INTEGRATING Sexual & Reproductive Health and HIV Services

1. INTEGRATING Sexual & Reproductive Health and HIV Services www.aids2010.org OVERVIEW & REVIEW OF EVIDENCE Susannah Mayhew, Kathryn Church, Manuela Colombini Acknowledgements: Aagje Papineau-Salm, Lydia Mungherera, Ron MacInnis

2. Background

3. Varying definitions and understandings of integration • Bundling of services e.g. IMCI (Becker et al., 1997) • Functional vs organisational (WHO, 1996; Lush et al., 2001; Fleishchman, 2006) • Active (provider-driven) vs responsive (client-driven) (Maharaj & Cleland, 2005) • Provider-level vs facility-level integration (Fleishchman, 2006) • Linkages (IPPF, WHO, UNFPA, etc.) • Are we integrating services, or are we simply adding in interventions? • Most importantly: what is being integrated with what?

4. SRH Care HIV Care Service Reality • FP/RH services • FP counselling (new and repeat users) • EC provision • Pregnancy testing • Abortion services (where legal) • HIV Prevention • HIV testing and counselling • Male circumcision • STI treatment How do these fit into a PHC context? • HIV care (pre ART) • Screening for TB and other OIs • Clinical staging (with CD4s) • Psycho-social support • OI Prophylaxis • Clinical monitoring and restaging • Positive prevention PMTCT • MCH services • ANC • PNC • Newborn and child health • Sexual health services • STI/HIV prevention (condom promotion, dual protection) • STI screening, diagnosis & treatment • Pap smears • Sexual health counselling • Refer out: • Delivery care • Specialised STI treatment • Infertility treatment • Cervical cancer treatment • Refer out: • TB care? • Home-based care • Specialised care for OIs • Palliative Care • ART • ART adherence counselling • ART provision & monitoring • Psychosocial support • Positive prevention

5. Literature overview

6. Recent review on impact of integrating HIV & STI services into FP contexts (Church & Mayhew 2008): 1. Integration into SRH services • Clients generally satisfied to received broader package of care • Increased access to STI/HIV services BUT persistence of missed opportunities • Mixed results on reaching men and youth • Evidence of reducing stigma, but also concerns over privacy and confidentiality, and poor treatment of PLWH • Many provider-related constraints identified, but also some preferences for integrated care • RESEARCH GAPS: • Weak evidence of impact on health outcomes • Difficulty in evaluating an integrated model; lack of controls & experimental designs • Little evidence on cost effectiveness/cost benefits

7. 2. SRH needs of PLWH • Multiple studies in sub-Saharan Africa have found PLWH (in either PMTCT, pre ART or on ART contexts) have high unmet needs for SRH care (Cooper et al, 2009; Heys et al 2009; Homsy et al 2009; Meyer et al, 2007; Stringer et al, 2009). • Both supply- and demand-side factors influence demand for FP for PLWH • High baseline unmet needs for family planning in many high prevalence settings “there was no planning whatsoever with any of them, it would happen by accident, and it’s like I woke up and I had 13 children and couldn’t do anything about it” (male client, ART clinic Swaziland, INTEGRA project) RESEARCH GAPS: • Impact of promoting long-term FP methods in HIV settings; impact on condom use in PLWH: are we doing any harm & should dual protection be a priority?

8. Evidence from programmes on meeting SRH needs of PLWH • Limited robust evidence on integration of SRH into HIV care contexts • Studies suggest integration can increase FP counselling or uptake through: • Referral models: Chabikuli, 2009 (Nigeria); suggest integrating FP into HIV care • Onsite delivery: Bradley et al, 2008 (Ethiopia), ACQUIRE, 2008 (Uganda); King et al 1995 (Rwanda); Mark, 2007; Peck et al 2003 (Haiti) • Mixed evidence on impact of integration: most studies record little or no impact on service uptake or health outcomes. • Limited individual programme data on costs; much aggregate data on cost-effectiveness of FP as an HIV prevention intervention (Reynolds; Stover; Halperin)

9. What model of service delivery best meets SRH needs of PLWH? The Integra project I haven’t told anyone [about my status] I only tell those that I find at the clinic when I go collect my pills, they talk about their situations and I also find myself sharing mine, but when it comes to my family, its still a challenge. (female client ) facility-level integrated site Qualitative interviews with 15 providers and 22 clients at 4 HIV clinics HIV client exit survey (cross-sectional) with 611 HIV patients • Integrated clinics not better at meeting SRH needs • Integrated clinics not less stigmatising for HIV patients • HIV clients satisfied at both types of services; reasons for choice = proximity, provider friendliness, referred or recommended

10. 3. HIV Provider attitudes to integration • Some providers see benefits to integration but many studies demonstrate common provider-level and health systems challenges • Even where providers were trained on SRH, many still lack knowledge on dual protection, and on appropriate contraceptive choices for PLWH • In some settings, providers fear HIV infection within clinics which has implications for offering more clinical FP methods. • Providers often assign ‘blame’ to clients for poor FP uptake/continuity • Useful strategies at provider level: provider/clinic participation in needs assessment before integration activities: opportunity to promote buy-in (ACQUIRE Project, 2008; Adamchak, 2007; Hayford, 2009)

11. Factors affecting uptake of and adherence to PMTCT services: • Health systems factors; Socio-cultural factors (community level); Individual factors (of HIV+ mothers) • Programmes with high rates of adherence offered: • same-day test results and knowledge on ARV benefits for HIV prevention, supported partner involvement, and gave the nevirapine tablet at post-test counseling (at first visit) (Spensley et al, 2010; Nassali et al, 2009; Temmerman et al., 2003) • Limited data on continuity of HIV/AIDS care to mothers and babies after delivery • High drop out rates of PMTCT post-partum care (Bwirire et al, 2008; Chinkonde et al, 2008) • Limited postpartum linkage of HIV mothers to HIV/AIDS care • RESEARCH GAPS • Implications of shift from single dose NVP to triple therapy • Impact of PMTCT on mother + long-term survival rates 4. PMTCT services and a continuum of care for pregnant women with HIV

12. Programme and Research Challenges

13. Challenges in SRH-HIV integration: Programme experiences Definition: what do we mean by integrated services? Is a good referral system sufficient? Should 1 person do it all? What are ‘linkages’ ? Differing service configurations: differ from clinic to clinic, town to town, region to region, country to country : how to formulate policy advice? Health systems challenges: staffing shortages; health worker management systems (rotation); space constraints; logistics systems derived from vertical programmes; management & supervision; weak referral systems Cultural challenges: client expectations; provider attitudes and expectations; cultures of practice within medical systems (task-orientation and specialism culture); challenges shifting to client-centred care Technical challenges: skills training – how much can multi-purpose health workers be expected to learn or do? Donors and funding streams: national & international policies may necessarily still be disease-specific, but leads to separate training, skills specialisation, and programme activities in clinics

14. Research gaps • Cost-effectiveness data on integrated vs stand-alone services • Impact data on health outcomes • Detailed assessments of process in intervention studies (WHY does integration work well in some settings and not others?) • Impact of integration in reducing HIV-related stigma • Is there a demand for integrated services, and how are clients currently accessing care? • What kinds of SRH services do PLWH want? Which types of services best meet their SRH needs? • Integration into primary care: what are the implications? How to integrate HIV into other PHC services such as child welfare? • Associations between pregnancy and HIV

15. Conceptual & Research Challenges • ‘Integration’ has no consistent definition and there are as many variations as clinics • Separating out treatment and prevention programmes: what different service configurations belong together? • VCT & dual protection in FP/ANC/PNC clinics • PMTCT in ANC clinics • ART and FP/SRH in HIV clinics • Isolation of the integration effect from other programmatic activities/interventions virtually impossible • Complex structure of health services & programmes inhibits measurement of specific models

16. IPPF, LSHTM and Population Council-NairobiAssessing the benefits & costs of different models of integration of HIV and SRH services in Swaziland, Kenya and Malawi 2008-2012. Aims: (a) determine the benefits of different integrated models; (b) determine the impact of different integrated services on changes in HIV risk-behaviour; HIV related stigma and unintended pregnancies; (c) establish the efficiency& cost-effectiveness of using different operational models for delivering integrated services; (d) ensure utilization of research findings by policy and program decision makers through extensive stakeholder involvementContact:Susannah.mayhew@lshtm.ac.uk or Atrossero@ippf.org