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 EthiopiaKenyaRwandaS. AfricaUganda Programs Clinics Managers Providers Clients

Policies and Guidelines Linked to Program Development Clinic Readiness Provider Preparation Provider Attitudes Services Reported Delivered Services Reported Received Monitor Evaluate Improve

Policies and Guidelines Linked to Program Development Clinic Readiness Provider Preparation Provider Attitudes Services Reported Delivered Services Reported Received Monitor Evaluate Improve Client Demand

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 Married60 No living children5 Not sexually active25

C&Tx Clients’ Current Need for Contraception (%)

Care and Treatment Client Modern Method Mix

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 7764 Stock outs of injectables 265 Has posters about FP 4023 Client forms record FP 6164

Kenya (n=13) Rwanda (n=11) Had any FP training6218 FP flip chart available Check list that includes FP Meet with supervisor weekly791 Care and Treatment Provider Readiness (%)

Kenya (n=13) Rwanda (n=11) Methods not appropriate for HIV+ women Pills Injectable IUCD Implants Condom is only method HIV+ women should use (agree) 00 Worried about IUCD insertion in HIV+ women (agree, DK) 2336 C&Tx Providers’ Attitudes about HIV+ Women and FP (%)

KenyaRwanda Provider reported they talked to C&Tx client today about FP 3891 Clients reported providers asked about FP today 1732 Provider reported they referred C&Tx client for FP in last week Client reported provider referred for FP today 106 Providers: Kenya = 13, Rwanda = 11 Clients: 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 Married6040 No living children544 Not sexually active259

CT Client Current Need for Contraception

CT Client Method Mix

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 Stock outs of injectables Has posters about FP Client forms record FP

CT Provider Integration Readiness (%) Ethiopia (n=11) Kenya (n=37) Rwanda (n=15) S. Africa (n=15) Uganda (n=15) Had any FP training FP flip chart available Checklist that includes FP Meet with supervisor weekly

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 Condoms are only method HIV+ women should use (agree) CT Provider Attitudes about HIV+ Women (%)

EthiopiaKenyaRwandaSAUganda Provider reports talked to CT client today about FP Client reports provider discussed FP today Provider reports referred CT client for FP in last week Client reports provider referred for FP today CT Providers and Clients: Reports of FP Counseling and Referrals (%) Providers: Ethiopia = 11, Kenya = 37, Rwanda = 25, SA=15, Uganda =24 Clients: 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 Married No living children5442 Not sexually active2599

FP Clients Potential Risk of Exposure to HIV

FP Client Current Contraceptive Method Mix

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 Stock outs of HIV kits Has posters of CT Client forms record HIV services

FP Provider Integration Readiness (%) Kenya (n=41) Rwanda (n=25) S. Africa (n=12) Uganda (n=25) Had any HIV training CT counseling guide Check list that includes HIV test Meet with supervisor weekly

Kenya (n=41) Rwanda (n=25) S. Africa (n=12) Uganda (n=25) Methods not appropriate for HIV+ women  Pills  Injectable  IUCD  Implants Condom is only method HIV+ women should use (agree) Worried about IUCD insertion in HIV+ women (agree, DK) FP Providers’ Attitudes about HIV+ Women (%)

Kenya (n=41) Rwanda (n=25) S. Africa (n=12) Uganda (n=25) HIV counseling topics HIV transmission HIV risk assessment HIV testing Messages for HIV+ women Do not get pregnant Use condoms FP Providers Communication (%)

Kenya (n=41) Rwanda (n=25) Uganda (n=25) Provider reports offering HIV services Client reports discussing HIV test Provider reports referring client for HIV service in last week Client reports receiving referral for HIV test today Providers: Kenya = 41, Rwanda=25,Uganda=25 Clients: 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.