Integrating Human Immunodeficiency Virus and Reproductive, Maternal and Child, and Tuberculosis Health Services Within National Health Systems

Integrating HIV services and other health services: A systematic review and meta-analysis

BACKGROUND

Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness.

METHODS AND FINDINGS

We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41-1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16-1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20-1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05-2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03-1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response.

CONCLUSIONS

Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of 'ending AIDS by 2030', while simultaneously supporting progress towards universal health coverage.

Integrating Oral PrEP Into Family Planning Services for Women in Sub-saharan Africa: Findings From a Multi-Country Landscape Analysis

Integration of HIV and family planning (FP) services is a renewed focus area for national policymakers, donors, and implementers in sub-Saharan Africa as a result of high HIV incidence among general-population women, especially adolescent girls and young women (AGYW), and the perception that integrating HIV pre-exposure prophylaxis (PrEP) into FP services may be an effective way to provide comprehensive HIV and FP services to this population. We conducted a focused desk review to develop a PrEP-FP integration framework across five key categories: plans and policies, resource management, service delivery, PrEP use, and monitoring and reporting. The framework was refined via interviews with 30 stakeholders across seven countries at varying stages of oral PrEP rollout: Kenya, Lesotho, Malawi, South Africa, Uganda, Zambia, and Zimbabwe. After refining the framework, we developed a PrEP-FP integration matrix and assessed country-specific progress to identify common enablers of and barriers to PrEP-FP integration. None of the countries included in our analysis had made substantial progress toward integrated PrEP-FP service delivery. Although the countries made progress in one or two categories, integration was often impeded by lack of advancement in other areas. Our framework offers policymakers, program implementers, and health care providers a road map for strategically assessing and monitoring progress toward PrEP-FP integration in their contexts.

Implementation and experiences of integrated prevention of mother-to-child transmission services in Tanzania, Malawi and South Africa: A mixed methods study

Although integration of HIV and maternal health services is recommended by the World Health Organization, evidence to guide implementation is limited. We describe facility-level implementation of policies for integrating HIV care within maternal health services and explore experiences of service users and providers in rural Tanzania (Ifakara), South Africa (uMkhanyakude) and Malawi (Karonga). Policy in all countries included HIV testing during antenatal care (ANC), same-day antiretroviral therapy (ART) initiation for HIV-positive pregnant women, and postpartum referral to ART clinics, between six weeks (Malawi, South Africa) and two years after delivery (Tanzania). All facilities offered HIV testing within ANC, most commonly during the first visit. Although most women were comfortable with HIV testing, some felt that opting out would lead to sub-standard services. Some facilities conducted group post-test counselling for HIV-negative women, raising concerns of unintended HIV status disclosure. ART initiation was offered on the same day, the same room as an HIV diagnosis in >90% of facilities. Women’s worries around postpartum referral included having unknown providers, insufficient privacy and queues. Adoption and implementation of policies on integrated HIV and maternal health services varied across settings. Patients’ experiences of these policies may influence uptake and retention in care.

Health systems software factors and their effect on the integration of sexual and reproductive health and HIV services

Despite a large and growing body of literature on sexual and reproductive health (SRH) and HIV integration, the drivers of integration of SRH and HIV services, from a health systems perspective, are not well understood. These drivers include complex so-called hardware (structural and resource) and software (values and norms, and human relations and interactions) factors. Two groups of software factors emerge as essential enablers of effective integration of SRH and HIV services that often interact with systems hardware: (1) leadership, management, and governance processes and (2) provider motivation, agency, and relationships. Evidence suggests the potential for software elements that are essential enablers to overcome some of the obstacles posed by the non-integration of health system hardware elements (eg, financing, guidelines, and commodity supplies). These enabling factors include flexible decision making, inclusive management, and support in motivating frontline staff who can work with agency as a team. Improved software, even within constrained hardware (especially in low-income and middle-income countries), can directly contribute to improved SRH and HIV service delivery.

Challenges in accessing and utilising health services for women accessing DOTS TB services in Kolkata, India

Challenges in accessing and utilising TB treatment are a major reason for the existing gaps in tuberculosis (TB) control in India. Twenty qualitative interviews were conducted with women who were attending or had attended a directly observed treatment short course (DOTS) clinic in Kolkata, India. The resulting data were analysed using a thematic approach. Our results indicated that women experienced several challenges categorised as (1) DOTS specific challenges, (2) lack of client friendly services, and (3) resource constraints. DOTS specific challenges included having to come to the clinic for medicines, lack of privacy, providers minimising contact with patients, length of treatment, drug side effects and pill burden. Lack of client friendly services led to mistrust in government services and a preference for private providers, which was compounded by corruption in the medical system. Inability to complete household duties due to inflexible clinic hours, long lines and overcrowded spaces, and mistreatment from providers were further challenges faced by women. Lastly, resource constraints meant women faced financial difficulties with additional treatment costs and suffered from lack of adequate food and nutrition. Our findings lead to several recommendations for addressing these challenges that should help improve women's experiences with DOTS TB treatment.

Current and future priorities for the development of optimal HIV drugs

PURPOSE OF REVIEW

To summarize global efforts to accelerate access to simpler, safer and more affordable antiretroviral drugs and how this has shaped HIV treatment policy over the last decade, and outline future priorities. Several expert consultations aimed at aligning opportunities for optimization of antiretroviral drugs have been convened by WHO in partnership with academic institutions, international agencies, innovators and manufacturers. The increased access to lifelong treatment for people living with HIV also brings about new challenges in the long-term use of antiretrovirals (ARVs).

RECENT FINDINGS

The article describes the evolution of global research agenda on ARV optimization ascribing the characteristics of a target product profile, the importance of sequencing of first-line and second-line regimens, the role of programmatic data when looking at policy transition for new ARVs, inclusion of more subpopulations living with HIV, as well as the challenges in identifying what improvements can be made in an era where drugs are already safe, tolerable and efficacious.

SUMMARY

Within a framework of evolving treatment harmonization and simplification, future therapeutic options in development must take into consideration safety and efficacy across a range of patient populations as well the mode of administration in the context of lifelong therapy.

Reorienting health systems to care for people with HIV beyond viral suppression

The effectiveness of antiretroviral therapy and its increasing availability globally means that millions of people living with HIV now have a much longer life expectancy. However, people living with HIV have disproportionately high incidence of major comorbidities and reduced health-related quality of life. Health systems must respond to this situation by pioneering care and service delivery models that promote wellness rather than mere survival. In this Series paper, we review evidence about the emerging challenges of the care of people with HIV beyond viral suppression and identify four priority areas for action: integrating HIV services and non-HIV services, reducing HIV-related discrimination in health-care settings, identifying indicators to monitor health systems' progress toward new goals, and catalysing new forms of civil society engagement in the more broadly focused HIV response that is now needed worldwide. Furthermore, in the context of an increasing burden of chronic diseases, we must consider the shift that is underway in the HIV field in relation to burgeoning policy and programmatic efforts to promote healthy ageing.

'Protecting Life in Global Health Assistance'? Towards a framework for assessing the health systems impact of the expanded Global Gag Rule

During his first week in office, US President Donald J Trump issued a presidential memorandum to reinstate and broaden the reach of the Mexico City policy. The Mexico City policy (which was in place from 1985–1993, 1999–2000 and 2001–2009) barred foreign non-governmental organisations (NGOs) that received US government family planning (FP) assistance from using US funds or their own funds for performing, providing counselling, referring or advocating for safe abortions as a method of FP. The renamed policy, Protecting Life in Global Health Assistance (PLGHA), expands the Mexico City policy by applying it to most US global health assistance. Thus, foreign NGOs receiving US global health assistance of nearly any type must agree to the policy, regardless of whether they work in reproductive health. This article summarises academic and grey literature on the impact of previous iterations of the Mexico City policy, and initial research on impacts of the expanded policy. It builds on this analysis to propose a hypothesis regarding the potential impact of PLGHA on health systems. Because PLGHA applies to much more funding than it did in its previous iterations, and because health services have generally become more integrated in the past decade, we hypothesise that the health systems impacts of PLGHA could be significant. We present this hypothesis as a tool that may be useful to others’ and to our own research on the impact of PLGHA and similar exogenous overseas development assistance policy changes.

Collaborative care for the detection and management of depression among adults receiving antiretroviral therapy in South Africa: study protocol for the CobALT randomised controlled trial

Background

The scale-up of antiretroviral treatment (ART) programmes has seen HIV/AIDS transition to a chronic condition characterised by high rates of comorbidity with tuberculosis, non-communicable diseases (NCDs) and mental health disorders. Depression is one such disorder that is associated with higher rates of non-adherence, progression to AIDS and greater mortality. Detection and treatment of comorbid depression is critical to achieve viral load suppression in more than 90% of those on ART and is in line with the recent 90-90-90 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets. The CobALT trial aims to provide evidence on the effectiveness and cost-effectiveness of scalable interventions to reduce the treatment gap posed by the growing burden of depression among adults on lifelong ART.

Methods

The study design is a pragmatic, parallel group, stratified, cluster randomised trial in 40 clinics across two rural districts of the North West Province of South Africa. The unit of randomisation is the clinic, with outcomes measured among 2000 patients on ART who screen positive for depression using the Patient Health Questionnaire (PHQ-9). Control group clinics are implementing the South African Department of Health’s Integrated Clinical Services Management model, which aims to reduce fragmentation of care in the context of rising multimorbidity, and which includes training in the Primary Care 101 (PC101) guide covering communicable diseases, NCDs, women’s health and mental disorders. In intervention clinics, we supplemented this with training specifically in the mental health components of PC101 and clinical communications skills training to support nurse-led chronic care. We strengthened the referral pathways through the introduction of a clinic-based behavioural health counsellor equipped to provide manualised depression counselling (eight sessions, individual or group), as well as adherence counselling sessions (one session, individual). The co-primary patient outcomes are a reduction in PHQ-9 scores of at least 50% from baseline and viral load suppression rates measured at 6 and 12 months, respectively.

Discussion

The trial will provide real-world effectiveness of case detection and collaborative care for depression including facility-based counselling on the mental and physical outcomes for people on lifelong ART in resource-constrained settings.

Trial registration

ClinicalTrials.gov (NCT02407691) registered on 19 March 2015; Pan African Clinical Trials Registry (201504001078347) registered on 19/03/2015; South African National Clinical Trials Register (SANCTR) (DOH-27-0515-5048) NHREC number 4048 issued on 21/04/2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2517-7) contains supplementary material, which is available to authorized users.

Integrating tuberculosis and antimicrobial resistance control programmes

Many low- and middle-income countries facing high levels of antimicrobial resistance, and the associated morbidity from ineffective treatment, also have a high burden of tuberculosis. Over recent decades many countries have developed effective laboratory and information systems for tuberculosis control. In this paper we describe how existing tuberculosis laboratory systems can be expanded to accommodate antimicrobial resistance functions. We show how such expansion in services may benefit tuberculosis case-finding and laboratory capacity through integration of laboratory services. We further summarize the synergies between high-level strategies on tuberculosis and antimicrobial resistance control. These provide a potential platform for the integration of programmes and illustrate how integration at the health-service delivery level for diagnostic services could occur in practice in a low- and middle-income setting. Many potential mutual benefits of integration exist, in terms of accelerated scale-up of diagnostic testing towards rational use of antimicrobial drugs as well as optimal use of resources and sharing of experience. Integration of vertical disease programmes with separate funding streams is not without challenges, however, and we also discuss barriers to integration and identify opportunities and incentives to overcome these.

Early infant diagnosis of HIV: review of current and innovative practices

PURPOSE OF REVIEW

Only 51% of HIV-exposed infants receive an HIV test between 4 and 6 weeks of age, with even lower repeat testing rates at older ages, and only 49% of infants tested are initiated on antiretroviral therapy. The purpose of this article is to discuss potential solutions for increasing coverage of early infant diagnosis (EID), decreasing turnaround time for result return, improving linkages to care and treatment and fulfilling the objective of improving outcomes for HIV-infected children.

RECENT FINDINGS

Differences in HIV testing guidelines have emerged in different countries, with some recommending HIV testing at birth. Although EID programs are not yet optimal, some solutions have proven successful including the use of short message service printers, community-based interventions and support and education of mothers. Birth and EID point-of-care testing have emerged as potential game changers for improving EID programs.

SUMMARY

For EID programs to impact on child health outcomes, by preventing HIV-associated morbidity and mortality, and provide more value than a mere surveillance tool, efforts need to be aligned toward the implementation of a comprehensive set of interventions that take cognizance of different contexts, epidemiology and health systems, and that are backed by political and community support.

Integration of sexually transmitted infection (STI) services into HIV care and treatment services for women living with HIV: a systematic review

OBJECTIVE

To review and critically appraise the existing evidence on integration of sexually transmitted infection (STI) services into HIV care and treatment services for women living with HIV.

DESIGN

Systematic review.

DATA SOURCES

Four electronic databases were searched through 16February 2017 using keywords for HIV, STIs and integration. Reference lists of included articles and other reviews were also screened.

REVIEW METHODS

We included studies that compared women living with HIV who received STI services integrated into HIV care and treatment services with those who received HIV care and treatment services without integrated STI services or standard of care.

RESULTS

Of 170 articles identified, 3 studies reported in 4 articles were included. Two studies evaluated comprehensive care for people living with HIV in the UK; in both cases, quality and uptake of STI services seemed to improve following integration. The third study conducted a comparative case study across different models of care in Swaziland: two clinics integrated with sexual and reproductive health services (including STI services), and two stand-alone HIV clinics (without STI services). Coverage for Pap smears among women living with HIV was higher at the fully integrated site, but there was no significant difference in the prevalence of sexual health screening or advice on sexual health. Reported client satisfaction was generally higher at the stand-alone HIV clinic, and a diverse range of factors related to implementation of different care models challenged the notion that integrated services are always superior or desired.

CONCLUSION

While there is a limited evidence base for integrating STI services into HIV care and treatment services, existing studies indicate that integration is feasible and has the potential for positive outcomes. However, diverse population needs and health system factors must be considered when designing models of care to provide STI services to women living with HIV.

Decentralising and integrating HIV services in community-based health systems: a qualitative study of perceptions at macro, meso and micro levels of the health system

INTRODUCTION

HIV services at the community level in Kenya are currently delivered largely through vertical programmes. The funding for these programmes is declining at the same time as the tasks of delivering HIV services are being shifted to the community. While integrating HIV into existing community health services creates a platform for increasing coverage, normalising HIV and making services more sustainable in high-prevalence settings, little is known about the feasibility of moving to a more integrated approach or about how acceptable such a move would be to the affected parties.

METHODS

We used qualitative methods to explore perceptions of integrating HIV services in two counties in Kenya, interviewing national and county policymakers, county-level implementers and community-level actors. Data were recorded digitally, translated, transcribed and coded in NVivo10 prior to a framework analysis.

RESULTS

We found that a range of HIV-related roles such as counselling, testing, linkage, adherence support and home-based care were already being performed in the community in an ad hoc manner. However, respondents expressed a desire for a more coordinated approach and for decentralising the integration of HIV services to the community level as parallel programming had resulted in gaps in HIV service and planning. In particular, integrating home-based testing and counselling within government community health structures was considered timely.

CONCLUSIONS

Integration can normalise HIV testing in Kenyan communities, integrate lay counsellors into the health system and address community desires for a household-led approach.