Integration of HIV services – what does that really mean?

At the 13th International AIDS Society Conference on HIV Science (IAS 2025) in Kigali, Rwanda, integration with the wider healthcare system was widely presented as a practical response to declining donor funding. But while policymakers and implementers explored different integration models, advocates warned that integration done poorly could risk undermining decades of progress in the HIV response. It was also clear there is no universal formula for integrating HIV services.

"Integration is not an all-encompassing solution to changing the HIV response. We have to stay critical about how we get services to different populations that need them," said Caroline Bulstra, research fellow at Harvard Chan School of Public Health. "We don't have to come up with one solution. We have to critically think about what works where."

Health experts at the conference outlined three broad types of integration that countries can adopt, depending on their health system capacity, population needs, and financial realities, rather than adopting approaches that may not work in their specific context.

Service-level integration focuses on which health services are delivered together at the point of care. This might involve combining HIV services with non-communicable diseases, sexual and reproductive health, tuberculosis, or mental health services. The key is determining which combinations make clinical and operational sense for specific populations.

Functional-level integration examines how HIV services are embedded within the broader health system infrastructure, including financing mechanisms, data systems, supply chains, and human resources. This integrates the operational backbone that enables services to function effectively.

Direction-based integration deals with the overall design approach within a health system. Services can be delivered vertically (keeping HIV services separate), horizontally (spreading them across multiple health areas), or diagonally. The diagonal approach uses HIV funding to strengthen the entire health system so it can handle multiple conditions, not just HIV.

The quality question

While most countries reported that they have already started integrating HIV by training general healthcare workers on HIV and ensuring people continue receiving treatment without interruption, continuity alone isn't enough. Community advocates warned that logistical co-ordination alone doesn't equal quality care.

When measuring integration outcomes, participants stressed the importance of evaluating integration not just by cost savings, but by considering the communities being served, the types of services offered, the healthcare providers delivering care, their training, and the locations where integration takes place. When done right, this broader perspective reveals whether integration is truly working or simply moving problems around.

David Black, an HIV advocate from Malawi, illustrated how integration can backfire when sensitivity is lacking: "If I'm part of a key population and I go to a provider at a public facility, and maybe I had anal sex so I have an STI, the provider will be asking me, why do you have an STI in your anus instead of your vagina or penis? And that puts me off."

Community-led services have long bridged gaps in access by offering stigma-free, person-centred support. Many already deliver integrated care across HIV, sexual health, harm reduction, and psychosocial services. Yet these services are now the most at risk due to the decline in funding.

"The only way to end AIDS as a public health threat is by ensuring that communities remain the beating heart and the strategic brain of this response," said Kenyan advocate Rosemary Mburu in the conference opening ceremony. "The journey to ending the pandemic is not paved with policy papers, scientific publications and procurement plans. It is carried on the backs of communities, and it needs to be led by communities whose expertise must guide the way forward."

What meaningful integration looks like

Many countries have leaned on task shifting – in other words, training existing health workers to provide more services – as a way to integrate HIV care. But the conference heard that for integration to work, it needs proper funding, not just efficiency measures.

"We need to integrate and fund what works to ensure equity," said Meghan DiCarlo, an independent HIV consultant. "Many people already seek care across different models. If we cut what works in the name of efficiency, we lose people."

Integration must not mean abandoning differentiated care models or overburdening under-resourced clinics. Instead, speakers called for the following.

Funding peer networks as part of the workforce. These networks, which have been critical for marginalised and key populations, should be considered as part of workforce development and integration.

"How do we integrate the peers into this system to make the system work? Because the burden on the bulk of the work has been taken up by peers, and they've been doing it successfully," asked Patricia Asero, a HIV advocate from Kenya. "We, as networks, need to be brought back in. How do you work with us so that we are running support groups? How do you work with us so that we're even doing treatment education?"

Asero emphasised that networks of people living with HIV deserve investment because they are their own experts. They can conduct follow-up, contact tracing, and peer support at low cost, and even support HIV-positive women throughout pregnancy and breastfeeding.

Investing in data systems that reveal disparities. Countries need integrated systems for collecting and using disaggregated health data to monitor and address differences in service uptake and outcomes. This includes tracking 95-95-95 outcomes among key populations and collecting costing data to inform financing mechanisms. Without this data, it's impossible to know whether integration is working equitably across different populations.

Creating flexible financing mechanisms. Critical to successful integration is blended financing that allows for safety nets and helps weather funding shocks. Community-led organisations need financial autonomy and flexible funding not only to survive donor cuts but also to fill gaps in structural interventions, which are often underfunded and unlikely to be prioritised in national health budgets. Community organisations can start businesses to generate income for costs not covered by traditional funding. This revenue can come from fee-for-service health provision, sales of data systems and products, or non-health businesses like hair salons.

Governments can also lead by including payment mechanisms for community organisations in their social health insurance and universal health coverage schemes. Both HIV treatment and prevention services should be included, though some stakeholders worry that integration of prevention services is being overlooked in favour of treatment.

Leveraging the private sector. In many countries, pharmacies are more common than health clinics and can offer discreet, fast access to prevention. But ensuring that quality and affordability are maintained will require strong regulation and oversight.

Kenneth Ngure, IAS President-elect, emphasised pharmacy-based antiretroviral therapy and PrEP refill models as examples. "Even in the US, you're going to find Walgreens, CVS every two, three blocks. There are people who like getting their services there, and they are willing to even pay for services that are free at public health facilities for the convenience and for the reduced stigma," he said.

Putting people at the centre

Integration, it emerged, demands investment in what works, respect for community expertise, and systems that can track whether equity is being achieved or undermined. Most importantly, it requires recognising that the people most affected by HIV must remain at the centre of any integration strategy.

"Integration must recognise a range of service providers and models," concluded Caroline Bulstra. "Differentiated and community-led services need to be part and parcel of integration and connected to national systems."