Designing Comprehensive HIV and FP/RH Programmes

Saiqa Mullick, Population CouncilRose Wilcher, FHI

Megan Dunbar, Pangaea Global AIDS Foundation

International AIDS ConferenceJuly 2010

Family Planning & HIV

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Zambia

Unmet Need for Contraception, Married Women HIV/AIDS Prevalence (ages 15–49)

Need for FP among PLHIV

• Evidence of high levels of unintended pregnancies among HIV+ women, ranging from 51-91%– Desgrées du-Loû et al. 2002; Rochat et al. 2006; Suryavanshi et al.

2008; Homsy et al. 2009

• In absence of treatment, HIV+ women less likely to want children– Hoffman et al. 2008; Taulo et al. 2009; Yeatman 2009

• Like all women, HIV+ women have a right to determine timing and spacing of their children

4-Element PMTCT Strategy

Support for Support for mother and mother and

familyfamily

Prevention Prevention of trans-of trans-mission mission

from an HIV+ from an HIV+ woman to woman to her infanther infant

Prevention Prevention of of

unintended unintended pregnancies pregnancies

in HIV+ in HIV+ womenwomen

Prevention Prevention of HIV in of HIV in women, women,

especially especially young young womenwomen

Family planning and

effective use of contraceptives

Family planning and

effective use of contraceptives

Best-kept Secret in HIV Prevention

• Contraception for HIV+ women who do not wish to become pregnant…– Prevents more infants from becoming infected

than ART prophylaxis– Reduces future orphans– Is a cost-effective HIV prevention intervention

• However, FP interventions have been underutilized in the fight against HIV

Barriers to FP/HIV integration

• Separate funding streams; lack of resources for integration

• Parallel departments within MOH• Vertically-oriented policies, training

programs, service delivery systems; lack of infrastructure/capacity at facility level

• Provider biases against and preparedness to address RH needs of PLHIV

• Political resistance to FPSources: Petruney et al. 2010; Wilcher et al. 2008

New Policy Environment

• Obama Administration’s Global Health Initiative

• New PEPFAR field guidance and 5-year strategy

• Global Fund’s “Gender Equality” strategy

• Plus, at least 10 other international statements on SRH/HIV linkages

Programmatic Framework

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?

What type of integration?

• Lots of potential service configurations

• Consider direction of integration

• Epidemiological context important

To what extent?

• No one-size-fits-all model of integration

• Different levels of integration, ranging from referral-based models to one-stop shop

• Will vary depending on physical, human, financial, and technical capacity to add new services

What steps are needed?

• Range of interventions across different levels of the health system– Policies and guidelines– Capacity training and task shifting– Facility set-up and facility staff sensitization– Record-keeping, information systems– Commodity supply– Community involvement

Systematic review (Spaulding A et al; 2009)

• To examine the effectiveness, optimal circumstances, and best practices for strengthening linkages between FP and HIV services

• Systematic review of peer-reviewed articles and unpublished program reports

• Methods: Post intervention evaluation results from interventions linking FP and HIV (1990-2007)

Overall Findings

• Sixteen studies included (10 peer reviewed and 6 promising practices)

• Most studies reported generally positive or mixed results for key outcomes; no negative results reported

• Few studies reported on outcomes such as uptake of HIV testing, condom use, contraceptive use, quality of services or cost

• Categories of intervention:– FP to VCT clients– FP and VCT to MCH clients– FP to PLH– FP and HIV services provided by CHWs– VCT to FP clients– VCT and FP to women receiving PAC

Conclusion

• Interventions linking FP and HIV services were generally considered feasible and effective, though overall evaluation rigor was low

Illustrative examples from new unpublished data

Integrating HIV into FP services in South Africa

(Mullick S et al: Population Council, unpublished)

• High HIV prevalence – Pregnant women 28% (DOH, 2007)– Between 15 and 49 years 16.2% (DOH, 2005)– VCT rolled out in 2000

• PMTCT in 2001• ARVs in 2003• High rates of unwanted pregnancy 34% in women < 20

years, 35% women 40-44 years (DHS 2003)

Overall study objective

• The general aim of the study was to evaluate the effectiveness of an acceptable and feasible model of integrating HIV into FP services compared with standard practice.

 

Specific study objectives

• To evaluate a model of integrated services against standard FP services in terms of the following:

Study Outcomes:

• Dual protection – measured by condom use at last sex

• Testing for HIV in the last year• Quality of care outcomes: assessing HIV

and FP service provision by providers

• Cluster Randomized Trial (6 intervention and 6 comparison clinics in North West Province)

• Pre and post intervention cross sectional evaluation conducted at one year interval

• Target population: all FP clients over 16 years of age attending the selected study clinics

Study design

• Implemented at clinic (cluster) level • Family planning services were standardized

and strengthened through training providers in the “Balanced Counseling Strategy” (BCS plus) approach to family planning

• HIV/STI prevention, dual protection and C&T awareness information were integrated into FP services in line with South African protocols

Description of Interventions

Algorithm for BCS Plus

Balanced Counseling Strategy Plushttp://www.popcouncil.org/frontiers/bestpractices/BCSPlus_102008.html

Difference in mean quality of care scores at follow up: cluster

level      Intervention Comparison Mean diff LCI UCI

General FP History Taking (0-4) 2.23 1.03 1.20 -0.43 2.83

Client Provider Rapport (0-4) 2.89 2.41 0.48 -0.81 1.77

Number of FP Methods (0-7) 2.41 1.58 0.83 -1.21 2.86

STI/HIV History Taking (0-3) 1.37 0.33 1.05 -0.03 2.12

STI Information Score (0-4) 2.17 0.87 1.30 -0.21 2.81

DP and Condom Counselling (0-7) 3.02 1.61 1.41 -1.67 4.50

HIV Test Counselling (0-4) 1.93 1.01 0.92 -0.93 2.76

Total quality (0-33) 16.02 8.82 7.19 -4.59 18.98

Data source: Endline client provider observations

Follow up: Primary Behavioural outcomes % (N=1,264)

Mean across clustersRelative Risk

Confidence interval

P value Intervention Comparison Lower Upper

Tested for HIV in last year

54.1 (233/431)

36.6 (143/396) 1.48 1.13 1.94 0.015

Condom use at last sex

45.0(275/611)

37.5 (245/653) 1.20 0.93 1.54 0.138

Data source: Follow up client exit interviews

Summary• Strong evidence (p=0.015) that FP clients at

intervention clinics were more likely to have tested for HIV in past year (RR = 1.48)

• Also trend towards higher condom use at last sex (RR = 1.20) but not significant

• All quality of care scores were higher in intervention clinics, but substantial variation across clinics and these differences were not significant.

Discussion• This study is one of the few rigorously conducted studies

assessing the impact of integrated services on behavioral outcomes and the first study assessing impact on HIV testing in a FP population

• A high degree of variability was seen across clusters and this may have been responsible for lack of demonstration of statistical significance despite large differences observed between intervention and comparison sites.

• There are a number of factors outside of the scope of the evaluation that may be responsible for the variation.

• Post evaluation monitoring visits were conducted to provide some explanations for the variation in results observed.

Integrating FP into HIV care and treatment services in Kenya

(FHI, unpublished data)

• ADD IN SOME DATA ON KENYA CONTEXT

Overall study objective

• This study tested if an integrated FP and HIV care and treatment intervention can increase contraceptive use among female clients who are receiving HIV care and treatment services at Comprehensive Care Centres (CCCs) in Kenya.

Specific study objective

• The main objective of the operations research was to determine whether the use of modern methods of contraception increased among female CCC clients after an FP/CCC integration intervention.

• A secondary objective was to determine how providers’ and male clients’ FP knowledge, attitudes, and practices changed during the intervention.

Study design

• A group of female clients was interviewed both pre- and post-intervention.

• Separate groups of male and female clients and CCC providers were interviewed at the two time points.

• Interviewees were drawn from 16 facilities that represented a random sample stratified on the basis of province and facility size

Description of intervention

• Training providers to offer FP services to CCC clients

• Provision of FP counseling job aids to CCC providers, including FHI’s toolkit, Family Planning for HIV-Positive Women and Couples

Results

• Frequency of modern method use among female clients increased from 36 percent to 52 percent between baseline and follow-up.

• Condom use increased by 8 percent (to 21 percent).

• The use of modern methods other than condoms also increased by 8 percent

• (to 31 percent); this includes a 3 percent• increase in dual method use

Summary

• These increases were all statistically significant, and increases were significantly larger in Coast Province (which had a lower contraceptive prevalence at baseline) than in Rift Valley.

Discussion

• Contraceptive use increased significantly among a group of HIV-positive, female CCC clients in Kenya. But, the large number of CCCs in the implementation areas and the complex and heterogeneous nature of the intervention make it difficult to determine exactly which component of the intervention produced the successful effect.

Other opportunities/needs for FP/HIV integration

• Integration of emergency contraception and PEP into post-rape care

• Youth-friendly/adolescent focused FP/HIV integration models

• Integration of FP into male circumcision services

• Community/village health worker models that combine FP and HIV-related education and services

• Partner focused strategies

Specialized Programming for Concentrated Epidemics

• FP/HIV counseling/services for discordant couples

• FP/HIV integration models for most-at-risk populations – sex-workers – Female IDUs – Partners of male IDUs– Partners of MSM– Incarcerated women

Conclusion• Need to acknowledge the role of FP services in HIV

prevention and care• Not enough evidence of what works, where, how it

works and its impact on health and health services, to make it more effective, how to scale up

• Identify opportunities for OR to generate more data on cost-effectiveness and impact

• Institute indicators for routine M&E• Produce data to inform scale-up• Huge gaps still remain