Strategic Considerations for Strengthening the Linkages between Family Planning and HIV/AIDS Policies, Programs, and Services

This document from the World Health Organization (WHO), Family Health International (FHI), and the United States Agency for International Development (USAID) reports on importance of linking reproductive health (RH), including family planning (FP), and HIV/AIDS policies, programmes, and services. As stated here, "Clients seeking HIV services and those seeking RH services share many common needs and concerns, and integrating services enables providers to efficiently and comprehensively address them. In addition, strong linkages help to ensure that the RH needs and aspirations of all people, including people living with HIV, are met.

...Integrating FP services into HIV prevention, treatment, and care services provides an opportunity to increase access to contraception among clients of HIV services who do not want to become pregnant, or to ensure a safe and healthy pregnancy and birth for those who wish to have a child. In countries where FP services are well used, integrating HIV services into the existing FP infrastructure is an opportunity to expand HIV prevention efforts and increase the use of care and treatment services. In both approaches, integration has the potential to draw on the strengths and resources of both programs in order to increase access to services, improve health outcomes for the mother and infant, and contribute to HIV and FP goals.... This document was developed in response to a growing call for strategic considerations on ways to strengthen the linkages between FP and HIV/AIDS policies, programs, and services."

The document reviews client benefits of integrating family planning and HIV/AIDS services and then gives programme planners, implementers, and managers (including Ministry of Health (MOH) officials and other country-level stakeholders) some strategic considerations for implementing or strengthening integrated FP/HIV services. These considerations attempt to answer four key questions and present corresponding activities that are described as central to systematically and strategically pursuing stronger linkages between FP and HIV policies, programmes, and services:

1. "What type of service integration, if any, is needed?
   
2. To what extent should services be integrated?
3. What steps are needed to establish and sustain high-quality integrated services?
   
4. What information is needed to measure program success and inform program or service delivery improvement, replication, or scale-up?"
   

The questions, key activities, and key considerations of integration are presented in chart format (on page 10 of the document), intended to guide readers through the process of finding answers to these questions that are appropriate to their countries' circumstances. It lists the benefits and challenges of integration of: FP into HIV services; FP into prevention of mother-to-child transmission (PMTCT) programmes; FP into HIV care, treatment, and support settings; HIV services into community-based FP programmes; and HIV Services into FP clinics. Where integration appears to be the right course of action, the document suggests how to identify action steps to establish or enhance integrated FP/HIV services. It also provides links to resources that will support the implementation of those action steps, such as facility assessment tools, training curricula, and job aids.

The document recommends that "a joint task force between the RH/FP, maternal and child health (MCH), and HIV departments within a country’s MOH be formed to lead the planning process. That process should begin with an analysis of what type of service integration is needed. These government leaders should invite other stakeholders, including policymakers, donors, providers, clients, PLHIV [people living with HIV], and community leaders to participate on the task force. Making informed decisions about the integration process could take time, but it should strengthen the overall quality and impact of health services." Challenges include the need for ensuring that HIV-positive women and couples are able to make informed reproductive decisions free of coercion and provider bias. A second challenge is the need to consider how the potential impact of integrated FP/HIV programs might be mitigated by prevailing gender norms. "For example, if integrating HIV counseling and testing into FP services helps more women learn their status, efforts should be made to ensure that these women are not at increased risk of gender-based violence for disclosing their status. Similarly, efforts to increase access to contraception through integration could have limited success if women do not feel empowered to initiate and use a method without their partners’ consent."

The extent of integration is discussed in light of existing services and resources. Cases of government MOH planning show that recommended combinations of counselling, contraceptives, testing, and referral through existing services must vary according to situational recommendations. "After decisions have been made at the national or regional level as to which type of integration to pursue, program planners, facility managers, and other stakeholders should assess their physical, human, financial, and technical capacity to add new services at the facility or community levels. Based on this analysis, planners can determine the extent to which they can integrate new services without compromising the quality of existing services." The document offers a list of FP services that can be integrated with HIV service settings and a list of HIV services that can be integrated into FP service settings, depending on whether the client's status is known or unknown. It includes a list of resource links to facilities assessment tools. Table 2 (on page 19 of the document) outlines policy and programmatic actions that are designed to enhance FP/HIV integration approaches. Overarching steps (details available in Table 2) include:

1. Creating policies and guidelines
   
2. Capacity training and task shifting
   
3. Facility staff sensitisation
   
4. Supportive supervision
   
5. Information, education, and communication (IEC), including:
   • Provide IEC materials on FP and HIV for clients and community-based groups and volunteers in order to increase interest in, knowledge about, and the availability of integrated services.
   • Use consistent messages about FP and HIV at all health-facility entry points, in community outreach activities, in providers’ messages to clients, and through the channels of mass media.

   
   

6. Establishing space
   
7. Record-keeping, information systems, measurement and evaluation (M&E)
   
8. Logistics
   
9. Referrals
   
10. Community-based activities including:
    • Actively engage community groups and representatives as partners in the integration process by identifying their needs for FP/HIV integrated services and soliciting their contributions to community programme design and outreach efforts to meet those needs.
    • Engage outreach workers, community-based distribution (CBD) agents, and other community leaders in discussions about potential biases against childbearing among HIV-positive women and couples.
    • Equip outreach workers to offer information on HIV prevention, provide referrals to HIV-testing services, counsel on all methods of FP, and provide select methods.
    • Organise activities to reach and educate adolescents about FP/RH and HIV, and link counselling and testing to school programmes and other appropriate programmes for adolescents.
    • Involve community health workers (CHWs) and outreach workers in community-based behaviour change communications activities  to maximise impact.
    • Link CHWs and all community outreach workers to the nearest health facility for supportive supervision, problem-solving, case management, supply distribution, and records management. Links to key resources for Technical Interventions are provided on page 22.

    
    

Additional strategic considerations are listed as: using a variety of entry points, such as waiting rooms, newborn consultations, well-child visits, etc.; presentation of points on healthy timing and spacing of pregnancy counselling; and presentation of points on breastfeeding and contraception for HIV-positive women.

Finally, the document discusses measurement of programme success for service delivery improvement, replication, and scale-up, including a list of key questions for investigation.