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

Ethiopia Kenya Rwanda S. Africa Uganda

Programs 2 6 6 2 4

Clinics 14 31 26 11 22

Managers 14 43 22 11 21

Providers 17 91 61 28 57

Clients 219 592 499 210 353

Policies and Guidelines Linked to Program DevelopmentClinic Readiness

Provider Preparation

Provider Attitudes

Services Reported Delivered

Services Reported Received

MonitorEvaluateImprove

Policies and Guidelines Linked to Program DevelopmentClinic Readiness

Provider Preparation

Provider Attitudes

Services ReportedDelivered

Services ReportedReceived

MonitorEvaluateImprove

ClientDemand

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 18-24

9

Married 60

No living children 5

Not sexually active 25

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

0%

20%

40%

60%

80%

100%

Kenya (n=107)

Rwanda (n=68)

Uganda (n=91)

Unmet need (not usingFP, using traditional FP,unintended pregnancy)Met need (usingmodern method)

No need (intendedpregnancy, not sexuallyactive, want pregnancy)

Care and Treatment Client Modern Method Mix

0%

20%

40%

60%

80%

100%

Kenya (n=44)

Rwanda(n=31)

Uganda(n=36)

Condoms

Pills

Injectable

LAPM

Dual method

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

77 64

Stock outs of injectables 26 5

Has posters about FP 40 23

Client forms record FP 61 64

Kenya(n=13)

Rwanda(n=11)

Had any FP training 62 18

FP flip chart available Check list that includes FP

5446

6464

Meet with supervisor weekly 7 91

Care and Treatment Provider Readiness (%)

Kenya(n=13)

Rwanda(n=11)

Methods not appropriate for HIV+ womenPillsInjectableIUCDImplants

1515168

450

360

Condom is only method HIV+ women should use (agree)

0 0

Worried about IUCD insertion in HIV+ women (agree, DK)

23 36

C&Tx Providers’ Attitudes about HIV+ Women and FP (%)

Kenya Rwanda

Provider reported they talked to C&Tx client today about FP

38 91

Clients reported providers asked about FP today

17 32

Provider reported they referred C&Tx client for FP in last week

62 100

Client reported provider referred for FP today

10 6

Providers: Kenya = 13, Rwanda = 11Clients: 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 18-24

9 49

Married 60 40

No living children 5 44

Not sexually active 25 9

CT Client Current Need for Contraception

0%

20%

40%

60%

80%

100%

Ethip[ia(n=204)

Kenya(n=115)

Rwanda(n=185)

S. Africa(n=54)

Uganda(n=155)

Unmet need (not usingFP, using traditional FP,unintended pregnancy)

Met need (usingmodern method)

No need (intendedpregnancy, not sexuallyactive, want pregnancy)

CT Client Method Mix

0%

20%

40%

60%

80%

100%

Ethiopia(n=32)

Kenya (n=47)

Rwanda (n=31)

S. Africa (n=14)

Uganda (n=58)

Condoms

Pills

Injectable

LAPM

Dual method

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

46 68 36 82 75

Stock outs of injectables

21 26 5 0 33

Has posters about FP 31 45 20 59 9

Client forms record FP 31 28 14 82 75

CT Provider Integration Readiness (%)

Ethiopia(n=11)

Kenya(n=37)

Rwanda(n=15)

S. Africa (n=15)

Uganda(n=15)

Had any FP training 36 57 36 47 76

FP flip chart available Checklist that includes FP

90

4149

4460

4733

8354

Meet with supervisor weekly

82 51 84 47 56

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

55453627

38301911

32164012

77

130

1620128

Condoms are only method HIV+ women should use (agree)

73 30 24 40 36

CT Provider Attitudes about HIV+ Women (%)

Ethiopia Kenya Rwanda SA Uganda

Provider reports talked to CT client today about FP

27 38 48 53 32

Client reports provider discussed FP today

25 43 29 55 39

Provider reports referred CT client for FP in last week

18 54 68 60 56

Client reports provider referred for FP today

2 5 2 24 4

CT Providers and Clients: Reports of FP Counseling and Referrals (%)

Providers: Ethiopia = 11, Kenya = 37, Rwanda = 25, SA=15, Uganda =24Clients: 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 18-24

9 49 34

Married 60 40 89

No living children 5 44 2

Not sexually active 25 9 9

0%

20%

40%

60%

80%

100%

Ethiopia* Kenya Rwanda SouthAfrica

Uganda**

More than one partner andinconsistent condom use

One partner and inconsistentcondom use

One partner and consistentcondom use

Not sexually active in last 3months

FP Clients Potential Risk of Exposure to HIV

FP Client Current Contraceptive Method Mix

0%

25%

50%

75%

100%

Ethiopia(n=66)

Kenya (n=268)

Rwanda (n=172)

S. Africa (n=71)

Uganda (n-53)

Condoms

Pills

Injectables

LAPM

Dual Methods

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

75 96 50 100 76

Stock outs of HIV kits 43 12 9 8 10

Has posters of CT 38 50 19 27 55

Client forms record HIV services

25 37 14 45 41

FP Provider Integration Readiness (%)

Kenya(n=41)

Rwanda(n=25)

S. Africa (n=12)

Uganda(n=25)

Had any HIV training 93 76 75 84

CT counseling guideCheck list that includes HIV test

4439

2832

7575

6852

Meet with supervisor weekly 32 80 42 48

Kenya(n=41)

Rwanda(n=25)

S. Africa(n=12)

Uganda(n=25)

Methods not appropriate for HIV+ women Pills Injectable IUCD Implants

2210297

4412208

17800

2412284

Condom is only method HIV+ women should use (agree)

7 24 50 36

Worried about IUCD insertion in HIV+ women (agree, DK)

29 52 50 68

FP Providers’ Attitudes about HIV+ Women (%)

Kenya(n=41)

Rwanda(n=25)

S. Africa(n=12)

Uganda(n=25)

HIV counseling topics

HIV transmission 61 76 42 80

HIV risk assessment 44 60 58 64

HIV testing 49 52 33 56

Messages for HIV+ women

Do not get pregnant 27 60 17 44

Use condoms 59 64 75 56

FP Providers Communication (%)

Kenya(n=41)

Rwanda(n=25)

Uganda(n=25)

Provider reports offering HIV services

49 56 75

Client reports discussing HIV test 16 54 25

Provider reports referring client for HIV service in last week

35 52 64

Client reports receiving referral for HIV test today

7 16 12

Providers: Kenya = 41, Rwanda=25,Uganda=25Clients: 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.