This article describes select country approaches to integrating services for the prevention of mother-to-child transmission of HIV (PMTCT) and identifies some key programming considerations. It focuses on the priority countries of the Global Plan Toward the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan). There were 22 Global Plan focus countries: Angola, Botswana, Burundi, Cameroon, Chad, Côte d'Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, India, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, South Africa, Uganda, United Republic of Tanzania, Swaziland, Zambia, and Zimbabwe. However data for India were unavailable, and so focus was on 21 countries.1 This paper describes how selected aspects of integration were implemented across the countries, what key outcomes were achieved, and what lessons were learned. However, it does not seek to compare and critique how countries implemented integration or evaluate attribution of outcomes to integration in a robust manner.
There is currently no standardized definition of integration, established framework, or country information source that captures all elements and processes of integration, making rigorous analysis and country comparison difficult. In the context of HIV and sexual and reproductive health and rights (SRHR), policy/legal approaches, health systems, and service delivery have been defined as “linkages,” of which integrated service delivery is an integral part. Although 2 indicators relevant for PMTCT integration have been developed that describe which HIV and SRHR services are combined and how they are delivered, these indicators are not yet widely used. They also are limited to HIV and do not include upstream policy and health system aspects.2–5 Definitions of integrated service delivery reflect the goal of providing clients with convenient access to the maximum number of comprehensive quality services during a single visit. Multiple models of service integration exist, ranging from services being provided by the same provider in the same room during the same visit to on-site and off-site referrals.
INTEGRATION OF SERVICES IN THE CONTEXT OF THE GLOBAL PLAN
PMTCT programs in Global Plan priority countries have become progressively integrated within maternal health (antenatal and postpartum), postnatal, pediatric, antiretroviral treatment, family planning, and tuberculosis (TB) services. Historically, PMTCT programs were sometimes described as vertical or stand-alone services,6 set apart from maternal, newborn, and child health (MNCH) when they had designated HIV health providers, separate infrastructure, dedicated funding, separate reporting, and parallel systems for planning, coordination, and management, reporting to national AIDS coordinating bodies instead of the ministries of health (where MNCH departments were located).4,7–10
From the outset, PMTCT services featured some degree of integration through inclusion of HIV information, counseling, and testing in antenatal care services. Pregnant women living with HIV were provided with infant feeding counseling and antiretroviral medicines—initially monotherapy with single-dose nevirapine or zidovudine—to prevent transmission to their infants. However, integration was incomplete. For example, the services were often provided by specialized HIV nurses or doctors in designated PMTCT rooms colocated within antenatal care or through referral to off-site antiretroviral therapy clinics. PMTCT programs became synonymous with providing services predominantly for pregnant women living with HIV, instead of serving all pregnant women or women living with HIV who were not pregnant.
With the introduction in 2000 of a comprehensive PMTCT strategy incorporating 4 prongs, however, the landscape was reset for the broader integration of PMTCT as part of other health services, particularly MNCH and family planning.11 The 4 prongs are as follows:
- Prong 1: primary prevention of HIV infection among women of childbearing age.
- Prong 2: preventing unintended pregnancies among women living with HIV.
- Prong 3: preventing HIV transmission from a woman living with HIV to her infant using antiretroviral medicines.
- Prong 4: providing appropriate treatment, care, and support to mothers living with HIV and their children and families.
Lack of adequate integration with MNCH and attention to Prongs 1 and 2 was widely acknowledged,12 and by 2007, global PMTCT guidance was unequivocal that accelerating PMTCT scale-up required delivery of all 4 prongs as part of routine quality sexual and reproductive health (SRH) and child health care; it also recommended a shift to provider-initiated HIV testing and counseling.13
The Global Plan, launched in 2011, further advanced global commitment and new targets for PMTCT, and it included the previously neglected goal of keeping mothers alive, which provided renewed emphasis on integrating PMTCT with antiretroviral therapy for women. Support for implementation of all 4 prongs was buttressed by modeling that showed achieving a 90% reduction of new HIV infections among children would not be possible without Prong 1 and 2 interventions.14
Integration of PMTCT interventions within broader health services raised many questions15:
- Which provider would do what, when, and how?
- What were country policies regarding the introduction of new services?
- What training and staffing were needed, and were task shifting and task sharing needed or possible?
- What would be the impact on workload and patient flow?
- What supply chain adjustments would be required to ensure the availability of commodities to implement comprehensive PMTCT services?
- Would the quality of services suffer?
- How would the community be engaged, and how would people respond to an expanded range of available services?
Each country had to develop and implement its own strategy to achieve greater integration of services, building on global guidance, evidence, and the experiences of other countries.
MODELS OF INTEGRATED SERVICE DELIVERY
Limited research exists on the various models for integrating PMTCT services with other health services, with mixed findings about the impact on health outcomes, client uptake, health worker productivity, client waiting times, acceptability, and cost-effectiveness and cost efficiency.16–19 In the absence of a defined optimal model, Global Plan priority countries took different approaches to expanding and integrating care.20 The following examples depict illustrative country experiences with integrating PMTCT interventions into MNCH, family planning, and antiretroviral therapy services.21 Additional country experiences are reflected in Boxes 1 and 2.
“One-Stop” Integrated Service Delivery in Namibia
As part of an SRHR and HIV linkage project, Namibia reorganized its service delivery in clinics and health centers at 7 pilot sites in 2014 to provide integrated services through a model of “one nurse, one patient, one room.”51 Under this one-stop model, the nurse
- follows the same client over time,
- is trained to provide an expanded range of primary health services, and
- facilitates referral as needed.
Analysis of baseline study at these sites conducted in 2011 and 2012, including a client time motion study, guided decision making on the optimal integration model by examining the following:
- who (provider),
- what (service),
- where (setting), and
- when (time).
The integrated model of care has done the following:
- improved nurse productivity by 2.5 times under the one-stop model compared with the previous model of multiple providers providing separate services to clients on site during one visit;
- reduced the average total time that clients spend waiting for services related to first antenatal care visit (down from 4 to 2 hours);
- reduced stigma and discrimination; and
- enabled health care providers to offer more services to clients.
Based partly on this experience, the government has developed guidance to scale-up integrated services nationwide.52 The project is entering its second phase, with a cost study and evaluation of the first phase underway.
Comprehensive Integration of HIV and SRHR in Swaziland
Swaziland has embarked on an ambitious plan to integrate SRHR and HIV by doing the following:
- launching its first SRHR strategy in 2013, which fully integrates HIV services;
- developing frameworks and protocols for its operationalization; and
- piloting models for stigma-free integrated HIV and SRHR service delivery in 5 Centers of Excellence.27
A 2013 survey of health provider and client perceptions of integrated SRHR and HIV services revealed the following:
- overall satisfaction with the integrated services,
- fewer client trips required to the health clinic,
- reduction in client expenditures on health,
- long waiting times, and
- staff shortages and overload.53
Integration of Adult HIV Testing With Family Planning and Postpartum Services (Prongs 1 and 3)
HIV counseling and testing serve as a gateway to treatment by diagnosing HIV status, and it can link with other prevention services, including treatment as prevention among HIV serodiscordant partners, pre-exposure prophylaxis (PrEP) and postexposure prophylaxis, and behavior change interventions.14 In Kenya, integrating HIV counseling and testing into family planning services increased uptake of services and improved overall quality of joint family planning and HIV counseling.22 In Ethiopia, testing uptake increased as much as 7-fold when the same health worker offered HIV testing and counseling and family planning services in the same room as opposed to in separate sections of the clinic.23 Over half of HIV transmission to infants currently occurs during breastfeeding,24 and countries are now offering HIV testing to mothers in the postpartum period to identify seroconversion during breastfeeding.25 In general, efforts to help pregnant women who test HIV negative in antenatal clinics to remain so have been inadequate; offering treatment to HIV seropositive partners or providing PrEP to women can protect them from acquiring HIV and transmitting it to their children.
Integration of Family Planning Into Antiretroviral Therapy, Immunization, and Community-Based Services (Prong 2)
Services for preventing unintended pregnancies among women living with HIV have been integrated into antiretroviral therapy clinics, HIV testing sites, and community-based HIV services, with some studies finding resultant increases in the uptake of family planning services and contraceptive use among women living with HIV.26 In Botswana, 9 pilot sites integrated family planning into antiretroviral therapy clinics, resulting in 79% of antiretroviral therapy clinic clients accessing family planning from 2012 to 2013.27 In Kenya, a pilot to integrate family planning services into 12 HIV care clinics enabled clients to be offered contraceptives by the same provider during the visit, which resulted in increased use of effective contraceptive methods (compared with 6 control sites where clients were referred for family planning services within the same facility). However, no difference in pregnancy rates was observed between the pilot and control sites after 1 year.28 In Ethiopia, Malawi, and Nigeria, facilities that offered family planning services at child immunization visits significantly increased contraceptive uptake, particularly among adolescents, although the study did not differentiate by HIV status.29
Integration of HIV Treatment Into Maternal Health Services (Prongs 3 and 4)
Even as late as 2009, the baseline year of the Global Plan, only 37% of pregnant women living with HIV in the 21 high-burden countries in sub-Saharan Africa were receiving antiretroviral medicines.25 Typically, only single-dose nevirapine was given to the pregnant woman, which reduced early vertical transmission by up to 50% but did not treat the illness of the women themselves. In 2010, the World Health Organization (WHO) recommended new efficacious PMTCT antiretroviral medicine regimes that required CD4 measurement for eligibility. At that time, WHO recommended 3 approaches for the use of antiretroviral medicines to prevent mother-to-child transmission of HIV: option A, option B, and option B+ (WHO,30 2010). Both option A and B approaches consisted of immediate, lifelong triple antiretroviral medicines for the most immunocompromised pregnant women (CD4 count of ≤350). For their healthier counterparts, both options consisted of a short course of antiretroviral medicines prescribed over a specified period during pregnancy and breastfeeding. After that, use would stop, resuming when the woman became pregnant again or when she met the criteria for starting treatment for her own health. Option B+ avoided that stop-and-start approach: under option B+, all pregnant or breastfeeding women diagnosed with HIV were offered treatment for life, regardless of CD4 count.30
Because Malawi did not find CD4 testing feasible on a large scale, it adopted a national policy of offering all HIV seropositive pregnant women antiretroviral therapy without a CD4 test.31,32 This new approach, described in this series by Kalua et al31 simplified antiretroviral therapy initiation and increased the number of women eligible for treatment. Consequently, Malawi established a task-shifting policy enabling nurses and midwives to initiate and manage antiretroviral therapy within maternal health services, with 426 additional antenatal care clinics able to provide antiretroviral therapy directly without referral. These actions, coupled with community follow-up, demonstrated that simplification and integration of antiretroviral therapy into MNCH services was feasible at scale and that it also provided a platform for expanded antiretroviral therapy delivery to children and other family members.
More recently, Myer et al33 in South Africa examined opportunities for integrating postnatal maternal ART services into MNCH services. This randomized trial compared outcomes for women who were retained in MNCH services and offered ART care there, versus those who were referred to general adult ART services after delivery, which is the standard of care for many countries in sub-Saharan Africa. Women in the MNCH arm of the study were retained there for 12 months or until the end of breastfeeding, after which they were transferred out to the general adult clinic. The results showed that women in the MNCH arm had higher rates of viral suppression (77% vs 56%) and longer duration of breastfeeding. They demonstrate that that integrating maternal ART into MNCH services could be a simple and highly effective strategy to support retention and adherence.
Integration of Pediatric Diagnosis and Treatment Into Postnatal and Other Settings (Prong 4)
The PMTCT continuum of care includes diagnosis for HIV-exposed children within 6 weeks after delivery, followed by immediate treatment if seropositive. By 2012, only 30% of children living with HIV in the 21 Global Plan priority countries were receiving antiretroviral therapy. In response, recommendations were put forward to expand pediatric testing and treatment access by integrating these services into pediatric wards, schools, immunization clinics, nutrition services, programs for orphans and vulnerable children, and homes through community outreach.34 In Zimbabwe, early infant diagnosis was integrated into immunization and other postnatal visits to capitalize on routine visits by mothers with their infants. Of the 139 facilities responding to a follow-up survey of 151 sites, 83% of the immunization clinics and 80% of the postnatal clinics were providing dried HIV blood spot collection and nevirapine and co-trimoxazole prophylaxis for HIV-exposed infants along with routine postnatal services. However, 73% of these facilities were offering antiretroviral therapy only through referral.35
GOOD PRACTICES AND LESSONS LEARNED
Good practices and lessons learned from integrating PMTCT services, particularly regarding upstream policy and health system practices to facilitate integration are presented on Box 3. Key lessons learnt include the following:
Good Policy and Health System Practices That Facilitate PMTCT Integration
- Foster political will and leadership to enable the policy and health system changes required for integration by gaining buy in from policy makers and managers overseeing PMTCT programs and the relevant related HIV SRHR, and ART and TB programs
- Develop thorough and sustainable integration strategies to explain how integrated services are to be organized and delivered and to carefully guide the process of restructuring health systems to support integration.
- Establish a coordination mechanism to enable communication, alignment of plans and budgets, and joint problem solving between the different line departments involved in service integration.
- Revise commodity management, monitoring, and evaluation to ensure any additional commodities are available in sufficient quantities to support newly integrated services and that systems are in place for facilitative supervision and evaluation of the impact of integrated service delivery.
- Support health providers and managers to be engaged in the process of restructuring services, to receive training to perform new tasks, and to adapt to changes in protocols, workload, and responsibilities.
- Inform and engage clients and communities to ensure that users of the services are aware of where to go for what services and to minimize potential stigma and discrimination.
Task Shifting and Task Sharing Are Essential for Successful Integration
Integration requires health workers to provide additional services that they initially may not be eligible, accustomed, or skilled to perform. These task shifting and task sharing frequently required changes in accreditation, prescribing authority, and training to enable a wider cadre of health workers to deliver interventions. In the Democratic Republic of Congo, nurses in primary care facilities were trained to deliver HIV and TB interventions with 98% agreement between nurses and physicians regarding decision making on antiretroviral therapy initiation and 95% agreement regarding the choice of antiretroviral therapy regimen.20 Antiretroviral therapy uptake by TB clients living with HIV rose from 17% when clients were referred for antiretroviral therapy to 67% under the integrated model, and mortality during TB treatment declined from 20% to 10%.
Health Information Systems Require Adjustment to Capture Integrated Service Delivery
Because integrated services are now being delivered at multiple points of care, health information systems have required adaptation to track clients (including mother–baby pairs) through the continuum of care. Although this is not necessarily a widespread practice elsewhere at this time, a program in Uganda has developed a special indicator to track retention of mother–baby pairs over 18 months. Health care providers trace mother–baby pairs through community follow-up, and facilities keep their charts together. As a result, retention of mother–baby pairs has increased from 2.2% to 60% in less than a year.36 In Swaziland, the registration form for antiretroviral therapy has been revised to include an entry on the fertility intentions of clients.37 In Malawi, the integration of antiretroviral therapy and PMTCT has required a revision of the monitoring and evaluation tools and reporting systems.
Integrating Services Require Availability and Joint Management of Commodities for HIV, SRH, and Other Services
Provision of integrated services for the 4 prongs has required an expanded, coordinated, and secure supply chain to provide HIV test kits, antiretroviral medicines for treatment and PrEP and postexposure prophylaxis, contraceptives, penicillin to treat syphilis, and supplies to detect and treat precursor lesions and early stage cervical cancer. In addition, integrated services would require greater attention to both pediatric and maternal TB, especially in high-TB prevalence regions.
Integration May Minimize Costs and Increase Efficiency Gains
Evidence on costs, potential cost-effectiveness, and cost efficiency of integrating HIV and SRHR services is fairly limited and conflicting, partly because of variations in models of integration and lack of comparison with vertical services. Data from Kenya and Swaziland show that gains in efficiency when integrating HIV and SRHR services may be achieved through better use of human and capital resources and increased demand.38 Efficiency gains from HIV and SRHR service integration are not guaranteed, relatively modest, and most likely to occur where fixed costs have been high and client uptake increases.39
A review of cost savings gained by integrating PMTCT interventions into antenatal care facilities (task-shifting antiretroviral therapy delivery to nurses and increasing coverage) and integrating family planning into HIV care in Malawi, Mozambique, and Uganda found that integrating both saved costs and improved HIV and SRH outcomes.40 A systematic review of the literature on cost and cost-effectiveness, based on cost per averted pregnancy, concluded that integrating PMTCT and MNCH services was cost effective, especially when offering HIV counseling and testing in antenatal care and family planning at antiretroviral therapy sites. Evidence is limited on whether this observation holds true at scale and on the relative efficiency of different models of integration.41 A study in Kenya corroborated the cost-effectiveness of integrating family planning into HIV treatment clinics.42 The cost benefits of integrated services accrue through economies of scope and scale, time savings for clients, and lower opportunity costs because of better health status. However, additional studies are still needed to provide more robust cost savings of integration.
Integration Is Not a Panacea for Underlying Inadequate Health Systems but It Can Potentially Improve Service Delivery
Although integrating services can improve health provider productivity and client experiences, it can also have unintended consequences, such as overloading staff and creating longer client waiting times.19,33 In Zambia, merging the antiretroviral therapy clinic with the outpatient department led to a 32% increase in waiting times for outpatient department clients and a 36% increase for antiretroviral therapy clients, although the delays were partly attributable to the model of integration used, inadequate staffing levels, and other variables.43 Despite largely favorable results in rural Kenya, where HIV treatment was integrated into antenatal care, provider workload increased and any potentially longer visits for women living with HIV (compared with other antenatal care clients) added risk of inadvertent disclosure of HIV status.44
Other experiences with integrated service delivery have been more favorable. In Namibia, client wait times decreased and provider productivity increased after integration of services (Box 1).27 In several other countries, integrated service delivery reportedly reduced stigma and discrimination.27
Every additional step in accessing integrated PMTCT services—such as being seen by multiple providers during one visit, being referred on-site or to off-site clinics, or returning for services offered only on certain days—can place hurdles in the path of women and their infants. The Global Plan priority countries are overcoming some of these barriers by increasingly offering integrated services to meet the multiple health needs of clients simultaneously. Enabling nurses and midwives to initiate and manage long-term antiretroviral therapy in MNCH settings was a significant game changer in expanding access to PMTCT for pregnant women living with HIV: by 2015, 80% of pregnant women living with HIV in these countries were receiving more effective antiretroviral regimens.27 In contrast, primary prevention of HIV for pregnant and breastfeeding women as well as prevention and treatment of maternal and peditric TB, is not yet adequately programmed as part of PMTCT integration.
Integrating PMTCT services has shown potential for improving coverage, scope, and quality of services, reducing loss to follow-up, and using resources more efficiently.45,46 In Eastern and Southern Africa, integration of HIV and SRHR services has been advancing steadily,27 with governments developing guidance for national scale-up.47–50 The progressive WHO shift toward a “treat-all” approach can be expected to further accelerate service integration. Validation of “dual elimination” of mother-to-child transmission of HIV and syphilis also is likely to catalyze further integration with sexually transmitted infection prevention, treatment, and postpartum follow-up.
Policy, health systems, and financing considerations are paramount to supporting integrated service delivery.3 Informed and even visionary leadership is essential to forge partnerships among complex and often territorial separate programs, particularly under current funding constraints. A systematic study is needed to rigorously assess the impact of integrating PMTCT more broadly into existing health services, including cost implications, the effect on wider health systems, and outcomes related to health, stigma, and discrimination.
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