Can delivery of ARV treatment at the primary level of health care replace completely the work of AIDS Centres? Experience of Dushanbe

According to the experts’ assessment, about 14,000 people in Tajikistan are currently living with HIV. At the same time, only about 9,000 people are receiving antiretroviral therapy (hereinafter ART). Additionally is important to highlight that the number of new HIV cases has increased by more than 20% over the last 10 years, and there is no expected trend towards a reduction in the rate of HIV spread. In such conditions, optimisation of ART plays a key role: as it not only prolongs the life of people with HIV, but also helps to shape the overall commitment of the country’s population to the diagnosis and treatment of socially significant diseases.

More than 6 years have passed in the capital city of Tajikistan since the start of decentralisation of ART services began. For the end user, this guarantees the possibility to receive care at the primary level of the health care system, which means more comfortable conditions regarding logistics, absence of drug shortages, and minimising the chances of stigma and discrimination. The experience of Dushanbe has confirmed that such a step can be taken, increasing both accessibility and efficiency of HIV treatment. 

Strengthening primary care is one of the fundamental principles of Universal Health Coverage. Continuing the review of the dynamics of changes in this direction in different EECA countries (in previous article  we described the experience on Kyrgyzstan), today we are talking about the experience of Tajikistan: how specialised services have been transformed in practice and what this has meant for patients and medical staff.

INTEGRATING HIV-ASSOCIATED SERVICES INTO PRIMARY CARE: HOW IS THIS HAPPENING IN OTHER COUNTRIES?

In the European Union countries there are almost no AIDS centres or other similar structures – all services are provided by primary health care facilities. Even among Central Asian countries, there is a big difference in attempts to provide ART at the primary care level.

According to ICAP (International Centre for AIDS Care and Treatment Programs), in Kazakhstan, a pilot of ART delivery through primary care was operating since 2008, but was closed in 2011. And in Kyrgyzstan, in 2021 about 90% of people living with HIV outside the capital city were receiving ART from a family doctor or infectious disease specialist. In sites supported by PEPFAR programmes, the percentage of people with suppressed viral load reached even 96%: both at the primary care level and in specialised facilities. And in Dushanbe, the majority of patients are satisfied with receiving HIV treatment services at primary care – and almost 98% of them have already achieved a suppressed viral load. 

WHY TO MOVE ARV THERAPY TO THE PRIMARY CARE LEVEL?

The idea of HIV programme integration is represented in UN Political Declaration on HIV of 2021, UNAIDS Strategy 2021-2025, WHO European plans for HIV, viral hepatitis and STIs 2022-2030, Global Fund strategy and others, as global experience indicates that such practices are feasible, cost-effective and efficient. In some cases, it is about embedding and coordinating with related programmes, such as sexual health. In other cases, the process may focus on integrated service delivery approaches to better cover a person’s health, social and other needs. One practical example of ‘integration’ is the embedding of services in primary care settings: polyclinics, family medicine centres, health centres, etc. 

THE DUSHANBE EXPERIENCE: WHAT HAS DECENTRALISATION OF SERVICES BROUGHT TO PEOPLE LIVING WITH HIV IN PRACTICE?

In Dushanbe, 1,146 people PHIV are receiving ART at 15 health centres (as they have been called “polyclinics” since recently). These include both children and adults. At the beginning of 2022, after 4 years since the implementation of decentralisation, the number of patients per facility varied between 40 and 163. At the same time, some people had never received ART at a specialised facility – they started receiving it at the health centre after the AIDS Centre confirmed the diagnosis.

The results of the effectiveness of therapy in Dushanbe are very good, as evidenced by data from the city and republican AIDS Centres, as well as scientific institutions of the country. In 4 years from the start of ART delivery in outpatient clinics, 97.6% of patients achieved a suppressed viral load. At the same time, one third of adults on therapy in primary care are from key populations. In the coming months, we expect to have data for 2022 with comparative analysis on demographic and other characteristics between people receiving ART in primary care and people in specialised facilities. 

WHAT DO THE GOVERNMENT’S SUBJECT MATTER EXPERTS RECOMMEND?

Dilshod Saygufronovich Sayburkhonov from the AIDS Prevention and Control Centre of Dushanbe together with colleagues from medical universities and AIDS centres recommends to scale up the decentralisation of ART implementation to primary health care in other major cities outside the capital city of Tajikistan.  Their 3 main arguments are following: 
А) it’s physically more convenient for clients,
B) requires less economic cost on the part of the patient, 
C) the primary care sector has greater capacity to diagnose and assist with other medical needs – which are relatively high among key populations and increase with age among all PLHIV. 
In addition to these reasons for integration, Mr Saiburkhonov also points to a gradual reduction in HIV-related stigma, as well as an increase in the proportion of newly detected people among labour migrants and the group being tested for HIV on clinical grounds. 

WHAT ACTIONS AND RESOURCES ARE NEEDED TO IMPLEMENT DECENTRALISATION OF HIV SERVICES?

Anna Deryabina, Director of ICAP in Eurasia, refers to the 5 most common challenges in integrating ART provision into primary care health care:
А) Lack of staff and infrastructure at primary level, 
B) Insufficient coordination between primary care facilities and AIDS centres,  
C) Fear on the part of the patients, 
D) limited knowledge and skills on HIV care in primary health care centres,
E) As well as high levels of stigma and discrimination against PLHIV and members of key populations.

As ICAP assisted Tajikistan (and Kyrgyzstan) to directly implement decentralisation – we asked the team to allocate a list of resources that are necessary for success in the process: 

• Clinical face-to-face and remote mentoring, as well as counselling by more experienced specialists.
• Training of staff both in the traditional format and remotely.
• Active involvement of nurses to support adherence to treatment at home.
• Use of data to improve service quality and financial incentives.
• Motivational payments for meeting designated ART coverage targets.
• Support for infrastructural improvements (e.g. purchase of furniture and necessary equipment).

HOW DID THE CLIENTS OF THE CLINICS THEMSELVES PERCEIVE THE CHANGES REGARDING ART?

In March 2024, Pulod Jamolov, head of the community organisation SPIN Plus, conducted a focus group with 6 men and 7 women who receive treatment at the so-called ARV clinics at urban health centres (so called from the recent “polyclinics”). He asked the group to share their personal experiences: the positives and negatives of receiving primary care-based services. In general, patients are satisfied with the integrated approach to care in Dushanbe. Positive aspects include:
➕ there are no queues,
➕ reasonable hours of operation,
➕ no side effects with the current TLD regimen,
➕ some infectious disease doctors are flexible (for example, they communicate not only face-to-face but also by phone),
➕ there are no drug interruptions,
➕ it takes less time to get to the health centres than to the city AIDS centre.

Only one patient had problems with physical convenience, but this is due to more systemic problems – mandatory linkage to a polyclinic at the address of registration.

WHAT IS IMPORTANT TO REALISE NEXT FOR A QUALITATIVE TRANSFORMATION OF THE RANGE OF HIV TREATMENT SERVICES?

The experience of PLHIV in Tajikistan points to 2 areas that need to be worked on. Firstly, it is access to a range of health services at ARV clinics, which are mandatory for HIV in addition to ART and monitoring tests. For example, patients in the clinics do not receive TB prophylactic treatment with isoniazid (there is no drug available), and there is also no regular examination by a physiatrist even when undergoing X-ray diagnostics (scans without the opinion of a specialised doctor). Meanwhile, in the city AIDS centre, patients not only receive TB care, but also have free access to additional medicines – antibiotics, vitamins, painkillers.

The second area of important follow-up changes are issues of ethics, medical confidentiality and stigma and increased professional knowledge: both on the part of the nursing staff and the neighbourhood. For example, one focus group participant said that a nurse had disclosed a diagnosis to neighbours. Also, some of the interviewees had negative experiences with some doctors at health centres: they either refused to provide or avoided providing services – after learning about HIV-positive status, they had no understanding of whether the treatment protocol for patients with HIV differs from that for patients without HIV.