represent a unique opportunity to improve hypertension screening, awareness, and linkage to care. We conducted a qualitative study among hypertensive patients presenting to the ED and their healthcare providers to determine barriers to hypertension care and control.MethodsIn northern Tanzania, between November and December 2017, we conducted three focus group discussions among patients with hypertension presenting to the emergency department and three in-depth interviews among emergency department physicians. In our study, hypertension was defined as a single blood pressure of ≥160/100 mm Hg or a two-time average of ≥140/90 mm Hg. Barriers to care were identified by thematic analysis applying an inductive approach within the framework method.ResultsWe enrolled 24 total patients into three focus groups and performed three in-depth interviews with individual providers. Thematic analysis identified two major domains: 1) patient knowledge, attitudes, and practices, and 2) structural barriers to hypertension care. Four major themes emerged within the knowledge, attitudes, and practices domain, including disease chronicity, provider communication, family support, and fear-based attitudes. Within the structural domain, several themes emerged that identified barriers that impeded hypertension follow-up care and self-management, including cost, access to care, and transportation and wait time.ConclusionPatients and physicians identified multiple barriers and facilitators to hypertension care. These perspectives may be helpful to design emergency department-based interventions that target blood pressure control and linkage to outpatient care.

One in three people with HIV (PWH) has hypertension. However, most hypertensive PWH in sub-Saharan Africa are unaware of their hypertension diagnosis and are not on treatment. To better understand barriers to hypertension care faced by PWH, we interviewed 15 medical providers who care for patients with HIV and hypertension in northern Tanzania. The data revealed barriers at the patient, provider, and system level and included: stress, depression, and HIV-related stigma; lack of hypertension knowledge; insufficient hypertension training; inefficient prescribing practices; challenges with counselling; capacity limitations in hypertension care; high costs of care; and lack of routine hypertension screening and follow-up. Opportunities for improvement focused on prioritizing resources and funding towards hypertension care. System-related challenges were the underlying cause of barriers at individual levels. Strategies that focus on strengthening capacity and utilize existing HIV platforms to promote hypertension care delivery are urgently needed to improve cardiovascular outcomes among PWH.

BackgroundHypertension, a leading risk for cardiovascular mortality, is an important co-morbidity among people living with HIV (PLHIV). In Tanzania, hypertension prevalence among PLHIV approaches 20 to 30%. However, most patients are unaware of their diagnosis and are not receiving treatment. Understanding the barriers to hypertension care is a critical first step in developing interventions to improve cardiovascular outcomes among PLHIV in Tanzania and similar settings.MethodsBetween September 1st and November 26th, 2018 thirteen semi structured in-depth interviews were conducted with hypertensive patients engaged in HIV care in two HIV clinics located in government health facilities in northern Tanzania. Interviews were audio-recorded, translated into English, transcribed and thematically coded using NVivo. Data analysis was conducted using applied thematic analysis.ResultsParticipants had a median age of 54 (IQR 41-65) years. Of the 13 participants, eight stated they had used antihypertensive medication previously, but only one participant described current use of antihypertensive therapy. All participants were currently using antiretroviral therapy. The data revealed a range of themes including limited hypertension knowledge. Universally, all participants believed that "thinking too much", i.e. stress, was the major contributor to hypertension and that by "reducing thoughts", one may control hypertension. Additional emerging themes included a perceived overlap between hypertension and HIV, delays in hypertension diagnosis and linkage to care, challenges with provider communication and counseling, reluctance towards antihypertensive medication, lack of integration of hypertension and HIV care, and additional structural barriers to hypertension care.ConclusionsParticipants described multiple, intersecting challenges related to hypertension management. Barriers specific to PLHIV included siloed care, HIV-related stigma, and burden from multiple medical conditions. Multifaceted strategies that seek to address structural barriers, hypertension education, psychosocial stressors and stigma, and that are integrated within HIV care are urgently needed to improve cardiovascular outcomes among PLHIV in sub-Saharan Africa.