HIV Prevention and Family Planning:Integration Improves Client Services in Jamaica
Throughout the world, many women have no contact with an organized health system except an annual visit to a family planning clinic. Family planning programs offer ideal opportunities to reach an important population at risk of HIV infection--sexually active women of reproductive age--with assistance in preventing HIV/AIDS and other sexually transmitted diseases. But can family planning programs offer comprehensive reproductive health services? Some affiliates of the International Planned Parenthood Federation, Western Hemisphere Region (IPPF/WHR), have accepted that challenge. Peggy Scott of the Jamaica Family Planning Association (FAMPLAN), Julie Becker of IPPF/WHR and Rita Badiani of the Family Planning Association in Brazil describe their organizations' experiences with integration.
Two years ago, few clients of the Jamaica Family Planning Asso-ciation (FAMPLAN) used condoms. Counselors rarely mentioned condoms to their clients, except as a back-up contraceptive method.
Today, FAMPLAN staff distribute hundreds of condoms every day, and many clients are using two family planning methods: pills or another method for contraception and condoms to prevent HIV and other sexually transmitted diseases (STDs).
This new interest in condoms--and preventing HIV--is the result of a FAMPLAN program that integrates HIV and STD prevention into all clinical and community services. With technical and financial assistance from the International Planned Parenthood Federation/Western Hemisphere Region through financial support from the U.S. Agency for International Development (USAID), the program is designed to promote sexual behavior change, increase condom use, and improve STD diagnosis and treatment.
A New Model
In Jamaica, as in other parts of the world, HIV and other STDs are a growing threat to family planning clients. Many married women and women in other kinds of long-term relationships are becoming infected, often by their husbands. During the past five years, the male-to-female ratio of AIDS cases reported to the Pan American Health Organization dropped from 2.5 to 1 to 1.3 to 1.
Recognizing the increasing vulnerability of Jamaican women to the epidemic, FAMPLAN launched an integrated program in October 1993. The goal was to create a permanent change in the way family planning services were provided, rather than a short-term, isolated project. But since integration of STD prevention into family planning was something new, we faced many unanswered questions. Would the staff be willing to learn new skills? How receptive would our clients be? Would they be willing to even discuss HIV and STDs? Would integration compromise the quality of our family planning services?
Before the program began, staff members from the IPPF/WHR HIV/STD Prevention Program conducted a training needs assessment that included formal and informal discussions with FAMPLAN management, clinic staff and outreach workers and on-site observations of staff-client interactions. This assessment revealed that safe sex practices were not promoted in FAMPLAN services and counselors did not address sexual behavior change. Counselors seldom presented condoms as a family planning option or as a method to be combined with others. None of the staff members showed clients how to use condoms.
We also learned that FAMPLAN nurses had minimal knowledge of STD signs and symptoms and had difficulty distinguishing STDs from other infections. No referral system was in place for STD testing or treatment.
The findings of this baseline assessment provided the information needed to develop staff training curricula. All staff, including drivers, support staff and others who usually do not provide direct client services, were trained in HIV/STD education and counseling skills. Initial two-day training sessions focused on HIV/STD prevention information and basic counseling skills. More in-depth training in sexuality, sexual health, and education and counseling skills was provided at a later date.
Integration in Action
FAMPLAN has integrated HIV prevention and safe sex counseling into all its services, which include family planning clinics, rural outreach, and programs for factory workers, migrant workers and youth. FAMPLAN's HIV/STD project coordinator facilitated the process through continuous staff training and appraisal. She also conducted focus groups with current and potential male and female clients to learn about their knowledge of contraception and HIV/AIDS prevention and their attitudes and sexual practices.
Under the integrated program, individual and group counseling is offered to inform clients and build skills. Nurses and counselors help clients explore their sexual lives and relationships with partners, determine their own risk and develop safe sex negotiation skills. When they present a family planning method, counselors explain whether it offers any protection from STDs and emphasize the importance of using condoms with each method.
All clients learn how to use a condom and are asked to demonstrate how to put one on a penis model. FAMPLAN staff members found that demonstrating condom use with models encouraged clients' participation in educational sessions. Rural outreach workers report that now that they use models, word spreads quickly and people gather round to hear what they have to say. "I'm so happy since I got this penis model," one counselor said. "I just love to walk with it!"
Clients also receive a free sample of two condoms and learn where to purchase additional supplies. A promotional condom package developed by FAMPLAN promotes the dual benefits of condoms--protection against pregnancy and STDs--as well as dual method use, or the use of condoms with other family planning methods. Condom distribution has been expanded in rural areas by training shopkeepers and other well-known community members to complement the educational services provided by outreach workers.
To improve diagnosis and treatment of STDs that can increase the risk of HIV transmission, FAMPLAN clinic staff have been trained to recognize signs and symptoms of STDs, and treatment and referral procedures are being developed. Clinic staff members treat STDs using the syndromic management approach recommended by the World Health Organization, which involves treatment without a laboratory diagnosis based on a physical examination and a patient's reported symptoms. Laboratory diagnosis is used to complement the syndromic approach when needed.
FAMPLAN is also developing procedures to help staff identify women with potential asymptomatic infections through risk assessment. Since insertion of an intrauterine device (IUD) puts women with untreated STDs at increased risk of pelvic inflammatory disease, the risk assessment procedures will be particularly important for determining which clients should be screened for STDs or treated prophylactically prior to IUD insertion.
Meeting Challenges
Initially, convincing some staff members of the importance of integration was difficult. We emphasized that rather than asking them to take on additional duties, the program was meant to change the way services were provided. Instead of simply dispensing family planning methods and explaining how to use them, FAMPLAN staff would provide a more comprehensive reproductive health approach to client services. Participatory exercises, such as role plays, helped staff members feel more comfortable discussing sexuality and recognize their personal and professional biases against condoms.
Some rural outreach workers found that when they integrated HIV/STD prevention into their work, they were unable to reach as many clients because of the additional time needed to do counseling. We assured them, however, that the increased quality of services compensated for the small drop in client numbers.
We also emphasized that if counseling begins with an understanding of the sexual lifestyle and circumstances of a client, it can help a counselor determine what information is most relevant to that client. It might not be necessary, for example, to spend a great deal of time explaining the details of all methods. Therefore, changing the focus of a counseling session from an explanation of family planning methods to an exploration of the sexual health needs of a client can actually save time as well as improve the quality of the counseling.
The greatest barriers we face are the cultural barriers to sexual behavior change. Most women are unable to convince their partners to use condoms for fear of having their fidelity questioned--a moral double standard in a country where it is widely acknowledged and even accepted that men often have more than one sexual partner.
These barriers can only be overcome through continual face-to-face interventions. A family planning counselor can help a client strategize about responses to arguments against condom use, help her think about the best time and place to bring up the subject, and help empower her to refuse unsafe sex. Safe sex is defined as sex that is not only safe from HIV/STD transmission, but also from unwanted pregnancy and the abuse of power.
Two Methods?
FAMPLAN staff were not alone in their reservations about integration. Other family planning professionals have questioned our integration efforts, fearing that a shift from long-term methods to condom use might threaten the reductions in fertility rates Jamaica had achieved. To ensure that these gains are not reversed, FAMPLAN stresses correct condom use. We have found that most clients, both male and female, do not know how to use condoms correctly, which we believe contributes greatly to their reported low levels of effectiveness.
FAMPLAN also actively promotes dual method use. Although many family planning experts doubted that clients would use two methods at once, nurses at both FAMPLAN clinics report that an increasing number of women are asking for condoms along with their regular family planning method.
Integration Works
By mid-1995, FAMPLAN's integrated program had reached approximately 20,000 people. Condom distribution skyrocketed after the program began. In 1994, we distributed 213,000 condoms--up from only 60,000 in 1992.
Outreach workers report that there is more awareness of the need for safe sex. As one client puts it: "I never used anything before, but now I can't take a chance." Another client said that if her husband did not use a condom, then "no sex."
Integration has also enabled FAMPLAN to reach more men. Most of our clients are women, who often say that we should talk to men directly. More and more men are now finding their way to our clinics to purchase condoms for protection against AIDS and other STDs. "This thing is spreading too rapidly," one man said. "I have to protect myself."
Despite their initial fears, FAMPLAN staff found that integration actually improved the quality of family planning services. Staff capacity to counsel clients has been greatly enhanced, particularly in their ability to discuss the relationship between family planning methods and HIV/STD transmission and to help people develop safe sex negotiating skills.
FAMPLAN staff once believed that it would be difficult or even impossible to discuss sexuality openly with their clients. In fact, when asked sensitively, clients are often relieved to have an opportunity to express their concerns and fears about their partners' behavior. Many clients welcome the opportunity to get information about HIV and other STDs and to explore their personal risk.
Peggy Scott is chief executive officer of the Jamaica Family Planning Association. Julie Becker coordinates the International Planned Parenthood Federation, Western Hemisphere Region's HIV/STD Prevention Program.
