A comparison of patient flow in vertical vs. integrated HIV care models in Central Mozambique

Issues: The Mozambique Ministry of Health has been rapidly scaling-up national access to antiretroviral treatment (ART) since 2004. Evaluating the flow of patients through HIV care systems helps to identify bottlenecks and compare the efficiency of flow through different models of care.

Description: The initial phase of ART expansion in Mozambique followed a “vertical model”, where ART care was limited to clinics in larger urban centers with dedicated infrastructure and staff. HIV testing centers were often separate from these clinics necessitating referral and travel for clinical care. In order to expand ART access to a wider population, an “integrated model” was adopted in two central provinces in 2006 that placed ART care within smaller primary health care centers using existing infrastructure and staff. These sites often provided HIV testing so that travel to another facility was not necessary to continue in HIV care.

Lessons Learned: Under the “vertical model”, successful 30-day referral rates from HIV testing centers to off-site ART clinics averaged less than 60% from VCT centers and less than 30% for pMTCT centers, and only about 50% of eligible adult patients started ART. In sites with an “integrated model” approach, referral rates to HIV clinical services were frequently greater than 80% from on-site VCT centers and a higher proportion of eligible adult patients started ART.

Recommendations: While a vertical model may be appropriate to initially establish ART care in developing countries, centralized services lead to bottlenecks in care and poor population ART coverage. An integrated model allows for expansion to smaller health units with improvements in population coverage and drop-offs in care.