Integrating HIV services and other health services: A systematic review and metaanalysis

Bulstra C.A. Hontelez J.A.C. Otto M. Stepanova A. Lamontagne E. Yakusik A. El-Sadr W.M. Apollo T. Rabkin M. Atun R. Bärnighausen T. Ayala G. Benzaken A.S. Caswell G. Dukashe M. De Lima C.E. Freitas M. Friedman J. Ghys P. Godfrey-Faussett P. Gorgens M. Guarinieri M. Hader S. Izazola-Licea J.A. Kassymova S. Kelley E. Kim J. Kruk M.E. Low-Beer D. Mafiala F. Manzanero M. Mesbah I. Munar D.E. Odugleh-Kolev A.I.A. Pereira G. Radix A. Saavedra J. Sladden T. Stover J. Toro N. Torres-Rueda S. Vaughan J.
November 2021 Public Library of Science

PLoS Medicine
2021 #18 Issue 11

Background Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness. Methods and findings We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41-1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16-1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20-1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05-2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03-1.37], p = 0.025). Also, treatment success for non-HIVrelated diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response. Conclusions Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of ending AIDS by 2030, while simultaneously supporting progress towards universal health coverage.

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Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
Aix-Marseille School of Economics, CNRS, EHESS, Centrale Marseille, Aix-Marseille University, Les Milles, France
ICAP, Columbia University, New York, NY, United States
Ministry of Health and Child Care, Harare, Zimbabwe
Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, United States
Africa Health Research Institute, KwaZulu-Natal, South Africa
MPact Global Action for Gay Mens Health and Rights, United States
AIDS Health Care Foundation, Brazil
Georgina Caswell, Global Network of People Living with HIV, South Africa
HIV Survivors and Partners Network, South Africa
UNAIDS, Brazil
UNAIDS, Switzerland
Ministry of Health, Brazil
World Bank, United States
INPUD Secretariat, Switzerland
Ministry of Health, Kazakhstan
World Health Organization, Switzerland
Asia Pacific Network of Sex Workers, Australia
Harvard T.H. Chan School of Public Health, United States
SRHR Africa Trust, Malawi
Ministry of Health, Belize
El Kettar Hospital, Algeria
Howard Brown Health, United States
Ministry of Health of Brazil, Brazil
Callen-Lorde Community Health Center, United States
AHF México Wellness Center, Mexico
United Nations Population Fund, United States
Avenir Health, United States
London School of Hygiene & Tropical Medicine, United Kingdom
STOPAIDS, United Kingdom

Heidelberg Institute of Global Health
Department of Public Health
Joint United Nations Programme on HIV/AIDS
Aix-Marseille School of Economics
ICAP
Ministry of Health and Child Care
Harvard Center for Population and Development Studies
Africa Health Research Institute
MPact Global Action for Gay Mens Health and Rights
AIDS Health Care Foundation
Georgina Caswell
HIV Survivors and Partners Network
UNAIDS
UNAIDS
Ministry of Health
World Bank
INPUD Secretariat
Ministry of Health
World Health Organization
Asia Pacific Network of Sex Workers
Harvard T.H. Chan School of Public Health
SRHR Africa Trust
Ministry of Health
El Kettar Hospital
Howard Brown Health
Ministry of Health of Brazil
Callen-Lorde Community Health Center
AHF México Wellness Center
United Nations Population Fund
Avenir Health
London School of Hygiene & Tropical Medicine
STOPAIDS

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