Abstractobjectives Non-communicable diseases (NCD) are a growing cause of morbidity in low-income countries including in people living with human immunodeficiency virus (HIV). Integration of NCD and HIV services can build upon experience with chronic care models from HIV programmes. We describe models of NCD and HIV integration, challenges and lessons learned.methods A literature review of published articles on integrated NCD and HIV programs in lowincome countries and key informant interviews were conducted with leaders of identified integrated NCD and HIV programs. Information was synthesised to identify models of NCD and HIV service delivery integration.results Three models of integration were identified as follows: NCD services integrated into centres originally providing HIV care; HIV care integrated into primary health care (PHC) already offering NCD services; and simultaneous introduction of integrated HIV and NCD services. Major challenges identified included NCD supply chain, human resources, referral systems, patient education, stigma, patient records and monitoring and evaluation. The range of HIV and NCD services varied widely within and across models.conclusions Regardless of model of integration, leveraging experience from HIV care models and adapting existing systems and tools is a feasible method to provide efficient care and treatment for the growing numbers of patients with NCDs. Operational research should be conducted to further study how successful models of HIV and NCD integration can be expanded in scope and scaled-up by managers and policymakers seeking to address all the chronic care needs of their patients.

Alcohol use and depression negatively impact adherence, retention in care, and HIV progression, and people living with HIV (PLWH) have disproportionately higher depression rates. In developing countries, more than 76% of people with mental health issues receive no treatment. We hypothesized that stepped-care mental health/HIV integration provided by multiple service professionals in Zimbabwe would be acceptable and feasible. A three-phase mixed-method design was used with a longitudinal cohort of 325 nurses, community health workers, and traditional medicine practitioners in nine communities. During Phase 3, 312 PLWH were screened by nurses for mental health symptoms; 28% were positive. Of 59 PLWH screened for harmful alcohol and substance use, 36% were positive. Community health workers and traditional medicine practitioners screened 123 PLWH; 54% were positive for mental health symptoms and 29% were positive for alcohol and substance abuse. Findings indicated that stepped-care was acceptable and feasible for all provider types.

Scale-up of antiretroviral therapy (ART) for people living with HIV requires differentiated models of ART delivery to improve access and contribute to achieving viral suppression for 95% of people on ART. We examined barriers and enablers in South Africa via semistructured interviews with 33 respondents (program implementers, nurses, and other health care providers) from 11 organizations. The interviews were recorded, transcribed, and analyzed for emerging themes using NVivo 11 software. Major enablers of ART delivery included model flexibility, provision of standardized guidance, and an increased focus on person-centered care. Major barriers were related to financial, human, and space resources and the need for time to allow buy-in. Stigma emerged as both a barrier and an enabler. Findings suggest that creating and strengthening models that cater to client needs can achieve better health outcomes. South Africa's efforts can inform emerging models in other settings to achieve epidemic control.

Emerging HIV treatment distribution models across sub-Saharan Africa seek to overcome barriers to attaining antiretroviral therapy and to strengthen adherence in people living with HIV. We describe enablers, barriers, and benefits of differentiated treatment distribution models in South Africa, Uganda, and Zimbabwe. Data collection included semistructured interviews and focus group discussions with 163 stakeholders from policy, program, and patient levels. Four types of facility-based and 3 types of communitybased models were identified. Enablers included policy, leadership, and guidance; functional information systems; strong care linkages; steady drug supply; patient education; and peer support. Barriers included insufficient drug supply, stigma, discrimination, and poor care linkages. Benefits included perceived improved adherence, peer support, reduced stigma and discrimination, increased time for providers to spend with complex patients, and travel and cost savings for patients. Differentiated treatment distribution models can enhance treatment access for patients who are clinically stable.

BackgroundSupply chain bottlenecks that prevent community health workers (CHWs) from accessing essential medicines significantly increase under-5 child mortality, particularly in poor and rural areas.ObjectiveUsing implementation research, interventions aimed at improving supply chain practices and access to medicines were tested in Malawi and Rwanda. These interventions included simple demand-based resupply procedures, using mobile technology and traditional methods for communication, and multilevel, performance-driven quality improvement (QI) teams.MethodsMixed-method evaluations were conducted at baseline (2010), midline (2013), and endline (2014). Baseline assessments identified common bottlenecks and established performance levels. Midline assessments identified which intervention package had the greatest impact. Endline surveys measured the progress of scale-up and institutionalization of each innovation.ResultsIn both Rwanda and Malawi CHWs, health center staff, and district managers all cited many benefits of the establishment of resupply procedures and QI teams: such as providing structure and processes, a means to analyze and discuss problems and enhance collaboration between staff.ConclusionsImplementing simple, streamlined, demand-based resupply procedures formed the basis for informed and regular resupply, and increased the visibility of appropriate and timely community logistics data. QI teams played a critical role in reinforcing resupply procedures and routinely unlocking the bottlenecks that prevent the continuous flow of critical health products. While simple, streamlined, demand-based resupply procedures provide the basis for regular, functional, and efficient resupply of CHWs, the procedures alone are not sufficient to create consistent change in product availability. Supporting these procedures with multilevel QI teams reinforces the correct and consistent use of resupply procedures.