Tom Minior, Adult Clinical Branch Chief, Office of HIV/AIDS, USAID
Chis Akolo, Technical Director, EpiC Project, FHI 360
Michele Lanham, Director of Knowledge Management, EpiC Project, FHI 360

On March 19, 2024, the Meeting Targets and Maintaining Epidemic Control (EpiC) project hosted the webinar HIV and Primary Health Care: Unlocking the Synergies of Integrated Services, focusing on innovative approaches to integrating HIV and primary health care (PHC) services and featuring presenters from Vietnam, Mozambique, Thailand, Nigeria, and the Philippines. Highlights and key takeaways from the webinar follow.

As progress is made toward the goal of ending AIDS as a public health threat by 2030, transformative actions are needed to sustain the HIV response in the long term. In 2024, UNAIDS released a new sustainability framework that lays the groundwork for country sustainability roadmaps. Integrating HIV services into PHC platforms and integrating the HIV response into the national HIV platform was one of the recommended approaches in the new framework.

The U.S. President’s Plan for Emergency AIDS Relief (PEPFAR) is also increasingly focused on service integration. The five-year PEPFAR strategy, released in 2022, acknowledges that the current vertical HIV service delivery model that PEPFAR uses is not sustainable in the long-term. As countries reach the UNAIDS 95-95-95 targets, PEPFAR programs will work with governments and their national sustainability plans to integrate HIV service delivery into local health systems. In 2022, the United States Agency for International Development (USAID) launched Primary Impact, their approach to strengthen PHC, including reducing siloed health services and promoting service integration to advance whole-person care. Despite the increased focus on integrating HIV services and PHC, the evidence about how to do this effectively is limited.

Integration is a multifaceted concept with various interpretations, but it fundamentally entails combining previously siloed services into a comprehensive care package in mainstream health systems. Whether layering PHC onto HIV services or integrating HIV services into PHC platforms, the overarching goal is the same: to provide broader coverage and accessibility to essential health services for all populations.

Integrating PHC into HIV services has the potential to reduce morbidity and mortality among people living with HIV (PLHIV) by addressing other health needs that affect virologic suppression and overall well-being. This will become increasingly important because globally PLHIV are living longer and experiencing health needs associated with aging. COVID-19 brought mental health to the forefront and HIV programs are starting to address mental health issues. The USAID and PEPFAR-funded EpiC project in Vietnam is leveraging government-run HIV services, as well as pre-exposure prophylaxis (PrEP) services led by key populations (KPs) to screen for non-communicable diseases and mental health issues. EpiC used outcomes data to adapt their approach to service integration. For example, they expanded use of self-administered mental health screening after finding that it more effectively identified clients at risk of anxiety or depression. The program also recognized the critical role that on-site psychologists at HIV treatment facilities play in increasing screening and referral rates and in providing quality counseling.

Implemented by FHI 360 in Nigeria, the USAID-funded Strengthening Integrated Delivery of HIV/AIDS Services (SIDHAS) project also employed a checklist-administered screening and triaging approach to provide holistic care to PLHIV. Using the chronic care model, health workers in facilities and in the community screened more than one million PLHIV for communicable and non-communicable diseases including tuberculosis, nutritional status, gender-based violence, hypertension, diabetes, and malaria. Some services — including HIV counseling and testing, antiretroviral therapy (ART), prevention of mother-to-child transmission (PMTCT), and maternal and child health (MCH) — were offered in a one-stop-shop model, and a strong referral system was developed for other services.

Integrating HIV services into PHC services can increase the reach of HIV prevention services. An individual may not think they are at risk of HIV or be willing to go to a standalone PrEP clinic but may be willing to access HIV testing and prevention when these services are integrated with PHC. Integrating HIV services into PHC also has the potential to reduce the burden on individuals.

In Mozambique, mobile brigades are a model of integrated service delivery that use community workers to expand a health facility’s catchment zone by extending services into the community. Mobile brigades were initially used in Mozambique in 1979 to expand vaccination for infants and children and have since expanded to include family planning, nutrition, maternal and child health, tuberculosis, and HIV. The USAID- and PEPFAR-funded Efficiencies for Clinical HIV Outcomes (ECHO) project implemented by Abt Global has achieved notable success using this model, including 100% of clients being virally suppressed in some communities and many enrolled in multi-month dispensing of ART. However, some community workers find it challenging to deliver multiple services simultaneously, and weather and crisis situations can make it difficult for them to reach clients at times.

The most effective and sustainable ways to integrate services varies based on local health system factors and the needs and preferences of the populations being served. To understand the needs and preferences of clients, it is imperative to engage communities as collaborative partners in shaping health and social services. For example, through the EpiC project, the MPLUS Foundation in Thailand conducted surveys and focus groups with KP communities to develop and implement a KP-led health services model to address the comprehensive health needs of KPs, including mental health, sexually transmitted infection (STI) diagnosis and treatment, and diagnosis and treatment of non-communicable diseases.

Integration of HIV services into PHC also required integration of systems, including finance, workforce, supply chains, and information systems. In the Philippines, an ongoing barrier to HIV service delivery is that the national health insurance system only reimburses HIV services after someone is diagnosed with HIV; screening and confirmatory HIV testing are not covered. Moreover, PHC are typically not certified by the Department of Health (DOH) to provide HIV treatment, contributing to fragmentation in care and substantial gaps in meeting the 95-95-95 targets related to HIV diagnosis and treatment. Following the Universal Health Care Act of 2019, the DOH, in collaboration with the Philippine Health Insurance Corporation, is working toward a single integrated benefit in which HIV testing, ART, and viral-load monitoring are available to everyone — regardless of HIV status — through primary care facilities at little or no out-of-pocket cost.

When tailored to the local health system context and the needs of target populations, integration holds great promise in streamlining service delivery, promoting sustainability, and ultimately improving health outcomes for PLHIV. To be successful, knowledge sharing, collaboration, and evaluation are needed to identify approaches that promote local ownership and sustainability while delivering high quality, people-centered care.

Access the webinar recording here and the presentations here.

Featured image: MPLUS Foundation provides services through community staff certified by the Ministry of Public Health. Their staff have knowledge and understanding of the intricacies of sexual health and the lifestyles of service recipients who belong to the same population group. This ensures that service recipients feel comfortable discussing and exchanging information with empathy, and receive services tailored to their needs. Photo by Kiartisak A-jima, MPLUS Foundation