Integration Of Human Immunodeficiency Virus Services Research Articles

Modeling one-stop-shop integration of family planning and HIV services in Zimbabwe, 2021

Objectives: In October 2020, the Ministry of Health and Child-care Zimbabwe commenced integrating reproductive health with human immunodeficiency virus (HIV) services. Family planning (FP), sexually transmitted infection (STI) screening and treatment, HIV testing services (HTS), pre-exposure prophylaxis (PrEP), and antiretroviral therapy (ART) services were offered through an integrated one-stop-shop model. The project aimed to address unacceptably high incidences of HIV and STIs among FP clients and demonstrate improved access and uptake of integrated services at dedicated FP centers. Materials and Methods: We conducted an intervention study. A service package of STI symptom screening and HTS (including HIV self-test [HIVST] primary and secondary distribution) was offered to all FP clients by multi-skilled nurses. Service uptake was measured pre and post-introduction of the intervention, before which services were provided by different nurses, in different rooms. HIV-diagnosed clients were linked to ART and eligible negative testers were offered PrEP. Service uptake was measured at 1 year of implementation against the same period before. Results: A total of 20,947 clients were recruited between October 2019 and September 2021, 9386 pre-intervention and 11,561 post-intervention. We observed a 5.2% total increase in clients seen and a 27.1% increase in the average uptake of all integrated services (FP, STI, HTS, PrEP, and ART). Most (93.5%) clients received oral contraception (Progestogen-only pills and combined-oral-contraceptives), while fewer (4.8%) received injectables and implants (1.1%). Following the intervention, STI screening increased by 30.2% (2730 vs. 11,028). HTS delivery increased by 38.9% and PrEP by 44.1%. HIV positivity yield increased significantly (10.1%, 62/615 vs. 16.6%, 813/4910) and linkage to ART improved by 44.4%. HIVST distribution contributed to improved access to HIV testing with 3754 FP clients accepting distribution compared with 4910 receiving HTS by nurses, provider-delivered testing was accessed by reactive self-testers. The project increased (?) improved linkage to preventive and treatment services and reduced missed opportunities associated with fragmented services. Conclusion: The integrated one-stop-shop model demonstrated improved service uptake during the intervention period. This project shows the benefits of integrated FP/STI/HTS/PrEP in Zimbabwe’s high HIV burden settings.

Perspectives on linkage to care for patients diagnosed with HIV: A qualitative study at a rural health center in South Western Uganda.

Linkage to care for newly diagnosed human immunodeficiency virus (HIV) patients is important to ensure that patients have good access to care. However, there is little information about factors influencing linkage to care for HIV patients. We aimed to identify existing measures in place that promote linkage to care and to explore facilitators and barriers to linkage to care for clients diagnosed with HIV/acquired immune deficiency syndrome at a rural health center in Uganda. This descriptive qualitative study enrolled 33 purposively selected participants who included expert clients, linkage facilitators, heads of families with people living with HIV, and health workers. Data were collected using in-depth interviews that were audio-recorded, transcribed, and translated. The data were manually analyzed to generate themes. The following four themes were generated: 1) availability of services that include counseling, testing, treatment, follow-up, referral, outreach activities, and support systems. 2) Barriers to linkage to care were at the individual, health facility, and community levels. Individual-level barriers were socioeconomic status, high transport costs, fear of adverse drug effects, fear of broken relationships, and denial of positive results or treatment, while health facility barriers were reported to be long waiting time, negative staff attitude, and drug stock outs. Community barriers were mostly due to stigma experienced by HIV clients, resulting in discrimination by community members. 3) Facilitators to linkage to care were positive staff attitudes, access to information, fear of death, and support from others. 4) Suggestions for improving service delivery were shortening waiting time, integrating HIV services, increasing staff numbers, and intensifying outreaches. Our findings highlight the importance of stakeholder involvement in linkage to care. Access and linkage to care are positively and negatively influenced at the individual, community, and health facility levels. However, integration of HIV services and intensifying outreaches are key to improving linkage to care.

Patient outcomes in integrated HIV and non-communicable disease models of care: a scoping review

Background High rates of non-communicable diseases (NCD) among people living with human immunodeficiency virus (HIV) have been reported in high HIV burden, low-resource settings. The growing dual burden of HIV and NCD epidemics has necessitated introduction of integrated models of HIV and NCD care in order to leverage existing HIV care infrastructure for NCDs. There is a paucity of evidence on the effects of integrated care on long-term patient outcomes. We sought to review literature that described effects of integration on long-term patient outcomes. Methods We reviewed literature published between 01 Jan 2000 to 25 September 2019, that described long-term patient outcomes in HIV and NCD integrated models of care in order to understand the effects of integration on long-term patient outcomes. Relevant literature was searched in PubMed, Scopus, EBSCOhost and Web of Science. A manual search of abstracts in the International AIDS Society and the Journal of Acquired Immunodeficiency Syndrome was also conducted. Results One thousand six hundred and sixty articles were identified, 31 of which were read in full, with 11 meeting eligibility criteria. Patient outcomes in four models of integrated care were identified: (i) integration of NCD screening and treatment services into established HIV centres; (ii) integration of HIV screening and treatment services into established NCD centres; (iii) simultaneous integration of HIV and NCD services at health facilities; and (iv) integrated HIV and NCD care specifically for multi-morbid patients. Studies reported high rates of control of HIV and NCD across the various models of integrated care. However, majority of studies lacked comparator groups required to ascertain non-inferiority of integrated care over non-integrated care. Conclusions There is limited evidence on the effect of integrated HIV and NCD models of care on long-term patient outcomes especially in low-resource, high-burden settings. Randomized clinical trials with clearly defined comparator groups and standardized measures of HIV and NCD outcomes are needed to demonstrate non-inferiority of integrated against non-integrated care.

Towards evidence-based integration of services for HIV, non-communicable diseases and substance use: insights from modelling.

Towards evidence-based integration of services for HIV, non-communicable diseases and substance use: insights from modelling.

Health system challenges affecting HIV and tuberculosis integration at primary healthcare clinics in Durban, South Africa

BackgroundTuberculosis (TB) is the most common presenting illness among people living with human immunodeficiency virus (HIV), with co-infection occurring in up to 60% of cases in South Africa. In line with international guidelines, South Africa has adopted an integrated model at primary healthcare level to provide HIV and TB services by the same healthcare provider at the same visit.AimThe aim of the study was to conduct a rapid appraisal of integration of HIV and TB services at primary healthcare level in eThekwini District in 2015.SettingThe study was conducted in 10 provincial primary healthcare clinics in the eThekwini Metropolitan Health District in KwaZulu-Natal Province.MethodsAn observational, cross-sectional study was conducted. Key informant interviews with operational managers and community health workers were conducted, as well as a review of registers and electronic databases for the period of January to March 2015.ResultsTwo clinics complied with the mandated integrated model. Three clinics were partially integrated; while five clinics maintained the stand-alone model. Possible constraints included reorganisation of on-site location of services, drug provision, TB infection control and inadequate capacity building, while potential enablers comprised structural infrastructure, staffing ratios and stakeholder engagement.ConclusionHIV and TB integration is suboptimal and will need to be improved by addressing the systemic challenges affecting health service delivery, including strengthening supervision, training and the implementation of a change management programme.

Integration of tuberculosis and HIV services: Exploring the perspectives of co-infected patients in Ghana

ABSTRACTScaling up of integrated tuberculosis (TB)–human immunodeficiency virus (HIV) services remains sub-optimal in many resource-limited countries, including Ghana, where the two conditions take a heavy toll on the financial resources of health systems as well as infected persons. Previous studies have documented several implementation challenges towards TB–HIV service integration, but views of patients on integrated service delivery have not received commensurate research attention. This paper explored the experiences of 40 TB–HIV co-infected patients at different stages of treatment in Ghana. Using Normalisation Process Theory as a framework, data were coded using inter-rater coding technique and analysed inductively and deductively with the help of QSR NVivo 10. For several participants, either of the diseases was diagnosed ‘accidentally’, leading to inconsistencies in co-therapy administration, constraints regarding separate clinic appointment dates for TB and HIV and prolonged TB treatment due to treatment failure. Put differently, there were widespread negative experiences among TB–HIV co-infected patients with regard to treatment and care, especially among patients who were accessing care in separate facilities or separate units in the same facility. Co-infected patients unanimously support full-service integration. However, they felt powerless to request for reforms on a mode of service delivery.

Non-communicable diseases and HIV care and treatment: models of integrated service delivery.

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. A literature review of published articles on integrated NCD and HIV programs in low-income 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. 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. 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.

Unmet need for contraception among human immunodeficiency virus-positive women in Jos, Nigeria: A call to integrate family planning and human immunodeficiency virus services

PURPOSE: In the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV), contraception is one of the four strategies proposed by the World Health Organization. Closing the gaps of unmet need for contraception among people living with HIV (PLHIVs) is critical, especially for Nigeria which contributes about 30% of global PMTCT burden. We assessed contraceptive utilization and needs, partner support, and planning of pregnancies among female PLHIVs receiving care at the HIV Treatment Centre of Jos University Teaching Hospital (JUTH). MATERIALS AND METHODS: Structured questionnaires were administered to 350 postpartum women attending the PMTCT Unit of HIV Clinic of the JUTH in 2009 using a convenience sampling method. This was to access their knowledge and utilization of contraception. All were receiving PMTCT follow-up and were within 18 months postpartum. The data were analyzed with the Epi Info Statistical Package version 3.3. RESULTS: The participants' ages ranged 19–44 years and 81.4% were Christians. Most (36.1%) were homemakers and 87.1% were married. About 44.1% were discovered to be HIV positive during antenatal care, and 47.6% of husbands were HIV positive. The previous pregnancies had been planned in 38%, thus 62% of preceding pregnancies were unplanned, while 33.8% did not desire more children. Contraception awareness was high (84.5%) but 87.1% of the participants used no form of female contraception and 81.4% admitted regular sexual activity. Among those who did not desire more pregnancies, only 48.4% used modern female contraception. Majority (80.7%) of the respondents indicated that family planning (FP) would be easily accessed in the HIV clinic while male partners (49.4%) encouraged contraception. CONCLUSION: Among PLHIVs in northern Nigeria, there is a high rate of unintended pregnancy, and high contraceptive awareness did not translate into usage. Integration of HIV and reproductive health services holds potential to improve FP access and usage by PLHIVs.

Integrating tuberculosis and HIV services in rural Kenya: uptake and outcomes.

Seventeen rural public health facilities in Western Kenya that introduced three models of integrated care for tuberculosis (TB) and human immunodeficiency virus (HIV) patients. To assess the uptake and timing of cotrimoxazole preventive therapy (CPT) and antiretroviral treatment (ART) as well as anti-tuberculosis treatment outcomes among HIV-infected TB patients before (March-October 2010) and after (March-October 2012) the introduction of integrated TB-HIV care. A before-and-after cohort study using programme data. Of 501 HIV-infected TB patients, 357 (71%) were initiated on CPT and 178 (39%) on ART in the period before the introduction of integrated TB-HIV care. Following the integration of services, respectively 316 (98%) and 196 (61%) of 323 HIV-infected individuals were initiated on CPT and on ART (P < 0.001). The median time to CPT and ART initiation dropped from 7 to 2 days and from 42 to 34 days during the pre- and post-integration phases, respectively. Overall TB success rates did not vary with integration or with type of model instituted. Integration of TB and HIV services enhanced uptake and reduced delay in instituting CPT and ART in rural health facilities. There is a need to increase impetus in these efforts.

ART uptake, its timing and relation to anti-tuberculosis treatment outcomes among HIV-infected TB patients.

All public health facilities in two provinces of Zimbabwe. To determine, among tuberculosis (TB) patients with human immunodeficiency virus (HIV) registered in 2010, 1) the proportion started on antiretroviral treatment (ART), 2) the timing of ART in relation to the start of anti-tuberculosis treatment, and 3) whether timing of ART influenced anti-tuberculosis treatment outcomes. Retrospective cohort study. Of the 2655 HIV-positive TB patients, 1115 (42%) were documented as receiving ART. Of these, 178 (16%) started ART prior to anti-tuberculosis treatment. Of those who started after anti-tuberculosis treatment, 17% started within 2 weeks, 43% between 2 and 8 weeks and 40% after 8 weeks. Treatment success in the cohort was 82%, with 14% deaths before completion of anti-tuberculosis treatment. Not receiving ART during anti-tuberculosis treatment was associated with lower anti-tuberculosis treatment success (adjusted RR 0.70, 95%CI 0.53-0.91) and more deaths (adjusted RR 3.43, 95%CI 2.2-5.36). There were no differences in TB treatment outcomes by timing of ART initiation. ART uptake is low given the improved treatment outcomes in those put on ART during anti-tuberculosis treatment. Better integration of HIV and TB services is needed to ensure increased coverage and earlier ART uptake.

Human Immunodeficiency Virus-Associated Tuberculosis

Human Immunodeficiency Virus-Associated Tuberculosis

Integration of Tuberculosis and HIV Services in Sub‐Saharan Africa: Lessons Learned

Promoting linkages between tuberculosis (TB) and human immunodeficiency virus (HIV) treatment and prevention programs in resource-constrained environments where both diseases are prevalent is essential to improve the diagnosis, treatment, and outcomes for patients affected by both diseases. In this article, we share insights based on our experiences supporting integrated TB and HIV service delivery programs, including intensified TB case finding, isoniazid preventive therapy, infection control, and initiation of antiretroviral therapy. Our experience indicates that successful integration of TB and HIV services in resource-constrained environments is feasible, although programmatic, infrastructural, and staffing challenges remain. 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.

Timing of Initiation of Antiretroviral Drugs during Tuberculosis Therapy

The rates of death are high among patients with coinfection with tuberculosis and the human immunodeficiency virus (HIV). The optimal timing for the initiation of antiretroviral therapy in relation to tuberculosis therapy remains controversial. In an open-label, randomized, controlled trial in Durban, South Africa, we assigned 642 patients with both tuberculosis and HIV infection to start antiretroviral therapy either during tuberculosis therapy (in two integrated-therapy groups) or after the completion of such treatment (in one sequential-therapy group). The diagnosis of tuberculosis was based on a positive sputum smear for acid-fast bacilli. Only patients with HIV infection and a CD4+ cell count of less than 500 per cubic millimeter were included. All patients received standard tuberculosis therapy, prophylaxis with trimethoprim-sulfamethoxazole, and a once-daily antiretroviral regimen of didanosine, lamivudine, and efavirenz. The primary end point was death from any cause. This analysis compares data from the sequential-therapy group and the combined integrated-therapy groups up to September 1, 2008, when the data and safety monitoring committee recommended that all patients receive integrated antiretroviral therapy. There was a reduction in the rate of death among the 429 patients in the combined integrated-therapy groups (5.4 deaths per 100 person-years, or 25 deaths), as compared with the 213 patients in the sequential-therapy group (12.1 per 100 person-years, or 27 deaths); a relative reduction of 56% (hazard ratio in the combined integrated-therapy groups, 0.44; 95% confidence interval, 0.25 to 0.79; P=0.003). Mortality was lower in the combined integrated-therapy groups in all CD4+ count strata. Rates of adverse events during follow-up were similar in the two study groups. The initiation of antiretroviral therapy during tuberculosis therapy significantly improved survival and provides further impetus for the integration of tuberculosis and HIV services. (ClinicalTrials.gov number, NCT00398996.)

Advancing Integration of HIV, STD, and Viral Hepatitis Services: State Perspectives

How can we advance the integration of prevention services in public health programs for adults at risk for human immunodeficiency virus (HIV), sexually transmitted diseases (STDs), and viral hepatitis? From the perspective of the state acquired immunodeficiency syndrome (AIDS) directors from the Florida and Hawaii Departments of Health (DOH), we describe principles of integration, identify potential benefits of and key barriers to integration, and recommend changes to advance integration.

Models for Integrating Buprenorphine Therapy into the Primary HIV Care Setting

Opiate dependence among human immunodeficiency virus (HIV)-infected patients has been associated with negative clinical outcomes, yet few affected patients receive appropriate and coordinated treatment for both conditions. The introduction of buprenorphine maintenance therapy into HIV care settings provides an opportunity for providers to integrate treatment for opiate dependence into their practices. Buprenorphine maintenance therapy has been associated with reductions in opiate use, increased social stability, improved adherence to antiretroviral therapy, and lowered rates of injection drug use. We describe the following 4 models for the integration of buprenorphine maintenance therapy into HIV care: (1) a primary care model, in which the highly active antiretroviral therapy-administering clinician also prescribes buprenorphine; (2) a model that relies on an on-site specialist in addiction medicine or psychiatry to prescribe the buprenorphine; (3) a hybrid model, in which an on-site specialist provides the induction (with or without stabilization phases) and the HIV care provider provides the maintenance phase; and (4) a drug treatment model that provides buprenorphine maintenance therapy services with HIV services in the substance abuse clinic setting. The key barriers against effective integration of buprenorphine maintenance therapy and primary HIV services are discussed, and we suggest several mechanisms to overcome such obstacles.

Research Issues Involving HIV-Associated Tuberculosis in Resource-Poor Countries

Each year, there are an estimated 8 million new cases of tuberculosis (TB) and 3 million deaths due to TB, most of which occur in resource-poor countries. Tuberculosis incidence is increasing rapidly in countries with high rates of human immunodeficiency virus (HIV) infection, and despite the availability of effective interventions, many TB programs are failing to cope with the increased TB caseload. This report highlights gaps in current understanding of the interaction between TB and HIV that contribute to failure of optimal TB management and control; we focus on the diagnosis of TB, its epidemiology and transmission, preventive strategies, and programmatic issues in the integration of HIV and TB services. Research into how best to apply existing knowledge will be at least as important as searching for new knowledge. The global control of TB will also require increased resources, greater political commitment, and stronger international public health leadership.

Research issues involving HIV-associated tuberculosis in resource-poor countries.

Each year, there are an estimated 8 million new cases of tuberculosis (TB) and 3 million deaths due to TB, most of which occur in resource-poor countries. Tuberculosis incidence is increasing rapidly in countries with high rates of human immunodeficiency virus (HIV) infection, and despite the availability of effective interventions, many TB programs are failing to cope with the increased TB caseload. This report highlights gaps in current understanding of the interaction between TB and HIV that contribute to failure of optimal TB management and control; we focus on the diagnosis of TB, its epidemiology and transmission, preventive strategies, and programmatic issues in the integration of HIV and TB services. Research into how best to apply existing knowledge will be at least as important as searching for new knowledge. The global control of TB will also require increased resources, greater political commitment, and stronger international public health leadership.