Integrating HIV care into
primary care can improve survival of people living with HIV who are in need of antiretroviral therapy (with
CD4 counts of 350 cells/mm3 or less) in high-burden countries with
task-shifting and decentralisation of care in place, researchers report in the
advance online edition of the Journal of
Acquired Immune Deficiency Syndromes.
Measurement of the effect of
integration on survival in over 9000 people with CD4 counts at or under 350
cells/mm3, not yet on antiretroviral therapy (ART), in 31 clinics followed for 12 to18 months
in Free State Province, South Africa showed a decreased risk of death in those
clinics with high scores for integration, independent of other patient or
clinic characteristics known to affect survival.
Every one point increase in
total integration score was linked to a 3% decreased risk of death (HR 0.97;
95: CI: 0.95-1.00; p = 0.041) in this sub-study (a questionnaire) of a randomised
controlled trial looking at the effects of task-shifting and decentralisation of
care on patient outcomes in South Africa – the Streamlining of Tasks and Roles to
Expand Treatment and Care for HIV (STRETCH) trial.
This is of particular
relevance since ART is currently being integrated into primary care in South
With an estimated seven
million people having started ART in sub-Saharan Africa resulting in significant
decreases in mortality the importance of attaining universal coverage has been
recognised. Yet, close to half of those in need are still without
problems in sub-Saharan Africa led many countries at first to set up vertical
(stand-alone) HIV care programmes with separate funding, staff and facilities.
Such programmes unable to
reach all in need of ART in high-burden countries should be incorporated within
existing health systems' programmes to both provide HIV care and strengthen these
systems, the authors write.
Task-shifting has addressed
the problem of healthcare worker shortage in many countries with good patient
outcomes. Task-shifting alone, however, cannot resolve health systems' deficiencies
or identify sustainable strategies integrating HIV care.
Integration, a broad concept,
overlaps with that of decentralisation. In the absence of a clear definition, there is
scant evidence showing integration improves patient outcomes, write the authors.
As such, sustainable strategies are lacking.
A wide variety of programmes
described as decentralisation or integration of HIV care have significantly
improved access to care and include primary care-driven models, note the
authors. Studies have reported on strategies to integrate HIV care into all
primary care consultations. All have reported good outcomes but none, they
stress, were conducted as clinical trials.
So the authors chose to look
at the effect of integration of HIV care into primary care services on patient
survival in a sub-study, using a questionnaire developed during the trial to
answer two specific questions.
- Is there
evidence that integrating HIV care into primary care services improves survival
for patients with CD4 counts at or under 350 cells/mm3 and not on
- If so,
what level of integration of HIV care into primary care is important to improve
Free State Province has an
estimated adult HIV prevalence of 18.5% in a population of 2.8 million. In 2004,
using a vertical approach to HIV care, the public sector ART programme began.
While 57 ART assessment and
treatment clinics were in operation by mid-2007, most of the 222 primary care
clinics could not offer on-site access to ART. Those on ART did well but only
an estimated one in four people in need of ART were getting it. Fifty per cent of those awaiting
ART died within a year.
The STRETCH trial began in
2007 to determine strategies to improve access to ART. All 31 ART assessment
clinics in operation by the end of 2006 were randomised to 16 intervention and
15 control clinics. The two main interventions comprised 1) nurses starting and
repeating ART prescriptions in uncomplicated cases with referral of
complicated cases to doctors at treatment sites and 2) integrating elements
of HIV care into primary care services so patients could access most of their
care at primary care instead of the assessment clinic.
The questionnaire comprised
questions on the number of staff and referring primary care clinics and 19 on
integration of elements of HIV care.
Each question was scored: 0
for no integration, 1 for partial and 2 for full integration.
For each clinic five
integration scores were determined as follows:
integration – total score for all 19 questions.
integration – on provision of HIV care by all nurses for patients not yet
eligible for ART.
integration – on provision of HIV care for patients eligible for and on ART.
integration – on provision of pre-ART and ART care within the ART clinic.
HIV – on provision of pre-ART and ART care by nurses at referring primary care
Internal integration scores
could be assessed for all 31 clinics, while the other scores could only be
calculated for 23 clinics (13 intervention and 10 control) that still had
primary care clinics referring patients for HIV care at the end of the trial. The
other eight, all in rural areas, followed department of health policy to
establish more ART clinics in rural areas.
In all 31 clinics there was a
significant decrease in death for each increase in internal integration scores.
Hazard ratio analysis was
repeated without adjusting for clinic characteristics to see whether components
of integration made a difference to survival by affecting staff/patient ratios
and improving access to rural clinics.
In the 23 clinics, for every
one point increase in pre-ART integration there was a significant 8% decrease
in death (HR:0.92; 95% CI: 0.85-0.99; p = 0.027); 5% for every one point increase
in ART integration scores (HR:0.92; 95% CI: 0.93-0.98; p = 0.001) and 10% for
every one point increase in mainstreaming HIV scores (HR:0.90; 95% CI:
0.83-0.97, p = 0.007) but no difference in death rates in the 31 clinics with changes
in internal integration scores.
This would suggest that
internal integration in all 31 clinics, with a larger percentage of rural
clinics, has a significant impact on survival when HIV care is available in all
primary care clinics so improving patient/staff ratios, note the authors.
The potential means by which
integration of HIV care into primary care improved survival included improved access
to care, decreased stigma and improved confidentiality, continuity and
comprehensiveness of care, the authors write.
Another potential mechanism,
they add, is improved quality of care with evidence from the STRETCH trial
showing improved TB case detection, weight gain and increase in CD4 counts in
intervention clinic patients.
Strengths include quantifying
integration of different elements of HIV care and the levels at which
integration took place with a tool, validated within a randomised, controlled
Patient survival was
monitored by linkage to the national death register.
STRETCH showed a significant
difference in survival only among patients with CD4 counts between 200 and 350.
This sub-study showed that one intervention – integration of HIV care into
primary care clinics – was associated with improved survival of all patients with CD4
counts at or under 350.
The authors conclude “these
results…of practical importance to policy makers in high burden countries…suggest
that pre-ART and ART care be provided as part of the package of care provided
in all primary care services and efforts be made to integrate HIV care into all
consultations within primary care.”