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

Abstract

Joint United Nations Programme on HIV/AIDS (UNAIDS) established 90–90–90 HIV treatment targets for 2020 including the following: 90 % of HIV-infected people know their HIV status, 90 % of HIV-infected people who know their status are on treatment, and 90 % of people on HIV treatment have a suppressed viral load. Integration of HIV and other programs into the national health system provides an important pathway to reach those targets. We examine the case for integrating HIV and other health services to ensure sustainability and improve health outcomes within national health systems. In this non-systematic review, we examined recent studies on integrating HIV, tuberculosis (TB), maternal-child health (MCH), and sexually transmitted infection (STI) programs. Existing evidence is limited about the effectiveness of integration of HIV and other services. Most studies found that service integration increased uptake of services, but evidence is mixed about the effect on health outcomes or quality of health services. More rigorous studies of different strategies to promote integration over a wider range of services and settings are needed. Research on how best to maximize benefits, including sustainability, of integrated services is necessary to help inform international and national policy. We recommend additional interventions to test how best to integrate HIV and MCH services, HIV and TB services, HIV testing and treatment, and STI testing and treatment.

Introduction

Joint United Nations Programme on human immunodeficiency virus (HIV)/Acquired Immuno-Deficiency Syndrome (AIDS) (UNAIDS) has established ambitious 90–90–90 HIV treatment targets for 2020: 90 % of people living with HIV know their HIV status, 90 % of people who know their HIV-positive status are on treatment, and 90 % of people on HIV treatment have a suppressed viral load. In addition, UNAIDS is working toward a target of reducing new HIV infections from the current rate of two million per year to less than half a million a year by 2020 [1]. Further, the United Nation’s Sustainable Development Goal (SDG) #3.3 is to “end the epidemics of AIDS, tuberculosis (TB), malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases” by 2030.

In the past decade, countries have geared up their response to providing care and treatment for those HIV-infected in low- and middle-income countries, supported by initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United States (US) President Emergency Plan for AIDS Relief (PEPFAR), the World Bank Multi-Country AIDS Program (MAP), the Gates Foundation, and bilateral donors.

Those contributions have led to unprecedented attention for HIVas a health issue in low- and middle-income countries and have enabled many people living with HIV/AIDS (PLWHA) to live longer, healthier lives. However, the introduction of antiretroviral treatment (ART), along with other HIV prevention, care, and treatment interventions exposed the results of “decades of neglect of the health sector, economic crises, structural adjustments, declining public expenditures, and decentralized financing, particularly in Sub-Saharan Africa” [2]. This is one reason for the recent revival of the long-standing debate on whether scaling up the responses to specific health problems in developing countries, especially HIV, is strengthening or weakening their stretched and fragmented health systems [3–8].

PEPFAR was established as a disease-specific or vertical funding initiative. Other funders tend to use a horizontal or health systems approach to funding, for example, supporting infrastructure development, laboratory support, and training for all health professionals, instead of those only focused on one disease. Other funders have advocated for “diagonal” financing which aims for disease-specific results through improved health systems [9]. Evidence has shown that HIV-related deaths declined in PEPFAR focus countries relative to other African countries, but trends in HIV prevalence were not different between PEPFAR focus and non-focus countries [10]. In addition, Bendavid et al. found evidence that all-cause age-adjusted adult mortality declined more in PEPFAR focus countries compared to non-focus African countries (4.1 per 1000 (95 % CI, 3.6–4.6) in the focus countries and 6.9 per 1000 (95 % CI, 6.3–7.5) in the non-focus countries) [11]. However, Bendavid’s cross-sectional analysis did not prove a causal association between PEPFAR and mortality declines. There has been anecdotal evidence showing collateral benefits from HIV funding initiatives (e.g. PEPFAR) improve health systems and may improve other health outcomes. However, the ability of disease-specific program like PEPFAR or Global Fund to have a spill-over effect and improve health outcomes has been questioned. Duber et al. found that vertical programs, even on the scale of PEPFAR, may not impact health outcomes that were not specifically targeted on a national level [12]. Attempts have been made to integrate donor-funded HIV prevention, care, and treatment programs into national health systems to ensure efficiency and sustainability, including: TB [13••, 14], maternal-child health (MCH) [15–20], cervical cancer screening [21], sexually transmitted infection (STI) [16, 22], and family planning [23, 24] programs. In addition, ART has increased the life expectancy of people living with HIV, and HIV is now considered a chronic disease. The development of chronic care models, such as those for non-communicable diseases (e.g., diabetes and hypertension), is needed [25]. However, many of the abovementioned integration efforts were either small pilots or studies or were not sustained following initial investment. As a result, HIV prevention, care, and treatment programs tend to remain vertical, or even stand-alone, in many low- and middle-income countries.

Integration of HIV and other programs into the national health system provides an important pathway to reach the ambitious UNAIDS 90–90–90 and SDG targets. In this paper, we examine the case for integrating HIV and other health services to ensure sustainability and improve health outcomes within national health systems. In this non-systematic review, the authors discuss the mixed evidence around the impact of integrating HIV, TB, MCH, and STI programs and lay out research priorities to determine how to approach issues of integration of health services to advance progress toward global 90–90–90 and SDG targets.

Discussion

Since integrated health services mean different things to different people—it is important to be clear about our definition of integration first and foremost. There are several definitions which refer to different levels of health care organization (e.g., integration of funding, integration of program design, integration of facilities, provider tasks, etc.). For this paper, a working definition of integrated health services is “The management and delivery of HIV and health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system.” [26] However, integrating HIV and health services does not mean that everything has to be integrated into one package, as there are many possible permutations. Further, we acknowledge that integration is not a cure for inadequate resources, nor will it solve questions of longer-term sustainability.

Integration of HIV and other health services is thought to be critical to improve health outcomes and efficiency gains. Further, integration of HIV services into existing national routine care may be able to help improve the sustainability of such services [27–29]. As a result, several African countries have developed national policies to support integration of HIV into primary care. For example, Botswana has an integrated national health plan, which includes the goal of “strengthening coordination and integration of HIV prevention initiatives in all health care services.” [30]. However, Botswana, like most of its neighbors, suffers from a chronic shortage of available medical personnel and limited training or skills within a country with a small population spread over a vast geographic area, with high burden of diseases (TB HIV, cervical cancer, etc.). As part of the promise of equitable service provision, health facilities are spread around the country in an attempt to provide health care access within an 8-km radius for all communities, regardless of population density. However, this creates an additional strain to the resources. Although countries like Botswana have prioritized integration in the country health plan, the implementation of the plan remains incomplete because of constraints on human resource and infrastructure.

The need to integrate HIV, TB, MCH including family planning, and STI programs has been recognized at an international, national policy, and organization levels. However, the challenge is how to translate policies into action, followed by monitoring implementation to ensure that the anticipated benefits of integration, including sustainability and improved efficiency and health outcomes, are achieved. Below, we report on select recent progress and challenges to implementation of integrated health services and make recommendations for future research to build evidence on how best to integrate services for sustainability and health impact.

Integration of HIV and Reproductive and Maternal Health Services

In MCH, most of the literature around integration of HIV services focuses on the following: (a) contraception/family planning and (b) antenatal/obstetric care. The evidence around integration of HIV and MCH services is mixed and depends largely on what services were integrated and how the services were delivered. A 2010 Cochrane review found that adding family planning or HIV counseling and testing to routine services probably increases service utilization but probably does not improve health outcomes. The authors found evidence that integrating STI, family planning, and MCH services into routine care, as opposed to delivering vertical services, may de-crease utilization and client knowledge of and satisfaction with the services and may not result in any difference in health outcomes, such as child survival. Further, integrating HIV testing and treatment improved the effectiveness of STI treatment in males but resulted in no difference in health-seeking behavior, STI incidence, or HIV incidence in the population. The authors noted that there is some evidence that adding on services may improve the utilization and outputs of health care delivery [31].

One of our studies of PEPFAR countries found that integration of ART into antenatal care (ANC) was associated with increases in eligible women initiating ART before delivery compared to a separate ART clinic. Further, point-of-care CD4 cell testing was associated with decreased delays to ART initiation compared to clinics with laboratory testing [18]. Addressing the postnatal needs of new mothers is another neglected area of HIV care throughout sub-Saharan Africa. A 2015 study in Kenya by Kimani et al. found that integrating family planning and HIV counseling and testing increased the uptake of both services among postpartum women, when compared to stand-alone service delivery. The authors also found that partner’s testing also increased uptake of HIV testing [24]. Family planning is important in not only preventing unintended pregnancies, but also preventing perinatal HIV transmission among HIV-infected pregnant women who do not want children.

However, integration of HIV and MCH services is not a universal remedy. In Zambia, Killam et al. integrated ART into ANC and found that HIV diagnosis was higher in the intervention cohort (44.4 vs. 25.3 %), and ART initiation was also higher (32.9 vs. 14.4 %) compared to the existing approach of providing a referral to pregnant women to initiate ART. Even after training, providing additional resources, and integrating ART into ANC, a full 62 % of pregnant women did not initiate ART, indicating that there may be other factors to address, outside of direct health service provision [32]. Another example is the SHAIP cluster randomized trial which evaluated the integration of HIV care and treatment into ANC in Nyanza, Kenya. The SHAIP trial found that patient attrition was high in both arms. The authors also found that HIV transmission was not lower in integrated clinics vs. non-integrated clinics (7.3 % of infants tested HIV positive at intervention sites compared with 8.0 % of infants at control sites, OR 0.89, 95 % CI=0.56, 1.43), indicating that there are larger structural barriers to accessing adequate prevention of mother-to-child transmission (PMTCT) and ANC services beyond simple service integration [17].

Another study evaluated the integration of syphilis and HIV testing into PMTCT services in Tanzania. Despite the fact that the Ministry of Health and US Government partners in Tanzania received greater than $1 billion of PEPFAR funds to support comprehensive HIV prevention, treatment, and care programs from 2009 to 2012 [33], basic integration of PMTCT services and syphilis screening was incomplete. Balira et al. evaluated the integration of PMTCT and syphilis testing in Tanzania in 2015 and found that only one quarter of health workers had been trained in both PMTCT and syphilis screening and that HIV and syphilis tests were sometimes performed in different rooms by different people, with separate registers. About 80 % of women had been tested for both HIV (79.4 %) and syphilis (88.1 %) during pregnancy, and 70.1 % were tested for HIV at delivery but none for syphilis [16]. Considering recent studies on effective dual syphilis and HIV rapid testing, this integration should be simplified in the near future [34].

Evidence also exists that integrating HIV services into routine MCH care may increase stigma attached to MCH services. An et al. found in 2015 in Tanzania that stigma surrounding HIV was reported to lead some women to discontinue services or seek care through other access points in the health system [19]. However, another study using pooled results from Demographic and Health Survey datasets from four countries (Congo, Mozambique, Uganda, and Nigeria) found higher odds of being tested for HIV if women received their ANC services from a skilled attendant (adjusted odds ratio = 1.79, 95 % CI = 1.45, 2.18) [35].

Integration of HIV and Child Health Services

Most literature on integration of health services focuses on adults; however, there is increasing evidence about the impact of service integration on children. Most recent studies of integration of child health services and HIV focus on early infant diagnosis (EID) and children who are HIV-exposed follow-up and referral to care. There are various promising practices that have demonstrated impact on improving HIV testing and treatment outcomes; however, few have documented the benefits of integration on child survival. One example of an innovative approach, which has yet to be tested, is the Double Dividend framework, an intervention with the dual goal of improving child survival and pediatric HIV care. The Double Dividend framework integrates child health and HIV services bi-directionally, e.g., into either service. Service integration has been used to support case-finding strategies for children missed from PMTCT programs and as a way to diffuse point-of-care diagnostics. The framework hopes to support progress toward the 90–90–90 targets by providing a pathway for early identification of HIV-infected children with co-morbidities, prompt initiation of treatment, and improved survival [36••].

There is increasing evidence about the impact of integration of HIV infant testing into immunization programs to in-crease EID and linkage to care. Wang et al. evaluated immunization and infant HIV testing in integrated clinics in Zambia. The comprehensive intervention facilities had higher rates of infant immunization and greater average monthly infant HIV testing compared to control clinics. Wang’s study demonstrated that improving health logistics and commodities, including HIV testing material supply reinforcement, can increase HIV testing rates without harming immunization uptake [37]. In response, Zambia’s Ministry of Health issued a memo to re-mind health facilities to provide HIV testing at under-five clinics and to include under-five HIV testing as part of district performance assessments. Another recent study in Nigeria demonstrated that integrating ANC and HIV testing, care with male engagement, and point-of-care CD4 T cell testing, along with task shifting, had strong effects on multiple outcomes including mothers initiating ART and mother and infant retention in care [38].

Integration of HIV and TB Services

TB remains a leading cause of death among people living with HIV. There were approximately 1.5 million TB-related deaths in 2014, of which 400,000 were HIV-infected. TB now ranks alongside HIV as a leading cause of death worldwide. Worldwide, 12 % of the 9.6 million new TB cases in 2014 were HIV-infected, though this proportion is much higher in HIV-hyperendemic regions like southern Africa. For example, 60 % of people with incident TB are also HIV-infected in South Africa [39]. ART initiation and viral suppression significantly reduce the risk of developing active TB disease. Early diagnosis of HIV and access to treatment reduce the risk of contracting TB by 65 %. When treatment of latent TB infection is combined with antiretroviral therapy, the risk of developing active TB disease falls by about 90 % [40].

PEPFAR-supported activities fall within the WHOs’ framework for collaborative TB and HIV activities, including critical interventions to (1) develop organizational methods of collaboration across the two programs, (2) reduce the burden of HIV infection among patients with TB, and (3) reduce the burden of TB among persons with HIV infection or AIDS [41]. A 2010 report showed that PEPFAR and partners made important gains in coverage and scope of HIV testing, referral, and ART for patients with TB, but the authors called for the need to focus on increasing access to isoniazid preventive therapy and strengthening TB infection control in integrated programs [42].

In general, we found that studies have inconsistent findings regarding approaches to integrating TB and HIV care. We know that the quality of care of patients co-infected with TB and HIV can be compromised if health services are not provided in an integrated setting. In a study from a township in South Africa, delays in starting ART among TB patients were almost three times greater for patients who were referred between non-integrated TB services and ART clinics compared to those in whom TB was diagnosed in the ART clinic [41, 43, 44]. Those studies demonstrate the importance of TB/HIV service integration, and how the lack of integration compromises patient care and may even increase risk of mortality. Another study demonstrated that successful integration of TB and HIV services in resource-constrained environments is feasible, although programmatic, infrastructural, and staffing challenges remain [41, 43, 44]. Successful implementation of TB and HIV collaborative activities requires consideration of the realities that exist on the ground and the importance of tailoring interventions in a manner that enables their seamless introduction into existing programs that are often overwhelmed with large numbers of patients and a paucity of human and other resources [45].

A South African study in 2010 by Scott et al. found that client access to HIV/TB/STI programs was limited to 50 % of health facilities where HIV-infected patients were referred. The authors found adequate infrastructure, but insufficient staff training (for example, only 40 % of clinical staff trained in HIV care). In addition, weaknesses were identified in quality of care [14]. Scott et al. followed up their survey in 2013 and evaluated integration of health services across two dimensions—disease programs and the prevention-therapeutic axis. Because of co-located services, HIV and TB services were better integrated in primary care services. However, consistent with their 2010 study, rural facilities did not always have staff trained to enable the health service integration, and nurses worked without the support of a doctor and supervision which threatened the quality of care [15].

A 2013 systematic review of TB and HIV health service integration identified five models of integration: entry via TB service, with referral for HIV testing and care; entry via TB service, on-site HIV testing, and referral for HIV care; entry via HIV service with referral for TB screening and treatment; entry via HIV service, on-site TB screening, and referral for TB diagnosis and treatment; and TB and HIV services provided at a single facility. The authors found that the referral models were easiest to implement, but loss to follow-up was a key weakness. On the other hand, integration required additional staff training and infrastructure (e.g., integrated patient records and shared space). Importantly, infection control was a major concern in all studies reviewed. The review did not analyze outcomes in terms of patients with TB on ART or mortality in integrated vs. stand-alone settings [46].

Recommendations

Research Priorities

We found that evidence on integration of HIV into health services is surprisingly limited. Despite the focus of health integration, the data on the effectiveness remain scarce. Existing evidence is mixed about the effectiveness of integration of HIV and other services. Most studies found that service integration increased uptake of services, but evidence is mixed about the effect on health outcomes or quality of health services. More rigorous studies of different strategies to promote integration over a wider range of services and settings are needed. In addition, research on how best to maximize benefits, including sustainability, of integrated services is necessary to help inform international and national policy. Very few studies address the perspectives of service users or staff or costs or cost-effectiveness. In addition, we recommend additional interventions to test how best to integrate HIV and MCH services, including family planning into PMTCT services, infant HIV testing and immunizations, and HIV testing and treatment, and STI testing and treatment.

Our review showed that the vast majority of research focuses on health outcomes when evaluating the impact of integration of HIV and other health services. However, we argue that patients’ values and preferences and economics (e.g., cost-effectiveness) are equally important given the need for efficient and acceptable services, as well as improved clinical outcomes. We recommend that future studies should include an economic evaluation, as well as an analysis of the views of patients, as their views will influence the uptake of integration strategies at the point of delivery and the effectiveness on community health of these strategies. Further evaluation is needed on integrated diagnostics including dual testing of syphilis and HIV, HIV and TB, and prevention technologies such as pre-exposure prophylaxis and oral contraceptives for at-risk HIV-negative women.

Further, the success of combination ART has improved survival in patients with HIV, but aging, chronic disease, and therapeutic complications have led to changes in morbidity and mortality and the need for improved primary care delivery and alternative models of HIV care. As guidelines shift to support earlier initiation of ART, the overall number of patients needing HIV treatment will likely increase. In low- and middle-income countries, chronic care service provision, especially in primary care, remains underdeveloped. More research is needed about how to address the chronic care of people living with HIV (see Table 1 for research questions).

Table 1.

Research questions on HIV and maternal, reproductive, child, and TB health service integration

1. What is the cost of integrating HIV and maternal/child/reproductive/TB health services?

(a) Which model is most cost-effective? Cost-efficient?

2. What kind of service integration do HIV-infected patients prefer (patient values and preferences)?

(a) Which models retain patients in care longer?

(b) Cost-effectiveness of different models?

3. What are the benefits of integrating HIV and other health services with regard to clinical outcomes?

4. What are the chronic co-morbidity-related outcomes among HIV-infected populations?

5. Who manages other chronic comorbidities (e.g., diabetes, heart disease, hypertension) and delivers primary care to HIV-infected patients?

(a) How?

6. What kind of training is needed to integrate HIV care into existing primary care models?

7. What funding model is most effective in promoting integration of HIV and maternal and child and reproductive health services within national health systems?

Programmatic/Policy Recommendations

We encourage funders, including PEPFAR, the Gates Foundation, and Global Fund for Malaria TB and HIV, to support implementation science on HIV service integration. In addition, funders should consider requiring evidence of written collaboration through letters of agreement between partners, governments, and different divisions (e.g. HIV, STI, TB, or MCH) within the Ministry of Health, as well as funding to ensure training, resources, and logistics in an integrated fashion. Multi-lateral organizations should also encourage integrated health services through their consultations, trainings, and policies, to ensure a focus on improved HIV, MCH, STI and TB outcomes as a result of improved integration of health services. To complement those interventions, additional funding is needed to improve surveillance and monitoring of HIV and co-morbidities to evaluate the impact of integrated health services over time.

Conclusions

By coordinating and intensifying efforts to support people living with HIV and TB, the epidemics can be reduced and ended in parallel. To do this, National Health Service integration, including coordinated training, logistics, and resources, will be crucial to increasing awareness about testing and treatment options and to strengthening health care capacities. This integration entails patient-centered approaches that are tailored according to national health services and delivered in a coordinated and integrated manner. Evidence-based and locally tailored models of integrated service delivery have to be better defined and then scaled up.