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The prevalence of hypertension in Nigeria is high and growing. The burden and risk factor distribution also vary by geographical zone. Information about prevalence, risk factors and disease status awareness are needed to guide evidence based public health response at the national and sub- national levels. This paper describes the prevalence of hypertension and its correlates, as well as hypertension status awareness among men in North Central, Nigeria. A cross sectional survey was administered to male partners of pregnant women participating in the Healthy Beginning Initiative program from 2016-2018. Information on socio-demographic characteristics, risk factors, physical measurement and blood pressure readings were collected using a standardized protocol. Data was analyzed with simple and multiple logistic regression. The 6,538 men had a median age of 31 years [IQR: 26-37]. The prevalence of hypertension was 23.3% (95% CI: 22.3%-24.4%), while 46.7% had prehypertension. The odds of hypertension was associated with increasing age (OR:1.02, CI:1.01-1.03), being overweight (aOR:1.5,CI:1.3-1.8), being obese (aOR:2.6,CI:2.0-3.3), living in an urban area (aOR:1.6,CI:1.2-2.1), and alcohol use in the 30 days prior (aOR:1.2,CI:1.1-1.4). Overall, 4.5% (297/6,528) of participants had ever been told they have hypertension. Among the 23.3% (1,527/6,528) with hypertension, 7.1% (109/1,527) were aware of their disease status. Men aged 41-50 years (aOR: 1.8, CI: 1.0-3.3), and > 50 years (aOR: 2.2, CI: 1.1-4.3), had higher odds disease status awareness. Living in an urban area was associated with lower odds (aOR: 0.2, CI: 0.03-0.7) of hypertension status awareness. This study showed that hypertension is already a significant public health burden in this population and that disease awareness level is very low. Alcohol use and obesity were associated with hypertension, highlighting some modifiable cardiovascular disease risk factors that are prevalent in the study population. Taken together, these findings can inform the design of interventions for primary and secondary cardiovascular disease prevention in Nigeria and similar settings.

The transition to PEPFAR 2.0 with its focus on country ownership was accompanied by substantial funding cuts. We describe the impact of this transition on HIV care in a large network of HIV clinics in Nigeria. We surveyed 30 comprehensive HIV treatment clinics to assess services supported before (October 2013-September 2014) and after (October 2014-September 2015) the PEPFAR funding policy change, the impact of these policy changes on service delivery areas, and response of clinics to the change. We compared differences in support for staffing, laboratory services, and clinical operations pre- and post-policy change using paired t-tests. We used framework analysis to assess answers to open ended questions describing responses to the policy change. Most sites (83%, n = 25) completed the survey. The majority were public (60%, n = 15) and secondary (68%, n = 17) facilities. Clinics had a median of 989 patients in care (IQR: 543-3326). All clinics continued to receive support for first and second line antiretrovirals and CD4 testing after the policy change, while no clinics received support for other routine drug monitoring labs. We found statistically significant reductions in support for viral load testing, staff employment, defaulter tracking, and prevention services (92% vs. 64%, p = 0.02; 80% vs. 20%, 100% vs. 44%, 84% vs. 16%, respectively, p<0.01 for all) after the policy change. Service delivery was hampered by interrupted laboratory services and reduced wages and staff positions leading to reduced provider morale, and compromised quality of care. Almost all sites (96%) introduced user fees to address funding shortages. Clinics in Nigeria are experiencing major challenges in providing routine HIV services as a result of PEPFAR's policy changes. Funding cutbacks have been associated with compromised quality of care, staff shortages, and reliance on fee-based care for historically free services. Sustainable HIV services funding models are urgently needed.

Background The Nigeria Hypertension Control Initiative (NHCI) program, launched in 2020, integrates hypertension care into primary healthcare using the HEARTS technical package, which includes screening, health counselling, and standardized hypertension treatment protocols. This package has been piloted through NHCI in Kano and Ogun States and in the Federal Capital Territory (FCT) Abuja, as part of the Hypertension Treatment in Nigeria (HTN) project. Objective To assess the costs of scaling up the HEARTS hypertension control package and compare these costs with those of usual care. Methods Data on the costs of implementing the HEARTS program were collected from 15 purposively sampled primary health facilities in Kano, Ogun, and FCT Abuja between February and April 2024. Costs included training, medicines, provider time, and administrative expenses. We used the HEARTS costing tool, an Excel-based instrument, to collect and analyze the annual costs from a health system perspective, using an activity-based approach. Results The estimated annual cost of implementing HEARTS was USD 16 per adult primary care user (PCU), with variations across the three locations: USD 21 in Abuja, USD 11 in Kano, and USD 16 in Ogun. Average annual medication costs per patient treated under HEARTS also varied by location, amounting to USD 28 in Abuja, USD 27 in Ogun, and USD 16 in Kano. Under usual care, annual medication costs per patient were estimated at USD 32 in Kano and USD 16 in Ogun (data for Abuja were unavailable). Major cost drivers for the HEARTS package included provider time (49%) and medication (47%), compared to usual care, where medication alone accounted for 80% of costs. Implementing HEARTS requires a full-time equivalent of 0.45 doctors, 1.59 nurses, and 5.21 community health workers per 10,000 primary care users. Conclusions In the Nigerian primary care setting, provider time costs and medication costs emerge as major considerations in scaling up hypertension services. Policy options could consider reducing follow-up visit frequency for well-controlled patients to decrease provider time costs. Additionally, medication costs may be reduced by prioritizing first-line treatments and volume-driven purchasing as program scale-up continues.

BackgroundExpanding treatment for hypertension requires ensuring access to affordable, high-quality blood pressure (BP) lowering medications. We describe the design, implementation and evaluation of a BP-lowering medication drug revolving fund (DRF) embedded in the Hypertension Treatment in Nigeria (HTN) Programme in 60 primary healthcare centres (PHCs) in the Federal Capital Territory, Nigeria.MethodsWe used the exploration, preparation, implementation and sustainment framework to describe the DRF design and implementation and the reach, effectiveness, adoption, implementation and maintenance framework to report implementation outcomes. From June 2022 to December 2023, the DRF programme was implemented, and the data were collected from PHCs’ drug stock and finance records, quarterly DRF-supportive supervision visits and the HTN Programme. We performed descriptive statistics using complete case analysis and used an interrupted time-series design to explore temporal trends in the 3-month rolling average rate of BP-lowering prescriptions dispensed.ResultsDRF design and implementation strategies included stakeholder engagement, leveraging the existing supply systems, developing medication and financial management protocols, training of site staff and DRF-supportive supervision visits, including joint problem solving. DRF was implemented in all 60 PHCs (100% reach). Adoption was high, with an increase in facilities selling DRF-supported medications from 80% to 100% (p value=0.01). Fidelity improved, including correct financial documentation (70%–100%; p value<0.0001) and stock cards (68%–94%; p value=0.0004). Effectiveness was high with low rates of medication stockouts of DRF-supported medications (1.7%–16%), with most medications at affordable prices, but a 12.1% drop in BP-lowering medications dispensing rate when the DRF replaced study-supplied free medication. Maintenance was high, with 100% of PHCs having a functional DRF after 1 year.ConclusionA DRF programme to expand access to BP-lowering medications was implemented and effective in the Federal Capital Territory, Nigeria, and may serve as a model for other hypertension control programmes.

While there has been a rapid global scale-up of antiretroviral therapy programs over the past decade, there are limited data on long-term outcomes from large cohorts in resource-constrained settings. Our objective in this evaluation was to measure multiple outcomes during first-line antiretroviral therapy in a large treatment program in Nigeria. We conducted a retrospective multi-site program evaluation of adult patients (age ≥15 years) initiating antiretroviral therapy between June 2004 and February 2012 in Nigeria. The baseline characteristics of patients were described and longitudinal analyses using primary endpoints of immunologic recovery, virologic rebound, treatment failure and long-term adherence patterns were conducted. Of 70,002 patients, 65.2% were female and median age was 35 (IQR: 29-41) years; 54.7% were started on a zidovudine-containing and 40% on a tenofovir-containing first-line regimen. Median CD4+ cell counts for the cohort started at 149 cells/mm3 (IQR: 78-220) and increased over duration of ART. Of the 70,002 patients, 1.8% were reported as having died, 30.1% were lost to follow-up, and 0.1% withdrew from treatment. Overall, of those patients retained and with viral load data, 85.4% achieved viral suppression, with 69.3% achieving suppression by month 6. Of 30,792 patients evaluated for virologic failure, 24.4% met criteria for failure and of 45,130 evaluated for immunologic failure, 34.0% met criteria for immunologic failure, with immunologic criteria poorly predicting virologic failure. In adjusted analyses, older age, ART regimen, lower CD4+ cell count, higher viral load, and inadequate adherence were all predictors of virologic failure. Predictors of immunologic failure differed slightly, with age no longer predictive, but female sex as protective; additionally, higher baseline CD4+ cell count was also predictive of failure. Evaluation of long-term adherence patterns revealed that the majority of patients retained through 84 months maintained ≥95% adherence. While improved access to HIV care and treatment remains a challenge in Nigeria, our study shows that a high quality of care was achieved as evidenced by strong long-term clinical, immunologic and virologic outcomes.

Fixed‐dose combination (FDC) therapy is recommended for hypertension management in Nigeria based on randomized trials at the individual level. This cluster‐randomized trial evaluates effectiveness and safety of a treatment protocol that used two‐drug FDC therapy as the second and third steps for hypertension control compared with a protocol that used free pill combinations. From January 2021 to June 2021, 60 primary healthcare centers in the Federal Capital Territory of Nigeria were randomized to a protocol using FDC therapy as second and third steps compared with a protocol that used the same medications in free pill combination therapy for these steps. Eligible patients were adults (≥18 years) with hypertension. The primary outcome was the odds of a patient being controlled at their last visit between baseline to 6‐month follow‐up in the FDC group compared to the free pill group. 4427 patients (mean [SD] age: 49.0 [12.4] years, 70.5% female) were registered with mean (SD) baseline systolic/diastolic blood pressure 155 (20.6)/96 (13.1) mm Hg. Baseline characteristics of groups were similar. After 6‐months, hypertension control rate improved in the two treatment protocols, but there were no differences between the groups after adjustment (FDC = 53.9% versus free pill combination = 47.9%, cluster‐adjusted p = .29). Adverse events were similarly low (<1%) in both groups. Both protocols improved hypertension control rates at 6‐months in comparison to baseline, though no differences were observed between groups. Further work is needed to determine if upfront FDC therapy is more effective and efficient to improve hypertension control rates.

In low- and middle-income countries where the majority of preventable cardiovascular disease deaths occur, less than 10% of eligible patients receive statins for primary cardiovascular disease prevention. Since 2017, the Global Hearts initiative has implemented simple World Health Organization (WHO) HEARTS hypertension and diabetes treatment protocols. In this editorial, we propose an approach of integrating statin treatment into existing HEARTS hypertension and diabetes protocols as a way of expanding statin coverage in low-and middle-income countries.

Introduction: Non-communicable diseases (NCDs) pose significant public health challenges in Bhutan. In 2019, Bhutan's Ministry of Health introduced a set of interventions associated with the World Health Organization's Package of Essential Noncommunicable Disease Interventions for Primary Health Care in Low-Income Settings called PEN HEARTS. This initiative encompassed six components: healthy lifestyle intervention, evidence-based protocols, access to medicines and technology, risk-based management, team-based care, and systems monitoring. Evaluations of PEN interventions in other countries documented barriers to implementation. The present report provides the result of a 2019-2020 evaluation assessing implementation of PEN HEARTS in Bhutan and initial impacts on provision of care for NCDs and patient outcomes. Methods: A cross-sectional, mixed-methods evaluation was conducted in six districts, two where the interventions were first initiated, two where they were implemented subsequently, and two where no implementation had begun. In each district, data were collected at the district hospital and three basic health units. Quantitative data collection encompassed facility checklists, health worker surveys, and patient record abstraction. For the survey, health workers were selected using random or convenience sampling depending on facility size. For patient record abstraction, enumerators created a sampling frame at each facility to include eligible patients who were then selected randomly for record review. Qualitative data collection included in-depth interviews (IDIs) with health workers, and IDIs with NCD patients. A convenience sample of health worker IDI participants was selected randomly at hospitals; all health workers at BHUs were invited to participate. A convenience sample of NCD patients was recruited from facility waiting rooms on the day(s) of data collection. Lastly, a convenience sample of homebound patients was recruited to participate in IDIs. Quantitative analysis methods included bivariate analysis of categorical and continuous variables, and pairwise comparisons among groups. Qualitative data were analyzed using thematic content analysis with inductive coding. Results: A total of 153 health workers participated in the knowledge survey and 121 patient records were reviewed. IDIs were conducted with 13 health workers, 18 hospital or BHU patients, and four homebound patients. Most elements of the PEN HEARTS program were implemented as planned, including monitoring and supervision. PEN HEARTS had a positive impact on disease control: group A districts had a significantly lower proportion of patients with a treatment gap (p<0.001) and a significantly higher proportion of patients retained in care (p<0.001). Health workers experienced implementation challenges in four main areas: human resources, medicine shortages, equipment failure, and record-keeping. They also described benefits from increased supervision and peer support. Patients described experiencing more patient-centered care and overall positive experiences with the program. Conclusion: The evaluation identified areas of PEN HEARTS implementation that should be strengthened and improved, particularly training, record-keeping, and the use of AUDIT and cardiovascular disease risk assessments. The evaluation also showed evidence of improved disease control across achievement of treatment goals, reduction of treatment gaps, and improved patient retention in care. PEN HEARTS has potential to make a difference for NCD patients, and focusing on improving future implementation may further yield benefits in Bhutan.