Integrating hypertension care into the existing HIV services package in Botswana (InterCARE): a pair-matched, cluster-randomised, type 2 hybrid effectiveness–implementation trial

BACKGROUND: People with HIV have poor access to care for other chronic conditions despite the increasing disease burden and associated mortality. We evaluated the impact of integrated HIV and hypertension care on blood pressure control, electronic prescribing of antihypertensive medicines, and HIV viral suppression in Botswana. METHODS: We conducted a 24-month, pair-matched, cluster-randomised, type 2 hybrid effectiveness-implementation trial at 14 HIV clinics among adults aged 20-75 years with HIV and hypertension. HIV clinics were eligible if they had the Patient Integrated Medical Record System (PIMS), the national electronic health record (EHR) platform for HIV care in Botswana. Clinics were pair-matched by catchment population size, antiretroviral therapy access, age structure, and geographical location before one clinic from each pair was randomly allocated to the intervention or standard-of-care group. The main implementation strategy in the intervention group included HIV health-care provider training, ongoing coaching, engagement of community treatment partners, and the use of the EHR to support diagnosis, management, and electronic prescribing during routine HIV clinic visits. The coprimary outcomes, at 12 months, were (1) the proportion of participants taking antihypertensive medicines with blood pressure controlled within the targets (systolic and diastolic blood pressure <140 mm Hg and <90 mm Hg, respectively; or <130 mm Hg and <80 mm Hg for those with diabetes or chronic kidney disease), and (2) the proportion of clinic encounters with documented antihypertensive prescriptions in the EHR (ie, prescriptions for antihypertensive medicines generated electronically using the PIMS). The trial was registered at ClinicalTrials.gov (NCT05414526) and is complete. FINDINGS: Between Jan 13, 2023, and Sept 10, 2025, 4654 participants were enrolled (2327 per group). At 12 months, blood pressure control among participants receiving antihypertensive medication was attained in 719 (67·1%) of 1072 participants in the intervention group versus 593 (51·5%) of 1152 in the standard-of-care group (risk ratio [RR] 1·29, 95% CI 1·10-1·51; p=0·0013 unadjusted). The prescription for antihypertensive medicines was issued electronically to 428 (39·9%) of the 1072 eligible encounters in the intervention group compared with 124 (10·8%) of the 1152 in the standard-of-care group (RR 5·95, 2·18-16·2; p=0·0005 unadjusted). At 12 months, serious adverse events were infrequent and did not differ significantly between the intervention and standard-of-care groups (22 [0·9%] of 2127 vs 20 [0·9%] of 2188; p=0·69), and viral suppression rates also did not differ significantly between the two groups (1759 [98·6%] of 1784 vs 1821 [99·0%] of 1839; p=0·39). INTERPRETATION: Integrating hypertension care into HIV care programmes is an effective way to achieve blood pressure control and to increase the prescription of antihypertensive medicines electronically among people with HIV without compromising HIV outcomes. FUNDING: The National Heart, Lung, and Blood Institute of the US National Institutes of Health.