Advancing Person-Centered Integrated Care for a Sustainable HIV Response

Photo credit: JSI / Zambia

By Muka Chikuba-McLeod, Deborah Goldstein, Yogan Pillay, Beatrice Ajonye, Njeri Kamere

Global progress against HIV transmission, morbidity, and mortality is one of the most remarkable public health achievements of modern times. But the epidemic is far from over, with an estimated 29–46 million people expected to be living with HIV by 2050 and 400,000 new infections occurring each year. Health systems must, therefore, adapt and be able to meet the needs of people living with HIV, reduce transmission, and simultaneously address other health conditions and challenges. To achieve this we must develop and maintain integrated, person-centered care models and approaches that ensure high-quality services, streamline and simplify care delivery, and enhance financial sustainability.

Integration is not new to the HIV response. Services like HIV counseling, testing, and prevention have been integrated into antenatal care clinics for decades. These integrated programs have successfully identified women living with HIV and provided them with antiretroviral therapy for their own health and to reduce HIV transmission to their children. Too often, however, program integration is constrained by the limitations of policy, financing, and siloed health care delivery systems. In many resource-limited settings, while HIV service delivery systems are relatively robust and well resourced, systems that support non-HIV services tend to be under resourced and, as a result, face challenges in effectively addressing the needs of patients and clients. Thoughtful integration of HIV into primary health care will require strengthening core health systems to drive better health outcomes across the board.

The Case for Integration

At its core, integration is about managing and delivering health services together in ways that prioritize people, not merely their diseases. This approach responds to what clients are asking for: care that is convenient, efficient, accessible, addresses their wide range of health needs and diverse life experiences, and offers the information and choice necessary for clients to make decisions about their health.

Closing remaining gaps to achieve HIV epidemic control requires extending the health system’s reach to those communities with limited HIV prevention and treatment services; integrating care helps us do that. For example, screening and treating noncommunicable diseases like hypertension and diabetes provides additional opportunities to reach men for HIV testing and linkage. Integrating HIV care with non-HIV services also reduces stigma and discrimination, resulting in fewer interruptions in HIV treatment.

A robust and growing evidence base indicates that various models of integration improve not only HIV care cascade outcomes but those of non-HIV services as well, per Caroline Bulstra and colleagues in their systematic review and meta-analysis. Additionally, a study of 3.4 million Brazilians showed lower advanced HIV incidence and lower AIDS-related mortality among those receiving integrated HIV and primary health care.

Lastly, given declining donor funding, cost-effective innovations are needed to sustain HIV epidemic progress. The costs of basic HIV and non-HIV services tend to be lower in integrated programs. Similarly, integrating HIV services into primary health care settings creates efficiencies that benefit the entire population, not just those living with HIV. Integration offers a pathway to sustainability by allowing investments in HIV programs to strengthen primary care systems — and vice versa.

Taking Integration to Scale

To take integration to scale, we must address the systemic barriers that have impeded broader implementation. This requires us to rethink every level of the health system — from creating strong policies that outline integration implementation models and accountability frameworks to ensure that integration does not come at the expense of quality to involving the recipients of care in both design and ongoing implementation, as appropriate. Additionally and importantly, secure, supportive, aligned, and sustainable funding mechanisms at all levels (subnational, national, and global) will also be critical for effective integration. Beyond other core health system strengthening considerations, the following actions will be central to ensuring quality HIV care and retention in care in an integrated primary care model and system:

Co-Design Care with Community

Integration models should be context specific: country led, aligned with local priorities, tailored to the current health system, responsive to health disparities, and address the needs of those most impacted by the local epidemic. Model design should incorporate input from clients through the active involvement of people living with HIV, health care workers, health service managers, and national health policy stakeholders. Key considerations for co-design include the following:

• A holistic approach that spans service delivery as well as ongoing monitoring, evaluation, and adaptation efforts. Consistent feedback mechanisms, such as engagement with community-led monitoring efforts, will help tailor programs over time for continuous quality improvement.
• A consultative process that taps into the strengths, critical expertise, and experience of local organizations and their members to inform co-design and efficient implementation, especially in resource-constrained environments. Funders must help facilitate this by offering implementing partners, including local organizations, the flexibility to adapt integration models in close collaboration with service providers and managers, communities and service users.

Invest in Human Resources

Health workers, at both health facility and community levels, are the backbone of any successful integration effort, but they are often left out of the design phase, undertrained, and overburdened. For successful integration, these key elements are needed to provide person-centered care:

• The co-design phase must include health workers and management representatives to ensure ownership and follow-through.
• More health workers will need capacity strengthening to deliver a full range of services or better link clients to other providers for comprehensive service delivery.
• Providers must also be trained on the soft skills required to provide stigma-free care. Without these skills, those living with HIV or with other diverse experiences may feel unwelcome and dis-incentivized to continue care or treatment in a broader health system.
• Managers will experience significant changes in how their teams and facilities function and collaborate with others. To navigate these transitions effectively, management training is crucial, equipping these workers to lead through change, support their staff, and uphold the delivery of high-quality care for clients.

Leverage Data and Digital Tools

Digital tools like electronic medical records and artificial intelligence have the potential to transform integrated care, but to fully utilize these tools, we propose the following:

• Carefully consider the indicators necessary to evaluate programmatic success, especially as they integrate with other health areas and primary health care. Data collection associated with additional indicators is costly and should be carefully scrutinized.
• As HIV programs integrate into national health systems, HIV data will need to feed into national systems first and only then be shared for funder reporting. This protocol ensures that data is locally and nationally owned, and may require funders to align their reporting requirements with national systems. This will also require these systems to be centralized, harmonized, simplified, and digitalized so they are sustainable and interoperable.
• Integrate community data from initiatives such as community-led monitoring into national data systems for a sustained and accountable response. This could mean including community data indicators into national monitoring and evaluation frameworks.
• Although digital innovations hold promise, they require strong national socioeconomic infrastructure, such as reliable energy and internet connectivity, and equipment, such as servers and other devices, that also require maintenance. This digital infrastructure, as well as innovations in mobile technology and renewable energy, must be scaled if we hope to harness the power of technology.
• As new measurement and tracking systems are put in place and fed into national systems, clients’ rights to choice, confidentiality, and access to their health care data must be safeguarded.

Innovate Financing

Sustaining integrated care demands bold and innovative financing approaches. As international funding for HIV plateaus and or even declines, national governments will need to play a larger role by taking the following actions:

• Increase collaboration among governments, international donors and stakeholders, regional institutions/entities, the private sector, and civil society on creative ways to utilize existing resources to simplify care and share investments.
• Reimagine performance-based models or blended financing mechanisms that can drive quality, efficiency, reduce corruption, and enhance accountability, ensuring that every dollar spent goes further toward building sustainable, high-impact care systems.

A Path to Lasting Change

Person-centered integration offers a path to more sustainable and equitable health systems. But it requires bold action. To successfully integrate HIV care into primary health care settings, we must address existing gaps in infrastructure and services. The HIV response offers a valuable blueprint for effective service delivery and adaptation, showcasing models that can be adapted and scaled to enhance broader health system performance. The success of the response thus far shows that, with the right support, integrating HIV services while retaining people in care is not just aspirational — it’s achievable. Integration must evolve into a comprehensive approach that uplifts entire health systems while meeting the diverse needs of clients in different contexts.

This will require innovation, cultural shifts, continued investment, and unwavering commitment. Yet the potential rewards — a stronger, more sustainable health system and healthier lives for millions — are worth the effort. Together, we can advance person-centered primary care that addresses the needs of the HIV response as well as the needs of the broader health system.

The authors are global health leaders committed to advancing person-centered care. Muka Chikuba-McLeod is JSI’s president and CEO. Deborah Goldstein is a medical officer at USAID. Yogan Pillay is the director of HIV and TB delivery at the Gates Foundation. Njeri Kamere is the managing director of health systems at the Aurum Institute. Beatrice Ajonye is the national project coordinator of community-led monitoring for the International Community of Women Living with HIV East Africa.