AIDS 2010 Update: Smart Integration: Challenges and Successes in Expanding Access to HIV & AIDS and Other Services

AIDS 2010 Update: Smart Integration: Challenges and Successes in Expanding Access to HIV & AIDS and Other Services

At the International AIDS Conference in Vienna, Austria, my colleagues and I gathered to discuss the principles of smart integration and its challenges, successes, and recommendations for implementation. 

Smart integration means coordinating HIV & AIDS programs with other health programs that have operated independently in the past; providing comprehensive services at all levels of the health system – from households to health facilities and across the continuum of prevention, treatment, and care; and building stronger partnerships between public and private sectors.

There are three perspectives of integration that must be kept in mind when discussing integration – the client, provider, and the efficiency. Smart integration is important now because AIDS has become a chronic disease and we need to move away from the emergency response interventions.

“Ten years ago we could not have conversations like this because there weren’t services available to integrate,” said  Jonathan D. Quick, MD, MPH, President and Chief Executive Officer of MSH. “I’m a family physician. Diseases are integrated in the patient’s body, so we should provide integrated services to match their needs. Additionally, if an HIV positive woman on ART has a sick child with TB, she shouldn’t have to travel to the HIV clinic and then to the TB clinic. Services should be close to home.”

Bitra George, MD, Country Director of the FHI program in India, shared his experiences of integrating services for sex workers in Mumbai. There are over 600,000 sex workers in the dense city, there is a 7% prevalence rate among the sex worker population.

The program, funded by the Gates Foundation, provided services to 75,000 sex workers.  The program integrated HIV testing, family planning services, STI testing, and tried to provide comprehensive services. It was successful because it responded to a need perceived and demanded by the sex workers themselves to integrate services

Dr. George explained that HIV and family planning integration took minimal effort and resources. FHI added family planning materials to the clinics, upgrades services, and trained the health workers. Dr. George quoted one of the client’s as he concluded, “the life of a sex worker goes beyond HIV and STI’s – we need advice on pregnancy and basic health needs.”

Chifundo Kachiza, MPH, is the project lead for the Tuberculosis Control Assistance Program (TB CAP) in Malawi, and she noted an increase in TB patients accessing HIV services as well. “If we scale up ART, we should also scale up TB.” She discussed the importance of integrating HIV and TB programs. In Malawi, 60% of people living with HIV/AIDS are co-infected with tuberculosis. Many patients live in remote areas and they had to travel a long distance to receive treatment and care. “We had a situation in Malawi that needed integration,” said Mrs. Kachiza. “Many people think you need a lot of resources to integrate, but usually you can rearrange and synchronize the funding.”

New HIV/TB clinics were developed and in the first quarter, 63% received access to the integrated services. Through this process, they learned that services need to be integrated at all levels- national, district, and community level to be successful.

Rwanda has a high burden of HIV and about 30% co-infection with TB. Jean Kagubare, MD, MPH, PhD, Principal Technical Advisor for HIV & AIDS and Other Services at MSH,  presented on the integration of services in Rwanda. In 2005, the Ministry of Health decided to integrate HIV and TB services because there is a high burden on patients. Technical working groups managed to produce a policy at the national level and were able to integrate forms, tools, registration and provide one-stop services. They decided to only integrate half of the 420 health facilities in Rwanda because only a targeted population was co-infected. Dr. Kagubare suggests that integration only makes since in high prevalence areas. You can integrate very quickly, but you have to streamline donors and also establish a policy environment that enables integrated services.

As some audience members noted, there is not a one size fits all approach to integration. The needs of the community need to be considered. Integration can mean ensuring there is a proper referral from an AIDS clinic to a TB clinic or that both AIDS/TB services are performed in the same facility (partial integration) and integration the same facility and by the same health workers (full integration). Some said that health workforce skills need to be considered as well as work overload, particularly given the shortage of doctors and nurses. Co-infection guidelines are also key.

One health worker from Uganda compared the situation to two people in a race—one is fast and the other is slow. The options  for the slow person are to either lose the race or catch up –in Uganda TB care is slower to scale up than ART.

Festus Ilako, MB, ChB, M.Med, Deputy Country Director of Kenya from AMREF said that integration is not the silver bullet and should only happen with significant public health issues. You must listen to clients, providers, and policy makers. You have to tailor integrated services to each local context – there is no way to integrate the same way everywhere. There will be a lot of resistance from many stake holders, but you must try to find the most effective and efficient way to implement the integrated services. High level leadership and commitment is needed and integration shouldn’t happen without it.

The benefits of integration are evident, but there are also many challenges that remain. Integration is the best option in some instances, but not in others. The motive behind integration should be to maximize impact, efficiency, and sustainability by providing services that are accessible, useful, and are of good quality. It is therefore essential that an initial assessment is conducted to assess the feasibility of integration towards these results, build commitment to integrate, and identify underlying factors that must be addressed to maximize benefits of integration. What combination of services will give us maximum synergies deserve further study.

Daraus Bukenya is MSH’s Global Lead on HIV/TB.