Integrating cervical cancer prevention with HIV/AIDS & FP Services Raveena Chowdhury Marie Stopes International Introduce myself and RHN Presentation is based on both a literature review and real life experience from the field Last 5 yrs, managed CCS&PT, consortium project to integrate CCS&PT into FP organisation Why integrate: Start with Anecdote from the field on typical woman found with cervical cancer- she has had 5 children, she had assisted care during delivery, she is HIV positive, has access to ART. However, has now got advanced cervical cancer and will die a painful death.

Integration The World Health Organization defines integrated service delivery as the management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system. Key characteristics of integration efforts a package of health interventions for a particular population group The aim of this for the target group to receive all appropriate interventions, ideally at a “one-stop shop”. from the client’s perspective is the opportunity to receive co-ordinated care Multi-purpose service delivery points

Justification for integration Benefits of Integration Places the client at the centre of service delivery, often leads to higher client satisfaction Improved efficiency and cost effective use of limited resources   Why integrate cervical cancer with HIV/FP services? FP and HIV programmes are natural entry points for cervical cancer prevention Both HPV and HIV are sexually transmitted Cervical cancer screenings are targeted towards women aged 30-49. These women also have FP needs. Women living with HIV are at increased risk of HPV co-infection This comes from the literature review that we carried out earlier this year

Examples of integration of CCS and HIV care services Countries: Zambia, Malawi and Botswana Type of integration: CCS & cryo were integrated into the existing National HIV/AIDS care and treatment services. Primary result: An increase in coverage of screening and treatment services for HIV positive women. Country: Zambia Type of Integration: integration of CCS&PT initially for HIV positive women and then all women in the target age group Result: an increased use of cervical cancer services by the general population Country: Ethiopia Type of Integration: Cervical cancer screening integrated with HIV care and treatment services Results: reported high service uptake in the pilot phase.

RHN Cervical Cancer Project A 5-year consortium project in Kenya, Nigeria, Tanzania & Uganda Objective: Integrate CCS with FP services Scope:1200 screening sites, 150 treatment sites established Centres Outreach Social franchising The RHN cervical cancer project was implemented in K,N,T&U The RHN consortium is led by MSI, and includes PSI, IPPF and SFH in Nigeria Objective: Integrate Scope, initially 1200 screening sites and 150 treatment sites New strategy: fewer screening sites (450) and a larger no of sites providing SVA (250)

Integration: Practical Considerations Service provider skills Client profile in static centres Client load on outreach Supervision of service providers Demand generation Key take away: adds several levels of complexity Needs careful management and supervision

RHN Results Cervical Cancer Screenings : 1.9 m Preventative therapy: 29,000 Treatment completion rate: 72% What we achieved: Our target aged group is 30-49, but in some countries we need to adhere to MoH guidelines and screen younger women. Treatment rate: Increased from 7% in the first quarter to over 80% this year. This is due to the implementation of SVA where there are no mechanisms for follow up. Prioritising funding for family planning Marie Stopes International

Marie Stopes International Lessons on Integration: Increased Demand for Services [Operations Research in Uganda] Implant & IUD Provision Before and After CCS&PT* Introduction of CCS&PT June 2013, Investment in training, demand generation and equipment What we learned: OR in Uganda (all partners, all channels) , Programme data from Tanzania Significant increase in uptake Implants and IUDs 77% (95% CI 71-84%) accessed other services in addition to CCS&PT. Just under 35% of all respondents in our exit interviews took up a LARC Aug 12- Apr 13 Aug 13- Apr 14 *Routine data from N=223 facilities (centres and social franchises) Marie Stopes International

Integration: Provider’s Perspective* [Operations Research in Uganda] Pros Cons Opportunity to learn new skills Increased responsibilities and workload Improved access to, demand for and use of SRH services, especially IUD and STI management. Increased complexity of service provision (e.g. clients requesting IUD & CCS) Improved efficiency in co-morbidity management Longer waiting times for clients Improved availability and standard of SRH services BENEFITS Integrating CCS&PT into services improved access to, demand for and use of SRH services, especially IUD and STI management. This occurred: Clients made aware of the other available services through contacts with the healthcare workers or other clients. During clinical procedures, esp pelvic exams, discover that the woman had other unsuspected infections CHALLENGES Perceived increased workload higher numbers of clients required to provide more complex care. Complexity was increased through more clients requesting cervical cancer screening and other services during their appointment, and that some of these services were time consuming, e.g. IUD insertion. Requests for combined services in one visit were difficult to plan for in advance. Marie Stopes International * Results from qualitative interviews with N=22 providers

Cross-selling CCS in Marie Stopes Tanzania [CYP increases] Marie Stopes International

Key Takeaways Overwhelmingly a positive strategy Integration ensures better community engagement and service uptake Requires robust MIS, supervision and Logistics systems High client flow resulting from integration must be carefully managed Important to be mindful of the target age-groups when defining integrated services Enabling global health policy environment Policy environment: UNAIDS released a comprehensive report on leveraging the synergies between HIV, HPV, and cervical cancer [8], and the 2016 UN General Assembly Political Declaration on HIV and AIDS called for integration of HIV and cervical cancer services [9]; The annual UNAIDS-led Global AIDS Monitoring report (GAM) decided to include two new indicators on HPV vaccination and cervical cancer screening for HIV-positive women beginning in 2017; Global Fund now allows countries to include cervical cancer activities in their requests Pink Ribbon Red Ribbon is working most closely with a group of countries that have identified unused money for 2017 that can be reprogrammed to address cervical cancer.

Thank you for your time. http://onlinelibrary.wiley.com/doi/10.1002/ijgo.12194/epdf 12 Marie Stopes International