In 2016, the United Nations General Assembly on HIV and AIDS published a statement with a commitment to reach zero new human immunodeficiency virus (HIV) infections, zero acquired immunodeficiency syndrome (AIDS)-related deaths, and no discrimination by 2030.1,2 Two programs were then designed to achieve some of these goals (access to preventative therapies for 90% of the most at-risk individuals by 2020 and coverage for HIV testing and antiretroviral therapy [ART] for individuals with HIV).1 However, for several reasons, these goals have not been met in every country.1 12.6 million people living with HIV still have not been able to obtain treatment.3 Additionally, despite new HIV infections being reduced globally by 23% since 2010, they have increased in eastern Europe and central Asia (72%), the Middle East and North Africa (22%), and Latin America (21%) as of 2019.3 Regarding deaths, there were 690,000 AIDS-related deaths in 2019, missing the goal of fewer than 500,000 by 2020.3 It is estimated that there were 3.5 million more new infections between 2015 and 2020 and 820,000 more deaths during that time period than if the “Fast-Track” objectives had been met.3
Why the world has not reached its “Getting to Zero” goals for HIV
Several underlying reasons exist for why these goals haven’t been met. Less support, both financial and political, is available globally for universal coverage for this response to be possible.1 The COVID-19 pandemic has added to the decrease both in attention to HIV and funding of programs.1 The progress that has been made over the past 20 years has mostly been with stand-alone programs for HIV care, rather than from incorporating them into a patient’s general medical care.1 As people live longer and have more comorbidities and side effects of ART, there may be better ways to manage their healthcare.1
Improving HIV care and outcomes
Caroline A. Bulstra, DVM, MSc, of the Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany, and the Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands, and colleagues, hypothesized that “…integrating HIV services may lead to powerful benefits for patients, such as HIV status knowledge and needed ART.”1 In their study, published in PLOS Medicine, they investigated the integration of health services for HIV and at least 1 other condition or disease.1 Although they postulated that there would be improvement to healthcare, they also realized that some aspects might be worsened.1
One improvement could be an increase in access and continuity of care, as well as an improvement in coordination of treatments for different diseases, such as coronary heart disease, cancers, mental illness, kidney, and liver disease.1,4 A previous study looked at several models of integrated care (HIV and AIDS with diabetes, HIV and AIDS with diabetes and hypertension, cardiovascular disease with HIV and AIDS, and HIV and AIDS with diabetes, hypertension, cardiovascular diseases, and other diseases) and concluded that many of these were successful.4 Healthcare costs could also be lowered with integration. Conversely, the costs could increase if multiple diseases need to be treated by different specialists or by a single provider with knowledge and expertise in multiple diseases.1 Another concern mentioned by the authors is the possibility of overburdening healthcare providers, particularly where the prevalence of HIV is high.1
Will integration of services work?
The study assessed data from articles published between 2010 and 2021, both on the general population and on people living with HIV.1 The data were from studies on HIV care cascade outcomes, HIV health outcomes, non-HIV health outcomes, and costs and cost-effectiveness and were conducted in East Africa, Zambia, Malawi, South Africa, and Uganda.1 The integrated services in the studies included maternal child health, tuberculosis, family planning, primary healthcare, and sexual and reproductive health or sexually transmitted infection services.1 The integrations they found were integration of HIV testing and counseling into non-HIV services, integration of additional services with ART, and integration of ART into non-HIV programs.1
Regarding the HIV cascade of care, testing and counseling uptake was significantly higher for health services that were integrated (pooled RR 1.67; 95% CI, 1.41–1.99; P<0 .001).1 Initiation of ART was also significantly higher in programs that were integrated (pooled RR 1.42; 95% CI, 1.16–1.75; P=0.002). ART was also started significantly faster in integrated programs (pooled RR 0.45; 95% CI, 0.20–1.00; P=0.050); however, ART adherence was non-significantly higher (pooled RR 1.13; 95% CI, 0.95–1.34; P=0.146).1 Continuation of care was significantly higher in integrated programs (pooled RR 1.68; 95% CI, 1.05–2.69; P=0.031).1 Viral suppression was also significantly higher in programs that were integrated (pooled RR 1.19; 95% CI, 1.03–1.37; P=0.025).1
Both uptake of other health services and success of treatment for non-HIV conditions and diseases were significantly higher in programs that were integrated (pooled RR 2.42; 95% CI, 1.59–3.66; P<0.001 and pooled RR 1.56; 95% CI, 1.11–2.20; P=0.014, respectively).1
When cost and cost-effectiveness were evaluated, the authors found that the costs of HIV and non-HIV care were lower in the integrated programs.1
Sometimes integration will not be successful
The investigators did find some explanations for integration not being successful in some programs:
- Increase in diverse patients in overburdened healthcare systems
- Integration was limited to only part of the care, eg, HIV testing or ART initiation, causing retention and/or adherence to not be successful
- Limitations relating to healthcare workers (limited availability, training, or coordination)
- Low quality of care
The authors concluded that their “…results support the integration of HIV services with other health services. The evidence indicates that integration of HIV testing and counseling services into non-HIV health [programs] for people at risk of acquiring HIV, and integration of non-HIV services into ART [programs] for [people living with HIV], tends to lead to improved service uptake and health benefits for HIV and other diseases or conditions.” However, they added, “…the effects of integrating HIV services into broader health systems and the economic impacts of integration are less clear and require further study. In addition, integration success will depend on a wide range of determinants and path dependencies, such as local epidemics and health system structures and processes. Despite the need for more studies on specific integration opportunities and key populations, it seems likely that integration of HIV and other health services can contribute to reaching the UNAIDS target of ending AIDS by 2030, while simultaneously meeting other universal health care targets.”1
- 1. Bulstra CA, Hontelez JAC, Otto M, et al. Integrating HIV services and other health services: a systematic review and meta-analysis. PLoS Med. 2021;18:e1003836. doi:10.1371/journal.pmed.1003836
- 2. Getting to zero. Joint United Nations Programme on HIV/AIDS (UNAIDS). Published December 2010. Accessed March 28, 2022.
- 3. Seizing the moment: tackling entrenched inequalities to end epidemics-global AIDS update 2020. Joint United Nations Programme on HIV/AIDS. Published 2020. Accessed March 28, 2022.
- 4. Haldane V, Legido-Quigley H, Chuah FLH, et al. Integrating cardiovascular diseases, hypertension, and diabetes with HIV services: a systematic review. AIDS Care. 2018;30:103-115. doi:10.1080/09540121.2017.1344350