With global commitments to ending AIDS as a public health threat and achieving universal health coverage (UHC) by 2030, primary health care has been tapped as the approach to achieving sustainable health for all. Yet, the fiscal space for global health is shifting and constricting; building towards integrated, person-centered health systems, leveraging lessons from the HIV response, offers a promising approach for sustaining the impact of disease-specific responses while advancing strengthened primary health care and epidemic preparedness and response systems.
On October 9, the World Health Organization (WHO), Friends of the Global Fight, the Global Network of People living with HIV (GNP+), and PATH hosted the “From UHC2030 to sustained HIV services: How strengthened primary health care systems are the key to getting us there” webinar.
The panel was comprised of thought leaders in this space, including:
● Andy Seale, Adviser—Strategy, Policy, and Partnerships, WHO
● Dr. Yvette Kisaka, Lead/Focal person—Sickle cell & Cardiovascular Diseases, HIV-NCD integration, Ministry of Health Kenya
● Dr. George Siberry, Chief Medical Officer—Office of HIV/AIDS, United States Agency for International Development (USAID)
● Chris Collins, President & CEO—Friends of The Global Fight
● Jaime Atienza Azcona, Director—Equitable Financing, Joint United Nations Programme on HIV/AIDS (UNAIDS)
● Florence Riako Anam, Co-Executive Director | GNP+
● Dr. Kimberly Green, Global Director, Primary Health Care, PATH (moderator)
Integration—an integral component of person-centered approaches—has been shown to improve service access, overall uptake and continuity, health outcomes, and efficiencies, and has been identified as a core strategy for sustaining the HIV response by and beyond 2030. The webinar considered the extent to which HIV services have been integrated with primary health care to ensure HIV services remain available, accessible, affordable, and delivered with quality as part of as part of UHC health system reforms.
Making the case: HIV and primary health care integration
Dr. Kimberly Green opened the session by framing the many ways that integration can be approached at the service, system, and policy levels, highlighting various pathways that countries are taking to advance integrated, person-centered health care—from community or private-sector led tailored services, such as for young people and key populations, to one-to-one service integration (for example, HIV and noncommunicable diseases [NCD]) to whole-of-system, public-sector HIV-primary health care integration. The intention behind most models of integration is to improve quality of care, increase uptake of services, and optimize use of resources.
"Each country will choose their own pathways to HIV and primary health care integration—guided by population service preferences—and solving for structural barriers, including stigma and cost." - Dr. Kimberly Green
Andy Seale framed the need for a person-centered—rather than disease or facility-centered—approach to health care, and cited the “Primary health care and HIV: convergent actions: policy considerations for decision-makers” report, which outlines opportunities for HIV and primary health care integration across systems and services. Referencing WHO and UNICEF's "Operational Framework for Primary Health Care," Andy called out the need for countries to concurrently advance strategic (governance, political commitment, financing, and robust community engagement) and operational levers (built around the health system building blocks): “[The framework] presents a helpful way to understand how to optimize connecting the dots…countries can excel in one area, but there’s an amplification opportunity if several areas are worked on at the same time and there’s deliberate cross-referencing.”
Dr. Yvette Kisaka followed with a case example of applying a one-to-one model for service integration from Kenya, where NCDs account for more than 50% of hospital admissions. Integrating HIV and NCD services through a chronic care model as part of strengthened primary health care is a core component of Kenya’s strategy for attaining UHC2030 goals. Decentralized NCD screening through community health promoters, integrated HIV/NCD treatment, and personalized adherence support have enabled earlier detection and improved continuity in care and health outcomes for people living with HIV (PLHIV) and those with hypertension, while enhancing system efficiencies and reducing costs in pilot integration sites.
"[Integration] is not possible without strong stakeholder engagement, so we brought stakeholders together…to support the integration agenda…bringing in the lived experiences of the people living with these conditions" said Dr. Kisaka.
Panel discussion: Where are we now, and where can we go from here?
Q: USAID has long prioritized investing in community health and primary health care approaches, and has anchored primary health care as a core strategy for advancing person-centered care. Tell us more about USAID’s perspectives on where you are now in delivering on HIV and primary health care integration, and where you hope to be in the next 3-5 years?
Dr. George Siberry: Primary health care is foundational to public health systems because it can satisfy 90% of a person’s health care needs throughout their life, making it the most effective way to advance and achieve UHC. Right now, the time is right for an integrated HIV-primary health care approach for a few reasons, one of which is that the way we treat and prevent HIV has changed dramatically over the years, and it can now be largely managed within primary health care and in communities.
Much of the U.S. President’s Emergency Plan for AIDS Relief’s footprint is at the primary health care level and is linked to community services, meaning delivery through Primary health care is not new but needs to be expanded. Incredible progress has been made in treating PLHIV and reducing new infections, but gaps remain. To reach 2030 UHC and HIV goals, we need a different approach where HIV services are delivered through primary health care and stronger health systems.
Integration of HIV into broader primary health care systems provides an inroad to reducing stigma and discrimination, and also enables expanded reach to people who are “hard to reach” by making services less hard to access. Integration could also encourage greater uptake of HIV services among young people by expanding youth-friendly, comprehensive care throughout health systems by partnering with schools and championing youth voices.
There are important considerations to be made, however. Equal emphasis should be placed on health systems and not simply service delivery. That requires country governments and civil society organizations to take stock of the status of health systems so they can assess their financing needs and drive context-specific planning. Lastly, integrated HIV-primary health care should not be limited to services provided by governments; the private health sector and non-governmental organizations also have a big role to play.
Q: As we look at mainstreaming HIV into primary health care, what do you think is possible? What do policymakers need to keep front and center to enable access to high-quality, respectful, and inclusive HIV and other health care for people living with and affected by HIV, particularly considering persistent stigma and criminalization in some settings?
Florence Riako Anam: We are living in a very transformative time and need to pay careful attention to changing systems and people’s way of life. That requires open communication pathways with people living with HIV to understand their unique needs and desires. Integrating HIV and primary health care is welcome because it acknowledges that the needs of PLHIV differ and have evolved over time. To move this forward, three things to consider are:
1) integration should not come at a cost to quality of care and services
2) stigma and discrimination are still huge barriers that should be considered in the broader health system
3) transparency within countries with donors and policymakers are key to making evidence-based decisions
Q: As a longstanding champion of the mission of the Global Fund to Fight AIDS, Tuberculosis, and Malaria and given your thinking on person-centered care and how the HIV platform could involve other health care areas, how far could the Global Fund go in partnering with countries to advance the integration agenda through their One Health Plan, One Budget, One M&E approach moving forward?
Chris Collins: The Global Fund is evolving its role in HIV and primary health care integration, and is uniquely placed to be at the forefront of driving integration given their considerable health systems investments and commitment to tackling human rights and gender-related barriers. They understand that investing in communities can be the bridge between disease-focused programs and broader healthcare, and in February 2023, they published a guidance note calling for partners to develop programs that emphasize integrated person-centered care and, therefore, holistically address the needs of PLHIV along their life course.
There are other publications that stress similar things. A UNAIDS and PEPFAR report, Equity in AIDS Response: Assessing progress and charting a way forward, shows how HIV response has clear equity advantage. Similarly, in The Lancet, authors discuss how to rethink HIV service delivery and move away from standalone HIV programming, with a report from the Elton John AIDS Foundation, UNAIDS, and Friends of the Fight sharing six case studies that show how countries have built out from their HIV platform to offer primary health care and other services that drive broader health gains.
Q: UNAIDS has launched guidance to support countries in preparing sustainability roadmaps. As countries are moving through this process, where do you see the potential for financial efficiencies (or not) with integrative approaches?
Jaime Atienza Azcona: In lower- and middle-income countries, domestic financing for health accounts for 96% of overall budgets, but only 34% for HIV. So, we see a large mismatch—HIV is financed internationally, and health systems are financed nationally. The reality is that we need to build the future of the HIV response within systems that are underfunded and, in many cases, very weak. So, we need to be strengthening health systems while simultaneously working to sustainably embed HIV within these systems.
We also need to recognize that we don’t need the same as what we needed in the past for the future. Transforming the HIV response will be equally important, and we need to consider the epidemic trajectory, the human rights environment and enabling policies, and structural drivers of a successful HIV response as we approach integration. Important financial efficiency gains are achievable with successful and well-planned HIV-primary health care integration—they can lead to better health outcomes for larger populations and better support for PLHIV.
Q: In the midst of mpox, where do you see integration in terms of utilizing investments in HIV toward addressing mpox?
George Siberry: If you have good community-based organizations involved, you will be set up to provide good health care, detect problems when they arise, and reach people with messages and services to respond to emerging health threats.
Chris Collins: The prevailing lesson from mpox and these continued outbreaks is the need for strong health systems. More people would have been diagnosed and given needed care if we had comprehensive systems of care.
Q: What are other examples of how integrated service delivery reaches key populations?
George Siberry: There needs to be a distinction between integration within specialized clinics that serve and are preferred by key populations and general public-sector health facilities. We must keep services for key populations separate until public-sector services can be delivered in a non-discriminatory and open way; meanwhile, we can integrate comprehensive services aligned with population needs outside the public sector within community-led clinics.
Chris Collins: Ideally, we want both to happen—a strengthened primary health care system and strong community systems that provide dedicated services to populations. We need to be working towards public health systems where everyone is welcome, feels safe, and is treated with respect.
Florence Riako Anam closed by framing three takeaways:
● Integration can result in efficiencies. Although we do not know the full extent of this, we have enough evidence to know that we can build resilient health systems through integrated, person-centered care.
● Policy and political commitment are important and key. We are not starting from scratch; there is WHO guidance that countries can adapt and learnings from those already piloting HIV and primary health care integration that can be shared to encourage broader commitment towards integration.
● Primary health care stakeholders must be intentional about resolving inequality and ensuring quality. Unequal access to high-quality health care is common across countries; centering communities and community leadership throughout this journey to integration can solve for this.
“We must determine how to address the realities faced by marginalized populations, key populations, and of course, populations with different vulnerabilities…so that we don’t further inequality." – Florence Riako Anam