HIV departments within Kenyan health facilities are usually better staffed and equipped than departments offering non-HIV services. Integration of HIV services into primary care may address this issue of skewed resource allocation. Between 2008 and 2010, we piloted a system of integrating HIV services into primary care in rural Kenya. Before integration, we conducted a survey among returning adults ≥18-year old attending the HIV clinic. We then integrated HIV and primary care services. Three and twelve months after integration, we administered the same questionnaires to a sample of returning adults attending the integrated clinic. Changes in patient responses were assessed using truncated linear regression and logistic regression. At 12 months after integration, respondents were more likely to be satisfied with reception services (adjusted odds ratio, aOR 2.71, 95% CI 1.32–5.56), HIV education (aOR 3.28, 95% CI 1.92–6.83), and wait time (aOR 1.97 95% CI 1.03–3.76). Men's comfort with receiving care at an integrated clinic did not change (aOR = 0.46 95% CI 0.06–3.86). Women were more likely to express discomfort after integration (aOR 3.37 95% CI 1.33–8.52). Integration of HIV services into primary care services was associated with significant increases in patient satisfaction in certain domains, with no negative effect on satisfaction.
Funding targeted for HIV care programs in sub-Saharan Africa has produced tremendous results over the past several years, most notably the delivery of antiretroviral therapy to almost 4 million people in sub-Saharan Africa by 2009 [
Nevertheless, the HIV epidemic has increased pressure on the Kenyan health care system as a whole by increasing the workload for health personnel—whose numbers have not increased proportionally to the demand [
Integration of HIV services into primary care can be defined in multiple ways. In the context of this paper, we define it as colocation and sharing of services and resources for HIV care and primary care, such as clinic space, clinicians, health education, pharmacy, laboratory services, and training. Integration of HIV services into primary care addresses the issue of skewed resource allocation, allowing people to access the health care they require regardless of HIV status. Available evidence suggests that integration offers several potential advantages at this point in the response to HIV in sub-Saharan Africa [
Despite the evidence suggesting system-wide and national-level benefits to integration, the patient- and service-level effects are unclear. Whereas the overall benefits of integration are likely to trickle down to patients and providers, it is also possible that the resulting reorganization of health care delivery may disrupt service provision and potentially cause dissatisfaction among patients, particularly in the short term. Further, integration of specialized services into primary care services may not always result in better patient- and service- level outcomes [
There is minimal evidence to suggest that stigma associated with HIV care may reduce with integration [
In 2008, a system that integrated HIV services into primary care was piloted in rural health facilities in Nyanza Province in western Kenya. We assessed the patient-level effect of this integration with a focus on patient satisfaction and perceived stigma.
From December 2008 to January 2010, we conducted an evaluation of the pilot integration project at three health facilities to assess the patient-level effect of integration. Family AIDS care and education services (FACES) implemented the integration in collaboration with the Suba District Health Management Team of the Kenya Ministry of Health. FACES is a collaboration between the Kenya Medical Research Institute (KEMRI) and the University of California, San Francisco (UCSF), funded through the US Centers for Disease Control (CDC)/PEPFAR [
The pilot was conducted in Suba District in Western Kenya, which has a population of 214,463 [
We addressed the different aspects of integration as shown in Table
Comparison of features of health facilities in an evaluation of HIV service integration in Suba District, Kenya.
Patient support center (HIV clinic) before integration | Out-patient department (OPD) before integration | Integrated facility | |
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Clinic space | Separate room for HIV clinical care | Separate room for primary care services other than HIV | All clinical rooms used for both HIV and other primary care services |
| |||
Clinical staff | One clinician (clinical officer or nurse) dedicated to providing HIV care | Other clinicians attending to patients seeking primary care exclusive of HIV | All clinicians attend to all patients regardless of HIV status |
| |||
Health education at waiting bay | General health education with emphasis on HIV care, treatment, and nutrition | General health education with equal emphasis on all topics. Messages about HIV mostly relate to prevention | General health education on all health topics including HIV prevention, care, and treatment |
| |||
Pharmacy/Supplies | Staff extensively trained and mentored on commodity management and supply chain logistics especially relating to ART | Little or no training on commodity management. No mentorship. |
Intensive on-job training and mentorship on commodity management. |
| |||
Laboratory | Lab samples sent to well-stocked central lab at district hospital. Tests available for HIV-positive patients include CD4, CBC, hematology, microscopy, biochemistry, and immunology. More reliable supply of reagents; specimen transport network for remote sites | Labs poorly equipped. Tests available: Hb, pregnancy, and simple microscopy. Frequent stock out of reagents | Samples that cannot be processed locally sent to central lab at district hospital. Specimen transport network used for all specimens. Training and mentorship offered to all staff. |
| |||
Focused HIV training and mentorship | Clinician well trained in HIV care (adult and pediatric ART, PMTCT); weekly mentorship by more experienced clinicians | Some staff trained but not actively practicing; no clinical mentorship | All staff trained in at least one HIV care course. Weekly mentorship and on-job training for all staff |
Before integration, HIV-positive patients were seen separately on one to four dedicated days each week. After integration, they were seen on any day of the week in the general outpatient clinic; all patients followed a uniform patient flow, and patient load was evenly spread out among the existing staff.
Integrated health education was conducted for all patients regardless of HIV status in a single shared waiting bay. This approach was seen as a way of reducing stigma against HIV and broadening health education reach.
With integration, all drugs were stored in the same storage space and dispensed from the same pharmacy; supply and inventory management at the clinics under evaluation were also integrated. The integrated pharmacy became the central repository and dispensing area for therapeutic food supplements (for eligible HIV-infected patients and HIV-negative children of certain ages) that would otherwise have to be stored in a separate food store. Orders for all drugs and food supplements were made within the same supply-chain network. Training and mentorship for pharmacy and supplies management were offered to both Ministry of Health (MOH) and FACES staff who then worked together in the integrated pharmacy and were able to share the daily workload.
Introduction of HIV services brought with it a well-equipped central laboratory at the district hospital; after integration, these lab facilities were used to conduct other tests not necessarily related to HIV. For example, a new automated biochemistry machine to be used for measuring liver enzymes to monitor the progress of patients on ART was also used for other patients when clinically indicated. Supportive supervision for the district lab network prior to integration was infrequently conducted by the MOH District Medical Laboratory Technician; however, after integration it was conducted by a combined FACES and MOH team. Laboratory supervision was more frequent and regular after integration because FACES had a more reliable transport system.
Before integration, only providers working in the HIV clinic underwent mentorship by experienced providers from FACES during weekly visits. After integration, all providers underwent mentorship. All clinical officers and nurses were offered training for HIV-related and non-HIV-related topics such as Rational Use of ART in Adults, Comprehensive Pediatric HIV Care, Integrated Management of Adult and Adolescent Illness, Prevention of Mother to Child Transmission of HIV, and Psychosocial Counseling for Pediatrics.
Study eligibility (inclusion criteria) at baseline included adult patients ≥18-year old who were HIV-positive and already enrolled in HIV care (including patients pre-ART and those on ART), attending a return visit to study facilities in rural Suba District. Exclusion criteria included patients <18-year old, patients not enrolled in HIV care, and patients enrolling in care that day. Inclusion and exclusion criteria remained the same at the followup with one exception: individuals enrolled in HIV care as well as those accessing general outpatient services were included, reflecting the integration of these services.
Patient participation involved a self-administered questionnaire on service satisfaction and perceived stigma. The questionnaire was available in the language of the patient’s choice (Dholuo, Kiswahili, or English), and all data collection was anonymous. A sample size of 10% of the patients enrolled into HIV care at each health facility was targeted: 94 of the 941 (474 at the subdistrict hospital and 467 at the health centers) patients actively enrolled at baseline, 107 of the 1,065 (521 at the subdistrict hospital and 544 at the health centers) patients actively enrolled at three-month follow up, and 142 of the 1,421 (673 at the subdistrict hospital and 748 at the health centers) patients actively enrolled at 12-month followup, for an overall sample target of approximately 343 patients. A consecutive convenience sampling approach was used. Trained Monitoring and Evaluation (M&E) staff employed by FACES approached each departing patient throughout the day, determined eligibility verbally, obtained verbal consent, and carried out the assessment. Patients were advised that they were free to participate or not without affecting their services, and no incentives were provided. Willing participants completed the self-administered questionnaires in private and upon completion placed the questionnaires in a secure box to maintain privacy. The assessment was conducted over a 3-day period at baseline (December 2008) and followup (March 2009 and January 2010).
Patient health facility satisfaction was assessed using a questionnaire that included questions adapted from the AIDS Clinical Research Trials Group (ACTG) tool. The questionnaire is a standard FACES program tool that was initially adapted, piloted, and validated for the local population at FACES-supported health facilities in Kisumu District and then used for this evaluation in Suba District (both in Nyanza Province, Kenya). Items included satisfaction with the office (courtesy and helpfulness), with clinicians (ability to listen, client respect, sufficient time with clients), and with each of seven departments: reception, community health assistants (who provide health talks and measure vital signs), health talks, nursing/counseling, laboratory, clinical, and pharmacy. Individual items addressed wait time, perceived usefulness of HIV education, and overall satisfaction with the clinic. Each item included three or four response options, such as “Very satisfied”, “Satisfied,” and “Not satisfied;” or “All the time,” “A lot of the time,” “Some of the time,” and “None of the time”. The two measures of office satisfaction and the three measures of clinician performance were each combined into linear scales for analysis. All other satisfaction measures were coded as binary responses with only the highest level of satisfaction coded as one.
Patient perception of stigma at the health facility was assessed using three items adapted from standardized items validated for use in this context [
The data were entered and cleaned using SPSS Software (SPSS for Windows, Version 14.0 SPSS Inc., Chicago, IL, USA) and were merged across clinic sites and time before being analyzed using Stata 11.0 (StataCorp, College Station, TX, USA). Change from baseline was assessed using truncated linear regression (office satisfaction and clinician performance) and logistic regression (all other outcomes) with robust standard errors. All models were assessed for effect modification by sex and analyzed within sex if the interaction term with either time point was significant at
Ethical review committee approval was obtained locally and internationally; the protocol was reviewed for human subject concerns and approved by the KEMRI Ethical Review Committee and UCSF Committee on Human Research.
Of the targeted sample of 343 surveys, 295 (86.0%) surveys were collected cumulatively over the three time points: 58 participants at baseline (61.7% of the 94 targeted), 104 participants at three months (97.3% of the 107 targeted), and 133 participants at 12 months (93.6% of the 142 targeted). Table
Patient demographics in an evaluation of HIV service integration in Suba district, Kenya (
Baseline | 3-month followup | 12-month followup | Total | |
---|---|---|---|---|
|
|
|
|
|
Male | 18 (36.0%) | 32 (35.2%) | 44 (38.3%) | 94 (36.7%) |
Female | 32 (64.0%) | 59 (64.8) | 71 (61.7%) | 162 (63.3%) |
| ||||
On ART | 28 (51.9%) | 61 (58.7%) | 78 (60.9%) | 167 (58.4%) |
Not on ART | 26 (48.2%) | 43 (41.4%) | 50 (39.1%) | 119 (41.6%) |
Patient satisfaction with the clinic office and with each department remained high throughout the assessment period (Table
Patient satisfaction and stigma responses over time in an evaluation of HIV service integration in Suba district, Kenya.
Baseline ( |
3 months ( |
12 months ( |
|
---|---|---|---|
|
|
|
|
Overall satisfaction | |||
Very satisfied | 34 (59.65) | 48 (46.60) | 93 (74.40) |
Satisfied | 22 (38.60) | 51 (49.51) | 28 (22.40) |
Not satisfied | 1 (1.75) | 4 (3.88) | 4 (3.20) |
Office courtesy | |||
All the time | 35 (61.40) | 68 (66.02) | 101 (76.52) |
A lot of the time | 14 (24.56) | 19 (18.45) | 23 (17.42) |
Some of the time | 7 (12.28) | 16 (15.53) | 7 (5.30) |
None of the time | 1 (1.75) | 0 (0.00) | 1 (0.76) |
Office helpfulness | |||
All the time | 36 (66.67) | 74 (71.84) | 86 (65.65) |
A lot of the time | 11 (20.37%) | 17 (16.50) | 33 (25.19) |
Some of the time | 6 (11.11) | 12 (11.65) | 8 (6.11) |
None of the time | 1 (1.85) | 0 (0.00) | 4 (3.05) |
Doctor listening | |||
All the time | 30 (53.57) | 68 (66.67) | 87 (66.92) |
A lot of the time | 16 (28.57) | 20 (19.61) | 31 (23.85) |
Some of the time | 9 (16.07) | 13 (12.75) | 8 (6.15) |
None of the time | 1 (1.79) | 1 (0.98) | 4 (3.08) |
Doctor shows respect | |||
All the time | 34 (62.96) | 69 (66.99) | 91 (70.54) |
A lot of the time | 11 (20.37) | 20 (19.42) | 24 (18.60) |
Some of the time | 7 (12.96) | 11 (10.68) | 11 (8.53) |
None of the time | 2 (3.70) | 3 (2.91) | 3 (2.33) |
Doctor time | |||
All the time | 29 (53.70) | 64 (62.14) | 78 (59.54) |
A lot of the time | 17 (31.48) | 28 (27.18) | 31 (23.66) |
Some of the time | 6 (11.11) | 9 (8.74) | 15 (11.45) |
None of the time | 2 (3.70) | 2 (1.94) | 7 (5.34) |
Wait time | |||
Just right | 28 (49.12) | 47 (46.53) | 80 (61.07) |
A bit long | 26 (45.61) | 45 (44.55) | 34 (25.95) |
Much too long | 3 (5.26) | 9 (8.91) | 17 (12.98) |
HIV education | |||
Very useful | 32 (58.18) | 63 (61.17) | 105 (80.15) |
Useful | 11 (20.00) | 38 (36.89) | 22 (16.79) |
Not at all useful | 12 (21.82) | 2 (1.94) | 4 (3.05) |
Reception | |||
Very satisfied | 30 (54.55) | 54 (51.92) | 97 (74.05) |
Satisfied | 25 (45.45) | 46 (44.23) | 27 (20.61) |
Not satisfied | 0 (0.00) | 4 (3.85) | 7 (5.34) |
Community health assistants | |||
Very satisfied | 20 (34.48) | 40 (38.46) | 64 (48.12) |
Satisfied | 35 (60.34) | 64 (61.54) | 64 (48.12) |
Not satisfied | 3 (5.17 | 0 (0.00) | 5 (3.76) |
Nurses or counselors | |||
Very satisfied | 26 (52.00) | 50 (48.08) | 86 (68.80) |
Satisfied | 20 (40.00) | 53 (50.96) | 34 (27.20) |
Not satisfied | 4 (8.00) | 1 (0.96) | 5 (4.00) |
Lab | |||
Very satisfied | 28 (56.00) | 47 (45.19) | 80 (62.99) |
Satisfied | 17 (34.00) | 53 (50.96) | 37 (29.13) |
Not satisfied | 5 (10.00) | 4 (3.85) | 10 (7.87) |
Clinician | |||
Very satisfied | 29 (56.86) | 47 (45.19) | 80 (62.50) |
Satisfied | 20 (39.22) | 55 (52.88) | 42 (32.81) |
Not satisfied | 2 (3.92) | 2 (1.92) | 6 (4.69) |
Pharmacy | |||
Very satisfied | 25 (50.00) | 48 (46.15) | 84 (65.12) |
Satisfied | 19 (38.00) | 49 (47.12) | 36 (27.91) |
Not satisfied | 6 (12.00) | 7 (6.73) | 9 (6.98) |
Privacy & confidentiality | |||
Strongly agree | 34 (60.71) | 49 (48.04) | 82 (63.57) |
Agree | 18 (32.14) | 44 (43.14) | 36 (27.91) |
Disagree | 4 (7.14) | 9 (8.82) | 6 (4.65) |
Strongly disagree | 0 (0.00) | 0 (0.00) | 5 (3.88) |
People with HIV treated the same as others | |||
Strongly agree | 28 (50.00) | 45 (43.69) | 81 (62.31) |
Agree | 17 (30.36) | 40 (38.83) | 36 (27.69) |
Disagree | 9 (16.07) | 16 (15.53) | 8 (6.15) |
Strongly disagree | 2 (3.57) | 2 (1.94) | 5 (3.85) |
Not comfortable receiving care here | |||
Strongly agree | 23 (42.59) | 23 (22.33) | 57 (46.72) |
Agree | 13 (24.07) | 39 (37.86) | 36 (29.51) |
Disagree | 13 (24.07) | 21 (20.39) | 14 (11.48) |
Strongly disagree | 5 (9.26) | 20 (19.42) | 15 (12.30) |
Regression analyses of changes in patient satisfaction over time in an evaluation of HIV service integration in Suba district, Kenya.
Outcome | 3 months | 12 months |
---|---|---|
| ||
Office courtesy and helpfulness† | 0.40 (−0.32, 1.21) | 0.61 (−0.08, 1.31) |
AOR (95% CI) | ||
Overall satisfaction |
|
1.32 (0.62, 2.78) |
Satisfaction: group talks and vitals (CCHAs)‡ | 1.11 (0.53, 2.31) | 1.55 (0.77, 3.13) |
Satisfaction: reception‡ | 1.02 (0.50, 2.11) |
|
Satisfaction: nurses‡ | 0.74 (0.34, 1.61) | 1.90 (0.89, 4.04) |
Satisfaction: lab‡ | 0.75 (0.34, 1.67) | 1.23 (0.57, 2.78) |
Satisfaction: clinicians‡ | 0.59 (0.27, 1.26) | 1.53 (0.73, 3.20) |
HIV education$ | 1.29 (0.64, 2.62) |
|
Wait time$ | 1.01 (0.51, 1.98) |
|
†Controlling for being on ARVs,
$Controlling for being on ARVs and language of survey,
‡Controlling for being on ARVs, language of survey, sex.
Regression analyses of changes in patient satisfaction and perceived stigma stratified by sex over time in an evaluation of HIV service integration in Suba District, Kenya.
Outcome | Stratum | 3 months | 12 months |
---|---|---|---|
Coefficient, | |||
Doctor respect, time, and listening$ | Males ( |
|
|
Females ( |
|
|
|
AOR (95% CI) | |||
Satisfaction: pharmacy | Males ( |
0.82 (0.22, 3.11) | 3.64 (0.94, 14.09) |
Females ( |
0.62 (0.25, 1.56) | 1.05 (0.42, 2.61) | |
People with HIV treated the same as others$ | Males ( |
0.71 (0.12, 4.26) |
|
Females ( |
1.82 (0.60, 5.51) | 1.92 (0.58, 6.32) | |
Privacy & confidentiality$ | Males ( |
0.65 (0.06, 7.20) | 5.98 (0.52, 68.70) |
Females ( |
0.27 (0.02, 2.96) | 0.41 (0.04, 3.87) | |
Not comfortable receiving care here$ | Males ( |
|
0.46 (0.06, 3.36) |
Females ( |
|
|
†Controlling for being on ARVs.
$Controlling for being on ARVs and language of survey.
All stigma-related items showed significant effect modification by sex (Table
Our findings suggest that integrating HIV care with primary care services does not negatively affect individual patients and may offer some benefits that extend beyond the health-system level to the individual patient. Assessment of the patient-level effect suggests that patient satisfaction remained high and that integration did not heighten perceived stigma. Before and after integration, patients generally agreed that care was provided confidentially and equitably regardless of HIV status although women expressed increased discomfort with receiving care at integrated clinics. In rural Kenya, other investigators from our group have found that overall client satisfaction with integrated HIV services among pregnant women is associated with satisfaction with administrative staff, satisfaction with health professionals, and convenient wait times and encounters with a receptionist [
As an initial assessment of the patient-level effect of integration, these findings may be a promising indication that integration may extend the resources concentrated within HIV care to a broader patient population without diminishing patients’ perceived satisfaction. Patient education sessions appeared to have a greater effect when done in an integrated setting. The significant increase in satisfaction with HIV education as well as reception and wait times may be an indication that the increased staff training positively affected patient-provider interaction. The increased satisfaction with HIV education may have also resulted because the mixed population of HIV-positive and general patients found the sessions more beneficial than HIV-positive patients alone, or because of the broader scope of topics after integration. While we found that patients trusted healthcare providers to keep information confidential and to treat all patients equally to similar degrees before and after integration; women were less comfortable about receiving care at the integrated clinic. Since the follow-up samples included HIV-negative patients, it is possible that this finding relates to their discomfort with integrated care or that it represents continued high levels of apprehension regarding others suspecting one is HIV positive. The effect of integrated care on inadvertent disclosure bears further investigation. Overall, our findings suggest that despite the challenges involved in integrating HIV care into routine health care, it is possible to pursue integration without significant disruption of patients’ experience, and in fact with some benefits observable even within a 12-month period.
Our finding that patient satisfaction remained high with integration may be evidence that the restructuring required to achieve the system-wide benefits of integration [
This study provides important integration findings. However, there are limitations to consider. The first limitation was the absence of a control group. It is possible that the changes observed could have been due to factors beyond the intervention. Second, the health facilities and the small number of patients interviewed within them may not be representative of the target population, limiting the generalizability of the findings. However, the proportion of respondents recruited out of the targeted number of participants increased substantially from 62% at baseline to greater than 90% at the followup. Third, the patient population changed between baseline and followup due to the nature of the intervention. In particular, the inability to distinguish between patients receiving HIV care and general care patients in the follow-up surveys limits the ability to determine how these two different patient groups responded to the intervention. Although we controlled for ARV status in multivariate analysis, we are unable to fully identify the impact of the intervention on patients receiving HIV care versus general patients. However, the consistently high percentages of patients on ART were an indication that a large proportion of respondents were in HIV care even when the survey was administered to an integrated patient population. By interviewing only patients who attended clinic and only tracking the number of willing participants, we were unable to capture the experiences of those who may have avoided clinic due to integration or who may have refused to participate, potentially introducing bias. Individual confounding factors may also influence the findings. Fourth, the questionnaire was self-administered; therefore, only literate respondents completed the questionnaire. In addition, the sampling strategy was not systematic and was therefore subject to selection bias from the research team. Other biases inherent in our evaluation design included social desirability bias and courtesy bias. Finally, the study may have benefitted from qualitative interviews to provide more insight into the results, especially in relation to improvements (or decline) in service delivery. However, this evaluation was done in the context of a mature HIV program in a real-world setting. We demonstrate the utility of operational research within HIV programs to improve program quality.
This study is a step towards developing a model of care that integrates HIV care into primary care in resource-limited settings. Given the potential positive aspects, it is worth exploring integration as one innovative way of improving primary care services that receive little donor funding, while at the same time maintaining the achievements of donor-supported HIV care at the patient level. Larger, cluster-randomized or stepped-wedge and longitudinal studies should be conducted to confirm these findings and address other critical issues, including the effect of integration on quality of care, long-term health outcomes, and cost-effectiveness.
The authors declare that they have no conflict of interests.
Thomas A. Odeny designed and conducted the study, interpreted the data, and drafted the paper. Jeremy Penner conceptualized and designed the study, provided mentorship during study conduct, and made substantial contributions to the interpretation of the results and drafting of the paper. Jackson Kioko designed the study instruments, led data collection activities, and substantially contributed to paper development. Hannah H. Leslie performed the statistical analysis and contributed to drafting of the paper. Starley B. Shade provided mentorship for statistical analysis and contributed to paper development. Walter Adero assisted in the conceptualization, design, and conduct of the study. Jayne Lewis-Kulzer supported study implementation. Elizabeth A. Bukusi and Craig R. Cohen provided overall mentorship on conceptualization, design, and implementation of the study, as well as revising the paper and approving the final draft. All authors read and approved the final paper.
The authors thank the Director, KEMRI, for permission to publish this work. The authors would like to thank the Medical Officer of Health for Suba District, Dr. David Soti together with the Suba District Health Management Team. Additionally, they would like to thank the FACES staff who conducted mentorship. The authors would also like to acknowledge the funding support from the CDC (Grant/Cooperative Agreement U62PS924511/1U2GPS001913) and logistical support from KEMRI and UCSF. The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official position of the CDC.