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Integrated HIV Care
Integrated HIV Care as a Global Care Model: Implications for Canada

Released: August 17, 2023

Marissa Becker
Marissa Becker, MSc, MD, FRCPC
Activity Information

Activity

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Key Takeaways
  • HIV care can be coordinated with primary care or specialized care of other medical issues to address healthcare inequity.
  • Three models of coordinated services presented at IAS 2023 showed improvements in linkage and care for various illnesses, including hypertension, cervical cancer, and HCV.

At the recent 12th IAS Conference on HIV Science, which took place in Brisbane, Australia, results were presented from several studies that examined integration of HIV care with other health services for better health outcomes. Although most of the studies were set in Africa, several takeaways can be applied worldwide, including in my practice in Manitoba, Canada. 

In Canada, HIV treatment is completely covered by the national health service, regardless of age and income. As with any large country, however, inequities in service delivery and coverage exist. Integration of services for persons living with HIV may help address some of these inequities.  

Integrated Models of HIV Care

Global, national, and local efforts are underway to explore and examine models of integrated care. Integrated care requires strengthening health systems to be able to deliver coordinated health services with the goals of reducing inequities in health and achieving better health outcomes.

In the HIV field, there have been many different approaches to integration. These approaches have included integrating HIV prevention and/or care into primary care services and models that have focused on broadening the services provided through HIV platforms to be more comprehensive, including treatment of sexually transmitted infections, hepatitis, drug addiction, mental health, or other associated medical problems. Any approach to integration requires consideration of local contexts and local epidemiology, an understanding of the health needs of a population, and consideration for the local health system structures and data infrastructure.

INTE-Africa: Hypertension and HIV

INTE-Africa, a large cluster-randomized trial in Tanzania and Uganda, compared blood pressure control among patients in an integrated care clinic vs blood pressure control among patients receiving standard care. In the integrated care clinic, participants living with either HIV, diabetes, or hypertension were cared for in a common clinic by a single clinical team, with shared laboratory, counseling, and pharmacy services. Standard care was organized in separate clinics.

The investigators found some improvement in blood pressure control with 586 of 1190 (49.2%) participants in integrated care vs 480 of 1259 (38.4%) participants in standard care.

Tanzania: Cervical Cancer and HIV

Investigators from Mwanza, Tanzania, described the scale-up of cervical cancer prevention services for women living with HIV. Between January and March 2022, facilities offering cervical cancer prevention services were scaled up from 29 to 54, and 97 facilities were added as outreach sites.

The number of women living with HIV screened for cervical cancer increased from 1294 in the first quarter of 2022 to 10,188 in the second quarter of the same year. By the end of 2022, 25,701 women were screened—and 65% of these screenings were at outreach sites.

Among those screened, 753 (3%) were found to have precancerous cervical lesions, and the majority were linked (99%) and treated (92%). Of the 25,701 women screened, 103 (0.4%) were suspected to have cancer and were referred for further diagnosis.

This program demonstrates feasibility in reaching cervical cancer screening targets through program integration.

Nigeria: HIV and HCV

Finally, the integration of hepatitis C virus (HCV) services into antiretroviral therapy (ART) clinics was explored in Nigeria as a pilot program across 4 ART clinics. In a 30-month period, people living with HIV who were attending clinics for ART were screened for HCV, and those found to be positive were linked to treatment and care. Using clinic data, those unscreened for HCV were contacted by patient navigators and encouraged to return to clinics for screening or were screened in the community.

This program helped improve the entire cascade of HCV care among people living with HIV. Of the 4042 receiving ART, 3831 were screened for HCV, 426 (11.1%) were seropositive for HCV, 371 (87.1%) received a confirmatory HCV RNA, 218 (58.8%) were viremic, and 175 initiated HCV treatment.

This pilot program demonstrated successful expansion of HCV screening and treatment for people living with HIV.

Takeaways?

These studies all demonstrated the potential for integration of services for people living with HIV. However, more program-embedded research is required on models for integration, as well as pathways for scale. In addition, the impact of integration on reducing inequities in service coverage and health outcomes still requires further research.

In Canada, delivery of services for people living with HIV is configured differently across provinces. In Manitoba, care is provided by both infectious disease specialists and primary care providers. Efforts have been put forth to integrate more comprehensive services in both clinics, including provision of mental health services and obstetrics care. Lessons from the studies presented at IAS 2023 can be applied to inform further expansion of services and models of care.

Your Thoughts?

What services does your HIV clinic provide? How successful are you in providing integration of services? Leave a comment below to join the conversation.