The need for HIV integration in a post-2030 world

On the brink of reaching UNAIDS’ 95-95-95 targets and passing a landmark policy for universal health coverage, Namibia is among a handful of countries leading the way in a sustainable HIV response. To protect those gains, programming must shift from being stand-alone to being integrated within countries’ primary care systems, according to global health agencies and experts. In Namibia, Dr. Lawrence Kahindi, chief of party for the USAID-funded HIV prevention project, Scaling up Access for Expanded Voluntary Medical Male Circumcision, led by Abt Global, agreed.

Although the project excelled at demand creation for the highly effective HIV prevention strategy — nearly doubling Namibia’s voluntary medical male circumcision, or VMMC, rate by reaching over 270,000 males — Kahindi says that HIV prevention services are less integrated as those for counselling, testing, and treatment. And despite successes, after years of support for stand-alone HIV programming from the United States President's Emergency Plan for AIDS Relief, or PEPFAR, many countries aren’t fully prepared to make that integration happen, Kahindi said.

“I would not expect that any country would be 100% ready for integration, for the reason that, for quite a long time now … HIV programming has been verticalized, and well-resourced in terms of finances, personnel, and technical support,” he said. “Without PEPFAR, a key resource partner, I think most countries would be somewhat ill-prepared in terms of integrating HIV programming into their mainstay.”

PEPFAR, created in 2003, has predominantly focused on achieving HIV epidemic control with partners in the most affected countries — the majority in Africa — by providing funding and technical expertise to ensure improved diagnostics, access to treatment, and awareness. Its efforts are estimated to have saved 25 million lives, but the longer-term goal is to end HIV/AIDS as a public health threat by 2030. With that date in mind, Kahindi agreed there’s a need for countries to prepare themselves to shift the diagnosis, prevention, and treatment work into the primary health systems to protect peoples’ long-term access to these services.

“I'm sure in all these countries there are some aspects of HIV programming that they have already integrated because integration is not either or. It's a gradual continuum of where services are being provided in an integrated manner,” he said. “For instance, HIV testing and counselling could already have been integrated, but another aspect of the cascade, viral load monitoring, might not have been integrated.” The next step is working on expanding that continuum, he said.

Speaking to Devex, Kahindi explained what HIV programming integration should look like, the barriers to achieving it, and how to overcome them.

This conversation has been edited for length and clarity.

How would you define an integrated approach to HIV programming, and what do you see as the most effective components of integration?

For me, I would look at an approach that’s addressing the needs of the patient. Also looking at a system where, if we look at the community level, the community is engaged. The community should be driving the demand rather than the health care provider, and it should be integrated in terms of leadership and policies.

Also looking at the supply chain, the existing pharmaceutical or other commodity supply chain should have all the supplies for HIV programming flowing and the processes for reorder and monitoring levels would already be within these structures. Basically, the whole system is working together for improved patient outcomes, as well as improved system outcomes.

Based on what you've seen in your 20 years of working on HIV and AIDS, what elements do you think need to be present at the local level to ensure successful integration?

At the local level, it helps if there is a co-location of services, and that is almost by default at the lower entry point of the health care level. For instance, in a primary health care clinic or dispensary, there are often one or two health care providers who offer services to the community, and by default they already get integrated. However, moving up the levels of care, district and tertiary co-location of services would be essential to ensuring successful integration.

The other essential element is strong stakeholder engagement, because there are service providers; there are politicians who will be looking at financing; and there are managers who will be looking at systems. All the stakeholders need to have a common understanding for integration to work.

Finally, I think one of the most critical aspects of integration is adequate resourcing for health workers and in terms of financing. For commodities or for systems, it is crucial that integration should not compromise quality of care. Very often at the very local level, that's where the workload is highest and integrating HIV prevention services or HIV programming at that level can result in increased or unbearable workloads. So, it is important to look at what level of resourcing is required for a particular workload and to adequately match for that workload integration to happen.

Are there circumstances that you think might prevent countries from effectively integrating HIV programming into primary care?

I think in specific contexts, whether political, cultural, or otherwise — whenever there is no buy-in by the community — that may pose a challenge to integrating HIV care. HIV programming has been a vertical intervention in primary health care for over two decades. Obviously, those who have interfaced with the system for a long time are already in their comfort zone now, or they already have a rapport with their service provider. Being put in a different environment of integration, they might not pursue that quite well.

In addition, I think we have to accept that some of the scale-up models that have been applied so far with the available resources might not be feasible moving forward. As such, it will be difficult to integrate the whole package, and it might need further consultation into what is feasible or not.

How integral has PEPFAR's support been in Namibia when it comes to the provision of HIV care?

PEPFAR has been a very influential and critical partner to the Namibian government in scaling up and in providing the much-needed HIV treatment and prevention program. PEPFAR has invested a substantial amount of funding over the past two decades that has been supporting the country in the HIV treatment program. It has provided valuable technical support, has been a consultative partner in addressing or in shaping the direction of the programs, and Namibia has been highlighted as a very successful country in terms of HIV prevention.

In the last co-planning session, Namibia received an award recognizing the effort of the host government and, with support from PEPFAR, what they've managed to achieve in terms of HIV prevention and treatment programs.

Do you feel like HIV care has been integrated into Namibia's health systems?

To some extent, yes, certainly. Counseling and testing are already integrated. Initiation and monitoring of treatment is already integrated. And procurement and supply of HIV testing and treatment commodities is already integrated. But integration is further ahead on the treatment side, compared to prevention services. HIV services are already integrated in the health care system, but certainly not 100%.

Learn more about sustaining HIV progress while leveraging integrated health systems in our forthcoming report, Pathways to Sustainability, produced in partnership with Abt Global.