INTEGRATING SEXUAL REPRODUCTIVE HEALTH AND HIV/AIDS SERVICES

Demographic information Kenya Population – 30 million (census 99) MMR – 414/100,000 live births Infant Mortality Rate – 77/1,000 live births CPR – 39% TFR – 4.9 DHS figures, the Sentinel are a bit different

Demography cont. 56% of sexually assaulted are below 15yrs 50% of new HIV/AIDS infections occur among the youth (15-24 years) Regional disparity highest in Nyanza province (14%, Suba District 34%), lowest in Eastern (4%) and North Eastern (0%) provinces

CPR and TFR in Kenya for currently married women: 1978-2003 Family Planning Programme Started 1967 Strengthened Programme After incorporation of MCH/FP as integrated package in early ’80s Decline in the Programme in the late ‘90s due to several issues TFR is rising and CPR has stagnated at a low level of 39% Source: KDHS 1978-2003

Strong Gender Dimensions HIVPR among women and men 15-49 Years Source : KDHS 2003

Access to HIV/AIDS services Access to HIV testing has improved with the rapid expansion of VCT sites, currently 600 Access to ART, About 70,000 HIV Positive clients currently on ARVS against the 2OO,OOO eligible Currently 2080 PMTCT Sites HBC Care services, mainly through CBOs in different parts of the country

Integration What is integration?

Integration Definition “Offering two or more services at the same facility during the same operating hours, with the provider of one service actively encouraging clients to consider using the other services during the same visit in order to make those services more convenient and efficient”

FP/VCT Integration Definition: This is the incorporation of some or all of FP services into VCT services

Rationale for Integrating RH and HIV/AIDS Services HIV/AIDS and FP services target the same population of sexually active individuals common route of entry (sex): pregnancy & HIV have many similar desired outcomes HIV/AIDS and FP services target the same population of sexually active individuals Similar population and outcome: reproductive age and behavior change and safe sex practices Outcomes: Prevention of unwanted/unplanned pregnancies, STI/HIV transmission All these outcomes increase adult, maternal and childhood morbidity, mortality Increasing access to high quality FP services for HIV positive couples can be a very effective PMTCT program Due to vertical nature of HIV/AIDS programs, clients attending these services will not have access to other critical services without integration HIV/AIDS and FP programs have many similar desired outcomes Common outcomes include prevention of unwanted/unplanned pregnancies, HIV transmission, and STIs

Rationale for Integrating RH and HIV/AIDS Services cont… Rapid increase of resources for VCT/PMTCT programs in country due to global focus Good quality FP services have great potential for reducing MTCT of HIV/AIDS

Rationale Cont. HIV/AIDS services such as VCT attract a broader range of clients including men/youth who would benefit from FP services Reduce missed opportunities

Rationale Cont. In a context of limited resources like ours integration is a cost effective and sustainable approach and provides SYNERGY of actions

TYPES OF INTEGRATION OF HIV/ RH SERVICES At Facility level: FP in VCT CT in FP FP/STI in CCC FP in PMTCT Integrated Youth Friendly Services Comprehensive Post rape care services

Types Cont…. Community level: FP in HBC to PLWHA HIV in CBD program

Models of FP and HIV Integration Family Planning into VCT Counseling and Testing into FP

Levels of FP/VCT Integration Level 1:Condoms and pills LEVEL 11: Condoms, pills and injectables LEVEL 111: Condoms, pills, injectables and IUCD LEVEL IV: A full range of contraceptive methods

Levels of CT/FP Integration Level 1: (Referral) Includes the provision of information about CT to new and repeat FP clients with referral for those that are interested.

Levels of CT/FP Integration Level 2 (testing model) Includes on-site testing and post-test counselling of FP clients, rather than referring for CT

Components of the two programmes that can be integrated FP Services VCT Services  Risk assessment for FP/STI/HIV and referral  Counselling and IEC on FP/STI/HIV and referral  Screening for pregnancy and STIs and referral  Provision of non-clinical methods (condoms/pills)  Provision of clinical (but not surgical) methods–(injectables/IUCD)  Provision of surgical methods (Norplant, TL, Vasectomy)  Continuous counselling and follow up  Risk/Needs assessment for STI/HIV  IEC (information on all available services)  Pre-test Counselling on HIV test and test results  Testing for HIV  Post-test Counselling for behaviour change based on test results  Referral to post-test clubs and other appropriate services Source: MOH, Draft Strategy for the Integration of HIV-VCT and FP Services

Enabling factors for Integration Supportive policy environment, NHSSP 11 emphasis on delivery of integrated KEPH for all life-cycle cohorts

Enabling factors for Integration cont… MOH structure conducive; HIV/AIDS and FP exist as components of the country’s RH strategy Existence of the relevant technical committees both programmes report to the Department of Preventive and Promotive Health services

Enabling Factors cont. Existence of service provision policy and guidelines RH Policy, FP, VCT, ASRH and PMTCT , Medical management of sexual violence survivors guidelines includes both HIV guidelines etc RH Policy, VCT and PMTCT guidelines includes provision of FP services and Maternity care services

Integration requires A conducive policy environment Service protocols and training materials Strong health management systems Training for service providers and managers Moving from IEC to BCC Restructure institutions

Is Integration Worth the effort? FP-PMTCT -A recent USAID-funded analysis estimated that by the year 2007,32000 child infections,55,000 child deaths and 155,000 orphans could be prevented and 7000 mothers lives could be saved in 14 high HIV prevalence countries by adding family planning to PMTCT, thus doubling the effectiveness of PMTCT programs

CONTD The recent USAID-Funded analysis indicated that by adding Family planning to PMTCT, the cost of each HIV infection averted would be an estimated $660 as compared to $1300 per infection averted with PMTCT alone. Similarly ,the cost of each child death averted would be estimated$360, as compared to $2600 with PMTCT alone.[ Stover et al ]

CONTD Increasing use of contraceptives among women who do not want to get pregnant is at least as cost-efficient for PMTCT as increasing the coverage of prenatal care programs that offer nevirapine to HIV –infected women. [Reynolds ET AL] Preventing pregnancy in HIV-positive women or slightly decreasing Adult HIV prevalence are estimated to be as effective in reducing HIV-positive births as treating HIV mothers with Nevirapine[Sweat et al]

Opportunities for RH in the era of HIV/AIDS Resources for HIV/AIDS programs have been on the increase over the last few years Majority of those targeted by HIV/AIDS programs are people with RH needs

Opportunities for RH in the era of HIV/AIDS cont.. Expansion of HIV/AIDS programs, especially VCT and PMTCT provides an opportunity for linkage with RH Services

Opportunities for RH in the era of HIV/AIDS cont.. Linking RH to VCT services is a good strategy for increasing access to RH services for young, sexually active men and women.

PRIORITY AREAS FOR INTERGRATION Safe Motherhood and Neonatal Health ASRH Family Planning Post Rape care

Challenges of service provision Lack of appropriate knowledge by both providers and clients Negative attitudes amongst providers Shortage of staff Infection prevention practices Appropriate infrastructure