Integrating HIV and AIDS into Primary Health Care: A Pathway to Sustainability
The US response to HIV and AIDS—the US President’s Emergency Plan for AIDS Relief (PEPFAR)—has been one of the most significant success stories in global health. Twenty years of bipartisan support and an investment of nearly $100 billion has saved more than 21 million lives. New HIV infections have been reduced by half, AIDS-related deaths have declined by 64%, and many countries are at or near viral load suppression. There is emerging evidence of the positive spillover effects of PEPFAR’s spending on all causes of mortality, maternal and infant mortality rates, immunization coverage, antenatal care, macroeconomic growth, girls’ education, and labor markets.
This success has centered long-term sustainability discussions around transitioning responsibility for the HIV response to countries. A core element of the overarching vision, as well as the draft strategy released by PEPFAR’s new ambassador, Dr. John Nkengasong, is “integrating HIV and AIDS services into country health systems.” While this is both inevitable and necessary, it is important to do so in a strategic, transparent, and data-driven manner.
We propose a six-pronged approach to strategic integration of HIV and broader health systems:
Assuage the Real Concerns of the HIV Community. The HIV community is concerned about a decline in both funding and attention to HIV and AIDS, as demonstrated by the latest Global Fund replenishment. With integration, the HIV community fears that it will become more difficult to advocate for funding, resources meant for HIV will be diverted to broader health issues, and the impact will be felt by the most vulnerable communities. PEPFAR needs to proactively assuage these concerns by ensuring that civil society organizations are engaged in these discussions; core elements of the program, such as commodity security, are protected; and a strong and unwavering commitment is made to key populations.
Recognize Heterogeneity. PEPFAR focus countries are not homogenous. Among other parameters, they vary by income level, proportion of their budget going to health, and whether they have achieved viral load suppression. Some middle-income countries, as well as a few low-income countries, score well on all of these parameters. Starting with this subset of countries, PEPFAR should make this a country-led effort that recognizes that each country will be able to take on varied services and make a strong commitment to investing in the ability of countries to take on additional responsibilities. The lessons learned will inform integration plans for other countries.
Be Transparent, Realistic, and Strategic. PEPFAR, with its focus on outcomes and not cost, has put in place expensive and unsustainable program costs. A major concern of countries, therefore, is not knowing how much integration will cost them. Recent efforts by PEPFAR, the Global Fund, and UNAIDS around resource alignment and activity-based costing and management are starting to provide much greater granularity and transparency in how funds are allocated and spent. These data should be shared with governments and form the basis of discussions around integration and transition.
PEPFAR must acknowledge that countries will be unlikely to adopt the existing model. Service delivery models should reflect individual country health systems, and countries should integrate many of the routine functions, such as supervision and capacity building, into their own practices, data systems, and supply chains. This realism should inform how PEPFAR operates. Moving to leaner, more efficient, and less expensive service delivery models will make their integration into a country’s health system easier. PEPFAR also must invest in strengthening country health systems to adopt, integrate, and sustain HIV services.
As HIV and AIDS moves from a highly fatal infectious disease to one that is more akin to a chronic health condition, an increasing number of people living with HIV and AIDS are surviving longer and are living with co-morbidities such as cardiovascular disease and diabetes. PEPFAR should support strategic integration of primary health care services for these conditions. This will achieve the dual purpose of meeting the needs of the HIV community and strengthening the response for the broader population.
Support Human Resources for Health, Supply Chain, and other Infrastructure. PEPFAR employs more than 300,000 community and health care workers and supports nearly 70,000 health facilities, more than 3,000 laboratories, and an extensive supply chain infrastructure. Integrating HIV/AIDS services into a country’s health and primary health care system requires a plan to manage the parallel manpower and systems that PEPFAR has established. Recent data from activity-based costing and management show that facility-level health workers supported by PEPFAR spend nearly one-third of their time on other primary health care services. This is positive in terms of integration. However, country governments have little or no information on where these health workers are deployed or how they are compensated, and there is little support across countries on integrating community health workers into the broader health system. Finally, there is the question of how to ensure continued functioning of the thousands of labs supported by PEPFAR. Discussions around integration require a process and plan on transitioning these elements to the government. This will likely take protracted discussions with the government and years to implement.
Learn from Past Experience to Inform Future Actions. Efforts to integrate vertical programs or specific packages of services into the broader country health system continue. In the HIV space, there have been efforts around the prevention of mother-to-child transmission, postpartum family planning, mental health, cervical cancer, gender-based violence, and more. There have also been efforts to hand over HIV services, such as labs and blood banks, to countries. A systematic review of past experiences should be used to inform PEPFAR’s integration discussions with country governments. As there is a lack of adequate data on efforts to transition or integrate HIV services into country systems, PEPFAR should invest in operations research to gather, analyze, and produce the needed evidence.
Use Data and Benchmarks to Monitor and Inform Integration. PEPFAR must develop explicit benchmarks against which integration efforts can be evaluated and measured. Local research institutions and regional institutions should be involved in the collection, analysis, and interpretation of data on a regular basis. These data should then be used to monitor and course correct the integration effort. Cells should be established at ministries of health and supported by PEPFAR to oversee, implement, and monitor integration efforts.
While integrating HIV and AIDS into country health systems is necessary to ensure long-term sustainability, this will need to be a country-led and strategic process that will vary by country, take time, and require flexibility to make course changes using strong data and evidence to inform and monitor progress. Most important, this must be performed in a way that ensures continuity of quality services to those living with HIV, is informed by a strong community voice, and protects the interests of key populations and other groups that may be most at risk of neglect.