Application of Process Mapping to catalyze integration of HIV services in cancer care

Introduction: The World Health Organization advocates for integrated health services in low- and middle-income countries, with special focus on care for non-communicable diseases within HIV care. HIV diagnosis and management with antiretroviral therapy (ART) are crucial components of whole-person care; in addition to improving overall survival, ART provides basic immunotherapy during cancer treatment. However, most cancer centers in Africa are not currently equipped to provide integrated HIV care. We conducted process mapping at referral cancer centers in Malawi, South Africa, Uganda, and Zimbabwe to identify mechanisms of integrating HIV care interventions within established cancer treatment processes. Methods Our research consortium identified multidisciplinary clinical and non-clinical staff important to care delivery in four referral cancer hospitals and proximal HIV clinics. Consortium-level researchers met separately in-person or virtually with each site team to conduct training. High-level and detailed levels process maps were developed in process mapping sessions with diverse staff at each site and flow diagrams created to identify sites of opportunity for care integration within cancer centers. Results Forty-five diverse clinical and non-clinical staff participated in the process across the 4 cancer centers. Several points were identified in which care integration was already occurring, including requesting HIV diagnostic and monitoring laboratory tests and clinical consideration of HIV in care plan development. While HIV care was already available in a clinic within the same hospital campus in Soweto and referral and results pathways were more integrated than the other 3 sites, none of the centers provided ART, and all lacked the capacity to provide HIV-specific counseling and management of ART or non-cancer HIV complications. Discussion We identified multiple points at which persons in HIV care were referred for cancer treatment and where people in cancer treatment not previously known to be living with HIV or not currently on ART could be referred for HIV treatment. Some services, while not integrated, had appropriate pathways in place; for others, we identified intervention points to improve care integration of HIV services into the cancer centers. While each cancer center has distinct features, we identified general service points that could be interrogated for HIV care integration opportunities.