Systems Analysis and Improvement Approach to Optimize the Hypertension Diagnosis and Care Cascade for HIV-infected Individuals (SAIA-HTN)

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Undiagnosed and untreated hypertension (HTN) is one of the largest drivers of cardiovascular disease (CVD) in sub-Saharan Africa (sSA). Across sSA, evidence-based, clinical guidelines to screen and manage hypertension exist; however, country level application is low and uneven due to lack of service readiness, uneven health worker motivation, lack of accountability for health worker performance and poor integration of HTN screening and management with chronic care services. In Mozambique – like many countries with high HIV burden – the HIV treatment platform was the first broadly implemented chronic care service. With large numbers of patients on anti-retroviral treatment (850,000 in Mozambique), it presents a unique opportunity to standardize and scale hypertension screening and management. Low-cost, systems level interventions are effective and efficient approaches to improve linked cascade services, and may be effective for routinizing HTN diagnosis and management within existing chronic care services; addressing both individual and systems-level barriers; improving flow through the HTN cascade; and ultimately improving patient level outcomes. The Systems Analysis and Improvement Approach (SAIA) is designed to optimize cascade performance, is feasible for frontline healthcare workers and managers, and is applicable to optimize the HTN testing and treatment cascade for people living with HIV (PLHIV) across multiple contexts. We have successfully piloted SAIA for the HTN cascade for PLHIV, and as HTN screening and management is mainstreamed into chronic care services in sSA (including in Mozambique), demonstrating SAIA-HTN potential effectiveness as an adaptable, scalable model for broad implementation. The overall goal of SAIA-HTN is to evaluate a model for systematic assessment and improvement of HTN diagnosis and management services for PLHIV in Mozambique. Our specific aims are to: (1) Determine the effectiveness of SAIA-HTN on HTN cascade optimization for HIV-infected individuals; (2) Determine the drivers of SAIA-HTN intervention implementation heterogeneity across facilities; (3) Determine the costs and cost-effectiveness of SAIA-HTN for care cascade optimization. We will deploy a cluster randomized trial to evaluate the impact of the SAIA-HTN intervention on hypertension management in 8 intervention and 8 control facilities. Effectiveness will be measured via HTN cascade flow measures for PLHIV and HTN and HIV clinical outcomes. Intervention costs will be assessed from the payer perspective (e.g. MOH), and cost effectiveness analysis conducted to estimate the incremental costs for additional patients passing through the HTN cascade steps, and the cost per additional disability-adjusted life year averted (DALY). The implementation process will be described using focus group discussions and key informant interviews analyzed using the Consolidated Framework for Implementation Research, with complementary data from study logs to describe fidelity to the SAIA-HTN intervention design.