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HIV Outcomes Beyond Viral Suppression - Series Lancet HIV,
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December 01, 2019
Health service integration, although not a new strategy, is becoming relevant to increasingly more people living with HIV and their health-care providers, including primary care providers who are assuming a greater role in the long-term care of people with HIV. This interest is being driven in part by the emphasis that global health leaders have placed on integrated health services as a key to achieving universal health coverage and the Sustainable Development Goals.
Integration in the HIV field might entail expanding the range of services provided by existing HIV clinics, or alternately, primary health-care clinics or other types of clinical facilities might incorporate HIV care into their services. 24 Services that have been combined with HIV care in integrated clinics include services for sexual and reproductive health, sexually transmitted infections, cervical cancer screening, tuberculosis, diabetes, hypertension, chronic respiratory disease, mental health, substance use disorders, methadone maintenance, and hepatitis C treatment. 63, 64, 65, 66
The colocation of services is often a feature of integrated service delivery models, but is not an absolute requirement as effective referral, including the use of telemedicine, might be seen as a form of service integration.
1. Patient-reported outcomes to enhance person-centred
HIV care
Person-centred health care is central to achieving this goal: delivering services that patients need, can access, and which address the wider determinants of poor health. To ensure that people living with HIV enjoy healthy ageing with sustained viral suppression, clinicians and health systems must respond to the lifelong needs of people living with HIV, from diagnosis until the end of life.
In recognising the importance of looking at the health and wellbeing of people with HIV we are delighted to introduce a Series, HIV Outcomes Beyond Viral Suppression, published in The Lancet HIV, the first paper of which is included in this issue.
Another issue of growing importance is the effects of ageing with HIV. UNAIDS estimates that in 2018 the number of people aged 50 years or older living with HIV globally was 7·5 million, more than double the 3·3 million from a decade earlier. The inevitable and inexorable ageing of the HIV epidemic is beginning to create a whole new raft of challenges in providing care for people not only beset with the well known effects of time, but allied issues of stigma, long-term treatment, and life-long infection.
As the health-care needs of people living with HIV continue to move beyond specialist services, good quality care, free from stigma and discrimination, is essential. HIV status must not lead to exclusion from or denial of services. Achieving these aims will require changes across health and social care. Universal and adaptable approaches to measure progress towards this goal are needed to ensure everyone living with HIV can achieve health and wellbeing beyond viral suppression.
In 2019 it is not enough that people living with HIV are alive. They should also be living well.
2. People ageing with HIV face an uncertain future
As an increasing number of people age with HIV, social and health services could struggle to adapt to their complex needs. Talha Burki investigates
Data on self-perceived wellbeing must, by definition, be patient-reported, as opposed to originating from a clinician or from laboratory reports traditionally used in HIV reporting. One way of obtaining data is to survey patients via HIV clinics or national HIV cohorts that can be linked to surveillance, using methods to ensure that the sample is representative. 94, 95
Alternatively, questions on wellbeing and quality of life can be integrated into routine clinical care and captured by electronic patient records for routine reporting.
Community-based NGOs have a long history of providing HIV populations with peer support, which is likely to remain a prominent element of psychosocial wellbeing as people living with HIV age and encounter new challenges in relation to their health and other aspects of their lives. 100
Health system leadership, technical support, and funding are needed to foster a new era of NGO activity addressing this broader agenda.
3. Reorienting health systems to care for people with HIV beyond viral suppression
The effectiveness of antiretroviral therapy and its increasing availability globally means that millions of people living with HIV now have a much longer life expectancy. However, people living with HIV have disproportionately high incidence of major comorbidities and reduced health-related quality of life. Health systems must respond to this situation by pioneering care and service delivery models that promote wellness rather than mere survival. In this Series paper, we review evidence about the emerging challenges of the care of people with HIV beyond viral suppression and identify four priority areas for action: integrating HIV services and non-HIV services, reducing HIV-related discrimination in health-care settings, identifying indicators to monitor health systems' progress toward new goals, and catalysing new forms of civil society engagement in the more broadly focused HIV response that is now needed worldwide. Furthermore, in the context of an increasing burden of chronic diseases, we must consider the shift that is underway in the HIV field in relation to burgeoning policy and programmatic efforts to promote healthy ageing.
Finally, there is the question of how to measure health system progress toward a fourth 90 target meant to represent whatever is crucial for people living with HIV to attain in addition to viral suppression. The desired outcome is widely described as good HRQoL, but this does not necessarily mean that progress should be assessed solely in terms of the self-reported data that are collected with HRQoL instruments. In fact we originally conceived of the fourth 90 target as encompassing two domains: self-reported quality of life and comorbidities. 15 Guaraldi and colleagues 96 have suggested that health-adjusted life expectancy, frailty assessment, and measures of intrinsic capacity all might also contribute to providing a composite picture of healthy ageing in HIV populations. Further work is needed to develop consensus regarding the appropriate instruments for quantifying health system performance in regard to a new target and to pilot such instruments.

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