Access to hypertension care remains insufficient, particularly in remote rural areas in resource-limited settings. Community health workers (CHWs), lay providers living in the communities they serve, may help close this gap, but the effectiveness and safety of lay CHW-led hypertension care-including independent initiation and titration of medication-remain uncertain. We conducted a 1:1 cluster-randomized trial nested within the Community-Based Chronic Care Lesotho (ComBaCaL) cohort study in 103 rural villages in Lesotho. Following community-based hypertension screening, 547 nonpregnant adults with blood pressure (BP) ≥140/90 mm Hg were enrolled (274 control and 273 intervention). In intervention clusters, lay CHWs independently prescribed and titrated a fixed-dose combination of amlodipine and hydrochlorothiazide, guided by a mobile clinical decision support system. In control clusters, participants were referred to health facilities for standard care. The primary objective was to assess the effectiveness and safety of lay CHW-led care, with the primary outcome defined as BP <140/90 mm Hg at 12 months. In the intention-to-treat analysis (543 participants with 4 exclusions owing to intercurrent pregnancy), BP control was achieved by 156/271 (58%) versus 130/272 (48%) in intervention and control arms, respectively (adjusted odds ratio 1.52, 95% confidence interval 1.01 to 2.29, P = 0.046). A predefined complete case analysis yielded consistent results. No relevant differences in safety outcomes were observed. Among people with uncontrolled hypertension, lay CHW-led, CDSS-supported care was safe and more effective than referral to facility-based professional care. These findings support expanding first-line hypertension management by lay CHWs in remote, resource-limited settings. Clinicaltrials.gov registration: NCT05684055 .
© 2026. The Author(s), under exclusive licence to Springer Nature America, Inc.