1. Addressing the Family Planning Needs of People Living with HIV Betty Farrell, CNM, MPH Laura Subramanian, MS Grace Nagendi, MPhil Charles Ngobi, MD The ACQUIRE Project/ EngenderHealth EOP Concurrent Session September 17, 2008

2. Session Outline Integrating family planning (FP) and HIV services: definition, rationale and goals Applications of ACQUIRE’s FP-HIV integration approach Lessons learned and recommendations for FP-HIV integration programs

3. Quality client-provider interaction Leadership and champions fostered Supportive service policies promoted Human and financial resources allocated Leadership and champions fostered Supportive service policies promoted Human and financial resources allocated Service sites readied Staff performance improved Training, supervision, referral, and logistics systems strengthened Service sites readied Staff performance improved Training, supervision, referral, and logistics systems strengthened Accurate information shared Image of services enhanced Communities engaged Accurate information shared Image of services enhanced Communities engaged Fundamentals of Care Stakeholder Participation “More More More Services People Places” Services People Places” to in to in Data for Decision Making Increased knowledge + acceptability Increased availability Improved policy + program environment DemandSupply Advocacy Increased Access, Quality and Use Gender Equity

4. What is Integration? “An approach in which health care providers use opportunities to engage the client in addressing her/his broader health and social needs than those prompting the health encounter”

5. Why Integrate Family Planning with HIV Services? Increased availability of ART 16.5 million women of reproductive age living with HIV Family planning helps HIV-positive women: –avoid transmitting HIV to partners and children –prevent unintended pregnancies and avoid stress of pregnancy –plan desired pregnancies while minimizing HIV transmission risk HIV clinic = key service point for people living with HIV

6. Goals of FP-HIV Integration Comprehensive HIV services with family planning as an integral component of care –Family planning information specific to PLHIV –Risk assessment and behavior change strategies –Health monitoring –Counseling and provision of family planning commodities

7. Choosing a Level of FP Integration Level ALevel BLevel CLevel DLevel E Provides all of the following functions :  Provides FP information to clients accessing ART services  Performs risk/ intention assessment for pregnancy or spacing  Counsels on FP methods including ability to prevent HIV/STIs, dual protection, potential drug interactions and availability/access  Provides condoms, instructs/demonstrates correct use  Provides Emergency Contraceptive Pills*  Refers for methods not offered on site Provides all of Level A functions plus:  Provides oral contraceptives* with instructions for use and caution to adhere to daily, on-time pill taking  Counsels on potential drug interactions with oral contraceptives  Provides follow-up or refers for follow-up Provides all of Level B functions plus:  Provides injectable hormones with instructions for use and caution to return on schedule for re-injection  Counsels on potential drug interactions with injectable methods  Provides follow-up or refers for follow-up Provides all of Level C functions plus:  Provides IUD with instructions for use, including discussion of new evidence for safe use among HIV+ and those clinically well on ARVs  Provides implants with instructions for use  Provides follow-up or refers for follow-up Provides all of Level D functions plus:  Provides surgical contraceptive methods with instructions for self- care and provides follow-up * If facilities or programs providing Level A functions are not immediately prepared to provide oral contraceptives for ongoing uses, they may provide emergency contraceptive pills with referral for ongoing FP management. If the facility or program already provides oral contraceptives (Level B), it can also offer emergency contraceptive pills.

8. Identify/ refine level of integration that can be adopted Assess HIV program’s capacity to support FP** Build or strengthen systems to support new services Identify resources to support integration Phase in FP methods to expand mix within HIV program’s capacity STEP 1*STEP 2* STEP 3 STEP 4 STEP 5 * Steps 1 and 2 interchangeable depending on stakeholders’ pre-existing desires for level of integration ** Include orientation of stakeholders to staff tasks and system functions required to support levels of integration SYSTEMS Supervision Logistics Referral Training RESOURCES Partnerships Capacity ACQUIRE ’ s Approach to Integrating FP and HIV Services

9. ACQUIRE’s Integration Approach: Ghana FP-ART Pilot 2 government hospitals providing ART and FP ART Provider Trainings July-Dec 2005 FP-ART training curriculum developed and field-tested Jan/Feb 2006 32 providers trained to counsel on FP and provide pills and injectables Job Aids and IEC materials Contraceptive chart Counseling flow chart Client brochure Needs Assessment April-June 2005 PNA at 2 sites  action plan Evaluation May 2006 128 clients received FP methods Further attention needed to clients’ fertility desires and SD systems to support FP

10. Ghana FP-HIV Community Pilot: “Family Planning for Healthy Living” PLHIV support groups in 4 regions PE-Provider Partnerships FP providers attended monthly PLHIV support groups FP Provider Trainings July/August 2007 Stigma reduction training & CTU for 19 FP providers Job Aids and IEC Materials Contraceptive chart Sample FP method card Client brochure Peer Educator Trainings July/August 2007 75 members from 43 PLHIV support groups trained in FP messaging and referral Endline Assessment April/May 2008 Increased FP knowledge of PLHIV Expanded FP method mix Persisting barriers to FP uptake

11. Ghana: Peer educators, providers and clients as advocates for FP “I feel confident that I can prevent pregnancy until I am ready to have another child.” “I am taking care of my health.” Role models in the PLHIV community Advocates and partners for FP Peer educators and ProvidersSatisfied FP clients

12. ACQUIRE’s Integration Approach: Uganda TASO/Mbale Pilot TASO/Mbale ART center Community Outreach Sep-Dec 2006: 33 FP awareness sessions; 4 field officers and 2 volunteers trained in FP. April 2007: 12 community nurses trained in FP FP-ART Provider Trainings July-Sep 2006 23 trainers and 15 ART providers trained in FP (pills, injectables, ECP) 16 referral providers updated in FP Job Aids and IEC Materials Contraceptive chart, counseling flowchart, client brochure Needs Assessment March/April 2006 PNA  action plan 2 Stakeholder meetings FS/COPE® Trainings Feb 2007 Trainings for QI, staff performance and needs

13. TASO/Mbale: Stories of FP Advocates Community nurses talk about FP and address myths ART Providers support FP for PLHIV “Family planning is about people’s lives. I don’t want PLHIV to have unintended pregnancies.” HIV-positive mothers adopt FP “We now encourage others to come for family planning. We share the information we got from TASO. Now clients are learning to plan.”

14. Training Record- keeping Supervision Referral Logistics TASO/Mbale Pilot: Systems Challenges and Solutions Infrastructure

15. System Challenge: Training What Would You Do? TRAINING ChallengesInterventions Staff do not ask ART clients about their fertility desires or family planning needs

16. System Solution: Training What TASO Did TRAINING ChallengesInterventionsResults Staff do not ask ART clients about their fertility desires or family planning needs  Train staff about clients’ FP rights/needs via staff meetings, CME  Train staff to provide FP counseling and methods  Note clients’ FP preferences in chart  Observe providers discussing with clients their fertility desires  Develop IEC materials/job aids FP included in health talks FP counseling part of standard for care FP method provision carried out Content and quality of FP counseling observed

17. System Challenge: Supervision What Would You Do? SUPERVISION ChallengesInterventions Supervisors do not give timely or constructive feedback on staff performance in FP

18. System Solution: Supervision What TASO Did SUPERVISION ChallengesInterventionsResults Supervisors do not give timely or constructive feedback on staff performance in FP  FS training to practice communication skills and constructive feedback  COPE® training to strengthen capacity for monitoring quality of FP services  Performance checklists to support provision of objective feedback including FP practices Staff oriented to giving and receiving constructive feedback Supervisors providing timely, supportive feedback on FP activities with help of checklists Staff acknowledge more collaborative relationship with supervisors and support in problem-solving

19. TASO/Mbale Pilot: Evaluation ART providers respect RH rights and fertility desires of PLHIV PLHIV satisfied to receive FP services from ART providers Strengthened systems for training, supervision, logistics, recordkeeping, referral, etc. to support FP TASO/Mbale has provided FP to 605 clients (406 DMPA, 131 COC, and 68 referred for LAPMs)

20. Implementation differences: Ghana and Uganda pilots Ghana FP-ART pilotUganda FP-ART pilot  2 public sector sites  Multiple project partners with competing demands  3-month implementation  3-day update of trainers and 5-day training of ART and FP clinic providers  1 private sector site  1 dedicated project partner  12-month implementation  10-day provider training with practicum  FP referral staff updated  Attention to supervision, QI, logistics, recordkeeping  Community outreach

21. Uganda Positive Prevention Project Strengthening HIV Counselor training (SCOT) Project Curriculum Development 2007 Developed and field-tested FP modules for HIV counselor and peer educator training curriculums FP training 2007-2008 Orientation, training TA and post-training follow-up for 69 trainers from SCOT partners 359 providers trained in FP 213 community based peers trained from 9 PLHIV groups Job Aids and IEC Materials Contraceptive chart RH fact sheet Client brochure Stakeholder engagement 2006 PNA  action plan Identified 4 liaisons from MoH

22. Positive Prevention: Advocates for FP “People with HIV have the right to have children. They deserve choice, not chance.” Providers “Men need to seek family planning if they love their family.” Clients

23. Integrating FP and HIV Services: Lessons Learned FP-integrated HIV services are acceptable, feasible and effective Integration can be implemented at a variety of levels Holistic Supply-Demand-Advocacy approach contributes to successful sustained integrated services

24. ACQUIRE’s Integration Approach: Lessons Learned Supply: strengthening systems is key –Counseling/clinical training in FP with practicum, post-training follow-up, job aids/ IEC materials –FS/COPE® to strengthen overall systems and supervision –TA for using FP commodity supply system –Accurate, organized records to track provision of FP counseling and methods –Strong referral linkages –Assistance from volunteers to manage increased workload

25. ACQUIRE’s Integration Approach: Lessons Learned (continued) Demand: generate FP awareness and link HIV- positive clients with services –Disseminate FP info through awareness sessions and campaigns –Develop partnerships with peer educators and PLHIV groups Advocacy: gain buy-in to create/maintain a supportive environment for integration –Collaborate with stakeholders, including community –Orient donors to integration rationale and approach –Engage senior health personnel in integration process –Create fora for collaboration between FP and HIV leadership –Develop supportive guidelines and policies for integration

26. Recommendations for FP-HIV Integration 5-step integration approach with SDA elements and attention to systems strengthening –Engage multiple levels of facility and MoH staff –Consider LOE required for integration –Implement comprehensive FP training + follow-up package including addressing provider attitudes toward PLHIV –Update referral site staff to strengthen linkages –Partner with PLHIV communities as advocates for FP –Assess site capacity for expanding FP method mix Explore modifications to ACQUIRE integration approach

27. Acknowledgments USAID – Mary Ann Abeyta-Behnke, Sereen Thaddeus, Peter Wondergem TASO – Drs. K. Mugisha & C. Ngobi; G. Ochieng; Center staff Uganda MoH – Drs. Sentongo, Madra, Latigo, Esiru, Lukoda Mbale Regional Hospital FP Unit – the late Sr. Tunde ACQUIRE/Uganda – Dr. H. Kakande, G. Nagendi QHP – O. Aglah, Drs. P. Preko and E. Bonku, P. Ampofo, R. Killian OICI, CRS, SHARP and Ghana Health Service ACQUIRE/NY – A. Kaniauskene, N. Johri, N. Russell, J. Wickstrom Photo credits: N. Russell and TASO/Mbale

28. Featured Materials FP/HIV Integration Framework document (NY, June 2006) ACQUIRING Knowledge: TASO/Mbale Project Brief (NY, 2007) Evaluation of the TASO FP/ART Pilot (NY, August 2008) Job Aids from Ghana and Uganda (2005, 2006) Contraception for Women and Couples with HIV (FHI/ACQUIRE product collaboration) FP-HIV Integration Toolkit (FHI/ACQUIRE product collaboration) Positive Prevention Family Planning Module #9 (from the tool Positive Prevention Counseling: A training manual (Uganda, 2007) Integrating Family Planning with HIV Care and Treatment Services: A Training Curriculum for Providers & Counselors (Uganda, July 2006) Ghana Peer Educator training manual: Family Planning for People Living with HIV and AIDS, July 2007

29. Want to Know More? Visit the ACQUIRE Project website: www.acquireproject.org or email us at info- acquire@acquireproject.org To learn more about TASO and their activities, visit their website at www.tasouganda.org. For specific information on TASO/Mbale, visit http://www.tasouganda.org/mbl.php