Susan Adamchak, Heidi Reynolds,
Barbara Janowitz, Thomas Grey, Emily Keyes
October 21, 2008
FP and HIV/AIDS Integration: Findings from 5 Countries
2 Big Questions
Is there a need to integrate FP and HIV programs to provide combined services?
How well is that need being met?
Models and Countries Selected
Models with high potential for public health impact
– FP in CT and FP in C&Tx
• Increase access to FP
• Decrease infant HIV infections
– HIV services in FP
• Increase knowledge of HIV status for decision making and access to C&Tx
Countries with active integration efforts
– Ethiopia, Kenya, Rwanda, South Africa & Uganda
Inclusion Criteria and Number of Programs by Country
Programs were included if they:
• Had a specific integration strategy
• Had been functional for a minimum of 3 months
• Operated in a minimum of 3 sites
Countries and programs• Ethiopia: 2• Kenya: 6• Rwanda: 6• South Africa: 3• Uganda: 4
Up to 6 facilities per program determined by program managers to be “high performing”
Distribution of Assessment Participants
Ethiopia Kenya Rwanda S. Africa Uganda
Programs 2 6 6 2 4
Clinics 14 31 26 11 22
Managers 14 43 22 11 21
Providers 17 91 61 28 57
Clients 219 592 499 210 353
Policies and Guidelines Linked to Program DevelopmentClinic Readiness
Provider Preparation
Provider Attitudes
Services Reported Delivered
Services Reported Received
MonitorEvaluateImprove
Policies and Guidelines Linked to Program DevelopmentClinic Readiness
Provider Preparation
Provider Attitudes
Services ReportedDelivered
Services ReportedReceived
MonitorEvaluateImprove
ClientDemand
The Foundation: How are policies linked to programs?
Each of the 5 countries have national policies and guidelines for various aspects of FP and HIV service delivery. Some mention integrated services. Few have explicit guidance to operationalize integration.
So….
• Who are the drivers of integration?
• Where are the resources controlled?
• What are lines of authority responsible for operationalizion?
• How are policies translated into action?
Client Needs
Site Readiness
Provider Prep
Implications
Roadmap of the presentation
• For each model of service (FP in C&Tx, FP in CT, and HIV in FP) we will:– Review clients’ characteristics and need for services– Consider indicators of clinic readiness to provide integrated
services– Assess provider readiness to offer integrated services– Compare provider reports of services offered with client
reports of services received
Family Planning in Care and Treatment
(C&Tx)
Kenya: Client Characteristics (%)
C&Tx(n=107)
Age 18-24
9
Married 60
No living children 5
Not sexually active 25
C&Tx Clients’ Current Need for Contraception (%)
0%
20%
40%
60%
80%
100%
Kenya (n=107)
Rwanda (n=68)
Uganda (n=91)
Unmet need (not usingFP, using traditional FP,unintended pregnancy)Met need (usingmodern method)
No need (intendedpregnancy, not sexuallyactive, want pregnancy)
Care and Treatment Client Modern Method Mix
0%
20%
40%
60%
80%
100%
Kenya (n=44)
Rwanda(n=31)
Uganda(n=36)
Condoms
Pills
Injectable
LAPM
Dual method
Inconsistent condom use among C&Tx Clients
• 83% of Kenyan women in C&Tx who use condoms as contraception report consistent use.
• 64% of Ugandan women in C&Tx who use condoms as contraception report consistent use.
Care and Treatment Clinic Integration Readiness (%)
Kenya(n=42)
Rwanda(n=22)
Same provider offers multiple services
77 64
Stock outs of injectables 26 5
Has posters about FP 40 23
Client forms record FP 61 64
Kenya(n=13)
Rwanda(n=11)
Had any FP training 62 18
FP flip chart available Check list that includes FP
5446
6464
Meet with supervisor weekly 7 91
Care and Treatment Provider Readiness (%)
Kenya(n=13)
Rwanda(n=11)
Methods not appropriate for HIV+ womenPillsInjectableIUCDImplants
1515168
450
360
Condom is only method HIV+ women should use (agree)
0 0
Worried about IUCD insertion in HIV+ women (agree, DK)
23 36
C&Tx Providers’ Attitudes about HIV+ Women and FP (%)
Kenya Rwanda
Provider reported they talked to C&Tx client today about FP
38 91
Clients reported providers asked about FP today
17 32
Provider reported they referred C&Tx client for FP in last week
62 100
Client reported provider referred for FP today
10 6
Providers: Kenya = 13, Rwanda = 11Clients: Kenya = 107, Rwanda = 68
C&Tx Providers and Clients: Reports of FP Counseling and Referrals (%)
Implications for Care and Treatment Services
• There is unmet need among clients, which may be underestimated.
• Providers need updated information about medical eligibility.
• Only limited FP counseling being done based on both provider (Kenya) and client (Kenya, Rwanda) reports.
• Job aids and FP checklists are needed to facilitate counseling.
Family Planning in Counseling and Testing (CT)
Kenya: Client Characteristics (%)
C&Tx(n=107)
CT(n=115)
Age 18-24
9 49
Married 60 40
No living children 5 44
Not sexually active 25 9
CT Client Current Need for Contraception
0%
20%
40%
60%
80%
100%
Ethip[ia(n=204)
Kenya(n=115)
Rwanda(n=185)
S. Africa(n=54)
Uganda(n=155)
Unmet need (not usingFP, using traditional FP,unintended pregnancy)
Met need (usingmodern method)
No need (intendedpregnancy, not sexuallyactive, want pregnancy)
CT Client Method Mix
0%
20%
40%
60%
80%
100%
Ethiopia(n=32)
Kenya (n=47)
Rwanda (n=31)
S. Africa (n=14)
Uganda (n=58)
Condoms
Pills
Injectable
LAPM
Dual method
Inconsistent condom use among CT Clients
• 44% of Ugandan women in CT who use condoms as contraception report consistent use.
CT Clinic Integration Readiness (%)
Ethiopia (n=13)
Kenya(n=19)
Rwanda(n=22)
S. Africa(n=11)
Uganda(n=20)
Same provider offers multiple services
46 68 36 82 75
Stock outs of injectables
21 26 5 0 33
Has posters about FP 31 45 20 59 9
Client forms record FP 31 28 14 82 75
CT Provider Integration Readiness (%)
Ethiopia(n=11)
Kenya(n=37)
Rwanda(n=15)
S. Africa (n=15)
Uganda(n=15)
Had any FP training 36 57 36 47 76
FP flip chart available Checklist that includes FP
90
4149
4460
4733
8354
Meet with supervisor weekly
82 51 84 47 56
Ethiopia(n=11)
Kenya(n=37)
Rwanda(n=25)
S.Africa(n=15)
Uganda(n=25)
Methods not appropriate for HIV+ women Pills Injectable IUCD Implants
55453627
38301911
32164012
77
130
1620128
Condoms are only method HIV+ women should use (agree)
73 30 24 40 36
CT Provider Attitudes about HIV+ Women (%)
Ethiopia Kenya Rwanda SA Uganda
Provider reports talked to CT client today about FP
27 38 48 53 32
Client reports provider discussed FP today
25 43 29 55 39
Provider reports referred CT client for FP in last week
18 54 68 60 56
Client reports provider referred for FP today
2 5 2 24 4
CT Providers and Clients: Reports of FP Counseling and Referrals (%)
Providers: Ethiopia = 11, Kenya = 37, Rwanda = 25, SA=15, Uganda =24Clients: Ethiopia = 204, Kenya =115, Rwanda = 185, SA = 54, Uganda=155
Implications for CT Services
• CT clients have large unmet need for FP.
• While inconsistent condom use in indicative rather than conclusive, it is of concern given the high reliance on this method.
• Most CT providers lack training in FP.
• Few CT clients receive referrals for FP services.
HIV Services in Family Planning (FP)
Kenya: Client Characteristics (%)
C&Tx(n=107)
CT(n=115)
FP(n=370)
Age 18-24
9 49 34
Married 60 40 89
No living children 5 44 2
Not sexually active 25 9 9
0%
20%
40%
60%
80%
100%
Ethiopia* Kenya Rwanda SouthAfrica
Uganda**
More than one partner andinconsistent condom use
One partner and inconsistentcondom use
One partner and consistentcondom use
Not sexually active in last 3months
FP Clients Potential Risk of Exposure to HIV
FP Client Current Contraceptive Method Mix
0%
25%
50%
75%
100%
Ethiopia(n=66)
Kenya (n=268)
Rwanda (n=172)
S. Africa (n=71)
Uganda (n-53)
Condoms
Pills
Injectables
LAPM
Dual Methods
FP Clinic Integration Readiness (%)
Ethiopia (n=14)
Kenya(n=42)
Rwanda(n=22)
S. Africa(n=12)
Uganda(n=21)
Same provider offers multiple services
75 96 50 100 76
Stock outs of HIV kits 43 12 9 8 10
Has posters of CT 38 50 19 27 55
Client forms record HIV services
25 37 14 45 41
FP Provider Integration Readiness (%)
Kenya(n=41)
Rwanda(n=25)
S. Africa (n=12)
Uganda(n=25)
Had any HIV training 93 76 75 84
CT counseling guideCheck list that includes HIV test
4439
2832
7575
6852
Meet with supervisor weekly 32 80 42 48
Kenya(n=41)
Rwanda(n=25)
S. Africa(n=12)
Uganda(n=25)
Methods not appropriate for HIV+ women Pills Injectable IUCD Implants
2210297
4412208
17800
2412284
Condom is only method HIV+ women should use (agree)
7 24 50 36
Worried about IUCD insertion in HIV+ women (agree, DK)
29 52 50 68
FP Providers’ Attitudes about HIV+ Women (%)
Kenya(n=41)
Rwanda(n=25)
S. Africa(n=12)
Uganda(n=25)
HIV counseling topics
HIV transmission 61 76 42 80
HIV risk assessment 44 60 58 64
HIV testing 49 52 33 56
Messages for HIV+ women
Do not get pregnant 27 60 17 44
Use condoms 59 64 75 56
FP Providers Communication (%)
Kenya(n=41)
Rwanda(n=25)
Uganda(n=25)
Provider reports offering HIV services
49 56 75
Client reports discussing HIV test 16 54 25
Provider reports referring client for HIV service in last week
35 52 64
Client reports receiving referral for HIV test today
7 16 12
Providers: Kenya = 41, Rwanda=25,Uganda=25Clients: Kenya= 370, Rwanda=246, Uganda=115
FP Providers and Clients: Reports of HIV Counseling and Referrals (%)
Implications for FP Services
• Risk of HIV infection may be underestimated as partners’ behavior is unknown.
• Providers need medical eligibility updates.
• Providers talk with clients about HIV transmission, but don’t translate into risk assessment.
Monitor, Evaluate, Improve
• Inconsistent recording of client information across services
• Few good quality evaluations have occurred to date
• Use implications from the assessment, Cochrane review, and programmatic guidance to critically examine service delivery and develop creative solutions to improve quality of care.
Implications for all services
• Given that these are “high performing” sites, we find that clinics and providers are not well prepared to offer integrated services as we thought.
• Systems lack readiness to provide services, evidenced in lack of training, job aids, supervision.
• Providers are not ready to deliver integrated services: not trained, no job aids, not well supervised, poor attitudes about FP use by HIV+ women, especially in counseling and testing.
2 Big Questions
Is there a need to integrate FP and HIV programs to provide combined services?
How well is that need being met?
2 Big Answers
Yes, integrated FP and HIV services are warranted, based on client characteristics and need.
Current efforts are implemented at a rudimentary level, with much need for improvement before programs are brought to scale.
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