Key determinants of integrated health service delivery: lessons from a pilot study on HIV and non-communicable disease integration in Zambia

Integrating HIV and non-communicable disease (NCD) services is an essential strategy for improving health outcomes for people living with HIV (PLHIV) and NCDs, and may optimize resource utilization, use of patient time, and healthcare costs. This paper examines the determinants that motivate and shape the implementation process of NCD integration into HIV services, as well as the factors that influence successful integration. Nested in a pilot implementation trial, this study employed a qualitative case study design to collect data following the introduction of an integrated HIV/NCD intervention based on the WHO Package of Essential Non-communicable Disease (WHO PEN) interventions in two health facilities in Lusaka, Zambia. Data collection included four focus group discussions (two with professional non-physician healthcare workers (NPHWs) such as nurses and two with lay NPHWs, such as community healthcare workers, (CHWs)), eight in-depth interviews with PLHIV with comorbid cardiometabolic NCDs like hypertension, and one key informant interview with a clinician. The data were analysed using a thematic approach guided by the Consolidated Framework for Implementation Research (CFIR). The integration of NCD into HIV services improved patient satisfaction, increased NCD medication availability, and enhanced documentation of vital signs. However, limited staffing and facility space, pill burden, treatment prioritisation, work overload, and fear of mismanagement by CHWs hindered integration. These barriers could affect the sustainability of HIV/NCD service integration. Empowering NPHWs through training and providing NCD guidelines and job aids enabled task shifting and built confidence among healthcare providers. Task-sharing also increased coordination among NPHWs, especially nurses and CHWs. Strong local leadership, driven by facility-appointed champions, and regular monitoring and supervision by study mentors, facilitated integration. Effective HIV/NCD integration requires a multifaceted strategy that addresses human resource capacity development, basic NCD resources such as diagnostic testing equipment and medications, facility-level leadership and coordination among healthcare providers, and reorganisation of clinical workflows. Addressing these factors is crucial for optimising health outcomes for PLHIV with NCDs in Zambia and other similar settings.