Adapting an intervention to improve hypertension care for adults with HIV in Tanzania: Co-design of the Community Health Worker Optimization of Antihypertensive Care in HIV (COACH) intervention.
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2025-11-27
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INTRODUCTION: There is a large burden of uncontrolled hypertension among people with HIV (PWH) in sub-Saharan Africa (SSA), including in Tanzania. Yet, few evidence-based interventions to improve hypertension control have been adapted for use in PWH in this region. This study describes the adaptation process of an evidence-based hypertension intervention to develop the Community Health Worker Optimization of Antihypertensive Care in HIV ( COACH ) intervention, a multi-component strategy designed to improve blood pressure control among Tanzanians with HIV and hypertension. METHODS: A 27 member interdisciplinary intervention design team consisting of HIV and hypertension clinicians, nurses, community health workers (CHWs), pharmacists, social workers and patients with HIV and hypertension from Tanzania met biweekly from May 2024 to October 2024. The design team used the Assessment-Decision-Adaptation-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT) framework supported by participatory co-design principles to iteratively adapt the intervention to the local context. RESULTS: To address the unique needs of PWH and hypertension in Tanzania, we iteratively adapted an evidence-based CHW intervention for hypertension care originally developed in Asia ( Control of Blood Pressure and Risk Attenuation-COBRA ), resulting in development of the COACH intervention for the HIV clinical setting in Tanzania. COACH , includes five key components: 1) CHW-delivered hypertension counselling integrated into HIV clinic visits, 2) Integration of routine blood pressure monitoring and referrals for antihypertensive medication management in the HIV clinic, 3) Hypertension management training for HIV providers and creation of an antihypertensive treatment algorithm, 4) CHW care navigation and coordination of hypertension care in the HIV clinic, and 5) Subsidization of antihypertensive medications. CONCLUSIONS: COACH is one of the first contextually-tailored interventions developed to address hypertension care among PWH in Tanzania. A pilot feasibility study of the intervention is in process and future studies will evaluate the implementation and clinical effectiveness outcomes of the COACH intervention. The rigorous, systematic application of the ADAPT-ITT framework to iteratively develop COACH supports reproducibility of the adaptation process, and strengthens the potential for COACH core components to be highly relevant for PWH with hypertension in other resource limited settings worldwide.
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Manavalan, Preeti, Blandina T Mmbaga, Nathan M Thielman, Melissa H Watt, Spencer F Sumner, Tazeen H Jafar, Hayden B Bosworth, Francis M Sakita, et al. (2025). Adapting an intervention to improve hypertension care for adults with HIV in Tanzania: Co-design of the Community Health Worker Optimization of Antihypertensive Care in HIV (COACH) intervention. medRxiv. 10.1101/2025.11.26.25340978 Retrieved from https://hdl.handle.net/10161/33898.
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Scholars@Duke
Nathan Maclyn Thielman
Broadly, my research focuses on a range of clinical and social issues that affect persons living with or at risk for HIV infection in resource-poor settings. In Tanzania, our group is applying novel methods to optimize HIV testing uptake among high-risk groups. We recently demonstrated that the Discrete Choice Experiment (DCE), a form of stated preference survey research, is a robust tool for identifying (a) which characteristics of HIV testing options are most preferred by different populations and (b) which tradeoffs individuals make in evaluating testing options. Building on more than a decade of productive HIV testing research in the Kilimanjaro Region, the next phase of our NIMH funded project will test the hypothesis that DCE-derived HIV testing options significantly increases rates of testing among groups at high risk for HIV infection. This work holds promise not only for optimizing HIV testing uptake in the Kilimanjaro Region, but also for applying novel tools in the service of translational epidemiology and implementation research.
Hayden Barry Bosworth
Dr. Bosworth is a health services researcher and Deputy Director of the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) at the Durham VA Medical Center. He is also Vice Chair of Education and Professor of Population Health Sciences. He is also a Professor of Medicine, Psychiatry, and Nursing at Duke University Medical Center and Adjunct Professor in Health Policy and Administration at the School of Public Health at the University of North Carolina at Chapel Hill. His research interests comprise three overarching areas of research: 1) clinical research that provides knowledge for improving patients’ treatment adherence and self-management in chronic care; 2) translation research to improve access to quality of care; and 3) eliminate health care disparities.
Dr. Bosworth is the recipient of an American Heart Association established investigator award, the 2013 VA Undersecretary Award for Outstanding Achievement in Health Services Research (The annual award is the highest honor for VA health services researchers), and a VA Senior Career Scientist Award. In terms of self-management, Dr. Bosworth has expertise developing interventions to improve health behaviors related to hypertension, coronary artery disease, and depression, and has been developing and implementing tailored patient interventions to reduce the burden of other chronic diseases. These trials focus on motivating individuals to initiate health behaviors and sustaining them long term and use members of the healthcare team, particularly pharmacists and nurses. He has been the Principal Investigator of over 30 trials resulting in over 400 peer reviewed publications and four books. This work has been or is being implemented in multiple arenas including Medicaid of North Carolina, private payers, The United Kingdom National Health System Direct, Kaiser Health care system, and the Veterans Affairs.
Areas of Expertise: Health Behavior, Health Services Research, Implementation Science, Health Measurement, and Health Policy
Julian T Hertz
Julian Hertz, MD, MSc, is an Associate Professor of Emergency Medicine & Global Health. He graduated summa cum laude from Princeton University and attended medical school at Duke University, where he received the Dean's Merit Scholarship and the Thomas Jefferson Award for leadership. He completed his residency training in emergency medicine at Vanderbilt University Medical Center and his fellowship in Global Health at Duke.
Dr. Hertz's primary interests include global health, implementation science, and undergraduate and graduate medical education. Dr. Hertz's research focuses on using implementation science methods to improve cardiovascular care both locally and globally. His current projects involve developing interventions to improve acute myocardial infarction care in Tanzania, to improve management of hypertension among Tanzanians with HIV, and to improve post-hospital care among patients with multimorbidity in East Africa.
Dr. Hertz has received numerous awards for clinical, educational, and research excellence, including the Duke Emergency Medicine Faculty Teacher of the Year Award, the Duke Emergency Medicine Faculty Clinician of the Year Award, and the Duke Emergency Medicine Faculty Researcher of the Year Award. He has also received the Golden Apple Teaching Award from the Duke medical student body, the Duke Master Clinician/Teacher Award, and the Global Academic Achievement Award from the Society of Academic Emergency Medicine.
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