1. INTEGRATING Sexual & Reproductive Health and HIV Services OVERVIEW & REVIEW OF EVIDENCE Susannah Mayhew, Kathryn Church, Manuela Colombini Acknowledgements: Aagje Papineau-Salm, Lydia Mungherera, Ron MacInnis www.aids2010.org

2. Background

3. Varying definitions and understandings of integration Bundling of services e.g. IMCI (Becker et al., 1997) Functional vs organisational (WHO, 1996; Lush et al., 2001; Fleishchman, 2006) Active (provider-driven) vs responsive (client-driven) (Maharaj & Cleland, 2005) Provider-level vs facility-level integration (Fleishchman, 2006) Linkages (IPPF, WHO, UNFPA, etc.)  Are we integrating services, or are we simply adding in interventions?  Most importantly: what is being integrated with what?

4. SRH Care FP/RH services FP counselling (new and repeat users) EC provision Pregnancy testing Abortion services (where legal) Sexual health services STI/HIV prevention (condom promotion, dual protection) STI screening, diagnosis & treatment Pap smears Sexual health counselling MCH services ANC PNC Newborn and child health HIV Care HIV Prevention HIV testing and counselling Male circumcision STI treatment ART ART adherence counselling ART provision & monitoring Psychosocial support Positive prevention HIV care (pre ART) Screening for TB and other OIs Clinical staging (with CD4s) Psycho-social support OI Prophylaxis Clinical monitoring and restaging Positive prevention Refer out: TB care? Home- based care Specialised care for OIs Palliative Care Refer out: Delivery care Specialised STI treatment Infertility treatment Cervical cancer treatment PMTCT How do these fit into a PHC context? Service Reality

5. Literature overview

6. 1. Integration into SRH services Recent review on impact of integrating HIV & STI services into FP contexts (Church & Mayhew 2008): Mixed results on reaching men and youth Evidence of reducing stigma, but also concerns over privacy and confidentiality, and poor treatment of PLWH Many provider-related constraints identified, but also some preferences for integrated care RESEARCH GAPS: Weak evidence of impact on health outcomes Increased access to STI/HIV services BUT persistence of missed opportunities Difficulty in evaluating an integrated model; lack of controls & experimental designs Clients generally satisfied to received broader package of care Little evidence on cost effectiveness/cost benefits

7. 2. SRH needs of PLWH Multiple studies in sub-Saharan Africa have found PLWH (in either PMTCT, pre ART or on ART contexts) have high unmet needs for SRH care (Cooper et al, 2009; Heys et al 2009; Homsy et al 2009; Meyer et al, 2007; Stringer et al, 2009). Both supply- and demand-side factors influence demand for FP for PLWH High baseline unmet needs for family planning in many high prevalence settings “there was no planning whatsoever with any of them, it would happen by accident, and it’s like I woke up and I had 13 children and couldn’t do anything about it” (male client, ART clinic Swaziland, INTEGRA project) RESEARCH GAPS: Impact of promoting long-term FP methods in HIV settings; impact on condom use in PLWH: are we doing any harm & should dual protection be a priority?

8. Evidence from programmes on meeting SRH needs of PLWH Limited robust evidence on integration of SRH into HIV care contexts Studies suggest integration can increase FP counselling or uptake through: –Referral models: Chabikuli, 2009 (Nigeria); suggest integrating FP into HIV care –Onsite delivery: Bradley et al, 2008 (Ethiopia), ACQUIRE, 2008 (Uganda); King et al 1995 (Rwanda); Mark, 2007; Peck et al 2003 (Haiti) Mixed evidence on impact of integration: most studies record little or no impact on service uptake or health outcomes. Limited individual programme data on costs; much aggregate data on cost-effectiveness of FP as an HIV prevention intervention (Reynolds; Stover; Halperin)

9. What model of service delivery best meets SRH needs of PLWH? The Integra project Qualitative interviews with 15 providers and 22 clients at 4 HIV clinics HIV client exit survey (cross- sectional) with 611 HIV patients  Integrated clinics not better at meeting SRH needs  Integrated clinics not less stigmatising for HIV patients  HIV clients satisfied at both types of services; reasons for choice = proximity, provider friendliness, referred or recommended I haven’t told anyone [about my status] I only tell those that I find at the clinic when I go collect my pills, they talk about their situations and I also find myself sharing mine, but when it comes to my family, its still a challenge. (female client ) facility-level integrated site

10. 3. HIV Provider attitudes to integration Some providers see benefits to integration but many studies demonstrate common provider-level and health systems challenges Even where providers were trained on SRH, many still lack knowledge on dual protection, and on appropriate contraceptive choices for PLWH In some settings, providers fear HIV infection within clinics which has implications for offering more clinical FP methods. Providers often assign ‘blame’ to clients for poor FP uptake/continuity Useful strategies at provider level: provider/clinic participation in needs assessment before integration activities: opportunity to promote buy-in (ACQUIRE Project, 2008; Adamchak, 2007; Hayford, 2009)

11. 4. PMTCT services and a continuum of care for pregnant women with HIV Factors affecting uptake of and adherence to PMTCT services: Health systems factors; Socio-cultural factors (community level); Individual factors (of HIV+ mothers) Programmes with high rates of adherence offered: same-day test results and knowledge on ARV benefits for HIV prevention, supported partner involvement, and gave the nevirapine tablet at post-test counseling (at first visit) (Spensley et al, 2010; Nassali et al, 2009; Temmerman et al., 2003) Limited data on continuity of HIV/AIDS care to mothers and babies after delivery High drop out rates of PMTCT post-partum care (Bwirire et al, 2008; Chinkonde et al, 2008) Limited postpartum linkage of HIV mothers to HIV/AIDS care RESEARCH GAPS Implications of shift from single dose NVP to triple therapy Impact of PMTCT on mother + long-term survival rates

12. Programme and Research Challenges

13. Challenges in SRH-HIV integration: Programme experiences Definition: what do we mean by integrated services? Is a good referral system sufficient? Should 1 person do it all? What are ‘linkages’ ? Differing service configurations: differ from clinic to clinic, town to town, region to region, country to country : how to formulate policy advice? Health systems challenges: staffing shortages; health worker management systems (rotation); space constraints; logistics systems derived from vertical programmes; management & supervision; weak referral systems Cultural challenges: client expectations; provider attitudes and expectations; cultures of practice within medical systems (task-orientation and specialism culture); challenges shifting to client-centred care Technical challenges: skills training – how much can multi-purpose health workers be expected to learn or do? Donors and funding streams: national & international policies may necessarily still be disease-specific, but leads to separate training, skills specialisation, and programme activities in clinics

14. Research gaps Cost-effectiveness data on integrated vs stand-alone services Impact data on health outcomes Detailed assessments of process in intervention studies (WHY does integration work well in some settings and not others?) Impact of integration in reducing HIV-related stigma Is there a demand for integrated services, and how are clients currently accessing care? –What kinds of SRH services do PLWH want? Which types of services best meet their SRH needs? Integration into primary care: what are the implications? How to integrate HIV into other PHC services such as child welfare? Associations between pregnancy and HIV

15. Conceptual & Research Challenges ‘Integration’ has no consistent definition and there are as many variations as clinics Separating out treatment and prevention programmes: what different service configurations belong together? –VCT & dual protection in FP/ANC/PNC clinics –PMTCT in ANC clinics –ART and FP/SRH in HIV clinics Isolation of the integration effect from other programmatic activities/interventions virtually impossible Complex structure of health services & programmes inhibits measurement of specific models

16. IPPF, LSHTM and Population Council-Nairobi Assessing the benefits & costs of different models of integration of HIV and SRH services in Swaziland, Kenya and Malawi 2008-2012. Aims: (a) determine the benefits of different integrated models; (b) determine the impact of different integrated services on changes in HIV risk-behaviour; HIV related stigma and unintended pregnancies; (c) establish the efficiency & cost-effectiveness of using different operational models for delivering integrated services; (d) ensure utilization of research findings by policy and program decision makers through extensive stakeholder involvement Contact: Susannah.mayhew@lshtm.ac.uk or Atrossero@ippf.org