Integrating HIV Care into Primary Care Services:
Quantifying Progress of an Intervention in South Africa
Kerry E. Uebel1*., Gina Joubert2., Edwin Wouters3,4., Willie F. Mollentze1., Dingie H. C. J. van
1Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa, 2Department of Biostatistics, Faculty of Health
Sciences, University of the Free State, Bloemfontein, South Africa, 3Department of Sociology and Research Centre for Longitudinal and Life Course Studies, University of
Antwerp, Belgium, 4Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, South Africa
Background: Integration of human immunodeficiency virus (HIV) care into primary care services is one strategy proposed to
achieve universal access to antiretroviral treatment (ART) for HIV-positive patients in high burden countries. There is a need
for controlled studies of programmes to integrate HIV care with details of the services being integrated.
Methods: A semi-quantitative questionnaire was developed in consultation with clinic staff, tested for internal consistency
using Cronbach’s alpha coefficients and checked for inter-observer reliability. It was used to conduct four assessments of the
integration of HIV care into referring primary care clinics (mainstreaming HIV) and into the work of all nurses within ART
clinics (internal integration) and the integration of pre-ART and ART care during the Streamlining Tasks and Roles to Expand
Treatment and Care for HIV (STRETCH) trial in South Africa. Mean total integration and four component integration scores at
intervention and control clinics were compared using one way analysis of variance (ANOVA). Repeated measures ANOVA
was used to analyse changes in scores during the trial.
Results: Cronbach’s alpha coefficients for total integration, pre-ART and ART integration and mainstreaming HIV and
internal integration scores showed good internal consistency. Mean total integration, mainstreaming HIV and ART
integration scores increased significantly at intervention clinics by the third assessment. Mean pre-ART integration scores
were almost maximal at the first assessment and showed no further change. There was no change in mean internal
Conclusion: The questionnaire developed in this study is a valid tool with potential for monitoring integration of HIV care in
other settings. The STRETCH trial interventions resulted in increased integration of HIV care, particularly ART care, by
providing HIV care at referring primary care clinics, but had no effect on integrating HIV care into the work of all nurses with
the ART clinic.
Citation: Uebel KE, Joubert G, Wouters E, Mollentze WF, van Rensburg DHCJ (2013) Integrating HIV Care into Primary Care Services: Quantifying Progress of an
Intervention in South Africa. PLoS ONE 8(1): e54266. doi:10.1371/journal.pone.0054266
Editor: Kara K. Wools-Kaloustian, Indiana University, United States of America
Received July 13, 2012; Accepted December 10, 2012; Published January 22, 2013
Copyright: ? 2013 Uebel et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The National Research Fund of South Africa was the source of a doctoral bursary. The funders had no role in study design, data collection and analysis,
decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: firstname.lastname@example.org
. These authors contributed equally to this work.
There is international agreement that universal access to
treatment for people with human immunodeficiency virus (HIV)
in high-burden countries will not be achieved by vertical or single
disease approaches to delivering HIV care, but rather by
providing HIV care within general health systems [1,2,3]. Calls
have been made to use international funding and support for HIV
care to strengthen general health systems, and broaden existing
vertical HIV programmes so as to provide HIV care within
general health systems – the so-called diagonal approach
[4,5].Various strategies have been used in order to do this in
countries with severe human resource shortages and struggling
health care systems. These include shifting tasks from highly skilled
to lower skilled and even lay health workers, mobilising
community support and integrating HIV care into primary care
services . There are many reports of the effectiveness of task
shifting [6,7,8,9,10,11], and community mobilisation [12,13] and
guidelines have been published by the World Health Organization
. However, there are few clear recommendations on effective
strategies to integrate HIV care into primary care services partly
because there is still little evidence that integration of health care
programmes does improve patient outcomes .
One of the problems is that integration is a broad concept. It
has been defined as ‘‘a variety of managerial or operational
changes to health systems to bring together inputs, delivery,
management and organisation of particular service functions’’
.Integration may take place in all or any combination of a
number of different health system functions including service
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delivery, management, financing, governance and monitoring and
evaluation . In order to provide evidence of the effectiveness of
integration, controlled studies of integration are urgently needed.
Such studies would need to describe what functions are being
integrated and what strategies are used, but would also need to
develop tools to monitor and quantify integration in order to
correlate integration with outcomes achieved and compare
outcomes across different studies .
There have been reports of strategies to integrate HIV care into
primary care services including: co-location of vertically run HIV
services in primary care facilities  down referral of stable
patients on antiretroviral treatment (ART) to primary care clinics
 and the provision of outreach support to primary care clinics
from existing ART sites . Other programmes have reported on
strategies to integrate HIV care into all primary care consultations.
These included staff training, standardised protocols, combined
medical records and waiting areas, and the inclusion of HIV
testing into triage [22,23]. There are reports of improved access to
ART with primary care driven models of HIV care [8,21,24,25].
However all of these reports were observational and none were
able to link patient outcomes with the extent to which HIV care
This paper describes the development of a questionnaire as a
tool to quantify integration of HIV care into primary care services
achieved during a controlled trial of a complex intervention in the
Free State Province of South Africa. This was a trial of a task
shifting and integration intervention, monitoring the outcome of
patients needing ART, called Streamlining Tasks and Roles to
Expand Treatment and Care for HIV (STRETCH) . The
STRETCH trial is registered at isrctn.org (ISRCTN46836853)
Approval to conduct this study was obtained from the head of
the Department of Health in the Free State. The protocol for this
sub-study was approved by the ethics committee of the Faculty of
Health Sciences of the University of the Free State. The main
STRETCH trial protocol was approved by the ethics committees
of the faculties of health sciences at the Universities of Cape Town
and the Free State. Clinic managers provided written informed
consent to take part in the trial. As the STRETCH trial was an
educational and managerial intervention aimed at entire clinics
and their staff, all patients in the intervention clinics would be
exposed to the same intervention. Informed consent was not
requested from individual patients. Patients in intervention clinics
were given written information about the trial. Ethical principles
for use of medical records for research without patients’ consent
were followed: the research had a clear public benefit, approval
was obtained for the study from the lead doctors and nurses
managing the programme, use of the data for research did not
influence individuals’ care, the data were already being used by the
research team for programme evaluation on behalf of the
provincial health department, and data confidentiality was strictly
enforced. Only selected data managers had access to personal
identifiers. Anonymised data were provided only to the principal
investigators, the lead statistician and the health economist. This
consent procedure was approved by both ethics committees.
Context of the study
The Free State province, with a population of 2.8 million ,
and an estimated HIV prevalence of 18.5% among 15–49 year
olds , commenced the public sector rollout of ART in 2004
with a vertical approach to delivery of HIV care. Patients
diagnosed as HIV-positive, by nurses from primary care clinics
(who diagnose and treat common conditions) were referred for all
further HIV care to designated ART nurses (also primary care
nurses but appointed for the ART programme) at ART assessment
sites located within selected primary care clinics. Patients eligible
for ART (CD4 ,200 cells/ml or Stage 4) had baseline bloods
taken, received drug readiness training and then were referred for
initiation of ART to doctors at ART treatment sites and
subsequently fetched monthly supplies of ART at the assessment
site. Those not yet eligible for ART continued to access care (CD4
counts through laboratory testing, staging, tuberculosis (TB)
screening and cotrimoxazole prophylaxis) with ART nurses at
the assessment site. By the end of 2007, 57 ART assessment and
treatment sites were functioning . However, the vast majority
of primary care clinics in the province could not provide on-site
access to HIV care but rather had to refer their patients to primary
care clinics with ART assessment facilities. While patients on ART
had good outcomes [30,31], estimated coverage was only 25%
[29,32], the mortality rate amongst patients awaiting ART was
high , and high rates of burnout in nurses working in ART
clinics were recorded .
In order to assess strategies to improve access to ART, a
pragmatic, cluster, randomised controlled trial, the STRETCH
trial was conducted. All 31 existing ART assessment sites at the
end of 2006, were randomised into 16 intervention and 15 control
clinics within 9 clusters of between 2–7 clinics. Clinics in a cluster
were usually under one local area or district management
structure, or referred patients to doctors at the same ART
treatment clinic, or both. The trial comprised two interventions: 1)
nurse initiation and repeat prescription of ART and 2) integration
of HIV care into primary care. The primary outcomes were
survival of patients with CD4,350 and not yet on ART (patients
eligible for ART or likely to become eligible during the trial) and
12 month viral load suppression rates for patients on ART [26,34].
The integration intervention was developed in consultation with
staff at all 31 clinics . They reported that the existing system of
ART nurses providing all HIV care at designated ART assessment
sites was overloading these ART nurses and was also cumbersome
for patients. One example of this was that HIV-positive patients on
ART and those not yet eligible for ART who needed cotrimox-
azole prophylaxis, accessed HIV care from ART nurses at the
ART assessment site but had to fetch cotrimoxazole from primary
care nurses at their local primary care clinic as cotrimoxazole was
supplied from the clinic’s primary care budget. The aims of the
intervention developed with the staff were twofold: 1) HIV care
was to be integrated into the work of all primary care nurses (and
not just the ART nurses) within the ART clinic so that patients
could access HIV care from any nurse at that clinic (internal
integration) and, 2) HIV care was to be provided by nurses at all
surrounding primary care clinics referring patients to that ART
clinic, so that patients could access HIV care from their local clinic
(mainstreaming HIV care). Staff also identified six elements of
HIV care that needed to be integrated: 1) voluntary counselling
and testing (VCT); 2) initial CD4 count; and 3) routine care
including cotrimoxazole prophylaxis for those not yet eligible for
ART (three elements of pre-ART care); 4) baseline blood tests; 5)
drug readiness training; and 6) monthly supply of ART for patients
eligible for ART (three elements of ART care). It was noted during
development of the intervention that integration of pre-ART care
had already commenced at some ART clinics and their
surrounding primary care clinics (‘‘referring primary care clinics’’).
ART prescription and adherence counselling could not be
integrated into all primary care services during the trial as
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provincial authorisation of nurse ART prescription was limited to
trained nurses in intervention clinics only.
The strategies used to implement the STRETCH interventions
have been described elsewhere  and are summarised in
Table 1. These included provincial training in diagnosis and care
of TB, respiratory disease, sexually transmitted diseases and HIV
at all primary care clinics using the PALSA PLUS primary care
guidelines [35,36], and extra training in ART prescription at
intervention clinics using a STRETCH edition of PALSA PLUS.
Clinic based teams, consisting of key clinic staff, implemented
changes within intervention clinics. Local management teams
comprising the local area manager, ART pharmacist and PALSA
PLUS trainer, and clinic managers from the intervention clinic
and referring primary care clinics, supported mainstreaming of
HIV care. The STRETCH coordinator (KU) provided clinical
and organisational support and was involved in facilitating the
management teams. An implementation toolkit with descriptions
of the trial interventions and changing roles of clinic staff, was
distributed to members of the clinic based teams. The intervention
was implemented in three phases at a pace decided by clinic teams.
Although provincial tools existed to monitor provision of HIV
care (such as HIV tests and CD4 counts) at primary care clinics,
there was no tool to assess whether HIV care was integrated into
all consultations within clinics. Thus, a new questionnaire was
developed in consultation with clinic staff (see Additional File S1
and a summary in Table 2). There were eleven questions on
internal integration. These questions assessed the integration of
care for HIV-positive patients into the consultations of all nurses
within the ART clinic. There were four questions on the
integration of HIV care for patients not yet eligible for ART
(pre-ART care) (Q1,3,5 and 7); four on the integration of HIV
care for patients eligible for and on ART (ART care) (Q12,14,16
and 18) and three questions on the integration of primary care
services needed by patients on ART at that clinic (TB diagnosis,
dispensing of cotrimoxazole and contraception) (Q9,10 and 11).
There were eight questions on mainstreaming HIV care. These
questions assessed the provision of HIV care by nurses at referring
primary care clinics. There were four questions each on the
provision of pre-ART (Q2,4,6 and 8) and ART care (Q13,15,17
Based on the initial discussions with staff, each question had
only two or three possible responses to describe integration.
Answers were scored 0 for no integration, 2 for full integration
and, in questions with three responses, 1 for partial integration.
The scores for each question were combined to give a total
integration score and four component integration scores. These
different combinations of questions and the resulting integration
scores are summarised in Table 2 and described below:
N Total integration score – total score for all 19 questions.
N Pre-ART integration score – total score for questions 1–8 on the
provision of HIV care for patients not yet eligible for ART by all
nurses (primary care and ART nurses) at the ART clinic and at
referring primary care clinics
N ART integration score – total score for questions 12–19 on the
provision of HIV care for patients eligible for, and on ART by all
nurses (primary care and ART nurses) at the ART clinic and at
referring primary care clinics
N Internal integration score – total score for questions
1,3,5,7,9,10,11,12,14,16 and 18 on the provision by all nurses
within the ART clinic, of pre-ART and ART care and on the
provision of three key primary care services for patients on
N Mainstreaming HIV score – total score for questions
2,4,6,8,13,15,17,and 19 on the provision of pre-ART and
ART care by nurses at referring primary care clinics
Internal integration scores could be calculated for all 31 clinics
throughout the trial. However, the other integration scores could
only be calculated for 23 clinics (13 intervention and 10 control)
Table 1. Intervention and control clinic characteristics during STRETCH trial.
Intervention ART clinics
Primary care clinics referring
to intervention clinic Control ART clinics
Primary care clinics referring
to control clinic
Nurse training 6–8 sessions of PALSA PLUS training.
Extra 4 sessions STRETCH training in
initiating and monitoring adults on ART
6–8 sessions of PALSA PLUS
6–8 sessions of PALSA
6–8 sessions of PALSA PLUS
of ART prescription
Trained professional nurses
authorised to initiate and repeat
prescriptions of ART for
Patients referred to intervention
site for ART prescription
Patients referred to
doctors at treatment
clinics for ART
Patients referred to control clinics
and thence to doctors at
treatment clinics for ART
STRETCH edition of PALSA PLUS
including guidelines for initiation
and repeat prescription of ART
Standard Free State edition of
PALSA PLUS guidelines
Standard Free State
edition of PALSA
Standard Free State edition of
PALSA PLUS guidelines
STRETCH toolkit issued to members
of clinic based team
Clinic based support
Clinic based STRETCH team to implement
integration of pre-ART and ART care into
work of all professional nurses in clinic
Local area management
Local area management team to
implement integration of pre_ART
and ART care into all primary care
clinics referring to intervention clinic
Elements of STRETCH trial intervention including nurse training, patient care guidelines, toolkit and support teams at intervention clinics and their referring primary care
clinics compared to standard care at control clinics and their referring primary care clinics.
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that still had primary care clinics referring patients to that ART
clinic throughout the trial. New ART assessment clinics were
established by the Department of Health during the trial and
consequently eight of the 31 trial clinics no longer had patients
referred from other primary care clinics by the last assessment of
The questionnaire was administered at all four assessments by
the trial coordinator (KU) with the clinic manager or senior ART
nurse at the clinic and preferably the same person at each
assessment, but this was not always possible. The answer that best
described the level of integration was decided by the interviewee in
discussion with the coordinator. The coordinator was involved in
local management teams responsible for the implementation of
integration and so had independent confirmation about the
progress of integration in each clinic. The assessments were done
at all 31 clinics, as it could not be assumed that integration would
not take place at control clinics . Integration of HIV care into
primary care services at the 16 intervention clinics commenced in
Phase 1 of the trial and six-monthly integration assessments were
planned. The first two assessments were conducted six months
apart during early trial support visits. The last two assessments,
when support visits were less frequent, were conducted telephon-
ically, and the interval was extended to nine months as the trial
had been extended due to a delay in nurse initiation of ART in
some clinics. Time taken to complete the questionnaire was short
(10–15 minutes), but as the coordinator had to travel to each
clinic, or phone the interviewees at a time convenient to conduct
the questionnaire, each round of assessments took four to six weeks
to complete. A mean date of assessment was assigned in order to
plot changes in mean scores.
Consistency and reliability of the questionnaire
Internal consistency of the questionnaire was tested using
Cronbach’s alpha coefficients. These were calculated from scores
at the first assessment for the entire questionnaire, and then the
groups of questions on internal integration and mainstreaming
HIV care, as well as the questions on pre-ART and ART
In order to test for inter-observer reliability, the interview was
repeated by a different interviewer at five clinics (three interven-
tion and two control) in two districts, two months after the first
assessments. These clinics were chosen by convenient sampling
from the 23 clinics that had primary care clinics referring patients
throughout the trial and could give scores for all 19 questions.
Differences in the mean values of total integration scores and in
the four component integration scores at intervention and control
clinics were analysed with one way analysis of variance ANOVA
(SPSS version 16.0) and a non-parametric analysis, Mann-
Whitney (SAS version 9.2). Repeated measures ANOVA was
used to analyse changes in mean scores over time (SPSS version
16.0). The level of significance was chosen as a p value of ,0.05.
Internal consistency and reliability of the questionnaire
Cronbach’s alpha coefficient was 0.85 for all 19 questions, 0.86
for the 8 questions on pre-ART integration, 0.68 for the 8
questions on ART integration, 0.73 for the eleven questions on
internal integration and 0.69 for the eight questions on
mainstreaming of HIV care.
The second observer, who conducted repeat interviews at 5
clinics, obtained the same integration score on all questions at two
clinics, a one point difference on one question only at two other
clinics and a total score of one point difference with three
questions scoring differently at the fifth clinic. The mean total
integration score was 23.5 (maximum possible score 38) for the
two assessments at the 5 sampled clinics by both observers. The
mean difference between the total integration scores at the 5 clinics
done by the two different observers was 20.6, with a standard
deviation of 0.55 giving 95% limits of agreement of 21.7 to 0.5.
Progress of integration
In an initial analysis of the changes in scores across all clinics for
individual questions, the four questions that showed the largest
absolute increases in integration scores (an increase of between 14–
16 points) between the first and fourth assessments were questions
13,15,17 and 19 – all questions dealing with the mainstreaming of
ART care. The questions that showed minimal variation in
integration scores (absolute changes between 1–3 points) were
questions 1–8 on mainstreaming and internal integration of pre-
Table 2. Component questions of the five different integration scores.
Integration score Component questions contributing to scoreExample question
Total integration scoreAll 19 questions
Pre-ART integration score Q1–8 on the provision of HIV care for patients not yet eligible for ART
by 1)all nurses within the ART site and 2) the patients local referring
primary care clinic
Q4. If a patient is diagnosed HIV-positive at
one of your referring PHC clinics is it possible
to access their initial CD4 count at that clinic?
ART integration score Q12–19 on the provision of HIV care for patients eligible for ART by
1)all nurses within the ART site and 2) the patients local referring primary
Q14. When patients from your clinic are about
to start ARVs and need Baseline bloods who
takes these bloods?
Mainstreaming HIV score Q2,4,6,8,13,15,17,19 on the provision of pre-ART and ART care by the
patients local referring primary care clinic
Q19. Is it possible for patients from your
referring PHC clinics who are on ARVs to fetch
their repeat supply of ARVs from their own
Internal integration Q1,3,5,7,9,10,11,12,14,16,18 on the provision of pre-ART and ART care
by all nurses within the ART clinic and the provision of three key primary
care services for patients on ART
Q1. If a patient needs an HIV test at your clinic
who is performing this test?
A summary describing which questions from the integration questionnaire contributed to each integration score during the four assessments of the trial. An example of
the questions contributing to each integration score is also included. The full questionnaire is included in Additional File 1.
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The changes in mean integration scores for intervention and
control clinics are plotted in Figures 1, 2, 3. As seen in Figure 1,
mean total integration scores at the first assessment at intervention
(25.7) and control clinics (25.4) were not significantly different. At
the third assessment, conducted in the middle of the trial, the
mean total integration score at intervention clinics (28.8) was
significantly higher than at control clinics (23.7) (ANOVA,
p=0.0174; Mann-Whitney, p=0.0267). The increase in mean
total integration score at intervention clinics from the first (25.7) to
the third assessment (28.8) was a significant change (rmANOVA,
p=0.0198). There was also a significant increase in mean total
integration scores at control clinics that occurred late in the trial
between the third (23.7) and fourth assessments (27.6) (rmA-
NOVA, p=0.0283). Consequently at the fourth assessment, there
was no longer a significant difference between mean total
integration scores at intervention and control clinics (ANOVA,
p=0.4581; Mann-Whitney, p=0.5342).
In order to determine whether there was any change in which
elements of HIV care had been integrated, differences in mean
pre-ART and ART integration scores at intervention and control
clinics and changes in these scores were analysed (see Figure 2).
Mean pre-ART and ART integration scores at the first assessment
at intervention clinics (14.4 and 6.2 respectively) and control
clinics (15.4 and 5.1 respectively) were not significantly different.
At the third assessment only, the mean ART integration score at
intervention clinics (8.5) was significantly higher than at control
clinics (3.8) (ANOVA, p=0.0015; Mann-Whitney, p=0.0029)
and was significantly higher than at the first assessment (6.2)
(rmANOVA, p=0.004). However the mean pre-ART integration
scores at intervention clinics were not significantly different from
control clinics at any assessment, and there was no significant
change at intervention or control clinics from the first assessment
to the last assessment. Thus, integration of elements of ART care
was the main contributor to the increased total integration scores
at intervention clinics during the trial. The increase in mean total
integration scores at control clinics late in the trial was likewise due
to a significant increase in mean ART scores between the third
(3.8) and fourth assessment (7.4) (rmANOVA, p=0.0078). It was
noted, however, that mean pre-ART integration scores were
already close to the maximum possible score of 16 at the beginning
of the trial and remained there throughout the trial.
In order to determine whether any significant change in
integration at the two levels of primary care had taken place
during the trial, differences in mean mainstreaming HIV and
internal integration scores and changes in these scores were
analysed (see Figure 3). Mean mainstreaming HIV and internal
integration scores at the first assessment at intervention (9.7 and
16.1 respectively) and control clinics (8.8 and 17.1 respectively)
were not significantly different. At the third assessment only, the
mean mainstreaming HIV score at intervention clinics (11.3) was
significantly higher than at control clinics (8.7) (ANOVA,
p=0.0073; Mann-Whitney, p=0.0158) and significantly higher
than at the first assessment (9.7) (rmANOVA, p=0.0023). There
were no significant differences in mean internal integration scores
between intervention and control clinics at any assessment, and no
significant changes in internal integration scores at intervention or
control clinics from the first assessment to the last assessment.
Mainstreaming of HIV care into primary care clinics was thus the
main contributor to the level at which integration of HIV care into
primary care took place at intervention clinics during the trial. The
increase in mean total integration scores, late in the trial at control
clinics, was also due to a significant increase in mean mainstream-
ing HIV scores occurring between the third (8.7) and fourth
assessments (11.1) (rmANOVA, p=0.0059).
This assessment shows that the strategies employed during the
STRETCH trial resulted in significant increases in total integra-
tion scores at intervention clinics. The specific areas in which the
integration score increased were in providing HIV care in primary
care clinics not previously involved in the ART programme
(mainstreaming HIV score) and in the provision of elements of
ART care, namely, the taking of baseline blood tests, drug
readiness training and monthly supply of ART for patients eligible
for ART (ART score). These findings have been independently
Figure 1. Progress of mean total integration scores during the STRETCH trial. Line graph of mean total integration scores at intervention
and control clinics plotted against mean date of assessment, for four assessments during the STRETCH trail. Error bars depict standard error on the
mean at each assessment.
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confirmed by a qualitative process evaluation of the STRETCH
trial which found that patients and nurses appreciated the
convenience of patients being able to access HIV care including
ARVs at their local clinic instead of having to travel to an ART
clinic . There was no increase in mean pre-ART integration
scores during the trial because these elements of HIV care, namely
VCT, initial CD4 count and routine care for those not yet eligible
for ART which had been identified by staff as critical elements of
pre-ART needing integration, had already been substantially
integrated into primary care services by local managers in the
months leading up to the trial.
In contrast it appears that the strategies used in the STRETCH
trial had no effect on internal integration scores at intervention
clinics, with no significant shift towards patients being able to
access HIV care from all nurses within the clinic. There may be
other more effective strategies to achieve integration of HIV care
into the work of all nurses within primary care clinics, or there
may be factors that mitigate against internal integration. Topp et
al described some strategies to integrate the provision of HIV care
into the work of all nurses within two primary care clinics in
Zambia . These strategies included training of all staff in HIV
care, as in the STRETCH trial, but also the use of other strategies
not used in the STRETCH trial – combined medical records and
waiting areas and the inclusion of HIV testing into triage of all
patients. They did document increased uptake of HIV testing and
good standards of HIV care. However, they also reported
resistance on the part of nurses and patients to completely
integrated ART services because of issues such as increased
waiting times and the loss of informal support for patients on ART
with the loss of ART waiting areas . A synthesis of the findings
of three qualitative studies on internal integration in Free State
clinics conducted at the same time as the STRETCH trial found
that administrative issues and patient and nurse preferences
tended to mitigate against internal integration of HIV care
(manuscript submitted for publication).
The increase in mean total integration, ARV and mainstream-
ing HIV scores by the fourth assessment late in the trial at control
clinics, resulted from provincial implementation of a new national
AIDS policy including nurse prescription of ART and the
provision of ART in all primary care clinics – the two main
Figure 2. Progress of mean pre-ART and ART integration scores during the STRETCH trial. Two line graphs of mean pre-ART and ART
integration scores at intervention and control clinics plotted against mean date of assessment, for four assessments during the STRETCH trial. Error
bars depict standard error on the mean at each assessment.
Figure 3. Progress of mean internal integration and mainstreaming HIV scores during the STRETCH trial. Two line graphs of mean
internal integration and mainstreaming HIV scores at intervention and control clinics plotted against mean date of assessment, for four assessments
during the STRETCH trial. Error bars depict standard error on the mean at each assessment.
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interventions of the trial . The STRETCH trial was a
pragmatic trial conducted under real conditions which include
such policy changes. The research team was able to negotiate with
the province that nurse initiation of ART would not be
implemented in control clinics till after the trial, but was not able
to delay integration of HIV care into primary care services in
control clinics in the last few months of the trial.
One of the strengths of this study is that it is a prospective
assessment using a new semi- quantitative tool to document
integration of HIV care. The contents of this questionnaire were
likely to be valid as the elements of HIV care and the need to
integrate them at both levels were identified in consultation with
staff at ART clinics. Internal consistency as shown by Cronbach’s
alpha was good. Real validity of the questionnaire was demon-
strated in that it captured an increase in integration scores at
control clinics as a result of the implementation of a new policy to
integrate HIV care into primary care in the last months of the
There were some potential limitations to this study. The first
two interviews were conducted during clinic visits while the last
two were conducted telephonically, interviews were not always
conducted with the same staff member and data on services at
referring primary care clinics were based on reports from staff at
the ART site and not at the primary care clinic. However, all
interviews were conducted by the trial coordinator who was well
known to the clinic staff and involved in local management teams
implementing integration and thus was able to independently
confirm progress of integration as described by the interviewee at
each clinic. Though there is a possibility that the coordinator may
have influenced answers, the results of inter-observer reliability
tests suggest that this was negligible. The lack of progress in
internal integration compared with the progress in mainstreaming
HIV, captured by the questionnaire, suggests that the interviewees
were not unduly influenced to report integration where there was
none. The integration questionnaire was developed to assess the
integration of HIV care into primary care as it affected service
delivery for patients and was therefore not able to assess the effects
of integration of other areas of health system functioning. The
questionnaire was not able to document the impact of integration
of HIV care on the provision of other primary care services. This is
an important area of research, and is the subject of a project
currently being conducted in all primary care clinics in the Free
This questionnaire was validated in the specific context of the
Free State and may need some further development, but it could
be a valuable tool for assessing integration of HIV care into
primary care clinics in other settings. The main results of the
STRETCH trial showed that patient survival was not significantly
different in intervention clinics compared with control clinics
.The integration scores obtained in this study will be
correlated with survival of patients with CD4 below 350 and not
yet on ART, from the STRETCH trial to determine if integration
of HIV care may have had an independent effect on patient
survival. These results, together with the process evaluation and
results of the STRETCH study, should be useful in identifying
whether integration is an effective strategy to improve survival of
HIV-positive patients in need of ART.
The integration questionnaire developed in this study is a valid
tool with potential to monitor integration in other high HIV-
burden countries. This study demonstrated an increase in total
integration scores in clinics in the Free State province during the
STRETCH trial. This was achieved by integrating ART care,
particularly at primary care clinics not previously designated as
ART clinics but there was no increase in integration of HIV care
into all consultations. The scores documented in this intervention
will be used to determine if integration is associated with an
improvement in survival of patients needing ART.
and their referring primary care clinics.
Survey of integration of HIV care in ARV clinics
Thanks to Tsotsa Polinyane for assistance with the questionnaire. Thanks
also to Lara Fairall, Max Bachman, Merrick Zwarenstein, Carl Lombard,
Simon Lewin, Daniella Georgeu, Chris Colvin, Eric Bateman, Gill Faris,
Pat Meyers, Andrew Boulle, Dewald Steyn and Cloete van Vuuren from
the STRETCH team.
Conceived and designed the experiments: KEU GJ DHCJVR. Performed
the experiments: KEU. Analyzed the data: KEU GJ EW. Wrote the paper:
KEU GJ EW WFM DHCJVR.
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