Integrated Health Systems Is Key to Decreasing HIV
Integrated Health Systems Is Key to Decreasing HIV
On this World AIDS Day, we reflect yet again on progress made toward global commitments to fight the HIV epidemic. According to UNAIDS, new infections have decreased this past year from 2.7 million to 2.6 million, but, 30 years into the epidemic, only 5.2 million people out of the estimated 15 million who need drugs have access to treatment. Stigma, discrimination and human rights violations against persons living with HIV still exist, even in countries with generalized epidemics.
Integrated HIV programming across the entire health system can minimize many of these barriers to HIV prevention, care and, treatment.
What is integrated HIV programming? It is “whole system” integration at all levels of the health system. Far too often, the focus is on “downstream” integration---at the point of service delivery, such as HIV/family planning or HIV/TB services integration. But more attention must be paid to “upstream” integration of policy, financing, coordination between governments and all donors, and between the public and private sectors in order to lessen HIV.
Integrated service delivery is not new to HIV responses. For example, HIV and other sexually transmitted infections have been managed in the same settings by the same providers since the first decade of the epidemic. In recent years, integrating HIV-related conditions, such as TB, into HIV services and vice versa have gained momentum with good results. Integrated HIV testing and counseling in community-based family planning services has resulted in reduced stigma against HIV and increased uptake of VCT (voluntary counseling and testing) by up to 7 times. Similarly, integrating reproductive health and HIV has resulted in increased access to reproductive health, family planning and HIV services by the same women in some countries, who would normally not have access to all these services.
Definition, interpretation and practice of integrated HIV programming have differed. For some providers, it is HIV and other services delivered as a one-stop shop under the same roof by the same or different providers. For others, it is linkage between services via referrals. There is concern that integration increases health provider workload and may compromise quality of care. These claims have not been substantiated by evidence. In some cases, increased morale and motivation among health providers is seen, when receiving sufficient support in tools, training, and mentoring.
In some areas, integration has been at the level of coordination, and rarely is it seen at the policy and strategy levels. In the absence of a whole system integration approach that includes integrated policies and systems, service delivery will remain unsupported and probably unsustainable over time.
Availability of drugs also remains a critical bottleneck to integrating HIV services, usually from parallel uncoordinated funding, procurement, or distribution systems. For example, when HIV test kits are available but not family planning commodities, it will not be possible to deliver HIV/family planning integrated services. It has been shown, however, in Malawi, when communities distributed both family planning commodities and HIV test kits during community and home visits, a large number of Malawian women and their partners in rural areas now know their HIV status while the contraceptive prevalence rate has also increased three fold in three years.
What is needed for effective integration of HIV and other health services ?
A whole system perspective that involves all components of the health system is desirable for integrated services that are efficient, effective, and sustainable.
The health workforce has to be sufficiently prepared and equipped with the right skills and tools to deliver integrated services. This may call for retraining of health care providers and mentorship.
Integrating services that are acceptable to the user and convenient to use---for example integrating HIV and PMTCT (prevention of mother to child transmission) has been successful since both services can occur during the same antenatal visit. Integration of health information is critical. For example, when a health provider is unsure where to record a particular clinical observation, it is unlikely that this will attract the attention it deserves. When multiple data registers for each condition have to be used, it becomes too difficult to meet the full health needs of the patient. To overcome this challenge, a checklist to ensure that health providers meet the whole range of integrated HIV services during service delivery is helpful. Integrating HIV data into routine national health information systems has also proven helpful. Health financing must be coordinated between the government and all donors.
Finally the health service delivery system should be analyzed to identify which service components are most feasible within a local context, most acceptable to the clients, and have most impact for the least amount of money. This calls for incorporating operational research into service delivery. Many possible configurations currently exist, but we do not know which ones provide the best return on investment of our scarce resources.
In order to achieve universal access and reverse the HIV epidemic, integrated HIV services must lie within a framework of stronger and integrated health systems at all levels.
Daraus Bukenya is MSH’s Global Lead on HIV/TB.