Health system strengthening through integration of HIV-care into primary health care: A mixed method province-wide study in South Africa

purpose: To analyse the impact on the health from integrating HIV-care into primary health care clinics in Free State, South Africa system -specifically on patients, health workers and primary health care (PHC) service provision.

methods: A mixed methods approach utilised quantitative (i.e. patient surveys and longitudinal analysis of administrative data across four years) and qualitative (i.e. key informant interviews and focus group discussions) methods. Statistical analysis included t-tests and linear regressions (patient survey data) and interrupted times series analysis and linear mixed effect modelling (longitudinal data). Qualitative data were thematically coded and applied to a health systems framework.

major findings: Concerning patients, advantages of integration were the provision of comprehensive care at PHC clinics (including HIV care), maintaining quality of care (QoC) as integration progressed, improved care across the continuum, family and community engagement. However, increased wait times, decreased QoC for chronic disease patients and concerns about retention were identified. For health workers, despite increased workload with staff shortages, integration positively influenced job satisfaction, morale, the promotion of teamwork and mentoring. Concerning PHC provision, notwithstanding an increase of nearly 60, 000 patients on ART in the 131 PHC clinics in our four year study, service delivery was mostly unchanged, except for decreased immunisation coverages.

recommendations: In conclusion, expansion of ART through integration to PHC clinics is a viable strategy with wide health system benefits. However, care must be taken to provide adequate support for health systems to ensure the provision of equitable patient-centred PHC, especially in highly HIV prevalent contexts.