Scaling Out and Scaling Up the Systems Analysis and Improvement Approach to Optimize the Hypertension Diagnosis andCare Cascade for HIV-infected Individuals (SCALE SAIA HTN)

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Undiagnosed and untreated hypertension (HTN) is a main driver of cardiovascular disease, contributing to a third of deaths globally, disproportionately affecting low and middle-income countries. Across sSA, country- level application of evidence-based guidelines to screen and manage HTN is low and variable due to lack of service readiness, uneven health worker motivation, weak health worker accountability systems, and poor integration of HTN screening and management with chronic care services. In Mozambique, where HIV prevalence is >13%, the HIV treatment platform is the only scaled chronic care service. With over 900,000 patients on anti-retroviral therapy, it presents an opportunity to standardize and scale HTN care cascade services. Low-cost, systems-level strategies are effective in improving linked cascade services and may be effective for routinizing HTN diagnosis and management within existing HIV services; improving flow through the HTN cascade; and improving patient-level outcomes. Our proposal builds on the ongoing SAIA-HTN trial. The overall objective of our UG3/UH3 (SCALE SAIA- HTN) is to establish a robust evidence base on the effectiveness of a multi-component implementation strategy (SAIA) on the HTN/HIV cascade using a ‘scaling-out’ framework, whereby strength can be ‘borrowed’ from prior effectiveness trials. SCALE SAIA-HTN will be ‘scaled out’ through a novel modality delivered by district health supervisors (rather than study nurses). We will also ‘scale up’ SAIA-HTN by expanding to all districts in two additional provinces (15 districts), serving as a foundation for national scale-up. We propose three aims for the UG3 (Planning) and two for UH3 (Implementation) phases. UG3-Aim 1: To develop a multi-sectoral partnership of key stakeholders and establish HTN technical working groups at the national level and with participating provinces. UG3-Aim 2: To identify key facilitators and barriers that could affect the adoption, integration, scale-up and sustainment of the SAIA-HTN implementation strategy. UG3-Aim 3: To conduct a pilot study to assess feasibility and acceptability of the district supervisor-led SAIA-HTN intervention over six months in one primary care facility and redesign tools and standard operating procedures as necessary for the UH3 phase. UH3-Aim 1: Develop a district-based dissemination and implementation strategy for SCALE SAIA- HTN using the RE-AIM model to evaluate the programs’ Reach, Effectiveness, Adoption, Implementation and Maintenance. UH3-Aim 2: Determine the costs of SCALE SAIA-HTN for care cascade optimization. We will estimate total incremental and unit costs of integrating HTN diagnosis and management into HIV care.