Healthcare provider and health system leader perspectives on barriers to hypertension care in Malawi: insights from integrated and non-integrated HIV care settings

BACKGROUND: Malawi has a significant burden of hypertension, including for people with HIV. The World Health Organization recommends integrated HIV-hypertension care, but such integration is not widely implemented in resource-constrained settings. OBJECTIVE: This study explored barriers to hypertension care in Malawi from the perspectives of healthcare providers and health system leaders. METHODS: We conducted a qualitative study of providers and health system leaders across 14 health facilities in Malawi. Interviews explored hypertension services in integrated (HIV and hypertension) and non-integrated clinics to identify barriers to hypertension care and compare barriers by integration status. Interview guides and analysis used the Consolidated Framework for Implementation Research. All transcripts were double coded and thematic analysis was performed. RESULTS: From April-May 2023, we interviewed 33 individuals (25 providers and 8 health system leaders). Barriers to hypertension care were largely the same in integrated and non-integrated clinics and included stockouts of antihypertensive medications, lack of equipment, lack of provider training, and weak medical record systems. Providers working in integrated care emphasized the benefits of reduced burden for clients and improved quality of care but also reported unique challenges, including capacity constraints (due to the large number of clients) and inability to provide aligned dispensing of antihypertensive medications and ART (due to antihypertensive medication stockouts). CONCLUSIONS: Barriers to integrated HIV and hypertension care in our study largely reflected challenges for hypertension care more broadly. Future efforts should focus on provider training, supply chain strengthening, equipment procurement, and medical record system strengthening to improve outcomes for people with hypertension and hypertension-HIV multimorbidity.