Evaluation of Integrated HIV/AIDS and Primary Health Care Services in Northern Nigeria

Background
This study assessed the performance of HIV/AIDS integrated care approach delivered as part of routine PHC service in Nigeria. The study further examined the factors that influence the service delivery, performance and impact.
Methods
A concurrent mixed methods design involving quantitative and qualitative methods was adopted. The quantitative study used a retrospective cohort design to collect and analyse medical records of service users. This was followed by a survey conducted with 241 randomly selected HIV positive and HIV negative patients. The qualitative study used focus groups and key informant interviews to explore the views/perceptions of service users and their providers regarding why and how the integrated care worked or did not work. Quantitative data were analysed using IBM SPSS statistics 22. Regression analysis was performed to assess trend in uptake of HIV services, while interrupted time series analysis was used to assess the effect of the integrated care on non-HIV services. The normal approximation test for two proportions and confidence intervals were used to test the difference in proportions of satisfied respondents between the HIV positive and HIV negative patients. Qualitative data were transcribed and analysed using the framework approach.
Findings
Medical records of 125,844 patients comprising 78,351 (62.3%) adults and 47,493 (37.7%) children (0-60 months old) were sampled and analysed. The mean age (SD) of the satisfaction survey respondents was 32.8 (9.1) years for the HIV positive patients and 26.5 (7.2) years for the HIV negative patients. Majority of the respondents were married (81.6%), females (78.8%) who have not had secondary level of education (72.0%). The qualitative participants were between 19 to 65 years old, and majority had at least secondary school level of education.
The study found that HIV counselling [Change/annum (95% C.I): 2.11 (1.19, 3.04), p = 0.0001], testing [Change/ annum (95% C.I): 1.89 (1.02, 2.76), p= 0.0001] and collection of test results [Change/ annum (95% C.I): 1.90 (1.03, 2.76), p = 0.0001] significantly increased over time. Uptake of ART on follow up increased over time [Change/ annum (95% C.I): 8.51 (6.95, 10.08), p = 0.0001]. ART enrolment decreased over time [Change/ annum (95% C.I): -0.02 (-0.28, 0.23, p = 0.855]. Fear of confidentiality and stigmatisation resulted in poor clinic attendance. HIV counselling and testing for pregnant mothers increased over time [Change/ annum (95% C.I): 24.32 (16.70, 31.95), p = 0.0001]. The number of HIV exposed babies decreased with time [Change/ annum (95% C.I): -0.09 (-0.19, 0.012), p = 0.08]. Use of maternal health services improved over time: antenatal care service [Effect/ month (95% C.I): 6.6 (4.55 to 8.65), p = 0.0001], family planning service (Effect/ month (95% C.I): 1.3 (0.26 to 2.26), p = 0.014] and delivery service [Effect/ month (95% C.I): 0.9 (0.39 to 1.45), p = 0.0009]. Child health services showed a moderate increase over time: BCG [Effect/ month (95% C.I): 1.8 (0.64 to 2.88), p = 0.002], and DPT1/ Penta 1 vaccinations [Effect/ month (95% C.I): 1.0 (0.20 to 1.73), p = 0.013]. Paediatric out-patient attendance improved [Effect/ month (95% C.I): -7.7 (-21.27 to 5.91), p = 0.264] but in-patient attendance decreased over time [Effect/ month (95% C.I): -0.04 (-0.17 to 0.08), p = 0.487]. Adult out-patient attendance improved [Effect/ month (95% C.I): 13.2 (9.88 to 16.44), p = 0.0001]. Majority of the HIV positive patients (98.4%) and HIV negative patients (99.2%) were satisfied with the quality of services they received. Qualitative participants reported improved access to health care, reduction of stigma and discrimination against HIV service users, maintenance of privacy and confidentiality of patients among providers, improved satisfaction with services, and knowledge of prevention of transmission of HIV from mother to an unborn baby. Barriers to integrated care reported included, inadequate funding, inadequate staffing, knowledge gap, and inadequate infrastructure and facility. Facilitators of service delivery were identified as available infrastructure, facility and services, as well as efficiency of PHC facility management.
Conclusion
The findings suggest that the integrated care improved access, outcomes and quality of both HIV and non-HIV services. However, poorly managed programme may affect desired quality negatively. A system wise approach to integrated care is therefore critical for ensuring success of the programme.