1. Susan Adamchak, Heidi Reynolds, Barbara Janowitz, Thomas Grey, Emily Keyes October 21, 2008 FP and HIV/AIDS Integration: Findings from 5 Countries

2. 2 Big Questions  Is there a need to integrate FP and HIV programs to provide combined services?  How well is that need being met?

3. 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

4. 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”

5. Distribution of Assessment Participants EthiopiaKenyaRwandaS. AfricaUganda Programs 26624 Clinics 1431261122 Managers 1443221121 Providers 1791612857 Clients 219592499210353

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

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

8. 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?

9. Client Needs

10. Site Readiness

11. Provider Prep

12. Implications

13. 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

14. Family Planning in Care and Treatment (C&Tx)

15. Kenya: Client Characteristics (%) C&Tx (n=107) Age 18-24 9 Married60 No living children5 Not sexually active25

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

17. Care and Treatment Client Modern Method Mix

18. 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.

19. 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

20. Kenya (n=13) Rwanda (n=11) Had any FP training6218 FP flip chart available Check list that includes FP 54 46 64 Meet with supervisor weekly791 Care and Treatment Provider Readiness (%)

21. Kenya (n=13) Rwanda (n=11) Methods not appropriate for HIV+ women Pills Injectable IUCD Implants 15 16 8 45 0 36 0 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 (%)

22. 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 62100 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 (%)

23. 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.

24. Family Planning in Counseling and Testing (CT)

25. Kenya: Client Characteristics (%) C&Tx (n=107) CT (n=115) Age 18-24 949 Married6040 No living children544 Not sexually active259

26. CT Client Current Need for Contraception

27. CT Client Method Mix

28. Inconsistent condom use among CT Clients 44% of Ugandan women in CT who use condoms as contraception report consistent use.

29. 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 4668368275 Stock outs of injectables 21265033 Has posters about FP 314520599 Client forms record FP 3128148275

30. CT Provider Integration Readiness (%) Ethiopia (n=11) Kenya (n=37) Rwanda (n=15) S. Africa (n=15) Uganda (n=15) Had any FP training 3657364776 FP flip chart available Checklist that includes FP 9090 41 49 44 60 47 33 83 54 Meet with supervisor weekly 8251844756

31. 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 55 45 36 27 38 30 19 11 32 16 40 12 7 13 0 16 20 12 8 Condoms are only method HIV+ women should use (agree) 7330244036 CT Provider Attitudes about HIV+ Women (%)

32. EthiopiaKenyaRwandaSAUganda Provider reports talked to CT client today about FP 2738485332 Client reports provider discussed FP today 2543295539 Provider reports referred CT client for FP in last week 1854686056 Client reports provider referred for FP today 252244 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

33. 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.

34. HIV Services in Family Planning (FP)

35. Kenya: Client Characteristics (%) C&Tx (n=107) CT (n=115) FP (n=370) Age 18-24 94934 Married604089 No living children5442 Not sexually active2599

36. FP Clients Potential Risk of Exposure to HIV

37. FP Client Current Contraceptive Method Mix

38. 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 75965010076 Stock outs of HIV kits 43129810 Has posters of CT 3850192755 Client forms record HIV services 2537144541

39. FP Provider Integration Readiness (%) Kenya (n=41) Rwanda (n=25) S. Africa (n=12) Uganda (n=25) Had any HIV training 93767584 CT counseling guide Check list that includes HIV test 44 39 28 32 75 68 52 Meet with supervisor weekly32804248

40. Kenya (n=41) Rwanda (n=25) S. Africa (n=12) Uganda (n=25) Methods not appropriate for HIV+ women  Pills  Injectable  IUCD  Implants 22 10 29 7 44 12 20 8 17 8 0 24 12 28 4 Condom is only method HIV+ women should use (agree) 7245036 Worried about IUCD insertion in HIV+ women (agree, DK) 29525068 FP Providers’ Attitudes about HIV+ Women (%)

41. Kenya (n=41) Rwanda (n=25) S. Africa (n=12) Uganda (n=25) HIV counseling topics HIV transmission61764280 HIV risk assessment44605864 HIV testing49523356 Messages for HIV+ women Do not get pregnant27601744 Use condoms59647556 FP Providers Communication (%)

42. Kenya (n=41) Rwanda (n=25) Uganda (n=25) Provider reports offering HIV services 495675 Client reports discussing HIV test165425 Provider reports referring client for HIV service in last week 355264 Client reports receiving referral for HIV test today 71612 Providers: Kenya = 41, Rwanda=25,Uganda=25 Clients: Kenya= 370, Rwanda=246, Uganda=115 FP Providers and Clients: Reports of HIV Counseling and Referrals (%)

43. 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.

44. 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.

45. 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.

46. 2 Big Questions  Is there a need to integrate FP and HIV programs to provide combined services?  How well is that need being met?

47. 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.