Introduction
A strong case has been made for the potential benefits of integrating HIV/AIDS services and standard care services like reproductive health (RH), maternal health and child health services. Clients and facilities can benefit, through increased uptake, quality and efficiency of services.1–5 A scoping study in 2014 found that integration is supported in major international health6 policies, national strategies and donor guidance,7 yet knowledge gaps remained about actual levels and performance of integration in public sector facilities, or how provision can be improved and scaled up.3 The authors called for rigorous health systems research on the integration of HIV services with sexual and RH services in sub-Saharan Africa, to inform the delivery of integrated services.
Since then, research—including two journal supplements on integration of RH and HIV services—has widened the knowledge base (most recently, the Health Policy and Planning supplement, 2017). Integration at policy level remains surprisingly weak8 and the need for systems-wide approaches to scale-up of integrated delivery of care is clear.9–12 Studies assessing systems considerations for HIV-service integration show the need for collaboration and coordination between teams, staff and patients,12–14 and the need to invest in the health workforce, particularly to support agency of decision-making, team working and load sharing.11 12 14 15
Studies on service delivery have shown that integration of family planning (FP) into HIV services in Kenya can improve uptake of contraception (other than condoms)6 and can expand access to cervical cancer screening and prevention of mother-to-child HIV transmission (PMTCT).16 Integrating HIV testing into FP services can improve the WHO’s recommended testing rates for HIV among FP clients where women are exposed to well-integrated services.17 Integration of HIV and postnatal care (PNC) services was found to increase provider-initiated counselling and testing and uptake of long-acting FP methods among postpartum women.18 Integrated health services could also play a role in combatting intimate partner violence.19 20
What is still lacking in evidence is the extent to which public sector services are able to deliver integrated services in practice and which combinations of integrated services are provided on a regular basis. The Integra Initiative was designed to evaluate different models of integration in Kenya and Swaziland and collected data on thousands of client visits over a 2-year period to determine integration patterns.21 An analysis of the client flow data in eight government facilities in Swaziland found that provision of HIV and sexually transmitted infection (STI) services with maternal, reproductive and child healthcare occurred at all facilities, yet only a small minority of women received integrated services.22 Four of the facilities showed increases in overall integration between 2010 and 2012, driven primarily by increases in HIV counselling. Specifically, HIV counselling was most often integrated with child health services, antenatal care (ANC) or FP, and least often with PNC. Sharp declines in integration over time suggested that integration is difficult to sustain, and hindered by factors such as frequent staff rotation and vertical HIV/AIDS campaigns, for example, for testing or treatment.
This study analyses client flow data collected in 24 public sector facilities in Kenya between 2009 and 2012. We track whether clients received integrated services, and if so, in what combinations. We also describe how the receipt of integrated services differs over time and between facilities.