Partnerships and Organisational Capacity Domains are most Influential in Program Sustainability of an Integration of Hypertension Care into HIV Services

Partnerships and Organisational Capacity Domains are most Influential in Program Sustainability of an Integration of Hypertension Care into HIV Services | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Partnerships and Organisational Capacity Domains are most Influential in Program Sustainability of an Integration of Hypertension Care into HIV Services Ambrose Byamukama, Mucunguzi Atukunda, Elizabeth Arinitwe, Brian Twinamatsiko, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7262810/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background : The co-occurrence of HIV and non-communicable diseases (NCDs), particularly hypertension, is a growing global health issue. As people living with HIV (PLHIV) live longer due to antiretroviral therapy (ART), they become more susceptible to NCDs like hypertension. The integrated HIV/HTN project implemented a feasible and cost-effective multi-component intervention in several public health facilities in Uganda. In this study, we sought to evaluate the program sustainability of the intervention by the public health delivery system. Methods : A mixed-methods cross-sectional study was conducted across 26 public health facilities in 13 intervention districts of southwestern Uganda. Quantitative data were collected using the Program Sustainability Assessment Tool (PSAT) from District Health Officers (N=15), HIV focal persons (N=10), and ART in-charges (N=25). Qualitative data were gathered through in-depth interviews with healthcare managers and analyzed using Stata and Dedoose software. Results : The PSAT Partnerships domain scored high (5.68), reflecting strong stakeholder engagement, communication, and leadership involvement. The Organizational Capacity domain also performed well (5.66), with strong integration of hypertension screening and data management, resource management and staff training rated at 4.24 and 4.9 respectively. Integration of HTN into HIV Care Evaluation scored (5.54), excelling in public communication but needing improvement in reporting and evaluation capacity. The Communications domain (5.51) showed moderate effectiveness, with room to enhance public engagement and feedback strategies. Environmental Support was the weakest domain (4.73), highlighting the need for better resource mobilization and training adequacy. Conclusion : The sustainability of a multi-component care modelwas strongly influenced by strong partnerships and leadership. To ensure long-term success, environmental support, resource management, and sustainability planning is essential. Addressing these gaps will strengthen ongoing integration efforts in resource-limited settings. Registry: ClinicalTrials.gov, TRN: NCT04624061, Registration date: 04 November 2022 Hypertension HIV Integration Program Sustainability Assessment Figures Figure 1 Background The dual burden of HIV and non-communicable diseases (NCDs), particularly hypertension, is an increasing global health challenge[ 1 ]. As people living with HIV (PLHIV) are living longer due to the widespread availability of antiretroviral therapy (ART), they are more susceptible to developing NCDs, including hypertension[ 2 ]. Globally, cardiovascular diseases, driven largely by hypertension, are the leading cause of mortality, accounting for approximately 17.9 million deaths annually, with hypertension contributing to over 10 million of these deaths[ 3 ] The global prevalence of hypertension is estimated at 31% among adults, affecting around 1.28 billion people[ 4 ]. This public health crisis is even more pronounced in low- and middle-income countries (LMICs)[ 5 , 6 ], where over two-thirds of individuals with hypertension reside. Meanwhile, HIV continues to be a major public health issue, with over 39 million people globally living with HIV as of 2023. Sub-Saharan Africa, home to 70% of the global HIV population[ 7 ], also faces a high burden of hypertension, creating a significant healthcare challenge. At a global level, the World Health Organization (WHO) has recognized the importance of integrated care approaches as part of its strategy to combat NCDs and strengthen health systems[ 8 ]. Many countries, including Uganda, have piloted programs to incorporate hypertension and other NCD care into established HIV services. However, the long-term sustainability of these programs remains a critical concern. Sustaining integrated services likely requires financial investment, trained personnel, consistent supply chains, and robust health system governance, which can be challenging in LMICs with limited resources To address this dual burden, the integration of hypertension care into HIV services has been proposed as a potentially sustainable, resource-efficient solution[ 9 ] By leveraging existing HIV care infrastructure, this model aims to provide comprehensive care for PLHIV who are also at risk of or already suffering from hypertension[ 10 ] Integrated care models have demonstrated improvements in patient outcomes, treatment adherence, and efficiency of service delivery, making them an appealing solution for resource-constrained health systems. Nationally, Uganda has taken steps to integrate NCD into HIV care delivery[ 11 ]. These efforts include the inclusion of NCD care into the national HIV treatment guidelines 2023 [ 12 ] and the implementation of the integrated HIV/HTN project a multi-component model. However, there is limited data on the sustainability of integrated HIV/HTN efforts over time. In this study, we sought to evaluate the program sustainability of the intervention beyond the project timeline. This sustainability assessment aims to evaluate the structural, financial, and operational dimensions of integrating hypertension care into HIV services, providing insights into how this model can be scaled and maintained long-term to improve health outcomes for PLHIV. Methods Study design This study employed a parallel convergent design. incorporating both qualitative and quantitative data collection and synthesis to provide a comprehensive understanding of the sustainability aspects of the Integrated HIV/Hypertension (HTN) care model. A cross-sectional survey was conducted among healthcare managers including District Health Officers (DHOs), HIV Focal Persons (HFP), and health facility in-charges who were involved in activities of the integrating HTN in HIV clinics in southwestern Uganda. Additionally, structured and in-depth interviews were conducted with purposively selected healthcare managers to gain deeper insights into the sustainability of the Integrated HIV/HTN care model. Overview of Integrated HIV/HTN care intervention The intervention included: 1) health worker training on integrating HTN care with HIV care; 2) promoting routine HTN screening and care at each clinic visit; 3) improvement of the health management information system, 4) WhatsApp messages for data coordination and communication among frontline Primary Health Care workers and district-level managers. Both arms received blood pressure (BP) machines, Non-Communicable Diseases (NCD) registers, patient cards, HTN care guidelines and buffer stock HTN medicines. Study setting. The study was conducted across 26 public health facilities located within 13 districts in the intervention arm. At the facility level, interviews were conducted with health facility in-charges. The facility in-charges heads the health facility and is responsible for direction and administration of delivery of health services. We selected health facilities because they were all Integrated HIV/HTN care model intervention facilities. From each district, two health Intervention facilities were selected for inclusion in the study. The healthcare facilities involved ranged from Health Centre IIIs (HCIIIs) which are primary healthcare facilities that offer essential services, including outpatient care, maternal and child health, immunizations, and chronic disease management, along with basic diagnostic services and some inpatient beds to Health Centre IVs (HCIVs) which are advanced primary healthcare facilities that serve as referral centers for HCIIIs, offering a broader range of outpatient and inpatient services, including specialized care, advanced diagnostics, and surgery, all participating in the Integrated HIV/HTN care program. The study was conducted between April 2024 to May 2024 for quantitative and January 2023 to February 2023 for qualitative. Study population The study population consisted of adults aged 18 years and above living in southwestern Uganda. Eligible participants included members of the district health team i.e. DHOs who oversees district health services, managing programs, allocating resources, implementing policies, and monitoring health outcomes, HIV Focal Persons who coordinates HIV programs, builds capacity, engages communities, manages data, collaborates with stakeholders, and advocates for HIV awareness and resources and health facility/ART in-charges associated with the Integrated HIV/HTN care model. A total of 15 DHOs, 10 HIV/NCD FP and 25 health facility/ART in-charges participated in the study, with each district and facility contributing at least two respondents respectively. The sample size was chosen to be sufficiently large to capture a range of insights across the participating districts and facilities. Participants were drawn from public health facilities and districts located in rural and semi-urban settings, where Integrated HIV/HTN care model was being implemented. Data Collection and Analysis Quantitative Data Collection and Analysis In the study we used The Program Sustainability Assessment Tool (PSAT) that was developed by the Center for Public Health Systems Science at Washington University in St. Louis.[ 13 ] The same tool has used to evaluate several health intervention programs. [ 14 – 16 ]. We adapted the tool for this program. (Supplementary file #1). The adapted Program Sustainability Assessment Tool was employed to collect quantitative data across seven domains ( Table 2 below) from District Health Officers (DHOs), HIV focal persons, and health facility/ART in-charges (N = 50). The PSAT utilizes a 7-point Likert scale to assess the sustainability of the Integrated HIV/HTN intervention components. Scores of 6 or 7 indicated "to a very great extent," while scores of 1 or 2 indicated "little to no extent." Responses marked as "NA" indicated an inability to answer. The questionnaire data collected were entered into VB software, and responses were appropriately coded for statistical analysis, reflecting the 1–7 Likert scale. The data were then analysed using Stata software. For each question, the mean score and variability (SD and range) were calculated. The questionnaire was structured into multiple domains, each reflecting a different aspect of project sustainability. To assess each domain, the mean scores of the questions within that domain were aggregated and analyzed to produce a domain-specific average. Qualitative Data Collection and Analysis In-depth semi-structured interviews (IDI’s) were conducted using a guide that included a section designed to elicit participants' insights on the sustainability of the multi-component intervention model. Two qualitative researchers carried out interviews at health centres and district headquarters with healthcare managers and health care providers. Audio recordings were translated and transcribed into English. Two team members independently coded each transcript using Dedoose software. An initial coding framework was developed based on emerging themes and subthemes. Coded excerpts were then summarized into themes, extracted, reviewed, and analyzed. For the mixed-methods synthesis, the investigators simultaneously reviewed the quantitative PSAT question and domain scores and identified qualitative themes to correlate areas of agreement, disagreement, and deeper contextual factors and explanatory meaning suggested by the qualitative themes. Ethical consideration All participants provided informed consent to take part in the study. The study was conducted in accordance with the Declaration of Helsinki and it was approved by Makerere University School of Medicine Research Ethics Committee on September 8, 2020 (approval number: 2020 − 156), the London School of Hygiene and Tropical Medicine on September 2, 2020 (approval number: 22196), and the Uganda National Council for Science and Technology on November 9, 2020 (approval number: HS979ES). Confidentiality was strictly maintained throughout the study. Results Participant demographics and characteristics A total of 15 District Health Officers (DHOs) were interviewed, making up 30% of the sample. Ten participants were HIV/NCD Focal Persons (FPs), representing 20%. The largest group was Facility/ART In-charges, with 25 participants, accounting for 50% of the sample. In total, there were 50 participants in the entire sample (Table 1). There were 24 participants representing individual health facilities and 26 participants representing district Table 1: Showing the distribution of participants by health facility, district, and title/position This table presents the number and percentage of participants categorized by health facility, district level and professional role (District Health Officer, HIV/NCD Focal Person, or Facility/ART In-Charge) across 26 intervention sites in southwestern Uganda Health facility/District Number of participants Percentage Healthy facility 24 48% District 26 52% Total 50 100% Role Number of participants Percentage District Health Officer 15 30% HIV/NCD Focal Person 10 20% Facility In-Charge 25 50% Total 50 100% Quantitative PSAT results in this section are presented based on the average sustainability scores by domain and by Items derived from a 7-point Likert scale as shown in Table 2 below. Table 2. PSAT Survey Results By Domain This table summarizes the mean scores, standard deviations (SD), and ranges for each of the seven PSAT domains and their respective items, as assessed by 50 respondents using a 7-point Likert scale. Higher scores indicate stronger perceived sustainability of integrated hypertension/HIV services. Domain Domain Mean Score (SD) (range) Item Item Mean Score (SD)(range) Environmental Support: (Having supportive internal and external climate for the Integration of Hypertension in HIV care and general implementation) 4.73 (1.04) (2-6.8) Existence of NCD champions. 4.94 (1.63) (1-7) The ability of district partners to mobilize resources 4.24 (1.80) (1-7) Leadership support for training and capacity building 5.34 (1.22) (2-7) 4. Training plans for providers 4.25 (1.73) (1-7) 5. Adequate training of healthcare providers 4.9 (1.42) (1-7) Partnerships: (Partnerships provide linkages/connections between the INTEGRATED HIV/HTN project and its stakeholders) 5.70 (0.94) (2.8-7) 1. Stakeholder interest in the program’s success 5.06 (1.61) (1-7) 2. Communication and involvement of stakeholder leaders 6.04 (1.14) (2-7) 3. Stakeholder leaders are involved with the project. 5.86 (1.16) (2-7) 4. Passionate commitment from stakeholders 5.86 (1.14) (3-7) 5. Stakeholder engagement in project goals 5.56 (1.30) (2-7) Organizational Capacity: (Health facilities and districts have the internal support and resources needed to effectively integrate Hypertension care into HIV clinics) 5.66(0.93) (3-7) 1. Integration of hypertension screening into HIV clinic operations 6.26 (0.88) (4-7) 2. Availability of HMIS tools 6.02 (1.06) (3-7) 3. Efficient resource management by leadership 4.94 (1.78) (1-7) 4. Adequate staff training for data management 5.1 (1.59) (1-7) 5. Leadership support for hypertension care. 5.98 (1.20) (1-7) Integration of HTN into HIV care evaluation: (Integration of HTN into HIV care informed planning and documentation of results) 5.54 (0.89) (2.2-7) 1. Capacity for quality evaluation of integration services. 5.2 (1.37) (2-7) 2. Reporting on short-term and intermediate outcomes 5.06 (1.45) (1-7) 3. Use of evaluation results for project planning 5.48 (1.34) (1-7) 4. Demonstration of success to stakeholders 5.68 (1.20) (1-7) 5. Providing evidence of successful integration 6.28 (0.70) (5-7) Project Adaptation: (Taking actions that adapt your district/facility goals to ensure its ongoing effectiveness) 5.49 (1.0.2) (1.6-7) 1. Periodic review of data on hypertension 5.26 (1.31) (1-7) 2. Adaptation of successful strategies 5.44 (1.33) (1-7) 3. Adaptation to new science. 5.6 (1.28) (1-7) 4. Proactive adaptation to changes in the health system delivery 5.74 (1.16) (2-7) 5. Decisions on ineffective components 5.42 (1.47) (1-7) Communications: (Communication and feedback with healthcare providers and managers about the Integration of Hypertension care into HIV clinics was happening) 5.51 (0.9) (3.4-7) 1. Strategies for communication and feedback 5.44 (1.3) (1-7) 2. Public communication about integration 5.56 (1.1) (3-7) 3. Generation of interest during reviews 5.46 (1.0) (3-7) 4. Promotion of community awareness 5.26 (1.4) (1-7) 5. Demonstrating value to stakeholders 5.84 (0.8) (4-7) Strategic Planning: (What processes guide the direction, goals, and strategies of continued implementation of Integration of HTN care into HIV clinics) 5.30 (0.9) (2.25-7) 1. Planning for future resource needs. 5.27 (1.4) (1-7) 2. Long-term sustainability planning 4.24 (1.5) (1-7) 3. Understanding of project goals by stakeholders 5.74 (0.9) (3-7) 4. Clear roles and responsibilities outlined for all stakeholders. 5.84 (1.1) (1-7) The PSAT scores for individual questions and aggregate domain are presented in table 2 above. Overall Sustainability The overall mean (SD) sustainability score was 4.6 (1.3) with a range of 1-7. Mean (SD) scores for individual items in the PSAT instrument ranged from a low of 4.24 (1.80) to a high of 6.28 (0.70). Partnerships The Partnerships domain emerged with a strong mean (SD) score of 5.68, indicating high levels of engagement from stakeholders. Effective communication (6.04) and stakeholder commitment (5.86) were notable strengths.A related issue that emerged qualitatively from both health care providers and managers was that partnership was repeatedly acknowledged, along with the provision of resources from partners such as BP machines, training for staff, mentorship, and tools like pink cards for data collection, all aimed at promoting sustainable practices in HTN/HIV screening. Organizational Capacity The Organizational Capacity domain scored well with a mean of 5.66, excelling in the integration of hypertension screening into HIV clinic operations (6.26), critical for sustainable care. This was supported qualitatively as health care providers frequently emphasized teamwork as a vital key factor for hypertension (HTN) screening and care. Specifically, providers noted that collaborative efforts, including the integration of peers and clinicians, played a critical role in maintaining continuity of HTN screening, especially during times of staff shortages or coverage gaps.HMIS tools scored 6.02, indicating solid data management structures. However, resource management (4.94) and staff training (5.10) were less well scored, highlighting challenges in human resources and operational efficiency that may impact sustainability. Integration of HTN into HIV Care Evaluation This domain, with an average score of 5.54, shows moderate success in evaluating the integration of HTN into HIV services. The highest score in this category was for providing evidence to the public about the effectiveness of this integration (6.28), demonstrating that the project effectively communicates its success. However, areas like reporting short-term and intermediate outcomes (5.06) and district capacity for evaluation (5.20) could be improved to enhance the overall evaluation process for long term sustainability of the program. Communications The Communications domain scored 5.51, indicating a moderately effective approach. Public communication about the need for integration (5.56) and strategies for feedback (5.44) show some potential for improvement in engaging both internal and external target groups. Healthcare managers and providers have successfully highlighted the benefits of integrating hypertension care into HIV services (5.84), which could help generate greater stakeholder interest . Qualitatively health care providers highlighted how Patients now have regular access to hypertension screening and treatment during their ART (antiretroviral therapy) visits, allowing those with HTN to receive timely care. This integration makes it possible to identify and manage HTN in patients who previously lacked awareness of their condition. Project Adaptation. The Project Adaptation domain scored 5.49, reflecting a strong ability of the district and health centres to integrate new changes (5.60) and adapt to changes in the healthcare system (5.74). This demonstrates a solid capacity for adaptation. However, there is a minor shortfall in addressing ineffective components, with a score of (5.42). Strategic Planning With an average score of 5.27, the Strategic Planning domain indicates adequate planning but highlights significant challenges, particularly in long-term sustainability (4.24). Planning for future resources (5.27) and clear roles and responsibilities (5.84) show good score, but the lower sustainability score suggests that more focus is needed on ensuring the continuity of Integrated HIV/HTN care model. Qualitatively, the insights shared by healthcare providers highlight those systemic barriers, including work overload, insufficient staffing, irregular drug supplies, and logistical challenges, hinder the sustainability of these essential services. Effective planning and coordinated action are urgently needed to address these issues, with a focus on the following priorities: strengthening human resource capacity, ensuring consistent and adequate medical supplies, improving infrastructure and resources, addressing knowledge gaps and resistance to training, promoting continuity of care despite staff transfers, and leveraging technology for communication and data sharing. Environmental Support. This domain had the lowest average score at 4.73, emphasizing the need for stronger environmental support. While leadership support for training (5.34) was relatively high, the ability to mobilize resources (4.24) and the adequacy of training for healthcare providers (4.90) scored lower. This was supported qualitatively as providers emphasized the critical need for consistent environmental support to improve and sustain integrated HIV/HTN care. A key recommendation was to ensure a reliable supply of diverse medications to support effective treatment. They also highlighted the importance of ongoing training and capacity building for healthcare workers to maintain service continuity, especially during staff absences and transfers. Regular training and refresher programs were suggested to equip staff for integrated care. Staff shortages and heavy workloads were identified as barriers, with recommendations to recruit additional staff and ensure backup personnel. Support from district health offices (DHOs) and better supervision were seen as crucial for maintaining service quality. Providers called for more frequent monitoring and regional-level support to ensure accountability and sustainability of integrated services. Variability across health centres and informant role To visualize the distribution of PSAT scores overall and by PSAT domain, we utilized a violin plot and then examined the plot for distribution patterns by domain (see Figure 1). We observed three distinct patterns of score distributions: 1) Scores for the Environment domain were shifted downward compared to the overall score distribution reaching further into the lower score ranges, 2) the Partnership and Capacity domain score distributions were shifted upwards towards higher scores with a wider inter-quartile range than all of the other PSAT score domains, and 3) similar score distributions and inter-quartile ranges for the Integration, Adaptation, Communications, and Planning domains. There were some suggestion of more scores of 3 or 4 in the Planning domain within the third observed score cluster pattern. This table ranks the PSAT domains based on their mean scores to identify the most and least influential domains contributing to sustainability of integrated hypertension and HIV care. Partnerships and Organizational Capacity emerged as the highest scoring domains, while Environmental Support scored lowest. Discussion The Partnerships domain stands out as a notable strength of the Integrated HIV/HTN care model sustainability. The high levels of engagement from stakeholders, coupled with effective communication and strong stakeholder commitment, reflect a solid foundation for collaboration. This strong engagement is crucial for the model’s sustainability, as it ensures that key players are actively involved and invested in the model’s success. However, there is an identified need to enhance stakeholder interest in the model’s long-term outcomes. Addressing this gap could foster deeper commitment and support, further strengthening the sustainability of the care model. Organizational Capacity is another domain where the model excels. The integration of hypertension screening into HIV clinic operations and the effective use of Health Management Information Systems (HMIS) tools highlight the model’s operational efficiency and data management capabilities. These strengths are vital for maintaining effective service delivery and supporting the care model’s sustainability. Nevertheless, challenges remain in resource management and staff training. Improving these aspects is essential for ensuring that the model can continue to operate smoothly and adapt to evolving needs, thereby reinforcing its long-term sustainability. The Integration of HTN into HIV Care Evaluation domain also demonstrates significant strengths. The high score for providing evidence about the effectiveness of integration highlights the model’s success in communicating its achievements and demonstrating the value of integrating hypertension care into HIV services. This effective communication is crucial for gathering support and confirming the model’s impact. However, there is room for improvement in reporting short-term and intermediate outcomes, stakeholder interest in the program's success and evaluating district capacity. Enhancing these evaluation processes could provide a more comprehensive understanding of the integration’s impact and support ongoing efforts to optimize the care model sustainability. Integration approaches for HIV and hypertension such as co-located services, same-day service integration, chronic care clinics, integrated health information systems, and combined screening and monitoring have been Implemented in the past. These approaches are sustained through investments in staff training, Regular updates, monitoring, cross-departmental collaboration, and ensuring an uninterrupted supply of necessary medications and diagnostic equipment. Support from national health policies, external funding, and partnerships with NGOs or private sector partners play crucial roles in maintaining these integrations over time. Sustainability assessments of such programs are essential to determine whether the integration efforts can be maintained over the long term by them without project support, ensuring that benefits continue to be delivered to patients. Factors influencing the sustainability of integrated HIV and hypertension care include the capacity of the health system, availability of financial resources, adequacy of staff training, level of political commitment, and the ability of health facilities to maintain service delivery beyond initial interventions or pilot programs. Overall, active collaboration and leadership involvement were key factors for Integrated HIV/HTN care model sustainability. Conclusion For the Integrated HIV/HTN care model to sustain its impact, active partnership and leadership involvement are essential. While the domain scores indicate a generally positive environment for partnerships, addressing the gaps in stakeholder interest can further strengthen the program’s sustainability. Ensuring that all involved parties remain engaged and see value in the program will help maintain their support and involvement, which is critical for long-term success. However, the lower scores in environmental support and resource management highlight areas that need focused attention. Addressing these gaps, particularly in sustainability planning and resource mobilization, will be critical for the long-term sustainability of integrating HIV and HTN care models. Declarations Ethics approval and consent to participate: The study received ethical approval from the Makerere University School of Medicine Research Ethics Committee (approval number: 2020-156), the London School of Hygiene and Tropical Medicine (approval number: 22196), and the Uganda National Council for Science and Technology (approval number: HS979ES). All participants provided informed consent to take part in the study. Consent for publication Not applicable Availability of data and material The datasets generated and analyzed during this study are available from the corresponding author upon reasonable request. Authors’ contributions: The authors confirm contribution to the paper as follows: A.B and M.A wrote the main manuscript text, E.D.C. prepared figure 1, M.A prepared table 2, A.B., E.A., W.T., AM collected PSAT data. B.A. and A.M. collected qualitative data and coded. And B.T., A.A., E.O., G.M., J.N., M.R.K., E.D.C and J.K. reviewed the manuscript. All authors have read and approved the final manuscript. Funding: This research was supported by European and Developing Countries Clinical Trials Partnership (EDCTP) Grant Number: CSA2018HS-2518. Competing interests None declared. Acknowledgment We would like to express our sincere gratitude to the District Health Officers (DHOs), HIV focal persons, and facility in-charges for their time, collaboration, and willingness to share valuable data, which were instrumental to the success of this manuscript. We deeply appreciate their commitment and support throughout the data collection process. References Owusu, R., et al., A qualitative exploration of policy interventions to improve the health-related quality of life of people living with HIV AIDS and co-morbidities of hypertension and/or diabetes in Ghana. PLoS One, 2024. 19 (10): p. e0311994. Kasango, A., A. Daama, and L. 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Tool, C.f.P.H.S.S.P.C.P.S.A. PSAT/CSAT: Program Sustainability Assessment Tool Washington University in St. Louis; . Available from: https://sustaintool.org/psat/resources/. Luke, D.A., et al., The Program Sustainability Assessment Tool: a new instrument for public health programs. Prev Chronic Dis, 2014. 11 : p. 130184. Moreland-Russell, S., et al., Action planning for building public health program sustainability: results from a group-randomized trial. Implementation Science, 2024. 19 (1): p. 9. Calhoun, A., et al., Using the Program Sustainability Assessment Tool to assess and plan for sustainability. Prev Chronic Dis, 2014. 11 : p. 130185. Additional Declarations No competing interests reported. Supplementary Files ProgramSustainabilityAssessmentToolIntegratedHIVHTNv1.13APR2024.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Oct, 2025 Reviews received at journal 11 Oct, 2025 Reviews received at journal 03 Sep, 2025 Reviewers agreed at journal 26 Aug, 2025 Reviewers agreed at journal 26 Aug, 2025 Reviewers agreed at journal 21 Aug, 2025 Reviewers invited by journal 21 Aug, 2025 Editor assigned by journal 14 Aug, 2025 Submission checks completed at journal 14 Aug, 2025 First submitted to journal 14 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7262810","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":505996274,"identity":"710172dc-8c56-47a2-b7ae-05170f104730","order_by":0,"name":"Ambrose Byamukama","email":"data:image/png;base64,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","orcid":"","institution":"Infectious Diseases Research Collaboration (IDRC)","correspondingAuthor":true,"prefix":"","firstName":"Ambrose","middleName":"","lastName":"Byamukama","suffix":""},{"id":505996275,"identity":"b9c5b6ea-e35e-4edb-9f95-a0d0236c7df3","order_by":1,"name":"Mucunguzi Atukunda","email":"","orcid":"","institution":"Uganda Heart Institute (UHI)","correspondingAuthor":false,"prefix":"","firstName":"Mucunguzi","middleName":"","lastName":"Atukunda","suffix":""},{"id":505996276,"identity":"32bc28c0-94e6-4525-82c9-3cc4a2804774","order_by":2,"name":"Elizabeth Arinitwe","email":"","orcid":"","institution":"Infectious Diseases Research Collaboration (IDRC)","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Arinitwe","suffix":""},{"id":505996277,"identity":"4e648c15-dae7-4ef5-8035-8d66cf4110e1","order_by":3,"name":"Brian Twinamatsiko","email":"","orcid":"","institution":"Infectious Diseases Research Collaboration (IDRC)","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"","lastName":"Twinamatsiko","suffix":""},{"id":505996278,"identity":"3942fd2b-0295-45ef-9dc0-b8cf53c0d379","order_by":4,"name":"Andrew Mutabazi","email":"","orcid":"","institution":"Infectious Diseases Research Collaboration (IDRC)","correspondingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"","lastName":"Mutabazi","suffix":""},{"id":505996279,"identity":"79c2e803-1a1e-49af-9573-b1da394882a3","order_by":5,"name":"Michael Ayebare","email":"","orcid":"","institution":"Infectious Diseases Research Collaboration (IDRC)","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Ayebare","suffix":""},{"id":505996280,"identity":"57664f50-fc1a-4a1b-ac49-e6618961e842","order_by":6,"name":"Winston Tindimwembwa","email":"","orcid":"","institution":"Infectious Diseases Research Collaboration (IDRC)","correspondingAuthor":false,"prefix":"","firstName":"Winston","middleName":"","lastName":"Tindimwembwa","suffix":""},{"id":505996282,"identity":"b8fd31b2-523e-4e32-b0c9-80340e8a2f03","order_by":7,"name":"Alan Asiimwe","email":"","orcid":"","institution":"Makerere University (MU)","correspondingAuthor":false,"prefix":"","firstName":"Alan","middleName":"","lastName":"Asiimwe","suffix":""},{"id":505996285,"identity":"d8f88dd5-c16c-4d61-99fc-c3cf96766f9d","order_by":8,"name":"Joan Nangendo","email":"","orcid":"","institution":"Uganda Heart Institute (UHI)","correspondingAuthor":false,"prefix":"","firstName":"Joan","middleName":"","lastName":"Nangendo","suffix":""},{"id":505996287,"identity":"da9ffc78-5a61-479a-a1d3-6d6489443070","order_by":9,"name":"Emmy Okello","email":"","orcid":"","institution":"Ministry of Health (MoH)","correspondingAuthor":false,"prefix":"","firstName":"Emmy","middleName":"","lastName":"Okello","suffix":""},{"id":505996289,"identity":"f79a2d07-411a-48fa-bc37-5004359a12e7","order_by":10,"name":"Gerald Mutungi","email":"","orcid":"","institution":"Infectious Diseases Research Collaboration (IDRC)","correspondingAuthor":false,"prefix":"","firstName":"Gerald","middleName":"","lastName":"Mutungi","suffix":""},{"id":505996291,"identity":"11f91074-1318-4f22-a777-3861961152a2","order_by":11,"name":"Moses R. Kamya","email":"","orcid":"","institution":"Infectious Diseases Research Collaboration (IDRC)","correspondingAuthor":false,"prefix":"","firstName":"Moses","middleName":"R.","lastName":"Kamya","suffix":""},{"id":505996293,"identity":"aed1049e-6afa-41aa-976d-f9d816b26cad","order_by":12,"name":"Jane Kabami","email":"","orcid":"","institution":"Infectious Diseases Research Collaboration (IDRC)","correspondingAuthor":false,"prefix":"","firstName":"Jane","middleName":"","lastName":"Kabami","suffix":""},{"id":505996294,"identity":"d2584628-c771-4d40-8edd-0eb457e6fde3","order_by":13,"name":"Edwin D. Charlebois","email":"","orcid":"","institution":"University of California San Francisco (UCSF)","correspondingAuthor":false,"prefix":"","firstName":"Edwin","middleName":"D.","lastName":"Charlebois","suffix":""}],"badges":[],"createdAt":"2025-07-31 13:38:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7262810/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7262810/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90197017,"identity":"60cba1e5-5132-4d57-8bef-f55d9b354525","added_by":"auto","created_at":"2025-08-29 17:34:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":269788,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePSAT Score Distribution by Domain\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7262810/v1/dcef2e4255308224f59e3964.png"},{"id":90197895,"identity":"ae5ad929-652d-46b5-9e26-9cee1b9a7858","added_by":"auto","created_at":"2025-08-29 17:50:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1330780,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7262810/v1/9b49fb02-111d-4d5f-ad21-9f3bbd9db470.pdf"},{"id":90197014,"identity":"ad468cea-2239-4777-8637-3b2b87383046","added_by":"auto","created_at":"2025-08-29 17:34:15","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":49954,"visible":true,"origin":"","legend":"","description":"","filename":"ProgramSustainabilityAssessmentToolIntegratedHIVHTNv1.13APR2024.docx","url":"https://assets-eu.researchsquare.com/files/rs-7262810/v1/bf253c2c159eb97921cc3e33.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Partnerships and Organisational Capacity Domains are most Influential in Program Sustainability of an Integration of Hypertension Care into HIV Services","fulltext":[{"header":"Background","content":"\u003cp\u003eThe dual burden of HIV and non-communicable diseases (NCDs), particularly hypertension, is an increasing global health challenge[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. As people living with HIV (PLHIV) are living longer due to the widespread availability of antiretroviral therapy (ART), they are more susceptible to developing NCDs, including hypertension[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Globally, cardiovascular diseases, driven largely by hypertension, are the leading cause of mortality, accounting for approximately 17.9\u0026nbsp;million deaths annually, with hypertension contributing to over 10\u0026nbsp;million of these deaths[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe global prevalence of hypertension is estimated at 31% among adults, affecting around 1.28\u0026nbsp;billion people[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This public health crisis is even more pronounced in low- and middle-income countries (LMICs)[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], where over two-thirds of individuals with hypertension reside. Meanwhile, HIV continues to be a major public health issue, with over 39\u0026nbsp;million people globally living with HIV as of 2023. Sub-Saharan Africa, home to 70% of the global HIV population[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], also faces a high burden of hypertension, creating a significant healthcare challenge.\u003c/p\u003e\u003cp\u003eAt a global level, the World Health Organization (WHO) has recognized the importance of integrated care approaches as part of its strategy to combat NCDs and strengthen health systems[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Many countries, including Uganda, have piloted programs to incorporate hypertension and other NCD care into established HIV services. However, the long-term sustainability of these programs remains a critical concern. Sustaining integrated services likely requires financial investment, trained personnel, consistent supply chains, and robust health system governance, which can be challenging in LMICs with limited resources\u003c/p\u003e\u003cp\u003eTo address this dual burden, the integration of hypertension care into HIV services has been proposed as a potentially sustainable, resource-efficient solution[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] By leveraging existing HIV care infrastructure, this model aims to provide comprehensive care for PLHIV who are also at risk of or already suffering from hypertension[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Integrated care models have demonstrated improvements in patient outcomes, treatment adherence, and efficiency of service delivery, making them an appealing solution for resource-constrained health systems.\u003c/p\u003e\u003cp\u003eNationally, Uganda has taken steps to integrate NCD into HIV care delivery[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These efforts include the inclusion of NCD care into the national HIV treatment guidelines 2023 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and the implementation of the integrated HIV/HTN project a multi-component model. However, there is limited data on the sustainability of integrated HIV/HTN efforts over time. In this study, we sought to evaluate the program sustainability of the intervention beyond the project timeline.\u003c/p\u003e\u003cp\u003eThis sustainability assessment aims to evaluate the structural, financial, and operational dimensions of integrating hypertension care into HIV services, providing insights into how this model can be scaled and maintained long-term to improve health outcomes for PLHIV.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThis study employed a parallel convergent design. incorporating both qualitative and quantitative data collection and synthesis to provide a comprehensive understanding of the sustainability aspects of the Integrated HIV/Hypertension (HTN) care model. A cross-sectional survey was conducted among healthcare managers including District Health Officers (DHOs), HIV Focal Persons (HFP), and health facility in-charges who were involved in activities of the integrating HTN in HIV clinics in southwestern Uganda. Additionally, structured and in-depth interviews were conducted with purposively selected healthcare managers to gain deeper insights into the sustainability of the Integrated HIV/HTN care model.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOverview of Integrated HIV/HTN care intervention\u003c/h3\u003e\n\u003cp\u003eThe intervention included: 1) health worker training on integrating HTN care with HIV care; 2) promoting routine HTN screening and care at each clinic visit; 3) improvement of the health management information system, 4) WhatsApp messages for data coordination and communication among frontline Primary Health Care workers and district-level managers. Both arms received blood pressure (BP) machines, Non-Communicable Diseases (NCD) registers, patient cards, HTN care guidelines and buffer stock HTN medicines.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy setting.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study was conducted across 26 public health facilities located within 13 districts in the intervention arm. At the facility level, interviews were conducted with health facility in-charges. The facility in-charges heads the health facility and is responsible for direction and administration of delivery of health services. We selected health facilities because they were all Integrated HIV/HTN care model intervention facilities. From each district, two health Intervention facilities were selected for inclusion in the study. The healthcare facilities involved ranged from Health Centre IIIs (HCIIIs) which are primary healthcare facilities that offer essential services, including outpatient care, maternal and child health, immunizations, and chronic disease management, along with basic diagnostic services and some inpatient beds to Health Centre IVs (HCIVs) which are advanced primary healthcare facilities that serve as referral centers for HCIIIs, offering a broader range of outpatient and inpatient services, including specialized care, advanced diagnostics, and surgery, all participating in the Integrated HIV/HTN care program. The study was conducted between April 2024 to May 2024 for quantitative and January 2023 to February 2023 for qualitative.\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe study population consisted of adults aged 18 years and above living in southwestern Uganda. Eligible participants included members of the district health team i.e. DHOs who oversees district health services, managing programs, allocating resources, implementing policies, and monitoring health outcomes, HIV Focal Persons who coordinates HIV programs, builds capacity, engages communities, manages data, collaborates with stakeholders, and advocates for HIV awareness and resources and health facility/ART in-charges associated with the Integrated HIV/HTN care model. A total of 15 DHOs, 10 HIV/NCD FP and 25 health facility/ART in-charges participated in the study, with each district and facility contributing at least two respondents respectively. The sample size was chosen to be sufficiently large to capture a range of insights across the participating districts and facilities. Participants were drawn from public health facilities and districts located in rural and semi-urban settings, where Integrated HIV/HTN care model was being implemented.\u003c/p\u003e\n\u003ch3\u003eData Collection and Analysis\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eQuantitative Data Collection and Analysis\u003c/h2\u003e\u003cp\u003eIn the study we used The Program Sustainability Assessment Tool (PSAT) that was developed by the Center for Public Health Systems Science at Washington University in St. Louis.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] The same tool has used to evaluate several health intervention programs. [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. We adapted the tool for this program. (Supplementary file #1). The adapted Program Sustainability Assessment Tool was employed to collect quantitative data across seven domains \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003ebelow)\u003c/b\u003e from District Health Officers (DHOs), HIV focal persons, and health facility/ART in-charges (N\u0026thinsp;=\u0026thinsp;50). The PSAT utilizes a 7-point Likert scale to assess the sustainability of the Integrated HIV/HTN intervention components. Scores of 6 or 7 indicated \"to a very great extent,\" while scores of 1 or 2 indicated \"little to no extent.\" Responses marked as \"NA\" indicated an inability to answer.\u003c/p\u003e\u003cp\u003eThe questionnaire data collected were entered into VB software, and responses were appropriately coded for statistical analysis, reflecting the 1\u0026ndash;7 Likert scale. The data were then analysed using Stata software. For each question, the mean score and variability (SD and range) were calculated. The questionnaire was structured into multiple domains, each reflecting a different aspect of project sustainability. To assess each domain, the mean scores of the questions within that domain were aggregated and analyzed to produce a domain-specific average.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eQualitative Data Collection and Analysis\u003c/h2\u003e\u003cp\u003eIn-depth semi-structured interviews (IDI\u0026rsquo;s) were conducted using a guide that included a section designed to elicit participants' insights on the sustainability of the multi-component intervention model. Two qualitative researchers carried out interviews at health centres and district headquarters with healthcare managers and health care providers. Audio recordings were translated and transcribed into English. Two team members independently coded each transcript using Dedoose software. An initial coding framework was developed based on emerging themes and subthemes. Coded excerpts were then summarized into themes, extracted, reviewed, and analyzed. For the mixed-methods synthesis, the investigators simultaneously reviewed the quantitative PSAT question and domain scores and identified qualitative themes to correlate areas of agreement, disagreement, and deeper contextual factors and explanatory meaning suggested by the qualitative themes.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical consideration\u003c/h3\u003e\n\u003cp\u003e All participants provided informed consent to take part in the study. The study was conducted in accordance with the Declaration of Helsinki and it was approved by Makerere University School of Medicine Research Ethics Committee on September 8, 2020 (approval number: 2020\u0026thinsp;\u0026minus;\u0026thinsp;156), the London School of Hygiene and Tropical Medicine on September 2, 2020 (approval number: 22196), and the Uganda National Council for Science and Technology on November 9, 2020 (approval number: HS979ES). Confidentiality was strictly maintained throughout the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant demographics and characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 15 District Health Officers (DHOs) were interviewed, making up 30% of the sample. Ten participants were HIV/NCD Focal Persons (FPs), representing 20%. The largest group was Facility/ART In-charges, with 25 participants, accounting for 50% of the sample. In total, there were 50 participants in the entire sample (Table 1). There were 24 participants representing individual health facilities and 26 participants representing district\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Showing\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ethe distribution of participants by health facility, district, and title/position\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis table presents the number and percentage of participants categorized by health facility, district level and professional role (District Health Officer, HIV/NCD Focal Person, or Facility/ART In-Charge) across 26 intervention sites in southwestern Uganda\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth facility/District\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHealthy facility\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDistrict\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e50\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e100%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRole\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of participants\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDistrict Health Officer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHIV/NCD Focal Person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFacility In-Charge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e50\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e100%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eQuantitative PSAT results in this section are presented based on the average sustainability scores by domain and by Items derived from a 7-point Likert scale as shown in Table 2 below.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. PSAT Survey Results By Domain\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis table summarizes the mean scores, standard deviations (SD), and ranges for each of the seven PSAT domains and their respective items, as assessed by 50 respondents using a 7-point Likert scale. Higher scores indicate stronger perceived sustainability of integrated hypertension/HIV services.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"945\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomain Mean Score (SD) (range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eItem Mean Score (SD)(range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnvironmental Support:\u003c/strong\u003e (Having supportive internal and external climate for the Integration of Hypertension in HIV care and general implementation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e4.73 (1.04) (2-6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExistence of NCD champions.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.94 (1.63) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eThe ability of district partners to mobilize resources\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.24 (1.80) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLeadership support for training and capacity building\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.34 (1.22) (2-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e4.\u0026nbsp;Training plans for providers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.25 (1.73) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e5.\u0026nbsp;Adequate training of healthcare providers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.9 (1.42) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003ePartnerships:\u003c/strong\u003e (Partnerships provide linkages/connections between the INTEGRATED HIV/HTN project and its stakeholders)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e5.70 (0.94) (2.8-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1. Stakeholder interest in the program\u0026rsquo;s success\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.06 (1.61) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2. Communication and involvement of stakeholder leaders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.04 (1.14) (2-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3. Stakeholder leaders are involved with the project.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.86 (1.16) (2-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4. Passionate commitment from stakeholders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.86 (1.14) (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5. Stakeholder engagement in project goals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.56 (1.30) (2-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrganizational Capacity:\u0026nbsp;\u003c/strong\u003e(Health facilities and districts have the internal support and resources needed to effectively integrate Hypertension care into HIV clinics)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e5.66(0.93) (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.\u0026nbsp;Integration of hypertension screening into HIV clinic operations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.26 (0.88) (4-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.\u0026nbsp;Availability of HMIS tools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.02 (1.06) (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.\u0026nbsp;Efficient resource management by leadership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.94 (1.78) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4. Adequate\u0026nbsp;staff training for data management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.1 (1.59) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.\u0026nbsp;Leadership support for hypertension care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.98 (1.20) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntegration of HTN into HIV care evaluation:\u003c/strong\u003e (Integration of HTN into HIV care informed planning and documentation of results)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e5.54 (0.89) (2.2-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.\u0026nbsp;Capacity for quality evaluation of integration services.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.2 (1.37) (2-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.\u0026nbsp;Reporting on short-term and intermediate outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.06 (1.45) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.\u0026nbsp;Use of evaluation results for project planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.48 (1.34) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.\u0026nbsp;Demonstration of success to stakeholders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.68 (1.20) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.\u0026nbsp;Providing evidence of successful integration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.28 (0.70) (5-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eProject Adaptation:\u003c/strong\u003e (Taking actions that adapt your district/facility goals to ensure its ongoing effectiveness)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e5.49 (1.0.2) (1.6-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1. Periodic review of data on hypertension\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.26 (1.31) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.\u0026nbsp;Adaptation of successful strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.44 (1.33) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.\u0026nbsp;Adaptation to new science.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.6 (1.28) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4. Proactive adaptation to changes in the health system delivery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.74 (1.16) (2-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5. Decisions\u0026nbsp;on ineffective components\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.42 (1.47) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunications:\u0026nbsp;\u003c/strong\u003e(Communication and feedback with healthcare providers and managers about the Integration of Hypertension care into HIV clinics was happening)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e5.51 (0.9) (3.4-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.\u0026nbsp;Strategies for communication and feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.44 (1.3) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2. Public\u0026nbsp;communication about integration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.56 (1.1) (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.\u0026nbsp;Generation of interest during reviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.46 (1.0) (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.\u0026nbsp;Promotion of community awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.26 (1.4) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.\u0026nbsp;Demonstrating value to stakeholders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.84 (0.8) (4-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrategic Planning:\u003c/strong\u003e (What processes guide the direction, goals, and strategies of continued implementation of Integration of HTN care into HIV clinics)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\"\u003e\n \u003cp\u003e5.30 (0.9) (2.25-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.\u0026nbsp;Planning for future resource needs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.27 (1.4) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.\u0026nbsp;Long-term sustainability planning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.24 (1.5) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.\u0026nbsp;Understanding of project goals by stakeholders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.74 (0.9) (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4. Clear\u0026nbsp;roles and responsibilities outlined for all stakeholders.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.84 (1.1) (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe PSAT scores for individual questions and aggregate domain are presented in table 2 above. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOverall Sustainability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall mean (SD) sustainability score was 4.6 (1.3) with a range of 1-7. Mean (SD) scores for individual items in the PSAT instrument ranged from a low of 4.24 (1.80)\u0026nbsp;to a high of 6.28 (0.70).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePartnerships \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Partnerships domain emerged with a strong mean (SD) score of 5.68, indicating high levels of engagement from stakeholders. Effective communication (6.04) and stakeholder commitment (5.86) were notable strengths.A related issue that emerged qualitatively from both health care providers and managers was that partnership was repeatedly acknowledged, along with the provision of resources from partners such as BP machines, training for staff, mentorship, and tools like pink cards for data collection, all aimed at promoting sustainable practices in HTN/HIV screening.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOrganizational Capacity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Organizational Capacity domain scored well with a mean of 5.66, excelling in the integration of hypertension screening into HIV clinic operations (6.26), critical for sustainable care. This was supported qualitatively as health care providers frequently emphasized teamwork as a vital key factor for hypertension (HTN) screening and care. Specifically, providers noted that collaborative efforts, including the integration of peers and clinicians, played a critical role in maintaining continuity of HTN screening, especially during times of staff shortages or coverage gaps.HMIS tools scored 6.02, indicating solid data management structures. However, resource management (4.94) and staff training (5.10) were less well scored, highlighting challenges in human resources and operational efficiency that may impact sustainability.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntegration of HTN into HIV Care Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis domain, with an average score of 5.54, shows moderate success in evaluating the integration of HTN into HIV services. The highest score in this category was for providing evidence to the public about the effectiveness of this integration (6.28), demonstrating that the project effectively communicates its success. However, areas like reporting short-term and intermediate outcomes (5.06) and district capacity for evaluation (5.20) could be improved to enhance the overall evaluation process for long term sustainability of the program.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Communications domain scored 5.51, indicating a moderately effective approach. Public communication about the need for integration (5.56) and strategies for feedback (5.44) show some potential for improvement in engaging both internal and external target groups. Healthcare managers and providers have successfully highlighted the benefits of integrating hypertension care into HIV services (5.84), which could help generate greater stakeholder interest\u003cstrong\u003e.\u003c/strong\u003e \u003cstrong\u003eQualitatively health care providers highlighted how\u003c/strong\u003e Patients now have regular access to hypertension screening and treatment during their ART (antiretroviral therapy) visits, allowing those with HTN to receive timely care. This integration makes it possible to identify and manage HTN in patients who previously lacked awareness of their condition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProject Adaptation.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Project Adaptation domain scored 5.49, reflecting a strong ability of the district and health centres to integrate new changes (5.60) and adapt to changes in the healthcare system (5.74). This demonstrates a solid capacity for adaptation. However, there is a minor shortfall in addressing ineffective components, with a score of (5.42).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrategic Planning\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWith an average score of 5.27, the Strategic Planning domain indicates adequate planning but highlights significant challenges, particularly in long-term sustainability (4.24). Planning for future resources (5.27) and clear roles and responsibilities (5.84) show good score, but the lower sustainability score suggests that more focus is needed on ensuring the continuity of Integrated HIV/HTN care model. Qualitatively, the insights shared by healthcare providers highlight those systemic barriers, including work overload, insufficient staffing, irregular drug supplies, and logistical challenges, hinder the sustainability of these essential services. Effective planning and coordinated action are urgently needed to address these issues, with a focus on the following priorities: strengthening human resource capacity, ensuring consistent and adequate medical supplies, improving infrastructure and resources, addressing knowledge gaps and resistance to training, promoting continuity of care despite staff transfers, and leveraging technology for communication and data sharing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnvironmental Support.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis domain had the lowest average score at 4.73, emphasizing the need for stronger environmental support. While leadership support for training (5.34) was relatively high, the ability to mobilize resources (4.24) and the adequacy of training for healthcare providers (4.90) scored lower. This was supported qualitatively as\u0026nbsp;providers emphasized the critical need for consistent environmental support to improve and sustain integrated HIV/HTN care. A key recommendation was to ensure a reliable supply of diverse medications to support effective treatment. They also highlighted the importance of ongoing training and capacity building for healthcare workers to maintain service continuity, especially during staff absences and transfers. Regular training and refresher programs were suggested to equip staff for integrated care. Staff shortages and heavy workloads were identified as barriers, with recommendations to recruit additional staff and ensure backup personnel. Support from district health offices (DHOs) and better supervision were seen as crucial for maintaining service quality. Providers called for more frequent monitoring and regional-level support to ensure accountability and sustainability of integrated services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVariability across health centres and informant role\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo visualize the distribution of PSAT scores overall and by PSAT domain, we utilized a violin plot and then examined the plot for distribution patterns by domain (see Figure 1). \u0026nbsp; We observed three distinct patterns of score distributions: 1) Scores for the Environment domain were shifted downward compared to the overall score distribution reaching further into the lower score ranges, 2) the Partnership and Capacity domain score distributions were shifted upwards towards higher scores with a wider inter-quartile range than all of the other PSAT score domains, and 3) similar score distributions and inter-quartile ranges for the Integration, Adaptation, Communications, and Planning domains. \u0026nbsp;There were some suggestion of more scores of 3 or 4 in the Planning domain within the third observed score cluster pattern.\u003c/p\u003e\n\u003cp\u003eThis table ranks the PSAT domains based on their mean scores to identify the most and least influential domains contributing to sustainability of integrated hypertension and HIV care. Partnerships and Organizational Capacity emerged as the highest scoring domains, while Environmental Support scored lowest.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe Partnerships domain stands out as a notable strength of the Integrated HIV/HTN care model sustainability. The high levels of engagement from stakeholders, coupled with effective communication and strong stakeholder commitment, reflect a solid foundation for collaboration. This strong engagement is crucial for the model\u0026rsquo;s sustainability, as it ensures that key players are actively involved and invested in the model\u0026rsquo;s success. However, there is an identified need to enhance stakeholder interest in the model\u0026rsquo;s long-term outcomes. Addressing this gap could foster deeper commitment and support, further strengthening the sustainability of the care model.\u003c/p\u003e\u003cp\u003eOrganizational Capacity is another domain where the model excels. The integration of hypertension screening into HIV clinic operations and the effective use of Health Management Information Systems (HMIS) tools highlight the model\u0026rsquo;s operational efficiency and data management capabilities. These strengths are vital for maintaining effective service delivery and supporting the care model\u0026rsquo;s sustainability. Nevertheless, challenges remain in resource management and staff training. Improving these aspects is essential for ensuring that the model can continue to operate smoothly and adapt to evolving needs, thereby reinforcing its long-term sustainability.\u003c/p\u003e\u003cp\u003eThe Integration of HTN into HIV Care Evaluation domain also demonstrates significant strengths. The high score for providing evidence about the effectiveness of integration highlights the model\u0026rsquo;s success in communicating its achievements and demonstrating the value of integrating hypertension care into HIV services. This effective communication is crucial for gathering support and confirming the model\u0026rsquo;s impact. However, there is room for improvement in reporting short-term and intermediate outcomes, stakeholder interest in the program's success and evaluating district capacity. Enhancing these evaluation processes could provide a more comprehensive understanding of the integration\u0026rsquo;s impact and support ongoing efforts to optimize the care model sustainability.\u003c/p\u003e\u003cp\u003eIntegration approaches for HIV and hypertension such as co-located services, same-day service integration, chronic care clinics, integrated health information systems, and combined screening and monitoring have been Implemented in the past. These approaches are sustained through investments in staff training, Regular updates, monitoring, cross-departmental collaboration, and ensuring an uninterrupted supply of necessary medications and diagnostic equipment. Support from national health policies, external funding, and partnerships with NGOs or private sector partners play crucial roles in maintaining these integrations over time.\u003c/p\u003e\u003cp\u003eSustainability assessments of such programs are essential to determine whether the integration efforts can be maintained over the long term by them without project support, ensuring that benefits continue to be delivered to patients. Factors influencing the sustainability of integrated HIV and hypertension care include the capacity of the health system, availability of financial resources, adequacy of staff training, level of political commitment, and the ability of health facilities to maintain service delivery beyond initial interventions or pilot programs. Overall, active collaboration and leadership involvement were key factors for Integrated HIV/HTN care model sustainability.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFor the Integrated HIV/HTN care model to sustain its impact, active partnership and leadership involvement are essential. While the domain scores indicate a generally positive environment for partnerships, addressing the gaps in stakeholder interest can further strengthen the program\u0026rsquo;s sustainability. Ensuring that all involved parties remain engaged and see value in the program will help maintain their support and involvement, which is critical for long-term success. However, the lower scores in environmental support and resource management highlight areas that need focused attention. Addressing these gaps, particularly in sustainability planning and resource mobilization, will be critical for the long-term sustainability of integrating HIV and HTN care models.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe study received ethical approval from the Makerere University School of Medicine Research Ethics Committee (approval number: 2020-156), the London School of Hygiene and Tropical Medicine (approval number: 22196), and the Uganda National Council for Science and Technology (approval number: HS979ES). All participants provided informed consent to take part in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm contribution to the paper as follows:\u0026nbsp;A.B and M.A wrote the main manuscript text, E.D.C. prepared figure 1, M.A prepared table 2, A.B., E.A., W.T., AM collected PSAT data. B.A. and A.M. collected qualitative data and coded. \u0026nbsp;And B.T., A.A., E.O., G.M., J.N., M.R.K., E.D.C and J.K. reviewed the manuscript.\u0026nbsp;All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by European and Developing Countries Clinical Trials Partnership (EDCTP) Grant Number: CSA2018HS-2518.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere gratitude to the District Health Officers (DHOs), HIV focal persons, and facility in-charges for their time, collaboration, and willingness to share valuable data, which were instrumental to the success of this manuscript. We deeply appreciate their commitment and support throughout the data collection process.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOwusu, R., et al., \u003cem\u003eA qualitative exploration of policy interventions to improve the health-related quality of life of people living with HIV AIDS and co-morbidities of hypertension and/or diabetes in Ghana.\u003c/em\u003e PLoS One, 2024. \u003cstrong\u003e19\u003c/strong\u003e(10): p. e0311994.\u003c/li\u003e\n\u003cli\u003eKasango, A., A. Daama, and L. Negesa, \u003cem\u003eChallenges in managing HIV and non-communicable diseases and health workers\u0026apos; perception regarding integrated management of non-communicable diseases during routine HIV care in South Central Uganda: A qualitative study.\u003c/em\u003e PLoS One, 2024. \u003cstrong\u003e19\u003c/strong\u003e(8): p. e0302290.\u003c/li\u003e\n\u003cli\u003eLopez, A.D., et al., \u003cem\u003eRemembering the forgotten non-communicable diseases.\u003c/em\u003e BMC medicine, 2014. \u003cstrong\u003e12\u003c/strong\u003e(1): p. 200.\u003c/li\u003e\n\u003cli\u003eAmbaw Kassie, G., et al., \u003cem\u003eUndiagnosed hypertension and associated factors among adults in ethiopia: a systematic review and meta-analysis.\u003c/em\u003e BMC Cardiovasc Disord, 2023. \u003cstrong\u003e23\u003c/strong\u003e(1): p. 278.\u003c/li\u003e\n\u003cli\u003eSchutte, A.E., et al., \u003cem\u003eHypertension in Low- and Middle-Income Countries.\u003c/em\u003e Circ Res, 2021. \u003cstrong\u003e128\u003c/strong\u003e(7): p. 808-826.\u003c/li\u003e\n\u003cli\u003eTopp, S.M., et al., \u003cem\u003eHow to assess and prepare health systems in low- and middle-income countries for integration of services-a systematic review.\u003c/em\u003e Health Policy Plan, 2018. \u003cstrong\u003e33\u003c/strong\u003e(2): p. 298-312.\u003c/li\u003e\n\u003cli\u003eAmuche, N.J., E.I. Emmanuel, and N.E. Innocent, \u003cem\u003eHIV/AIDS in sub-Saharan Africa: Current status, challenges and prospects.\u003c/em\u003e Asian Pacific Journal of Tropical Disease, 2017. \u003cstrong\u003e7\u003c/strong\u003e(4): p. 239-256.\u003c/li\u003e\n\u003cli\u003eTesema, A.G., et al., \u003cem\u003eHow well are non-communicable disease services being integrated into primary health care in Africa: A review of progress against World Health Organization\u0026rsquo;s African regional targets.\u003c/em\u003e PloS one, 2020. \u003cstrong\u003e15\u003c/strong\u003e(10): p. e0240984.\u003c/li\u003e\n\u003cli\u003eHeyeres, M., et al., \u003cem\u003eThe Complexity of Health Service Integration: A Review of Reviews.\u003c/em\u003e Front Public Health, 2016. \u003cstrong\u003e4\u003c/strong\u003e: p. 223.\u003c/li\u003e\n\u003cli\u003eRabkin, M., et al., \u003cem\u003eStrengthening Health Systems for Chronic Care: Leveraging HIV Programs to Support Diabetes Services in Ethiopia and Swaziland.\u003c/em\u003e J Trop Med, 2012. \u003cstrong\u003e2012\u003c/strong\u003e: p. 137460.\u003c/li\u003e\n\u003cli\u003eBukenya, D., et al., \u003cem\u003eIntegrated healthcare services for HIV, diabetes mellitus and hypertension in selected health facilities in Kampala and Wakiso districts, Uganda: A qualitative methods study.\u003c/em\u003e PLOS Glob Public Health, 2022. \u003cstrong\u003e2\u003c/strong\u003e(2): p. e0000084.\u003c/li\u003e\n\u003cli\u003eUganda, M.o.H., \u003cem\u003eConsolidated Guidelines for the Prevention and Treatment of HIV and Aids in Uganda\u003c/em\u003e. 2022, Ministry of Health.\u003c/li\u003e\n\u003cli\u003eTool, C.f.P.H.S.S.P.C.P.S.A. \u003cem\u003ePSAT/CSAT: Program Sustainability Assessment Tool Washington University in St. Louis; \u003c/em\u003e. Available from: https://sustaintool.org/psat/resources/.\u003c/li\u003e\n\u003cli\u003eLuke, D.A., et al., \u003cem\u003eThe Program Sustainability Assessment Tool: a new instrument for public health programs.\u003c/em\u003e Prev Chronic Dis, 2014. \u003cstrong\u003e11\u003c/strong\u003e: p. 130184.\u003c/li\u003e\n\u003cli\u003eMoreland-Russell, S., et al., \u003cem\u003eAction planning for building public health program sustainability: results from a group-randomized trial.\u003c/em\u003e Implementation Science, 2024. \u003cstrong\u003e19\u003c/strong\u003e(1): p. 9.\u003c/li\u003e\n\u003cli\u003eCalhoun, A., et al., \u003cem\u003eUsing the Program Sustainability Assessment Tool to assess and plan for sustainability.\u003c/em\u003e Prev Chronic Dis, 2014. \u003cstrong\u003e11\u003c/strong\u003e: p. 130185.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hypertension, HIV, Integration, Program Sustainability Assessment","lastPublishedDoi":"10.21203/rs.3.rs-7262810/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7262810/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e The co-occurrence of HIV and non-communicable diseases (NCDs), particularly hypertension, is a growing global health issue. As people living with HIV (PLHIV) live longer due to antiretroviral therapy (ART), they become more susceptible to NCDs like hypertension. The integrated HIV/HTN project implemented a feasible and cost-effective multi-component intervention in several public health facilities in Uganda. In this study, we sought to evaluate the program sustainability of the intervention by the public health delivery system.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e A mixed-methods cross-sectional study was conducted across 26 public health facilities in 13 intervention districts of southwestern Uganda. Quantitative data were collected using the Program Sustainability Assessment Tool (PSAT) from District Health Officers (N=15), HIV focal persons (N=10), and ART in-charges (N=25). Qualitative data were gathered through in-depth interviews with healthcare managers and analyzed using Stata and Dedoose software.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e The PSAT Partnerships domain scored high (5.68), reflecting strong stakeholder engagement, communication, and leadership involvement. The Organizational Capacity domain also performed well (5.66), with strong integration of hypertension screening and data management, resource management and staff training rated at 4.24 and 4.9 respectively. Integration of HTN into HIV Care Evaluation scored (5.54), excelling in public communication but needing improvement in reporting and evaluation capacity. The Communications domain (5.51) showed moderate effectiveness, with room to enhance public engagement and feedback strategies. Environmental Support was the weakest domain (4.73), highlighting the need for better resource mobilization and training adequacy.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e The sustainability of a multi-component care modelwas strongly influenced by strong partnerships and leadership. To ensure long-term success, environmental support, resource management, and sustainability planning is essential. Addressing these gaps will strengthen ongoing integration efforts in resource-limited settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistry: \u003c/strong\u003eClinicalTrials.gov, TRN: NCT04624061, Registration date: 04 November 2022\u003c/p\u003e","manuscriptTitle":"Partnerships and Organisational Capacity Domains are most Influential in Program Sustainability of an Integration of Hypertension Care into HIV Services","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-29 17:26:10","doi":"10.21203/rs.3.rs-7262810/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-27T04:37:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-11T16:36:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-03T16:06:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310044548940099812020167830972596497657","date":"2025-08-26T18:17:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319767676401619095432760947600714066851","date":"2025-08-26T17:20:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133275361695121842868406383964673825898","date":"2025-08-21T16:17:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-21T16:11:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-14T09:52:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-14T09:34:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-08-14T09:31:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b8bf680c-eec6-443a-b309-933baa33cfec","owner":[],"postedDate":"August 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T09:45:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-29 17:26:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7262810","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7262810","identity":"rs-7262810","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}