Study of Family Planning and HIV Integrated Services in Five Countries

From Family Health International (FHI) with funding from the United States Agency for International Development (USAID), this study provides a "snapshot" of early family planning (FP)/HIV services integration efforts to inform future integration planning. It uses data from 5 countries: Rwanda, Uganda, Kenya, Ethiopia, and South Africa.

From the Executive Summary: "Specifically, the research examined the following:

• The percentage of women in need of FP services or HIV services
  
• The preparedness of clinics and service providers to provide services to meet need
  
• The level of integrated service provision offered by providers to clients
  
• The availability of service data used to monitor integration
  

Three models of integrated HIV and FP services included in this study are: family planning in counseling and HIV testing (FP-CT), family planning in HIV care and treatment services (FP-C&Tx), and HIV services (particularly counseling and testing) into family planning (HIV-FP)."

Through structured interviews, observation, in-depth interviews, and questionnaires, the study found:

• FP offered through CT services: Pregnant women and those already using contraception were often not reached for CT. Not all clinics were prepared to provide CT, but all could be prepared using available staff, through training, supervision, and use of job aids. The study found a need to improve provider knowledge and attitudes, particularly in asking CT clients about FP needs. Monitoring and evaluation (M&E) forms, though available for CT service providers, did not include indicators about referral for contraceptive services.
• FP offered in HIV care and treatment services: There was a need for FP provider training, for integration guidelines, and for job aids, such as samples of FP methods, flip charts, and method checklists. M&E forms did include FP service recording.
  
• HIV Services in FP: Though more prepared than other settings for providing HIV services, many FP clinics lacked posters and client brochures on HIV testing and services. Most providers had training and guidelines but lacked job aids. "Risk screening, discussion about modes of transmission and prevention, and HIV testing or referrals constitute the elements of integrated HIV services expected in FP service delivery points. Providers were generally more likely to discuss HIV transmission, a relatively neutral and factual subject, than risk behaviors and testing." M&E forms often did not record information on HIV services.

Issues of concern across all services include the following:

1. The unmet need for FP services is higher for CT clients because they are sexually active.
   
2. Weaknesses in the capacity of programmes to deliver the original service might compromise the ability to successfully introduce the new service. Government officials and programme managers must consider whether the base service is strong enough to absorb the newly integrated service. Resource needs and costs to improve the base service include resources for training, materials, infrastructure, and supervisory support.
   
3. Due to unequal periods of client visits, the challenge in introducing new services and attracting new clients is to balance the workload throughout the day. "Health officials need to implement practical strategies to modify work patterns and encourage clients to seek services throughout the day."
   
4. "Providers have insufficient training to offer integrated services, and do not have the job aids and supportive supervision needed to facilitate service delivery. Programs should calculate the cost of improving services and prioritize interventions for training, materials provision, and improved supervision."
   
5. "Training to ensure that providers are knowledgeable in key concepts related to their base service and the integrated service, particularly WHO medical eligibility criteria, is necessary. This goal can be met by introducing systematic pre-service and in-service training...." Of particular concern is the lack of information on condom use by HIV-negative women as a preventative.
   
6. FP screening efforts need to be increased in order to improve the frequency of provision of FP counseling and methods.
   
7. FP providers need to give a higher priority to talking with clients about the risks of HIV and to promoting testing.
   
8. Much M&E data collection does not currently measure integration of services. "Consensus must be reached on a few standard indicators of integration, and they should be added to health information systems in order to track the delivery and effect of integrated services."

The study concludes that much remains to be done to offer fully integrated services, taking into account the human and financial resources and local data available. "The characteristics of their clients and local availability of complementary health services should drive the particular components included in integrated services."

From FHI: For copies or questions, please contact Rose Wilcher or Tricia Petruney at publications@fhi.org Provide your name, title, organisation name, mailing address, and country, and indicate the number of copies you would like to receive.