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.
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.
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”.
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.
resource demands make vertical programmes neither feasible nor appropriate in
rural settings or in areas of low HIV prevalence with other competing health
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.
- 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
- Improved programme cohesiveness.
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.
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.
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
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.
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.
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).
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.
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
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.
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
greater the programme experience, the more protective it was against death (aHR
0.77, 95% CI: 0.66-0.89).
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.
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.
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
programmes were larger and predominantly in urban centres so may have had an
unmeasured effect on outcomes.
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.
analyses, however, did not change the main findings.
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.”