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Opportunities and challenges for the integration of HIV / AIDS and non communicable diseases: a systematic review of different integrated care models

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  • Save Public Health Research 2021, 11(2): 44-58 DOI: 10.5923/j.phr.20211102.02 Opportunities and Challenges for HIV/AIDS and Non-Communicable Diseases Integration: A Systematic Review of Different Models of Integrated Care Njuguna K. David1,*, Oren Ombiro2, Caroline Kawila3 1Health Economist, Ministry of Health, Nairobi, Kenya 2Public Health Specialist, Department of NCDs, Ministry of Health, Nairobi, Kenya 3Health System Management Expert, Department of Health Systems Management, School of Medicine and Health Sciences, Kenya Methodist University, Nairobi, Kenya Abstract It is evident that HIV and Non-Communicable diseases (NCD) programs often intersect. However, HIV services are stand alone and decentralized making it attractive to patients in peripheral facilities, and retaining them in care. In contrast, NCD care is provided using a centralised model, with the majority of care provided by hospitals. Patients have limited access and commonly present late with symptoms of complications. Therefore, HIV/NCD integration would strengthen the health systems capacity to address the full range of needs for HIV patients, at both the population and individual level. This systematic review explores the pertinent opportunities and challenges for HIV/NCD integration in comparison to different models of integrated care. Twenty studies with some conducted in America, Africa and Asia that heavily relied on primary data and implied that HIV/NCD integration increases the utilization of healthcare services and improve health outcomes were examined. Three studies reported increased utilization and improved outcomes through a population-based model of integrated care, however, reported challenges with linkage to care, loss to follow up and low levels of male involvement. Seventeen studies reported on individual models of integrated care which translated into impressive health outcomes including efficiency gains in staffing, increased coverage, improved medication adherence, and high rates of retention in care. One study reported on a case management approach that was found to be more effective when supporting integrated services for depressed HIV patients. The review findings show that intense efforts are needed to improve male involvement, invest in point of care technologies, reduce the return visit rates and provide streamlined care to reduce the loss to follow up for individual-based models of integrated care. There is diversity in integration models combining HIV and NCD services, and they have the potential in yielding positive patient and service delivery outcomes when implemented within appropriate contexts. Keywords HIV/AIDS, Non-Communicable Diseases, Models of integration, Opportunities, Challenges 1. Introduction The World Health Organisation (WHO) defines integration in healthcare systems as “bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion” to “improve access, quality, user satisfaction and efficiency” [1,2]. Moreover, the WHO recognises the importance of integrated care and recently developed a ‘Framework on integrated people-centred health services’ calling for fundamental change in the funding, management, and delivery of health services [3]. The compelling reasons * Corresponding author: (Njuguna K. David) Received: May 28, 2021; Accepted: Jun. 16, 2021; Published: Jun. 26, 2021 Published online at to integrate healthcare services include the fact that the underlying determinants of the major health challenges are similar and synergistic. The key beneficiaries of health services are often the same, integration of care minimizes duplication of scarce resources, and promotes efficiency [4]. Integrating healthcare also improves the effectiveness of outcomes and enhances the sustainability of health, social and environmental goals broadly [5]. In 2019, 38 million people in the globe were living with HIV, 1.7 million people became newly infected with HIV, while 690,000 people died from AIDS-related illnesses [6]. Non-communicable diseases (NCDs), also known as chronic diseases cause 71% of all deaths globally. More than 15 million people aged between 30 and 69 years die every year from an NCD and 85% of these "premature" deaths occur in low- and middle-income countries [7]. The disability-adjusted life year (DALY) burden from NCDs was Public Health Research 2021, 11(2): 44-58 45 estimated to be 37% in low-income countries in 2015 [8]. NCDs, including cardiovascular disease, diabetes, cancer, and mental health problems, are common among people living with HIV (PLHIV) and threaten the progress of HIV treatment programs [9]. This can be attributed partly to HIV infection [10,11] and the complications of long-term antiretroviral therapy [12–14]. HIV services are stand-alone and are vertically delivered. Besides, they are decentralized and delivered by task shifting, which enables the treatment of many patients [15]. In contrast, health service coverage for NCDs remains very low [16,17]. The interventions for NCDs are rarely included in national primary care packages and are often paid for via out-of-pocket medical payments, which can lead to catastrophic health expenditure and impoverishment [18]. The global AIDS response is primarily donor-supported and addresses HIV and common opportunistic infections, with limited focus on other conditions [19]. Consequently, there are significant gaps in the cascade of care for NCDs in countries that are on track to meeting the aspirational 90-90-90 targets [20]. There is a need to coordinate efforts and achieve synergies to benefit patients. The epidemiologic transition and double disease burden from chronic infections and Non-communicable diseases (NCDs) worldwide require re-engineering of healthcare delivery systems [21]. HIV/NCD integration is the coordination, co-location, or simultaneous delivery of HIV and NCD services to people who need them when they need them [9]. Various models and approaches to integrated care have been applied based on different objectives. Individual models of integrated care deal with individual coordination of care for high-risk patients with multiple conditions, to facilitate the appropriate delivery of health care services and overcome fragmentation between providers [22]. Case management is an example of an individual model of integrated care. It ensures coordination of a patient’s care through the assignment of a case manager who assesses the patient’s and carer’s needs, develops tailored care plan, organizes and adjusts care processes accordingly, monitors the quality of care and maintains contact with the patient and carer. A patient-centred medical home is another example. It is physician-directed and provides care that is accessible, continuous, comprehensive, coordinated and delivered in the context of family and community [23]. Disease-specific integrated care models provide better integration of care for people with certain diseases and long-term conditions such as diabetes mellitus, cardiovascular diseases, chronic obstructive pulmonary disease (COPD) and bronchial asthma [24–28]. The chronic care model is one such model that aims to meet the needs of people with chronic illnesses and provide a comprehensive framework for the organization of health services to improve their outcomes. It suggests a shift from acute, episodic and reactive care towards care that embraces longitudinal, preventative, community-based and integrated approaches [29]. Population-based models of integrated care shifts the healthcare system from a narrow model of acute care targeted at the individual patient, to one that focuses on the health and overall wellness of the broader population it serves [30]. Kaiser Permanente (KP) is one such model and is based on stratification of the population and supply of different services based on needs. It ensures the population receives promotion and prevention services to control exposure to risk factors. The majority of chronic care patients receive support for self-management of their illness and high-risk patients receive disease and case management, which combines self-management and professional care [23]. While these models of integrated care aim to achieve continuity of care and address the complex needs of patients with chronic conditions, there is a lack of clarity in the actual degree of integration and the bottlenecks experienced specifically in the context of HIV/NCD integration. To date, documentation of health system challenges and opportunities presented for HIV/NCD integration using different models is limited. As such, this systematic review sought to unravel the pertinent opportunities and challenges for HIV/NCD integration using different models of integrated care. 2. Methods This systematic review explored the opportunities and challenges of HIV/NCD integration using different models of integrated care. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline [31] for systematic reviews design was adopted during the search for research articles in English. This systematic review was not registered with PROSPERO. Search strategy A systematic search for published literature in English was conducted on PubMed and Google Scholar. References of retrieved articles and reports were screened to identify additional studies. Publication date, or publication status restrictions were not imposed. Non-empirical studies (commentaries, editorials, etc.), conference abstracts based on tertiary data, and studies that did not examine HIV/NCD integration were excluded from the review. The keywords used in the search were HIV, integration and chronic diseases and their synonyms. The following Medical Subject Heading (MeSH) terms were used: ‘HIV’ and/or ‘Acquired Immunodeficiency Syndrome’ combined with one or more of the terms ‘hypertension’, ‘heart diseases’, ‘cardiovascular diseases’, ‘diabetes’ ‘cancer’, ‘lung disease’, ‘pulmonary disease, chronic obstructive, ‘asthma’, 'mental health', 'depression' and ‘primary health care. Additionally, we used the non-MeSH search terms ‘non -communicable diseases’ and ‘out-patient department and integration’. 46 Njuguna K. David et al.: Opportunities and Challenges for HIV/AIDS and Non-Communicable Diseases Integration: A Systematic Review of Different Models of Integrated Care Figure 1. Study flow diagram Study eligibility The following inclusion criterion were considered for all publications and reports;  Population: HIV positive patients presenting with NCDs. There were no geographical restrictions (Globally).  Intervention: Integration of HIV/NCD healthcare services.  Comparator: There was no comparator for this review.  Outcome: The outcome measures were the available opportunities for implementation of various integration models and the challenges experienced with the implementation of these models. All studies that reported on the effects of different models of HIV/NCD integration using quantitative, qualitative and mixed methods were included specifically including the following:  Studies reporting actual integration experiences.  Studies reporting screening or treatment for HIV within a service targeting other NCD or vice versa.  Studies describing services provided in health facilities or the community and concerning any adult population. Exclusion criteria Full texts and abstracts were excluded if  They were not primary studies e.g. reports, literature reviews.  They did not describe HIV/NCD integration.  Studies published in languages other than English. Study selection Two individuals independently reviewed these articles. Titles and abstracts of the identified selected studies were screened to exclude duplicates and studies not relevant to the topic. The eligible titles and abstracts were then reviewed in full text. Data Extraction Full-text articles that fit the inclusion criteria were extracted into a matrix (MS Excel file) for the following implementation-related content: title, author, publication year, country, disease condition, integrated care model, challenges and opportunities. All disagreements were re-examined jointly and appropriate corrections made for all studies included in the review. All information related to the study objective was then presented in narrative form. Assessment of methodological quality Assessment of the risk of bias in included studies was done using the recommended risk of bias tools. The reviewed literature was then summarised after the team was convinced that the evidence was certain using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool [32]. Public Health Research 2021, 11(2): 44-60 1 Public Health Research 2021, 11(2): 44-58 Table 1. Summary of findings Author and No. publication Title year Country Objective Disease condition Integrated care model Challenges Opportunities Leveraging Rapid Community-Based 1 Chamie et al. 2012 HIV Testing Campaigns for Non-Communicabl e Diseases in Rural Uganda Uganda 1) To test the feasibility and diagnostic yield of integrating NCD and other communicable disease services into a rapid, high-throughput, community-based HIV testing and referral campaign for all residents of a rural Ugandan parish. 2) To determine rates and predictors of post-campaign linkage to care by disease HIV, malaria, TB, hypertension and diabetes Population-bas ed model of integrated care 1. Linkage to care after a referral was insufficient and undermines the benefits of early diagnosis 2. Low participation by males 3. Referral to different health facilities for HIV and NCD care The campaign reached 74% of adults in a community of 6,300 people rapidly (in five days) with efficient, high-throughput (95 minutes/person) use of point-of-care diagnostics. It identified a high burden of undiagnosed diseases using active case finding. It overcame barriers to diagnosis and referral that are shared by multiple diseases in resource-limited settings e.g., community participation, field laboratory infrastructure, access to trained counsellors, and referral services To determine the yield of 2 Govindasamy et al 2013 Linkage to HIV, TB and Non-Communicabl e Disease Care from a Mobile Testing Unit in Cape Town, South Africa South Africa newly diagnosed HIV, tuberculosis (TB) symptoms, diabetes and hypertension, and to assess CD4 count testing, linkage to care as well as correlates of linkage and barriers to care from a HIV, TB, Hypertension, Diabetes Population-bas ed model of integrated care mobile testing unit. The yield of newly diagnosed HIV infection (5.5%) was high from this mobile unit and this platform can be used to effectively identify TB suspects (10.1%) and diagnose diabetics (0.8%) and hypertensives (58.1%). The proportion of those who ever linked to HIV care in this study (60.0%) is also higher than those ever linked to care in previous studies 3 Janssens et al 2007 Offering integrated care for HIV/AIDS, diabetes and hypertension within chronic disease clinics in Cambodia Cambodia To describe the experience and outcomes of offering integrated care for HIV/AIDS, diabetes and hypertension within the setting of chronic disease clinics. HIV/AIDS, diabetes and hypertension Individual models of integrated care Through integration, staff could effectively assume a multidisciplinary role and that skills to manage patients who need to start a lifelong treatment were relevant to and effective for both HIV/AIDS and diabetic care. Doctors adapted to the role of chronic diseases specialists and gradually adopted a patient-centred approach. Adherence support counsellors, a 47 2 Njuguna K. David et al.: Opportunities and Challenges for HIV/AIDS and Non-Communicable Diseases Integration: A Systematic Review of Different Models of Integrated Care 48 Njuguna K. David et al.: Opportunities and Challenges for HIV/AIDS and Non-Communicable Diseases Integration: A Systematic Review of Different Models of Integrated Care Author and No. publication Title year Magnitude and risk factors of non-communicable diseases among 4 Kagaruki et al. 2014 people living with HIV in Tanzania: a cross-sectional study from Mbeya and Dar es Salaam regions Early experiences integrating hypertension and 5 Pfaff et al. 2010 diabetes screening and treatment in a human immunodeficiency virus clinic in Malawi Country Tanzania. Malawi Objective Disease condition Integrated care model Challenges Opportunities new function in the health-care system that was created with expanding HIV/AIDS care, are valuable in supporting adherence and lifestyle changes for diabetics. At 24 months of care, 87.7% of all HIV/AIDS patients were alive and inactive follow–up. For diabetes patients, this proportion was 71%. Of the HIV/AIDS patients, 9.3% had died and 3% were lost to follow-up, while for diabetes this included 3 (0.1%) deaths and 28.9% lost to follow-up. Of all diabetes patients who stayed more than 3 months in the cohort, 90% were still in follow-up at 24 months. To explore and establish information on the magnitude, distribution of NCDs risk factors among people living with HIV (PLWHIV) which is scarce in Tanzania. HIV, Hypertension and diabetes mellitus Individual models of integrated care Loss to follow up due to the need for a return visit to obtain fasting blood samples. There were low participation levels among males Efficiency gains achieved through the short period of training for the existing medical personnel. To describe the early experiences of integrating hypertension and diabetes screening and treatment in a human immunodeficiency virus clinic in Malawi Hypertension, Diabetes Individual models of integrated care 1) The routine workload was inadvertently shifted from nurses to clinic officers. 2) Waiting time initially increased but then decreased to the pre-integration level. 3) Clinical officers were often unaware that patients went home without NCD drugs. Avoidable extra clinic visits occurred due to monthly dispensing of NCD drugs as opposed to 2- to 3-month intervals in concert with supply. 4) Measuring blood pressure on every visit was simple to implement but created additional 1. Task shifting using expert clients to perform screening supported existing human resources. 2) leverage the resources from the relatively well-funded HIV programme to the lesser-funded NCD programme and draw on lessons from the HIV programme, including strong monitoring and evaluation, consistent drug supply and task shifting. Public Health Research 2021, 11(2): 44-60 3 Public Health Research 2021, 11(2): 44-58 Author and No. publication Title year Country Objective Disease condition Integrated care model Challenges workload. 5)Separate diabetes screening was a duplication of work and led to some patients being missed. Opportunities 1. Decentralized care worked to 6 Wroe et al. 2015 Leveraging HIV platforms to work toward comprehensive primary care in rural Malawi: The Integrated Chronic Care Clinic Malawi 1) increase access to care for NCD patients, (2) maximize efficiency given the severe human resource shortages, and (3) replicate strong HIV outcomes for patients with other chronic conditions. HIV, TB, DM, HTN, Asthma, Epilepsy, Heart failure, Malnutrition Individual models of integrated care 1. Initial increase in workload for nurses following integration 2. Long patient time in a clinic of approximately 2hrs enhance follow-up. 2. Integrated data collection designed to increase ease of patient management by minimizing redundancy 3. Clear patient flow and health provider roles improved efficiency 4. Private-public partnership to supplement funding for NCD drugs Medication Adherence Clubs: a potential solution to 7 Kabala et al. 2015 managing large numbers of stable patients with multiple chronic diseases in informal settlements Kenya To assess the care of hypertension, diabetes mellitus and/or HIV patients enrolled into Medication Adherence Clubs (MACs). HIV, DM or HTN Individual models of integrated care 1. Drop-out experienced due to the need for a return visit 2. Male involvement levels were low. 1. Improved patient attendance due to time flexibility 2. Availability of protocols for care provision enhanced adherence to nurse-led consultations 8 Daughters et al. 2010 ACT HEALTHY: A Combined Cognitive-Behavio ural Depression and Medication Adherence Treatment for HIV-Infected Substance Users United States of America To examine the integration of combined depression and HIV medication adherence treatment program HIV, substance abuse and Depression Individual models of integrated care 1. There were challenges with assuring confidentiality and making clients feel comfortable returning to the residential treatment centre for outpatient follow-ups 2. Inconsistency in homework completion due to difficulty with time management in their real-world settings, low motivation, and poor physical health (e.g., low energy) 1. Reduced depression rates, initiation of a Highly active antiretroviral therapy (HAART) regimen, and HIV medication adherence across all cases 2. Increased behavioural activation and environmental reward in two out of three cases Feasibility of nurse-led antidepressant 9 Adams et al. 2012a medication management of depression in an HIV clinic in Tanzania Tanzania. To test the feasibility of a task-shifting model of measurement-based depression care in an HIV clinic HIV and depression Individual models of integrated care Follow-through of antidepressant prescription dosing recommendations by the prescriber was low. Limited availability of antidepressants was also noted. Retention was high and fidelity of the care manager to the MBC protocol was exceptional. 49 4 Njuguna K. David et al.: Opportunities and Challenges for HIV/AIDS and Non-Communicable Diseases Integration: A Systematic Review of Different Models of Integrated Care 50 Njuguna K. David et al.: Opportunities and Challenges for HIV/AIDS and Non-Communicable Diseases Integration: A Systematic Review of Different Models of Integrated Care Author and No. publication Title year Country Objective Case management 10 Husbands et al. 2007 community care for people living with HIV/AIDS (PLHAs) Canada To assess a case management approach used to support integrated services developed in a service organization to support HIV patients 11 Weaver et al. 2009 Cost-effectiveness analysis of integrated care for people with HIV, chronic mental illness and substance abuse disorders United States of America To evaluate the cost-effectiveness of integrated HIV primary care, mental health, and substance abuse services among triply diagnosed patients. 12 Winiarski et al. 2005 Outcomes of an inner-city HIV mental health programme integrated with primary care and United States of America To evaluate the effectiveness of an HIV mental health program integrated with primary care that emphasized cultural responsiveness Disease condition HIV and depression HIV mental health and substance abuse HIV mental health and substance abuse Integrated care model Challenges Opportunities Individual models of integrated care Individual models of integrated care Individual models of integrated care Case management does contribute to reducing risk-taking behaviours in PLHAs with depression. The results of this randomized controlled trial did not demonstrate that the integrated interventions significantly affected the health service costs or quality of life of triply diagnosed patients. There was a decrease in the total average monthly cost of the health services intervention group: $3,235 to $3,052; control group: $3,556 to $3,271 though not statistically significant 1. Those who were very depressed benefited the most from case management which markedly improved their physical, social and mental health functioning, and reduced their risk behaviours. Very depressed PLHAs receiving case management had a 45% improvement in social function compared with 27% deterioration by very depressed PLHAs directing their use of services 2. There was an economically important, though not statistically significant, $3,300 per person per annum lower expenditure for all services used by People Living with HIV/AIDs (PLHAs) who received case management, which more than offset the cost of the case managers ($3,300 x 38PLHAs $125,400 per year on average in lower expenditures among the 38 PLHAs receiving case management). For both groups, the percentage attributable to hospital care decreased significantly (intervention group: 37% at baseline to 28%, P < 0.001; control group: 32% to 29%, P < 0.001) 1. There was a reduction in mental health problems [F (1, 58) = 8.22, P < 0.01] 2. There was a reduction in HIV symptoms [F (1, 34) = 8.67, P < 0.01] Public Health Research 2021, 11(2): 44-60 5 Public Health Research 2021, 11(2): 44-58 Author and No. publication year Title emphasizing cultural responsiveness Country Objective Disease condition Integrated care model Challenges Opportunities 3. There was a decrease in alcohol use [F (1, 37) = 15.21, P < 0.01] and cocaine use [F (1, 79) = 7.03, P < 0.01] 4. There was improved social functioning [F (1, 83) = 4.35, P < 0.05] 5. Treatment group used mental health services at a higher rate than Hypertension control in integrated 13 Kwarisiima et al. 2019 HIV and chronic disease clinics in Uganda in the SEARCH study Uganda 1) characterize the patient population and HTN control over time among adult residents who linked to HTN care using an integrated chronic care delivery model that offered treatment for both HTN and HIV disease and 2) evaluate predictors of HTN control over time. HIV and Hypertension Individual models of integrated care 1. Problems with linkage to care. Blood pressure was controlled in slightly less than half (46%) of all follow-ups visits due to more frequent clinic visits precipitated by drug stock-outs. 1. Hypertension care was integrated into HIV clinic visits preventing redundant visits and HIV-infected patients also received extensive counselling about daily medication adherence and retention support which may have led to increased adherence among HIV-infected patients. 1. To investigate the effect of mental health centre 1. Mental health service providers staff (MHCS) turn-over on were aware of who other network Effects of mental HIV and AIDS service providers are, but integration broke 14 Lemmon and Shuff 2001 health centre staff turnover on HIV/AIDS service United States of America delivery integration across three service delivery components: primary HIV and Mental Health Individual models of integrated care down at the level of implementation in terms of contacts, exchange of information and referrals. Integrative 1. Higher staff turnover rates had no negative impact on integration, except for within-centre services. delivery integration health care, mental health efforts focused on care coordination services, and HIV and with little to no evidence of bi AIDS dedicated care directionality. coordination Integrating cervical 15 Odafe et al 2013 cancer screening with HIV care in a district hospital in Abuja, Nigeria Nigeria To document the programmatic experience of integrating cervical cancer screening using Visual Inspection and Acetic Acid (VIA) into HIV care as well as to describe patients’ characteristics associated with positive VIA findings amongst HIV+ women. HIV and cervical cancer Individual models of integrated care 1. Out of a total of 52 VIA positive women, 35 (67.3%) could not access further care at the tertiary site due to cost leading to loss to follow up 1. Increased uptake of cervical cancer screening among the HIV positive women 51 6 Njuguna K. David et al.: Opportunities and Challenges for HIV/AIDS and Non-Communicable Diseases Integration: A Systematic Review of Different Models of Integrated Care 52 Njuguna K. David et al.: Opportunities and Challenges for HIV/AIDS and Non-Communicable Diseases Integration: A Systematic Review of Different Models of Integrated Care Author and No. publication Title year Country Objective Disease condition Integrated care model Challenges Opportunities Building capacity for cervical cancer 16 Huchko et al. 2011 screening in outpatient HIV clinics in the Nyanza province of western Kenya Kenya To evaluate outcomes of cervical cancer screening within HIV care and treatment clinics in Kenya HIV and cervical cancer Individual models of integrated care 1. The main challenges reported were related to infrastructure limitations (lack of water, electricity and supplies; and long waits in the clinic) and perceived patient barriers. 1. Increased uptake of cervical cancer screening among the HIV positive women (87% of the 4186 women were offered screening) 2. During the first 3 years of the program, 28 (90%) clinical officers underwent training in VIA and colposcopy. Three medical officers and5 clinical officers were trained in LEEP. Staff reported a high level of satisfaction with their training and their role in implementing cervical cancer screening in the clinic Implementation of cervical cancer screening using To describe successes and visual inspection challenges of with acetic acid in implementing nested 17 Moon et al. 2012 rural Mozambique: successes and challenges using Mozambique cervical cancer screening into family planning clinics at select sites also HIV care and receiving PEPFAR treatment support for antiretroviral programme therapy (ART) rollout investments in Zambezia Province HIV and cervical cancer Individual models of integrated care 1. Health manpower shortages, equipment problems, poor paper record systems and a limited ability to follow-up patients inhibited the quality of the cervical cancer screening services. 1. Nurses screened 4651 women (more than double the target number) over the first year of program functioning, in partnership with FGH for program technical assistance and access to HIV programmatic resources. Before initiation of this service, there were no available cervical screening or colposcopy services and no cryotherapy or LEEP treatment for cervical precancerous lesions in Zambézia Province. Modified To evaluate an integrated 18 Sacks et al. 2011 therapeutic community aftercare for clients triply diagnosed with HIV/AIDS and co-occurring mental and substance use United States of America therapeutic community aftercare program in which clients were taught to coordinate service components (HIV + mental health + substance abuse) and integrate their HIV, Mental health and substance abuse Population-bas ed model of integrated care 1. Moderate treatment effects in terms of substance use and mental health favouring participants in the intervention group in the High propensity stratum (Hedge’s g -0.34, P < 0.002) 1. Subjects who continued MTC treatment in aftercare reported greater gains or sustained the improvements acquired during residential treatment disorders treatment Improving uptake 19 Talama et al 2020 of cervical cancer screening services for women living with HIV and Malawi To achieve the target of screening 80% of eligible HIV-positive women screened for cervical cancer (571 out of the 749 HIV and cervical cancer Individual models of integrated care 1. Due to high patient volumes, limited space and the existing integration of HIV and NCD services, it was not possible to integrate VIA and cryotherapy within the HIV clinic 1. Integration was high yield. At baseline (January to December 2016), only 13 women living with HIV were screened for cervical cancer. One year after Public Health Research 2021, 11(2): 44-60 7 Public Health Research 2021, 11(2): 44-58 Author and No. publication year Title attending chronic care services in rural Malawi The impact of an integrated depression and HIV treatment program 20 Stockton et al 2020 on mental health and HIV care outcomes among people newly initiating antiretroviral therapy in Malawi Country Malawi Objective eligible) and to achieve this target within 12 months of full integration of the two services. To evaluate the program’s impact on retention, viral suppression, and depression remission among patients with elevated depressive symptoms at antiretroviral therapy (ART) initiation after 6 months in care Disease condition HIV and Depression Integrated care model Challenges Opportunities Individual models of integrated care solely using existing staff 1. Retention was very low in both the intervention and control groups. Providing ongoing treatment proved more challenging, and few patients received a standard course of antidepressants or attended a sufficient number of Friendship Bench therapy sessions. 2. Providers at the study sites typically rely on an electronic medical records (EMR) system to provide antiretroviral therapy (ART), which did not incorporate PHQ-9 screening or depression treatment and thus did not alert providers to re-assess depressed patients returning for care. 3. Antidepressant stock-outs were also common and problematic. 4. The clinics also found it challenging to provide proper Friendship Bench therapy, in part due to community health care workers’ availability and in part due to patients’ ability to return to the clinic for therapy sessions, in light of financial, time, and transport barriers implementation of the QI project, 73% (n=547) of women aged 25 to 49 years living with HIV enrolled in HIV care were screened for cervical cancer, with 85.3% of these receiving the screening test for the first time. The number of women living with HIV accessing cervical cancer services increased almost 10 times (from four per month to 39 per month, p<0.001). 1. Nearly all participants who did remain in care and had a 6-month viral load drawn and PHQ-9 assessment achieved viral suppression and depression remission. However, the evaluation did not yield evidence that the integrated depression treatment program improved 6-month HIV care or depression outcomes among the intervention group compared to the control group. 53

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