Delivering Responsive, Person-Centered HIV Primary Health Care
In this podcast, Davina Canagasabey, with PATH, speaks about delivering responsive, person-centered HIV and primary health care. She also spoke about this topic during her presentation at the International AIDS Conference 2022 titled “Real world impact of integrated person-centered HIV primary health care: better uptake, retention, and health outcomes across 4 countries.”
- Canagasabey D. Real world impact of integrated person-centered HIV primary health care: better uptake, retention, and health outcomes across 4 countries. Talk presented at: the International AIDS Conference 2022; July 29-August 2, 2022; Montreal, Canada. Accessed September 8, 2022. https://programme.aids2022.org/Programme/Session/94
Davina Canagasabey is a senior technical advisor for HIV and Viral Hepatitis at PATH, a global organization dedicated to achieving health equity, including by reimagining how primary health care is delivered and the systems behind it are structured to transform health care to become data-driven, less siloed, and more person-centered so that everyone has a fair chance at health and well-being.
Jessica Bard: Hello everyone and welcome to another installment of Podcast 360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant 360, a multidisciplinary medical information network. The World Health Organization's (WHO) global strategy on integrated people-centered health services focuses on a fundamental paradigm shift in the way health services are funded, managed, and delivered. Davina Canagasabey is here to speak with us today about her presentation at the International AIDS Conference 2022 titled, "Real World Impact of Integrated Person-Centered HIV Primary Health Care: Better Uptake, Retention, and Health Outcomes Across Four Countries." Davina is a senior technical advisor for HIV and Viral Hepatitis with PATH. Thank you for joining us today. Can you please provide us with an overview of your session?
Davina Canagasabey: This presentation was part of a session at the AIDS 2022 Conference trying to answer the question of how do we practically facilitate advancing person-centered HIV and primary health care during project implementation and as part of everyday service delivery.
The idea of integrated person-centered health care is certainly not a new concept, but one that's been increasingly coming to the fore, especially during COVID-19 and as we look towards global goals in 2030 for achieving universal health coverage. But the question is what does integrated person-centered care look like in practice and how do we make that happen? And these are the questions that we were really trying to answer during the session at the conference, both through highlighting guidelines the World Health Organization has put out around person-centered care as well as providing some practical examples of how practitioners involved in HIV service delivery can advance integrated person-centered primary health care, which at the end of the day and at its core, is really about tailoring health care services to meet the needs and preferences of different populations across the contexts that they're based in.
And so, in my presentation, I highlighted four vignettes showing how we, at PATH, have adapted HIV service delivery to more holistically meet the needs of people living with HIV in the Democratic Republic of Congo and Kenya, to people in prisons in Ukraine, and then finally for gay, bisexual, and other men who have sex with men and transgender people in Vietnam.
The examples that I spoke to in my presentation really focus on three principles, among others, that PATH applies to advanced person-centered primary health care. So the first principle is taking a whole-person-care approach by building onto the HIV service delivery platform to provide entry points to other health and social services that are critical to a person’s overall wellbeing, from viral hepatitis and noncommunicable diseases to mental health. To provide an example, PATH in our PEPFAR and USAID-funded programming in Ukraine and Vietnam have been adapting our HIV service delivery models to integrate access to diagnostic, treatment and prevention services for other disease areas.
For example, in the Ukraine, we worked with the Ministry of Justice there to pilot, expand, and really systematize service integration, so providing people in prisons and other closed settings with access to sort of a menu of comprehensive services ranging from HIV, tuberculosis, hepatitis C, and most recently opioid agonist therapy at a single entry point. And this has also included using new multiplex diagnostic tools to support integrated diagnostic services so that people are able to get access to their results much faster and it’s a much more efficient process on the health clinic side as well. We did that by using the GeneXpert platform to accelerate simultaneous TB, hepatitis C, and HIV diagnosis and monitoring. And in Vietnam, we worked with key population-led organizations and private clinics as well as the Vietnam Administration of AIDS Control to pioneer a “one stop shop” clinic model with these clinics providing access at a single touchpoint to a number of services that are critical for a person’s health and wellbeing. This included HIV, sexually transmitted infections (STI), viral hepatitis screening and care, gender-affirming services, and most recently mental health services to address the longer-term complications of COVID-19 and its impact on the mental health of key populations and people living with and affected by HIV.
The second principle is promoting service differentiation. And we’re talking here about really simplifying and decentralizing service delivery, particularly developing models that shift services out of health facilities and into communities and other service delivery points. And as part of that, task shifting to give people options and the choice of how, where, and from whom they can receive health care services, including through community, peer, and private sector providers. And an example of this that I highlighted is from Kenya, where PATH has been working to integrate hypertension services into HIV and primary health care platforms in western Kenya with support from PEPFAR and Resolve to Save Lives since 2017.
Currently through one of our projects, we're working with three health facilities and government counterparts in western Kenya to also establish a “one stop shop” approach for integrated HIV and hypertension services—both focused on improving hypertension screening for people living with HIV as well as continuity in hypertension care and treatment. So we're doing this by pulling on elements of service differentiation, offering screening at four types of facility and community service delivery sites so that people are able to have a choice of where they can access those hypertension screening services, as well as integrating hypertension care services into two HIV treatment delivery models so that people are able to access care for hypertension at the same time that they might be picking up their HIV refills. And then as part of this model, we also promote task shifting by using existing community health volunteers and peer educators to offer education on hypertension and do initial blood pressure screening.
And the third principle and in my view the most critical one is ensuring that programming is really community-powered. And we can do this by embedding human centered design principles when we're developing new health care interventions and then also by incorporating structures that allow for clients and community stakeholders to monitor and share feedback on the quality of health care services that are being delivered and that they receive. So, both of these elements help to ensure that health services are delivered in ways that are aligned with client preferences while also helping to tackle some of the persistent access and continuity barriers that we continue to see in health care delivery.
And so, through our PEPFAR-funded project in the Democratic Republic of the Congo (DRC), we have applied human-centered design to co-create with people living with HIV and facility-based providers an electronic tool to gather feedback on service quality. And we use peer educators to conduct exit interviews with clients following their clinic appointments for HIV treatment and monitoring, and record the client's responses into an online application. We embedded this tool into quality improvement processes that we support at the clinic-level with facility-based providers working with clients to identify and implement solutions to issues that the clients raise during exit interviews.
Jessica Bard: Now, you certainly touched on this a little bit, but what are the benefits of integrated person-centered HIV primary health care and how does it shape the care experience?
Davina Canagasabey: So the benefits of an integrated person-centered delivery approach is really that it leads to more flexible and simplified models that allow people to more easily and at their convenience access a menu of health, social and other services at a single touchpoint. And these models, as I mentioned, also help to remove some of the barriers that keep people from engaging in care. And you can see the real-world impact of these models when you look at numbers around service uptake, continuity in care, and client satisfaction.
And so, to delve a little deeper into that, share some numbers, in Kenya, with the project I spoke to earlier, when we integrated hypertension screening services into the HIV platform, we were able to screen more than 3,500 people living with HIV at three facilities in nine months, and that represents 90% of people receiving HIV treatment at these facilities. So the uptake of HIV screening increased greatly in nine months, and all people living with HIV diagnosed with hypertension were retained in hypertension care services at three and six months after enrollment—that 100 percent continuity in care was fantastic and I think speaks to the fact that people with HIV were also able to receive hypertension care services while they were receiving their treatment, since it wasn’t another stop that they had to make at the clinic.
In Vietnam, through our key population-led “one stop shop” primary health care clinics, more than 3,000 key population clients were able to access a holistic package of essential health services in just four months, with many coming to these clinics seeking HIV prevention or testing services, but then also accessing viral hepatitis services or STI screening and treatment or mental health or drug addiction counseling through that single entry point of HIV prevention and testing.
And then, in the DRC, through our electronic client service quality feedback process, one of the key issues that came up from clients was the long wait times for HIV clinical care appointments. So after speaking with clients and making some adjustments to our delivery model, which included using peer and lay workers to prepare client files before appointments and also having them support triage, our facilities were able to reduce wait times from an average of 14 minutes to five minutes, leading to an increase in client satisfaction with wait times, with 99% of clients reporting wait times to be acceptable or excellent to them after just four months. And so, just being able to shorten that wait time so that clients don't have to wait for a long time at the health facility just to pick up a treatment refill was extremely important to our clients, and that's not something that would have necessarily come out if we didn't have this process for gathering client feedback.
Jessica Bard: What would you say are the challenges of implementing this integrated person-centered HIV primary care?
Davina Canagasabey: Some of the main challenges that really come to my mind, and this is speaking from more of a health systems perspective, is really thinking through how we can create an environment that enables us to advance integrated person-centered primary health care. Two key components of that relate to how integrated models are financed, as well as ensuring that national policy frameworks provide that normative grounding to support service integration. So, on the financing side, much of how health care delivery is financed by large donors is very siloed around specific health and disease areas. And that leads to service delivery models that are really built around delivering high-quality services focused on the specific disease, such as HIV, malaria, tuberculosis, or sexual and reproductive health, but doesn't allow as much room or as funding to also focus on some of the co- or multi-comorbidities that play into person's overall wellbeing.
So, there's a challenge here in rethinking how health care is financed, and I think that means having the global community and funders needing to shift towards more focused funding on health system strengthening. But in the interim, a solution that we've leveraged to promote person-centered care is using a disease service delivery platform; for example, our HIV platform and bringing in other sources of funding or donated products and co-creating with clients models that integrate other services. And I spoke to those earlier with how we've integrated hypertension into HIV services in Kenya as well as the holistic package of services that we provide through our “one stop shop clinics” in Vietnam.
And then on the policy side, something that's really critical is ensuring that national guidelines speak to service integration and provide that grounding for collaboration between various ministries that oversee health care services. And that was one of the key lessons coming out of the work that we did in western Kenya with HIV and hypertension integration—the Kenyan national guidelines provided for and called for more focused integration of hypertension into HIV services, and that was critical in bringing all government stakeholders around the table to really think through the model and get their buy-in as part of rolling out the model. So, the finance side and the policy side are both critical pieces in making sure that there is a platform that integrated person-centered services can be built upon and then, most critically, sustained.
And then, the final piece and challenge is, and one that's been talked about quite a bit in the health care delivery space, is also financing community health workers. Especially as we move towards service differentiation and models of health care delivery that are outside of the clinic, it's really community health workers, lay providers, and peer educators that bear the brunt of delivering those health care services and very often are not as well compensated as the clinician. So that's another aspect when you're thinking about financing is to really think about how we can build up these community delivery systems and make sure those are resourced so that they are able to be more sustainable.
Jessica Bard: Yeah. You mentioned financing and policy and you mentioned some ways that these challenges can be overcome. Do you have anything else to add to that? Any other ways that these challenges can be overcome?
Davina Canagasabey: Yeah on the financing side I spoke to and how—in the interim while the discussions are happening around how we really fund health systems and thinking through ways to make health systems work for the people that they support—it's really using a bricolage approach and seeing what other funding sources are there that we can build into existing health care delivery platforms, so that we're able to provide that one-stop integrated model of services.
On the policy side, WHO has put out guidelines around person-centered care, how we meaningfully integrate that into service delivery, and what that looks like. So using these guidelines to engage with government stakeholders and counterparts to ensure that those are reflected in national guidelines and then detail out a timeline and a plan for implementing and advancing some of those models is also that critical second piece in making sure that once it's there in [global] policy, we can then take that into action. And then really pulling on advocates and activists, especially at the community-level, to hold government counterparts responsible for ensuring that these policies that call for integrated primary health care are put into practice is also another critical piece.
Jessica Bard: What would you say is next for research on this topic?
Davina Canagasabey: As I mentioned, and especially with COVID-19, now is really the moment where you're seeing a lot of these more integrated models being piloted. The next few years is a critical moment and opportunity for us to really think and put the examples, proof points, and case studies [on models] being implemented right now out there, both in research as well as the normative guidelines, to show that integrated person-centered care is feasible; it's financially viable and cost effective; and can be sustainably done. I foresee that coming up in the next few years—there's a lot of momentum, especially as we get towards 2030 and the Sustainable Development Goals, in really rethinking how financing is done for health care, and how do we really finance primary health care services and integrated service delivery while shifting away from these more siloed sources of financing. One way to do that is being able to have those case studies and proof points out in research and literature that we're able to point to in discussions around financing.
Jessica Bard: And lastly, what are the overall take-home messages from our conversation today?
Davina Canagasabey: At the end of the day, person-centered care is really about people. And so, it's about the communities and the clients that health care services are being provided for, and for me that was the biggest and most important call to action coming out of AIDS 2022—how do we meaningfully include clients and communities into all aspects of health care programming, from research and design to implementation and monitoring?
I keep thinking back to a conference session on quality in health care where Solange Baptiste so succinctly and eloquently described what community-led monitoring and community inclusion and programming is.
She described it as, specifically community data, is data that is collected by,, owned by, and is used to improve an issue that has been identified as important to communities. And so, you're really seeing just within that how communities and clients are reflected across that entire programming spectrum. For me, as long as we as health care providers and implementers and managers actively work to ensure that clients are involved in and lead the design, delivery and monitoring of health care services, then we're well on our way to ensuring that health care services we are delivering and supporting are person-centered and help people not just survive, but really, truly thrive.
Jessica Bard: Well Davina, thank you so much for joining us on the podcast today. Is there anything else that you'd like to add?
Davina Canagasabey: No, I just wanted to thank you for the opportunity to be able to share out what we can practically do to advance person-centered health care and I think there's a lot of exciting prospects in this area going forward.