Home blood pressure monitoring and equity challenges of the 2025 ACC/AHA hypertension guideline in Africa

¹School of Public Health, University College Cork, Cork, Ireland, ²Kadisco General Hospital, Addis Ababa, Ethiopia

^&Corresponding author
Kirubel Tesfaye Hailu, School of Public Health, University College Cork, Cork, Ireland

Commentary    

The 2025 ACC/AHA hypertension guideline reaffirms < 130/80 mmHg as the treatment target and elevates out-of-office blood pressure measurement via home blood pressure monitoring (HBPM) or ambulatory monitoring as the diagnostic gold standard [1]. Yet in many low- and middle-income countries, especially across Africa, this evidence-based standard exposes a stark equity gap: validated HBPM devices remain scarce, unaffordable, and absent from most public health systems [2,3].

Surveys show that fewer than 1 in 10 households in sub-Saharan Africa own a validated blood pressure monitor, compared with more than 60% in high-income countries [4]. Many public clinics lack even a single device for patient loan schemes, and HBPM is rarely included on national essential medicines or device lists. Retail prices often exceed US$30-50 per unit, roughly a week's income for many families [3]. Without urgent intervention, the 2025 guideline could unintentionally widen inequities. Accurate diagnosis and follow-up may become a privilege reserved for those able to purchase private devices.

The WHO HEARTS technical package underscores the importance of standardized blood pressure measurement and endorses HBPM where feasible [2], but adoption has lagged due to financing gaps and weak supply chains. Some valuable lessons drawn from the pooled procurement of medicines and vaccines include bulk purchasing of validated monitors, regional tenders, and local manufacturing, which could dramatically lower costs.

Evidence from Ghana highlights that systemic barriers, including device shortages, financing gaps, and distribution challenges, remain significant obstacles to effective hypertension care [3]. Similar challenges recur across the continent. In Nigeria, many primary healthcare facilities lack validated blood pressure monitors, undermining guideline implementation [5]. In Kenya, studies show that up to 80% of individuals with hypertension in urban slums remain undiagnosed, with only about one-third ever screened and less than a quarter on treatment [6]. In Ethiopia, although trained health extension workers can accurately identify hypertension in rural communities, overall knowledge and use of home blood pressure monitoring remains low, even among patients attending public hospitals [7]. These examples underscore that the equity gap is not confined to a single setting but represents a systemic challenge across African health systems.

For African health systems to align with the 2025 ACC/AHA standards, HBPM must be recognized as an essential health technology. Priorities include adding validated devices to national essential lists, mobilizing donor support for procurement, and embedding HBPM within hypertension care pathways. Without these measures, a two-tiered system will persist: accurate, patient-centered care in wealthier settings versus reliance on single clinic readings in resource-limited ones. Equitable access to HBPM is not a technical detail; it is a cornerstone for closing the global hypertension treatment gap [1-3].

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Both authors contributed to the conception, drafting, and critical revision of the manuscript. Both read and approved the final version of the manuscript.

References