Organizational Readiness and Leadership to Implement Integrated HIV-Hypertension Care at HIV Clinics in Uganda: A Prospective Single Arm Study Nested in a Stepped Wedge Cluster Randomized Trial

Background: Uganda's established HIV service platform could support integrated hypertension care, but organizational conditions required for implementation in resource-limited settings are poorly described. We characterized organizational readiness, implementation leadership, and implementation citizenship behaviour during implementation of integrated HIV-hypertension care in Kampala and Wakiso districts, Uganda. Methods: We conducted a prospective cohort study nested within a stepped-wedge cluster-randomized trial at 16 public and private-not-for-profit HIV clinics implementing "hypertension BASIC- (basic training, supply of blood pressure devices and medications)" or "hypertension PLUS (BASIC components plus enhanced training, performance feedback and differentiated service delivery for hypertension)". Healthcare providers completed the 12-item Organizational Readiness for Implementing Change scale at intervention rollout and trial completion, and the 12-item Implementation Leadership Scale and Implementation Citizenship Behavior Scale (six items) at six months and post intervention. Scores were standardized to 0-100. Changes were assessed using independent-samples tests, with facility-clustered linear regression as sensitivity analyses. Intraclass correlation coefficients (ICCs) assessed agreement between clinic-lead self-ratings and staff ratings. Results: Forty-three healthcare providers participated at baseline, 42 at six months, and 41 at completion. The median age was 34 years (IQR: 30-42), and 24 (56%) were female Organizational readiness remained high (mean scores, 88.8-94.6% across arms and assessment periods), without significant changes over time. Leadership scores generally exceeded 75%, while citizenship behaviour scores exceeded 80%. In facility-clustered analyses, HTN PLUS clinic leads reported increases in overall leadership (10.7 percentage points; 95% CI 1.1-20.3, p=0.009) and proactive leadership (12.8; 95% CI 0.8-24.9, p=0.026); HTN BASIC clinic leads reported increased supportive leadership (19.2; 95% CI 6.0-32.4, p=0.012). Staff leadership ratings and citizenship behaviour did not change significantly. Conclusion: Trial-supported HIV clinics demonstrated sustained readiness, strong leadership, and supportive citizenship behaviours for integrated care. However, declining leader-staff agreement highlights the value of multisource feedback. Future analyses should determine whether these organizational conditions translate into improved adoption, fidelity, and clinical outcomes. Trial Registration #: NCT05609513. Registration date, November 8, 2022.