Using Facilitated Referrals to Integrate Family Planning Services into HIV Care and Treatment Clinics in Tanzania

Mackenzie S. Green, Mark A. Weaver, Thecla W. Kohi, Stella N. Mujaya, Christine Lasway, Gottlieb Mpangile, Joy Noel Baumgartner

Background

• 2006 FHI assessment found high levels of unmet need among sexually active ART clients

• 2008 MOHSW request to FHI to develop and test a facilitated referral model– Joint request from National AIDS Control Programme and

Reproductive and Child Health Section

• Facilitated referrals are enhanced referrals for additional services– Consist of specific actions to encourage completion of the

referral

Facilitated Referral Model

1. SCREEN

2. COUNSEL

3. REFER

4. RECORD

5. ACCOMPANY

6. ACCESS

7. MONITORFP

CTC

Screen clients to learn fertility intentions and current FP use

Provide minimal counselling on FP options or on safer pregnancy

Refer clients with need to FP clinic and Record referral

Accompany clients to FP clinic

Clients with referrals access FP services

Intervention Elements

• Service Delivery Guidelines

• Site Assessment Visit• Training

– 2 days for CTC staff– 3 day for FP staff– 1 day CTC & FP In-Charges

• Job Aids • Recording Codes• Supportive supervision

Intervention Facilities

• 12 intervention facilities– FHI-supported care and

treatment programs– Includes hospitals and

health centers

• Selected for:– High CTC client load– Co-location of CTCs with

FP clinics

Evaluation Study

• Quasi-experimental• Pre- and post-test• Cross-sectional

• CTC clients – Women, 18-45 years, WHO Stage I-III or CD4>100– Recruited at CTC; interviewed after all services

• CTC and FP providers, In-charges

Results

• CTC clients interviewed:– 323 at Baseline; 299 at Post-intervention

• Characteristics similar among Baseline & Post-intervention women– 3-4% currently pregnant– 35-40% would like another child– 70% on ARVs

FP Need Among Non-Pregnant CTC Clients at Baseline and Post-Intervention

8

12

43

33

49

55

0% 20% 40% 60% 80% 100%

Unmet Need Met Need No Need

Percent of Non-Pregnant CTC Clients

Post-Intervention

(n=291)

Baseline (n=309)

FP Methods Used by CTC Clients Sexually Active in Last 3 Months

Baseline (n=161)

Post (n=161)

% %Modern method use (non condom) 17 39

Pill 7 17Injection 7 16Implant 2 5Female sterilization 1 2IUD 1 1

Condom use 72 85Consistent 50 61Inconsistent 22 24

CTC Clients Sexually Active in Last 3 Months

FP Methods Used by CTC Clients Sexually Active in Last 3 Months

Baseline (n=161)

Post (n=161)

% %Dual-method use 12 31

Only modern method (non-condom) 6 8

Only condom use 60 54

No method 22 7

CTC Clients Sexually Active in Last 3 Months

Facilitated Referral Process Reported by CTC Clients at Baseline and Post-Intervention

0 10 20 30 40 50 60 70 80 90 100

Started FP/Got appt

Completed referral

Given referral slip

Referred to FP services

Told about FP available

Asked using FP now

Asked want pregnancy 1 yr

Asked sexually active

Post-Intervention (n=299) Baseline (n=323)

Percent CTC Clients

Future Planning

• Screen clients comprehensively• Target the right women for referrals• Take steps to minimize stigma• Ensure functioning referral system• Anticipate provider burden• Involve men

Summary

• Increase in reported screening, FP discussions, and provision of referrals

• Positive impact on FP uptake, particularly dual method use

• Feasible option for integrating services:– Facilities with co-located CTC and FP services– Locations with limited human or other resources– Utilize existing primary health system