Why stand-alone HIV clinics persist despite calls for integrated health services

In Uganda, HIV services are still offered as stand-alone services within health facilities. Typically, HIV clinics have their own dedicated staff and infrastructure such as patient waiting areas and they run on designated days of the week.
This ‘vertical’ clinic model has depended substantially on donor aid principally from PEPFAR and was touted as a pragmatic emergency strategy of overcoming sub-Saharan Africa’s weak health systems in the quest to rapidly enrol millions on HIV treatment.

Over the past five years, there have been persistent reports of declining international assistance for scaling up HIV services in sub-Saharan Africa. This has been one of the main drivers of calls for integrating HIV services with non-HIV services to eliminate duplication and promote programme sustainability. In addition, several policies (including by the WHO) have outlined ways in which HIV services can be integrated into general health systems.

However, research we conducted across Uganda’s eight geographic sub-regions demonstrates that Uganda is unprepared for integrating HIV services into general health systems. Integrating HIV services with other services would imply that as a patient, on a random visit to the outpatient’s department of my nearest health centre, the health worker I find on duty will be competent in managing antiretroviral therapy (ART). Our study identified challenges with that proposition.

Firstly, we found that HIV-related stigma by health workers is very widespread. In one big hospital we visited, HIV patients were served last at the hospital pharmacy because they first dealt with the paying patients and ended with HIV patients whose services are free of charge to the user which stigmatised clients. In a health centre IV, some health workers on the labour ward declined to ‘touch’ HIV positive expectant mothers.

Secondly, health workers maintained that HIV disease management is a specialty and that requiring that all health workers manage ART over-night would be infeasible due to continuous updates in HIV treatment algorithms.
The health workers we interviewed maintained that stand-alone HIV clinics have emerged organically from escalating HIV client loads over the past decade in Uganda and that they were not an outcome of long-term planning. It was pointed out that the sheer volume of HIV clients at health facilities was too large on its own to be merged with the general pool of patients. HIV clinics were described as ‘a hospital within a hospital’.

The majority of previous studies have evaluated integrating HIV with non-HIV services under experimental settings. The unique contribution of our study, published in BMC Health Services Research, is that the majority of health facilities we surveyed had experience of implementing both specialist HIV clinics and integrated care under non-experimental conditions. Several hospitals we visited had reverted back to a stand-alone clinic model after failed attempts at integrating HIV with non-HIV services. Health workers and patients described scenes of chaos when all hospital laboratory services were brought under one roof with multiple accounts of lost HIV client samples. A surge in workload was another concern raised by health workers in an integrated package of services.

The health facilities we visited across Uganda, clearly don’t have the capacity to concurrently conduct HIV and non-HIV laboratory tests. The shortage of physical space was the least of the problems in this regard. Typically, HIV tests take longer than common non-HIV tests such as those for malaria or pregnancy screening. Running a CD4 count test takes about 30 minutes and if you have 50 patients that will take the better part of the day.

We also found some peculiarities with HIV clients. In a regional referral hospital we visited, HIV services were integrated into general out-patient services after the loss of donor support. HIV clients reported that waiting time increased after the integration of health services. They reported being less able to tolerate long waiting times due to hunger, which is a side-effect of their medication. The need for patient privacy during counselling sessions (which is integral to HIV care) necessitated vertical infrastructure such as counselling rooms.

Our study suggests that a ‘wholesale’ switch to integrated health services is impractical and a more incremental approach is advisable. From our findings it is clear that the health system in Uganda is unprepared for integrated care and the re-tooling of health workers, client preparedness, physical space shortages are among the issues that need to be addressed.

Dr Zakumumpa is a health systems
researcher at Makerere University.
[email protected]