HIV treatment integrated into general health care delivers 'equal or better' results in MSF programmes

Outcomes for people taking antiretroviral treatment in Médecins sans Frontières’ (MSF) integrated general healthcare programmes were as good or better than those in vertical HIV programmes, researchers report in a nine-country study published in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes.

While those in integrated programmes may have started ART at a more advanced disease stage, the risk of death was similar to those in vertical programmes but loss to follow-up was less (aHR 1.02; 95% CI: 0.83-1.24 and aHR 0.71; 95% CI: 0.61-0.83, respectively) among patients followed for up to 30 months.

The authors say this analysis of retrospective observational cohort data from 17 programmes (7 vertical and 10 integrated) on ART delivery and care “validates the programme design of integration and its associated benefits”.

The success of scale-up of access to ART in resource-poor settings with outcomes matching those of resource-rich settings has been achieved primarily through large-scale vertical treatment programmes, notably in urban areas.

However, resource demands make vertical programmes neither feasible nor appropriate in rural settings or in areas of low HIV prevalence with other competing health issues.

The authors suggest programmes integrating HIV care into other health activities offer a possible feasible alternative model using HIV resources and staff to provide both HIV and non-HIV services.

Benefits include:

• Improved access to HIV care in areas where vertical programmes are not feasible.
• Retention in care made easier since services are both closer to the patient and spread across disciplines.
• Strengthened health programmes as HIV often brings additional resources including clinical training, improved laboratory services and procurement supply systems.
• HIV treated as any other illness may reduce stigma.
• Same staff able to treat many different conditions in the same place.
• Improved programme cohesiveness.

Yet the advantages that integration brings may mean sacrificing the quality of care that dedicated services and specialised staff provide in vertical programmes. With this in mind, the authors chose to compare outcomes of patients treated with ART in MSF’s integrated and vertical HIV programmes.

Vertical programmes were defined as specifically designed to treat HIV in a population. Integrated programmes were defined as providing comprehensive health care within which HIV was included as part of general healthcare services.

Although programmes differed in their degree of integration into general health services, all testing and treatment protocols, adherence counselling and patient follow-up, data collection and monitoring, laboratory protocols and drug supply and procurement were standardised across all MSF programmes; and out-of-programme training and advisory staff were the same. Drugs and materials were supplied through MSF but the programmes were integrated into Ministry of Health facilities.

The authors used Cox regression to determine the link between death and programme design, adjusting for potential confounders including gender, and at baseline: age, body mass index, clinical WHO stage, tuberculosis; programme age at the patient’s start of ART (providing ART for 12 months or more or less than 12 months) and setting (rural or urban).

Ninety per cent (15876) of the 17,561 adults who started ART in the 17 programmes were treated in the vertical programmes with the remaining 10% (1685) in the integrated programmes. Eighty-eight per cent (15,403) had at least six months of follow-up for inclusion in the 12-month treatment outcome analysis. A total of 14,523 people had complete data for inclusion in the Cox regression.

Median time on ART for all patients was 12.7 months (IQR: 4.5-24.0) and 6.8 months (IQR: 2.3-15.0) for vertical and integrated programmes, respectively.

Before adjusting for possible confounders, estimates showed a higher proportion of deaths in integrated programmes, 11.9% compared to 7.9%. The authors suggest this is explained because patients were more clinically immunosuppressed at baseline (a higher proportion at WHO clinical stage 4).

This is in keeping with other findings. Patients targeted in integrated programme often present for care when they are already sick - in contrast, the authors note, to vertical programmes that do large-scale community counselling and testing so attracting more asymptomatic patients.

After adjusting for other factors, the Cox proportional hazards model showed the risks of death were similar in both programmes, with clinical WHO stage at the start of ART the most significant influence (aHR 1.99, 95% CI: 1.74-2.29). The risk of loss-to-follow-up was 29% less in integrated than in vertical programmes.

Reasons include, the authors suggest, integrated services allowing for better treatment of co-existing illnesses, including tuberculosis; lower patient numbers meaning more individualised care and follow-up; easier access with services closer to the patient; and normalisation of HIV reduceing stigma.

The authors note these findings are comparable to other published studies. They cite the ART-LINC cohort of 18 programmes in low-income settings in Africa, Asia and Latin Americas. Combined death and loss to follow-up rates were 21, 19 and 24% for ART-LINC, MSF vertical and integrated programmes, respectively.

The greater the programme experience, the more protective it was against death (aHR 0.77, 95% CI: 0.66-0.89).

However, risk of loss to follow-up was greater in more experienced programmes (aHR 3.33, 95% CI: 2.92-3.79). The authors suggest that, as programmes grow in size, less time is spent on patient selection, preparation and counselling for ART adherence.

Not surprisingly, the risk was even greater among patients treated in rural settings (aHR 3.82, 95% CI: 3.49-4.20) because of travel distances and limited travel options, note the authors.

Limitations include the Cox hazards model which, because of the body mass index variable, did not follow the assumption of proportional hazards, so potentially reducing its power.

Vertical programmes were larger and predominantly in urban centres so may have had an unmeasured effect on outcomes.

The range of programmes from different countries over a number of years supports the generalisability of the findings, yet data quality, in spite of a standardised database, may have varied.

Sensitivity analyses, however, did not change the main findings.

The authors conclude: “In a time of intense debate regarding the merits of specific funding to HIV services, our data provide evidence in these settings [rural and relatively low prevalence] that resources dedicated to HIV through integrated programmes can benefit the individual patient, and as previously described can also strengthen the health system as a whole.”

Greig J et al. Reduced mortality and loss to follow-up in integrated compared with vertical programmes providing antiretroviral treatment in sub-Saharan Africa. JAIDS, doi: 10.1097/QAI.0b013e31824206c7, 2011.