The Relationship Between Service Integration and Client Satisfaction: A Mixed Methods Case Study Within HIV Services in a High Prevalence Setting in Africa Kathryn Church, Ph.D., 1 Alison Wringe, Ph.D., 2 Phelele Fakudze, B.A., 3 Joshua Kikuvi, M.A., 1 Dudu Simelane, M.A., 3 Susannah H. Mayhew, Ph.D., 1 and the Integra Initiative * Abstract Integration of HIV with other primary health services, including sexual and reproductive health (SRH) care, is being widely promoted in sub-Saharan Africa. However, evidence on its benefits is equivocal, and some studies indicate client preferences for stand-alone HIV services. A comparative case study investigated the relationship between integration and client satisfaction across different models of care in Swaziland: two clinics integrated with SRH services, and two stand-alone HIV clinics. An exit survey (n = 602) measured satisfaction across model using logistic regression. In-depth interviews (n = 22), repeated three times, explored satisfaction and how it was influenced by integration or not. Satisfaction was highest at the fully stand-alone clinic; in multivariable models, clients there were more satisfied than partially integrated and partially stand-alone sites (adjusted odds ratio [aOR] 0.45, 95% confidence interval [CI] 0.25–0.81; and aOR 0.53, 95% CI 0.31–0.90, respectively); there was no difference between the fully integrated and fully stand-alone sites. Qualitative analysis suggested that satis- faction was constituted by eleven dimensions of care, including access to HIV medication, interpersonal care, efficiency, and confidentiality. Some dimensions were positively influenced by integration, while others were positively influenced by stand-alone care; some were not influenced by integration at all. Assumptions on the inherent value of integrated care were challenged in this high HIV prevalence setting, where stand-alone HIV care could be equally if not more satisfying to many clients. Those aiming to scale-up access to HIV care in this region may need to consider providing a variety of treatment models for clients with different health care needs. Introduction W hile HIV treatment programs have rapidly ex- panded in the African region over the past decade, services have often been delivered through vertical stand- alone models of care. 1 In response to criticisms that such models are often unsustainable and ineffective at meeting complex needs, a more sustainable public health approach has been promoted, in which antiretroviral therapy (ART) services are decentralized and integrated with existing pri- mary care structures. 2 The integration of HIV with sexual and reproductive health (SRH) services has been one area of policy focus, given the overlapping determinant sexual be- haviors in SRH and HIV outcomes, and has been promoted by key bilateral and multilateral health and development agencies. 3–5 Integrated SRH-HIV services are considered to have distinct advantages over stand-alone models, including greater efficiency and cost effectiveness, enhanced service access and increased utilization of separate service compo- nents, increased client satisfaction, reductions in service- related stigma through the delivery of care in more generalist health care settings, and potential improvements in health outcomes due to greater and higher quality service access. 4,6,7 Integration, to quote the Director of Joint United Nations Programme on HIV/AIDS (UNAIDS), is therefore ‘‘intui- tively appealing.’’ 8(p806) However, evidence on the impact of SRH-HIV integration on these outcomes is neither robust nor extensive. 9 One area that remains particularly understudied is the impact of service integration on client satisfaction. While integration may in- crease satisfaction by delivering a broader range of services to 1 Department of Global Health and Development, 2 Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom. 3 Family Life Association of Swaziland. *Members of the Integra Initiative are listed in the Acknowledgments. AIDS PATIENT CARE and STDs Volume 26, Number 11, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/apc.2012.0191 662