Integrating HIV Care into Primary Care Services: Quantifying Progress of an Intervention in South Africa

Abstract

BackgroundIntegration of human immunodeficiency virus (HIV) care into primary care services is one strategy proposed to achieve universal access to antiretroviral treatment (ART) for HIV-positive patients in high burden countries. There is a need for controlled studies of programmes to integrate HIV care with details of the services being integrated.MethodsA semi-quantitative questionnaire was developed in consultation with clinic staff, tested for internal consistency using Cronbach's alpha coefficients and checked for inter-observer reliability. It was used to conduct four assessments of the integration of HIV care into referring primary care clinics (mainstreaming HIV) and into the work of all nurses within ART clinics (internal integration) and the integration of pre-ART and ART care during the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) trial in South Africa. Mean total integration and four component integration scores at intervention and control clinics were compared using one way analysis of variance (ANOVA). Repeated measures ANOVA was used to analyse changes in scores during the trial.ResultsCronbach's alpha coefficients for total integration, pre-ART and ART integration and mainstreaming HIV and internal integration scores showed good internal consistency. Mean total integration, mainstreaming HIV and ART integration scores increased significantly at intervention clinics by the third assessment. Mean pre-ART integration scores were almost maximal at the first assessment and showed no further change. There was no change in mean internal integration score.ConclusionThe questionnaire developed in this study is a valid tool with potential for monitoring integration of HIV care in other settings. The STRETCH trial interventions resulted in increased integration of HIV care, particularly ART care, by providing HIV care at referring primary care clinics, but had no effect on integrating HIV care into the work of all nurses with the ART clinic.

Treatment retention and care transitions during and after the scale-up of HIV care and treatment in Northern Tanzania

“…Decentralization of HIV care has been pursued by numerous sub-Saharan African (SSA) countries (see, e.g., Fayorsey et al, 2013; Pfeiffer et al, 2010; Topp et al, 2013; Uebel, Joubert, Wouters, Mollentze, & van Rensburg, 2013; World Health Organization, 2013) and is advocated by the President’s Emergency Plan for AIDS Relief (PEPFAR) as a means of expanding coverage, co-utilizing services for HIV and other illnesses, and improving engagement and retention in care (PEPFAR, 2009; Gilks et al, 2006; Mulamba et al, 2010). While several implementation studies (Mutemwa et al, 2013; Topp et al, 2013; Uebel et al, 2013) described efficiency gains due to decentralization and integration of HIV care with care for other conditions, little is known about changes in patients’ care-seeking behaviors in response to the availability of additional treatment options.…”

“…While several implementation studies (Mutemwa et al, 2013; Topp et al, 2013; Uebel et al, 2013) described efficiency gains due to decentralization and integration of HIV care with care for other conditions, little is known about changes in patients’ care-seeking behaviors in response to the availability of additional treatment options.…”

HIV, Tuberculosis, and Noncommunicable Diseases

“…166 Developing quality indicators for NCD and HIV outcomes will assist in programmatic feedback and assessment of these potential tradeoffs. 166-169 …”

Prevention of mother-to-child HIV transmission within the continuum of maternal, newborn, and child health services

“…Emerging data within the field of primary care, however, provide evidence of the incremental benefit possible through integrated models. In South Africa, Uebel and colleagues reported small but significant reductions in mortality at facilities that scored high for total integration, ART integration (i.e., care provided by all nurses in the facility), and internal integration (i.e., care provided by all nurses in the HIV treatment unit) (17, 18). In Zambia, Topp, et al demonstrated increased time spent by providers during non-HIV clinic visits following integration of HIV services in the primary care setting, highlighting the potential for collateral health benefits (19).…”