Is HIV integration a response or a death sentence? Communities demand answers

"When our leaders talk about integration, what do they really mean? It's hypocrisy when they tell us to use outpatient [clinics], when they know mobile clinics exist because of their criminalisation of our lives,” said Yvette Raphael, Executive Director of Advocacy for Prevention of HIV in Africa, during a protest at the IAS opening ceremony. “Integration is not the solution. Let's be honest: without decriminalisation, accountability and the funding needed, integration will be a death sentence for us."

At the just-concluded 13th International AIDS Society Conference on HIV Science (IAS 2025) in Kigali, Rwanda, one of the buzzwords was integration, specifically how it can bridge the gap in HIV services following US government funding cuts. Opinions were deeply divided: some opposed it, others championed it, and most remained uncertain about how it should be implemented. This was evident in conversations across the conference.

Dr Nathan Ford from the World Health Organization (WHO) points out that it isn't a new concept. "Integration has been on the agenda for decades, and there may be some nervousness that integration is happening too quickly as a response to funding cuts, but we shouldn't lose sight that integration was always a good idea."

Dr Proscovia Namuwenge from Uganda's Ministry of Health explained their approach: "Our Ministry of Health leadership issued a circular in February 2025… to remove standalone HIV clinics and integrate them into existing general services. We developed a practical guide for facilities and communities to offer integrated HIV service delivery and conducted capacity building for health workers who were initially not involved in HIV care."

Specialised clinics for HIV and TB are being phased out, and their responsibilities transferred to primary health care services. It’s not just Uganda, across many countries that have been dependent on US funding for HIV services, integration has been hailed as a quick fix. Yet even supporters acknowledged the challenges.

"I think a lot of people have been hesitant about integration," noted Dr Angela Mushavi from Zimbabwe's Ministry of Health. "When we say integration, what exactly do we mean? Whatever way countries integrate, there will certainly be need for guidance from WHO around smart integration so that we don't erode the quality of services."

Numan Afifi, Senior Research and Policy Officer at APCOM Foundation in Thailand, also raised critical concerns: "Integration is often sold as the ultimate efficiency win, but efficient for whom? Efficiency could mean streamlined budgets for ministries, reduced administrative burden for hospitals, or a one-stop shop for patients. Yet the communities we serve – MSM, transgender people, sex workers, people who use drugs – often have specific needs requiring trust, confidentiality and specialised expertise. Integration without a deliberate equity lens can leave those needs unmet."

This diversity of perspectives marked the entire conference. By its conclusion, the path forward with integration still remained unclear.

How to integrate right

WHO refers to integration as managing and delivering health services so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, and palliative care, through the different levels and sites of care within the health system and according to their needs throughout their life course.

It is contrasted with the ‘vertical’ structure of disease-specific programmes that operate independently from the rest of the healthcare system, an approach in part created by donors’ focus on specific issues such as HIV.

But according to Patricia Asero, a HIV advocate from Kenya, WHO’s description of integration is not what is happening at clinics. "What they are calling integration is just dispensing of HIV drugs. We also want integration, but we want a situation where we are given proper care. If I come in with my diabetes, my hypertension, my HIV, my mental health concern, my menopause, my asthma, I'm looked at holistically. So when they are talking about integration, and the only thing they mean is dispensing ART, that is not integration."

While integration is widely seen as beneficial, fundamental questions remain about implementation and whether equity and integration can coexist. The criminalisation of key populations, persistent stigma against people living with HIV, and under-resourced, overburdened health systems present significant barriers to meaningful integration.

Janet Bhila, an HIV advocate from Zimbabwe, worries that integration may create disparities and leave rural populations behind. "You have an instance where a provincial general hospital has the equipment and human resources and everything, but a local hospital in the community has maybe one nurse, the doctor comes just once a week, and there's all these patients now coming in. In such cases, integration will not really work. So you find that people living in villages or small communities will suffer completely. Can we not centralise everything?"

Bhila also emphasised the tension between quantity and quality of services. She warned that rushed implementation prioritises numbers over the quality of care that communities actually need.

With the latest UNAIDS report showing that criminalisation is rising again, key populations have concerns about accessing services at government healthcare facilities. Many had moved away to community-led facilities like mobile clinics and drop-in centres to avoid identification, criminalisation, or hostile treatment that drives them away from formal healthcare settings.

Professor Linda-Gail Bekker, former IAS president, highlighted this contradiction: "Even in my own country, my health minister's immediate response was, 'Well, people must go back into the health facilities.' And we've just spent 15 years providing opportunities for them to come out of the health facilities. I think this is a dilemma, because what will happen is it's going to drive our key and vulnerable populations underground. And it just isn't a good public health approach to lose these populations again. This is part of our last mile movement to 2030 control of the epidemic – that we find individuals who previously have not been reached."

"If integration simply presses people into generalised health systems without rights-based safeguards, we risk experiencing a step back in the response for answering the specific needs of people living with HIV and key populations, including the need for confidentiality and safe spaces," warned Jean Tugirimana from Rwanda Network of People Living With HIV/AIDS. "Integration will not be successful in the context where sex work, same-sex relationships and HIV non-disclosure remain criminalised."

But in south-east Asia, some mitigation strategies have shown promise for key populations, said Numan Afifi, the speaker from Thailand. In Vietnam, when district hospitals absorbed services from community-based organisations, service users needed social health insurance. The enrolment process required ID papers and household registration, excluding many people who inject drugs and sex workers. Only after the government funded civil society organisation outreach and waived social health insurance premiums for vulnerable groups did social health insurance coverage among people with HIV climb to 95%.

Thailand has also developed a model where the National Health Security Office supports civil society organisations in providing HIV services for key populations, with community-based organisations reimbursed per service through "social contracting." In Malaysia, expanding needle exchange and methadone programmes both in public clinics and non-governmental organisations between 2006 and 2023 prevented approximately 12,000 infections. “So integration succeeded only after an equity focus fix was implemented,” he said.

The fundamental question, as stakeholders increasingly recognise, should be: what populations do we serve, and what are the best ways to deliver services that truly address their healthcare needs? The answer, most agree, lies with the communities themselves.

Communities should lead in shaping integration

Many advocates feel that communities and community-led work has been pushed aside in integration conversations, despite their proven effectiveness.

HIV advocates also emphasise that integration must recognise diverse service providers and models. Differentiated and community-led services need to be integral to integration efforts and connected to national systems, whether supply chain, laboratory, or data systems.

They argue that networks of people living with HIV and key populations should not only be brought to the table in integration discussions but also receive necessary resources that will enable them to conduct follow-up, contact tracing, support groups, and treatment education at low cost, drawing on their lived experience as their own experts.

"We must strengthen the enabling environment for community-led services," was a resounding call of many advocates at the conference. This and the need to continuously advocate and ensure policy and decision makers understand the value of community-led services.

As the integration conversations evolve, one of the most vital needs, as Dr Mushavi from Zimbabwe noted, is the need for evidence: "However we integrate, at each of our respective countries' levels, I think we need to generate data around how successful those integration efforts are. Sometimes you just think by doing this, everything will be fine, but you also need to create and document evidence that what you are doing is useful, efficacious, and will not depreciate the quality of services you are giving to your clients."