Applying the Behavior Change Wheel to develop strategies to integrate hypertension and HIV care in South African urban primary care clinics

BACKGROUND: Hypertension is a leading comorbidity among people with HIV in South Africa, yet integration of hypertension screening and treatment into HIV care remains limited. To address persistent gaps in implementation, context-specific strategies grounded in implementation science frameworks are needed. PURPOSE: This formative study aimed to develop locally relevant implementation strategies for integrating hypertension and HIV care in South African primary care clinics using the Behavior Change Wheel (BCW). METHODS: Barriers to hypertension care were identified through patient interviews (n = 46), manager interviews (n = 7), and clinical staff focus group discussions (nine groups; n = 44 total participants) and were ranked by a Community Advisory Board (CAB) to inform implementation strategy development. Using the BCW, we mapped intervention functions and behavior change techniques based on prioritized barriers, then identified and specified strategies through community engagement. This process consisted of virtual meetings and workshops with CAB members, surveys, and qualitative feedback from clinic managers. RESULTS: Priority barriers identified included long clinic wait times, limited clinician training, poor patient understanding of hypertension, and weak information management systems. To address these barriers, the CAB identified feasible, high-priority strategies, including structured patient education, clinician training, use of care champions, providing audit and feedback, revising clinic workflows and record systems, and adding resources to support routine blood pressure checks. CONCLUSION: This study demonstrates the utility of the BCW to guide community-informed implementation strategy design. The resulting implementation strategies will be tested in a type 2 hybrid effectiveness-implementation trial to determine their impact on clinical and implementation outcomes.