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Integration of HIV services into primary health care: a health system approach in Free State South Africa

University of British Columbia

Improving access to antiretroviral therapy (ART) for HIV has improved life expectancy and reduced HIV transmission. The integration or decentralisation of HIV care into primary health care (PHC) clinics is a widely promoted strategy to expand access to ART. In South Africa, a national policy to integrate HIV care into PHC services was implemented in April 2010. Comprehensive HIV care, from testing to the initiation and management of ART, was provided largely by nurses in PHC clinics. Little evidence exists on the impact of integration on: 1) patients 2) health care workers and 3) PHC clinic function and service delivery. By examining this question in Free State, South Africa through a health systems approach, I aimed to understand the benefits and challenges of integrating HIV care into PHC services. A mixed methods approach was employed utilising quantitative (i.e. patient surveys and longitudinal analysis of administrative data across 4 years) and qualitative (i.e. key informant interviews and focus group discussions) methods. Statistical analysis included t-tests and linear regressions (patient survey data) and interrupted times series analysis and linear mixed effect modelling (longitudinal data). Qualitative data were inductively and deductively thematically coded, and applied to a health systems framework. Concerning patients, advantages of integration were the provision of comprehensive care at PHC clinics (including HIV care), maintaining quality of care (QoC) as integration progressed, improved care across the continuum, family and community engagement. However, increased wait times, decreased QoC for chronic disease patients and concerns about retention were identified. For health care workers, despite increased workload with staff shortages, integration positively influenced job satisfaction, morale, the promotion of teamwork and mentoring. Concerning PHC service delivery, notwithstanding an increase of nearly 60, 000 patients on ART in the 131 PHC clinics in our four year study, service delivery was mostly unchanged, except for decreased immunisation coverages. In conclusion, expansion of ART through integration to PHC clinics is a viable strategy with wide health system benefits. However, care must be taken to provide adequate support for health systems to ensure the provision of equitable patient-centred PHC, especially in highly HIV prevalent contexts.

Text

2016-04-30

Attribution-NonCommercial-NoDerivs 2.5 Canada

http://hdl.handle.net/2429/52728

Health Care and Epidemiology

University of British Columbia

UBCV

http://creativecommons.org/licenses/by-nc-nd/2.5/ca/