Integration of HIV care into primary care reduces deaths in South African trial

Integrating HIV care into primary care can improve survival of people living with HIV who are in need of antiretroviral therapy (with CD4 counts of 350 cells/mm³ or less) in high-burden countries with task-shifting and decentralisation of care in place, researchers report in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes.

Measurement of the effect of integration on survival in over 9000 people with CD4 counts at or under 350 cells/mm³, not yet on antiretroviral therapy (ART), in 31 clinics followed for 12 to18 months in Free State Province, South Africa showed a decreased risk of death in those clinics with high scores for integration, independent of other patient or clinic characteristics known to affect survival.

Every one point increase in total integration score was linked to a 3% decreased risk of death (HR 0.97; 95: CI: 0.95-1.00; p = 0.041) in this sub-study (a questionnaire) of a randomised controlled trial looking at the effects of task-shifting and decentralisation of care on patient outcomes in South Africa – the Streamlining of Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) trial.

This is of particular relevance since ART is currently being integrated into primary care in South Africa.

With an estimated seven million people having started ART in sub-Saharan Africa resulting in significant decreases in mortality the importance of attaining universal coverage has been recognised. Yet, close to half of those in need are still without treatment. 

Health infrastructure problems in sub-Saharan Africa led many countries at first to set up vertical (stand-alone) HIV care programmes with separate funding, staff and facilities.

Such programmes unable to reach all in need of ART in high-burden countries should be incorporated within existing health systems' programmes to both provide HIV care and strengthen these systems, the authors write.

Task-shifting has addressed the problem of healthcare worker shortage in many countries with good patient outcomes. Task-shifting alone, however, cannot resolve health systems' deficiencies or identify sustainable strategies integrating HIV care.

Integration, a broad concept, overlaps with that of decentralisation. In the absence of a clear definition, there is scant evidence showing integration improves patient outcomes, write the authors. As such, sustainable strategies are lacking.

A wide variety of programmes described as decentralisation or integration of HIV care have significantly improved access to care and include primary care-driven models, note the authors. Studies have reported on strategies to integrate HIV care into all primary care consultations. All have reported good outcomes but none, they stress, were conducted as clinical trials.

So the authors chose to look at the effect of integration of HIV care into primary care services on patient survival in a sub-study, using a questionnaire developed during the trial to answer two specific questions.

1. Is there evidence that integrating HIV care into primary care services improves survival for patients with CD4 counts at or under 350 cells/mm³ and not on ART?
2. If so, what level of integration of HIV care into primary care is important to improve patient survival?

Free State Province has an estimated adult HIV prevalence of 18.5% in a population of 2.8 million. In 2004, using a vertical approach to HIV care, the public sector ART programme began.

While 57 ART assessment and treatment clinics were in operation by mid-2007, most of the 222 primary care clinics could not offer on-site access to ART. Those on ART did well but only an estimated one in four people in need of ART were getting it. Fifty per cent of those awaiting ART died within a year.

The STRETCH trial began in 2007 to determine strategies to improve access to ART. All 31 ART assessment clinics in operation by the end of 2006 were randomised to 16 intervention and 15 control clinics. The two main interventions comprised 1) nurses starting and repeating ART prescriptions in uncomplicated cases with referral of complicated cases to doctors at treatment sites and 2) integrating elements of HIV care into primary care services so patients could access most of their care at primary care instead of the assessment clinic.

The questionnaire comprised questions on the number of staff and referring primary care clinics and 19 on integration of elements of HIV care.

Each question was scored: 0 for no integration, 1 for partial and 2 for full integration.

For each clinic five integration scores were determined as follows:

• Total integration – total score for all 19 questions.
• Pre-ART integration – on provision of HIV care by all nurses for patients not yet eligible for ART.
• ART integration – on provision of HIV care for patients eligible for and on ART.
• Internal integration – on provision of pre-ART and ART care within the ART clinic.
• Mainstreaming HIV – on provision of pre-ART and ART care by nurses at referring primary care clinics.

Internal integration scores could be assessed for all 31 clinics, while the other scores could only be calculated for 23 clinics (13 intervention and 10 control) that still had primary care clinics referring patients for HIV care at the end of the trial. The other eight, all in rural areas, followed department of health policy to establish more ART clinics in rural areas.

In all 31 clinics there was a significant decrease in death for each increase in internal integration scores.

Hazard ratio analysis was repeated without adjusting for clinic characteristics to see whether components of integration made a difference to survival by affecting staff/patient ratios and improving access to rural clinics.

In the 23 clinics, for every one point increase in pre-ART integration there was a significant 8% decrease in death (HR:0.92; 95% CI: 0.85-0.99; p = 0.027); 5% for every one point increase in ART integration scores (HR:0.92; 95% CI: 0.93-0.98; p = 0.001) and 10% for every one point increase in mainstreaming HIV scores (HR:0.90; 95% CI: 0.83-0.97, p = 0.007) but no difference in death rates in the 31 clinics with changes in internal integration scores.

This would suggest that internal integration in all 31 clinics, with a larger percentage of rural clinics, has a significant impact on survival when HIV care is available in all primary care clinics so improving patient/staff ratios, note the authors.

The potential means by which integration of HIV care into primary care improved survival included improved access to care, decreased stigma and improved confidentiality, continuity and comprehensiveness of care, the authors write.

Another potential mechanism, they add, is improved quality of care with evidence from the STRETCH trial showing improved TB case detection, weight gain and increase in CD4 counts in intervention clinic patients.

Strengths include quantifying integration of different elements of HIV care and the levels at which integration took place with a tool, validated within a randomised, controlled trial.

Patient survival was monitored by linkage to the national death register.

STRETCH showed a significant difference in survival only among patients with CD4 counts between 200 and 350. This sub-study showed that one intervention – integration of HIV care into primary care clinics – was associated with improved survival of all patients with CD4 counts at or under 350.

The authors conclude “these results…of practical importance to policy makers in high burden countries…suggest that pre-ART and ART care be provided as part of the package of care provided in all primary care services and efforts be made to integrate HIV care into all consultations within primary care.”