title: Strengthening health systems at facility-level: feasibility of integrating antiretroviral therapy into primary health care services in lusaka, zambia.
abstract: BACKGROUND
  HIV care and treatment services are primarily delivered in vertical antiretroviral (ART) clinics in sub-Saharan Africa but there have been concerns over the impact on existing primary health care services. This paper presents results from a feasibility study of a fully integrated model of HIV and non-HIV outpatient services in two urban Lusaka clinics.
  
  
  METHODS
  INTEGRATION INVOLVED THREE KEY MODIFICATIONS: i) amalgamation of space and patient flow; ii) standardization of medical records and iii) introduction of routine provider initiated testing and counseling (PITC). Assessment of feasibility included monitoring rates of HIV case-finding and referral to care, measuring median waiting and consultation times and assessing adherence to clinical care protocols for HIV and non-HIV outpatients. Qualitative data on patient/provider perceptions was also collected.
  
  
  RESULTS
  Provider and patient interviews at both sites indicated broad acceptability of the model and highlighted a perceived reduction in stigma associated with integrated HIV services. Over six months in Clinic 1, PITC was provided to 2760 patients; 1485 (53%) accepted testing, 192 (13%) were HIV positive and 80 (42%) enrolled. Median OPD patient-provider contact time increased 55% (6.9 vs. 10.7 minutes; p<0.001) and decreased 1% for ART patients (27.9 vs. 27.7 minutes; p = 0.94). Median waiting times increased by 36 (p<0.001) and 23 minutes (p<0.001) for ART and OPD patients respectively. In Clinic 2, PITC was offered to 1510 patients, with 882 (58%) accepting testing, 208 (24%) HIV positive and 121 (58%) enrolled. Median OPD patient-provider contact time increased 110% (6.1 vs. 12.8 minutes; p<0.001) and decreased for ART patients by 23% (23 vs. 17.7 minutes; p<0.001). Median waiting times increased by 47 (p<0.001) and 34 minutes (p<0.001) for ART and OPD patients, respectively.
  
  
  CONCLUSIONS
  Integrating vertical ART and OPD services is feasible in the low-resource and high HIV-prevalence setting of Lusaka, Zambia. Integration enabled shared use of space and staffing that resulted in increased HIV case finding, a reduction in stigma associated with vertical ART services but resulted in an overall increase in patient waiting times. Further research is urgently required to assess long-term clinical outcomes and cost effectiveness in order to evaluate scalability and generalizability.
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. stephanie.topp@cidrz.org
authors.forename: Stephanie M
authors.initials: SM
authors.lastname: Topp
authors.forename: Julien M
authors.initials: JM
authors.lastname: Chipukuma
authors.forename: Mark
authors.initials: M
authors.lastname: Giganti
authors.forename: Linah K
authors.initials: LK
authors.lastname: Mwango
authors.forename: Like M
authors.initials: LM
authors.lastname: Chiko
authors.forename: Bushimbwa
authors.initials: B
authors.lastname: Tambatamba-Chapula
authors.forename: Chibesa S
authors.initials: CS
authors.lastname: Wamulume
authors.forename: Stewart
authors.initials: S
authors.lastname: Reid
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D011320:Primary Health Care / Q000458:organization & administration*; D015024:Zambia
chemical_list: D019380:Anti-HIV Agents