HIV treatment integrated into general health care delivers 'equal or better' results
Outcomes 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.
While 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 among patients followed for up to 30 months. The 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.
The 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.
However, resource demands make vertical programmes neither feasible nor appropriate in rural settings or in areas of low HIV prevalence with other competing health issues.
The 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.
Benefits include: 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 same place. Improved programme cohesiveness.
Yet 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 MSFs integrated and vertical HIV programmes.
Vertical 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.
Although 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 Health facilities .
The 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. (13 January 2012)