[show abstract][hide abstract] ABSTRACT: BACKGROUND Integration of HIV treatment with other primary care services has been argued to potentially improve effectiveness, efficiency and equity. However, outside the field of reproductive health, there is limited empirical evidence regarding the scope or depth of integrated HIV programmes or their relative benefits. Moreover, the body of work describing operational models of integrated service-delivery in context remains thin. Between 2008 and 2011, the Lusaka District Health Management Team piloted and scaled-up a model of integrated HIV and general outpatient department (OPD) services in 12 primary health care clinics. This paper examines the effect of the integrated model on the organization of clinic services, and explores service providers' perceptions of the integrated model. METHODS We used a mixed methods approach incorporating facility surveys and key informant interviews with clinic managers and district officials. On-site facility surveys were carried out in 12 integrated facilities to collect data on the scope of integrated services, and 15 semi-structured interviews were carried out with 12 clinic managers and three district officials to explore strengths and weaknesses of the model. Quantitative and qualitative data were triangulated to inform overall analysis.Findings Implementation of the integrated model substantially changed the organization of service delivery across a range of clinic systems. Organizational and managerial advantages were identified, including more efficient use of staff time and clinic space, improved teamwork and accountability, and more equitable delivery of care to HIV and non-HIV patients. However, integration did not solve ongoing human resource shortages or inadequate infrastructure, which limited the efficacy of the model and were perceived to undermine service delivery. CONCLUSION While resource and allocative efficiencies are associated with this model of integration, a more important finding was the model's demonstrated potential for strengthening organizational culture and staff relationships, in turn facilitating more collaborative and motivated service delivery in chronically under-resourced primary healthcare clinics.
Health Policy and Planning 07/2012; · 2.65 Impact Factor
[show abstract][hide abstract] ABSTRACT: Rapid scale up of HIV treatment programs in sub-Saharan Africa has refueled the long-standing health policy debate regarding the merits and drawbacks of vertical and integrated system. Recent pilots of integrating outpatient and HIV services have shown an improvement in some patient outcomes but deterioration in waiting times, which can lead to worse health outcomes in the long run.
A pilot intervention involving integration of outpatient and HIV services in an urban primary care facility in Lusaka, Zambia was studied. Data on waiting time of patients during two seven-day periods before and six months after the integration were collected using a time and motion study. Statistical tests were conducted to investigate whether the two observation periods differed in operational details such as staffing, patient arrival rates, mix of patients etc. A discrete event simulation model was constructed to facilitate a fair comparison of waiting times before and after integration. The simulation model was also used to develop alternative configurations of integration and to estimate the resulting waiting times.
Comparison of raw data showed that waiting times increased by 32% and 36% after integration for OPD and ART patients respectively (p<0.01). Using simulation modeling, we found that a large portion of this increase could be explained by changes in operational conditions before and after integration such as reduced staff availability (p<0.01) and longer breaks between consecutive patients (p<0.05). Controlling for these differences, integration of services, per se, would have resulted in a significant decrease in waiting times for OPD and a moderate decrease for HIV services.
Integrating health services has the potential of reducing waiting times due to more efficient use of resources. However, one needs to ensure that other operational factors such as staff availability are not adversely affected due to integration.
PLoS ONE 01/2012; 7(4):e35479. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: Introduction: Building on earlier works demonstrating the effectiveness and acceptability of provider-initiated counselling and testing (PITC) services in integrated outpatient departments of urban primary healthcare clinics (PHCs), this study seeks to understand the relative utility of PITC services for identifying clients with early-stage HIV-related disease compared to traditional voluntary testing and counselling (VCT) services. We additionally seek to determine whether there are any significant differences in the clinical and demographic profile of PITC and VCT clients. Methods: Routinely collected, de-identified data were collated from two cohorts of HIV-positive patients referred for HIV treatment, either from PITC or VCT in seven urban-integrated PHCs. Univariate and multivariate analyses were conducted to compare the two cohorts across demographic and clinical characteristics at enrolment. Results: Forty-five per cent of clients diagnosed via PITC had CD4<200, and more than 70% (i.e. two thirds) had CD4<350 at enrolment, with significantly lower CD4 counts than that of VCT clients (p<0.001). PITC clients were more likely to be male (p=0.0005) and less likely to have secondary or tertiary education (p<0.0001). Among those who were initiated on antiretroviral therapy (ART), PITC clients had lower odds of initiating treatment within four weeks of enrolment into HIV care (adjusted odds ratio, or AOR: 0.86; 95% confidence interval, or CI: 0.75-0.99; p=0.035) and significantly lower odds of retention in care at six months (AOR: 0.84; CI: 0.77-0.99; p=0.004). Conclusions: In Lusaka, Zambia, large numbers of individuals with late-stage HIV are being incidentally diagnosed in outpatient settings. Our findings suggest that PITC in this setting does not facilitate more timely diagnosis and referral to care but rather act as a "safety net" for individuals who are unwilling or unable to seek testing independently. Further work is needed to document the way provision of clinic-based services can be strengthened and linked to community-based interventions and to address socio-cultural norms and socio-economic status that underpin healthcare-seeking behaviour.
Journal of the International AIDS Society 01/2012; 15(2):17352. · 3.94 Impact Factor
[show abstract][hide abstract] ABSTRACT: To increase case-finding of infection with human immunodeficiency virus (HIV) in Zambia and their referral to HIV care and treatment by supplementing existing client-initiated voluntary counselling and testing (VCT), the dominant mode of HIV testing in the country.
Lay counsellors offered provider-initiated HIV testing and counselling (PITC) to all outpatients who attended primary clinics and did not know their HIV serostatus. Data on counselling and testing were collected in registers. Outcomes of interest included HIV testing coverage, the acceptability of testing, the proportion testing HIV-positive (HIV+), the proportion enrolling in HIV care and treatment and the time between testing and enrolment.
After the addition of PITC to VCT, the number tested for HIV infection in the nine clinics was twice the number undergoing VCT alone. Over 30 months, 44,420 patients were counselled under PITC and 31,197 patients, 44% of them men, accepted testing. Of those tested, 21% (6572) were HIV+; 38% of these HIV+ patients (2515) enrolled in HIV care and treatment. The median time between testing and enrolment was 6 days. The acceptability of testing rose over time.
The introduction of routine PITC using lay counsellors into health-care clinics in Lusaka, Zambia, dramatically increased the uptake and acceptability of HIV testing. Moreover, PITC was incorporated rapidly into primary care outpatient departments. Maximizing the number of patients who proceed to HIV care and treatment remains a challenge and warrants further research.
Bulletin of the World Health Organisation 05/2011; 89(5):328-335A. · 5.25 Impact Factor
[show abstract][hide abstract] ABSTRACT: HIV care and treatment services are primarily delivered in vertical antiretroviral (ART) clinics in sub-Saharan Africa but there have been concerns over the impact on existing primary health care services. This paper presents results from a feasibility study of a fully integrated model of HIV and non-HIV outpatient services in two urban Lusaka clinics.
INTEGRATION INVOLVED THREE KEY MODIFICATIONS: i) amalgamation of space and patient flow; ii) standardization of medical records and iii) introduction of routine provider initiated testing and counseling (PITC). Assessment of feasibility included monitoring rates of HIV case-finding and referral to care, measuring median waiting and consultation times and assessing adherence to clinical care protocols for HIV and non-HIV outpatients. Qualitative data on patient/provider perceptions was also collected.
Provider and patient interviews at both sites indicated broad acceptability of the model and highlighted a perceived reduction in stigma associated with integrated HIV services. Over six months in Clinic 1, PITC was provided to 2760 patients; 1485 (53%) accepted testing, 192 (13%) were HIV positive and 80 (42%) enrolled. Median OPD patient-provider contact time increased 55% (6.9 vs. 10.7 minutes; p<0.001) and decreased 1% for ART patients (27.9 vs. 27.7 minutes; p = 0.94). Median waiting times increased by 36 (p<0.001) and 23 minutes (p<0.001) for ART and OPD patients respectively. In Clinic 2, PITC was offered to 1510 patients, with 882 (58%) accepting testing, 208 (24%) HIV positive and 121 (58%) enrolled. Median OPD patient-provider contact time increased 110% (6.1 vs. 12.8 minutes; p<0.001) and decreased for ART patients by 23% (23 vs. 17.7 minutes; p<0.001). Median waiting times increased by 47 (p<0.001) and 34 minutes (p<0.001) for ART and OPD patients, respectively.
Integrating vertical ART and OPD services is feasible in the low-resource and high HIV-prevalence setting of Lusaka, Zambia. Integration enabled shared use of space and staffing that resulted in increased HIV case finding, a reduction in stigma associated with vertical ART services but resulted in an overall increase in patient waiting times. Further research is urgently required to assess long-term clinical outcomes and cost effectiveness in order to evaluate scalability and generalizability.
PLoS ONE 01/2010; 5(7):e11522. · 3.73 Impact Factor