Meeting the sexual and reproductive health needs of HIV care and treatment clients in Swaziland: A comparative case study of integrated and stand-alone models of care

Background: The scale-up of HIV care and treatment services in sub-Saharan Africa has been accompanied by calls to address the broader health care needs of people living with HIV (PLWH), including their sexual and reproductive health (SRH) needs. The integration of HIV and SRH services has been proposed as an important means to achieve this. This thesis presents a comparative case study investigating health care structure, process and outcomes across four different models of HIV services in Swaziland: two integrated SRH-HIV clinics, one semi-specialist HIV outpatient unit at a hospital, and one stand-alone HIV clinic. Methods: Mixed methods were used including in-depth interviews with providers and clients, and an exit survey (N=611) with HIV clients. Qualitative data were analysed thematically. Quantitative data were compared across clinic models using chi-squared tests and analysis of variance. Selected outcomes were analysed with logistic regression modelling. Qualitative and quantitative data were triangulated and integrated in the presentation of results. Findings: A critical need for SRH services was identified across all four sites. Most clients relied on condoms alone for contraceptive protection, reflecting a service focus on reinfection rather than pregnancy risk. In multivariable analyses, integrated sites did perform better than the most stand-alone site in promoting access to family planning and pregnancy counselling, but were no better or worse in providing condoms, addressing unmet needs for family planning, achieving client satisfaction and reducing stigma. Provider capacity to move beyond HIV care was limited, even at integrated sites, by a range of contextual factors, including individual provider, interpersonal, infrastructural or systems, and institutional factors. In particular, heavy client loads and perceived needs for fast care inhibited exploration of clients’ holistic needs. Discussion & conclusions: While integrated services offer opportunities to promote service uptake, this capacity can only be translated into health outcomes when a range of contextual contingencies are addressed. Promoting more client-centred continuity care may help facilitate this. Widespread assumptions that integrated services are better than stand-alone models have been challenged by this study: a well-run stand-alone site can achieve positive outcomes, including impacts on family planning needs and client satisfaction. PLWH should be able to choose a model of care that suits their particular situation and needs best.