Strengthening Health Systems at Facility-Level: Feasibility of Integrating Antiretroviral Therapy into Primary Health Care Services in Lusaka, Zambia

Abstract

IntroductionHIV care and treatment services are primarily delivered in vertical antiretroviral (ART) clinics in sub-Saharan Africa but there have been concerns over the impact on existing primary health care services. This paper presents results from a feasibility study of a fully integrated model of HIV and non-HIV outpatient services in two urban Lusaka clinics.MethodsIntegration involved three key modifications: i) amalgamation of space and patient flow; ii) standardization of medical records and iii) introduction of routine provider initiated testing and counseling (PITC). Assessment of feasibility included monitoring rates of HIV case-finding and referral to care, measuring median waiting and consultation times and assessing adherence to clinical care protocols for HIV and non-HIV outpatients. Qualitative data on patient/provider perceptions was also collected.FindingsProvider and patient interviews at both sites indicated broad acceptability of the model and highlighted a perceived reduction in stigma associated with integrated HIV services. Over six months in Clinic 1, PITC was provided to 2760 patients; 1485 (53%) accepted testing, 192 (13%) were HIV positive and 80 (42%) enrolled. Median OPD patient-provider contact time increased 55% (6.9 vs. 10.7 minutes; p<0.001) and decreased 1% for ART patients (27.9 vs. 27.7 minutes; p = 0.94). Median waiting times increased by 36 (p<0.001) and 23 minutes (p<0.001) for ART and OPD patients respectively. In Clinic 2, PITC was offered to 1510 patients, with 882 (58%) accepting testing, 208 (24%) HIV positive and 121 (58%) enrolled. Median OPD patient-provider contact time increased 110% (6.1 vs. 12.8 minutes; p<0.001) and decreased for ART patients by 23% (23 vs. 17.7 minutes; p<0.001). Median waiting times increased by 47 (p<0.001) and 34 minutes (p<0.001) for ART and OPD patients, respectively.ConclusionsIntegrating vertical ART and OPD services is feasible in the low-resource and high HIV-prevalence setting of Lusaka, Zambia. Integration enabled shared use of space and staffing that resulted in increased HIV case finding, a reduction in stigma associated with vertical ART services but resulted in an overall increase in patient waiting times. Further research is urgently required to assess long-term clinical outcomes and cost effectiveness in order to evaluate scalability and generalizability.

Opt-out provider-initiated HIV testing and counselling in primary care outpatient clinics in Zambia

“…26,27 Between July 2008 and June 2010, an integrated approach to outpatient care for individuals with and without HIV infection was introduced in a staggered fashion into nine urban primary health-care clinics in Lusaka. [28][29][30] Clinical and administrative services at each clinic were harmonized for patients with and without HIV infection in three key ways: (i) the physical space used by patients and patient flows were amalgamated; (ii) medical records were standardized and (iii) routine PITC was introduced. All patients attending outpatient departments were referred for Abstracts in ‫,عريب‬ 中文, Français, Pусский and Español at the end of each article.…”

Integration of HIV Care and Treatment in Primary Health Care Centers and Patient Retention in Central Mozambique

“…7–9 In an effort to reduce the burden placed on the hospital systems, to increase geographic coverage, and to reduce the time and costs of transport, many ART programs began integrating HIV care and treatment services into primary health care centers resulting in a dramatic expansion in the number of people initiating treatment. 3–6,10,11 A few studies have demonstrated that these integrated programs resulted in faster enrollment and better retention. 3,12–14 However, given the lack of conclusive evidence, experts have called for further assessments of the potential benefits and risks of integrated models of delivery.…”

Linkage to HIV care before and after the introduction of provider-initiated testing and counselling in six Rwandan health facilities

“…This hypothesis is supported by the finding that out-patients in this study who enrolled into pre-ART care had lower absolute CD4 counts than VCT patients both before and after the introduction of PITC. Several studies report that operational problems such as increased waiting times are common under PITC (Evans & Ndirangu, 2009;Roura et al, 2013;Topp et al, 2010). This could also have led to lower linkage-to-pre-ART-care after PITC in this study.…”