Integrating HIV clinical services into primary health care in Rwanda

Integrating HIV clinical services into primary health care in Rwanda: a measure of quantitative effects.

With the intensive scale-up of care and treatment for HIV in developing countries, some fear that intensified attention to HIV programmes may overwhelm health care systems and lead to declines in delivery of other primary health care. Few data exist that confirm negative or positive synergies on health care provision generally resulting from HIV-dedicated programs. Using a retrospective observational design Price and colleagues compare aggregate service data in Rwandan health facilities before and after the introduction of HIV care on selected measures of primary health care. The study tests the hypothesis that non-HIV care does not decrease after the introduction of basic HIV care. Overall, no declines were observed in reproductive health services, services for children, laboratory tests, and curative care. Statistically significant increases were found in utilization and provision of some preventive services. Multivariate regression, including introduction of HIV care and two important health care financing initiatives in Rwanda, revealed positive associations of all with observed increases. Introduction of HIV services was especially associated with increases in reproductive health. While hospitalization rates increased for the whole sample, declines were observed at health facilities that offered basic HIV care plus highly active antiretroviral therapy. The authors indicate that their results partially counter fears that HIV programs are producing adverse effects in non-HIV service delivery. Rather than leading to declines in other primary health care delivery, they say their findings suggest that the integration of HIV clinical services may contribute to increases.

Editors’ note: This study of 30 primary health centres that had at least 6 months experience offering basic HIV care, defined as voluntary counselling and testing, prevention of mother-to-child transmission services, and preventive therapy with cotrimoxasole, found positive synergies between HIV care and the delivery of other primary care services, particularly antenatal care. This study would be strengthened by consideration of outcome indicators, such as maternal mortality and incidence of congenital syphilis, rather than solely service utilisation indicators. The changes documented here occurred against a backdrop of two important nationally coordinated health care financing programmes that the researchers did try to take into account– the mutuelle de santé, Rwanda’s nationwide primary health insurance system, and performance based financing of health centres. Both of these programmes would be expected to increase uptake and improve outcomes.