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Integrating Family Planning into VCT ServicesThe feasibility of integration is demonstrated in Africa and the Caribbean. |
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As efforts begin to shift toward integrating family planning into HIV/AIDS services, voluntary counseling and testing (VCT) centers are emerging as primary targets for integration. Research from Africa and the Caribbean shows that such integration is feasible and acceptable, and large-scale integration efforts are being launched and expanded there.
VCT services have become one of the most common means of preventing, detecting, and improving access to care and support for HIV/AIDS. And VCT services are likely to greatly expand with support from the five-year U.S. President's Emergency Plan for AIDS Relief (PEPFAR), which focuses on fighting the HIV/AIDS epidemic in 15 resource-poor countries, mostly in Africa and the Caribbean. In terms of family planning, VCT centers offer a rare opportunity to reach many people with contraceptive needs who may not normally visit a family planning clinic. Women are the primary clients of family planning clinics, but VCT centers attract large numbers of women, men, and couples. At the centers, provision of or referral for contraceptive services can help prevent pregnancies among uninfected women who wish to postpone or space childbirth. And among HIV-infected women or women who may be at risk of infection, pregnancy prevention can ultimately help in the prevention of mother-to-child transmission (PMTCT) of HIV (see Averting HIV-Infected Births). For male clients and couples, especially those whose HIV serostatus is discordant, counseling and provision of condoms alone or in combination with other, more effective contraceptives can provide dual protection against unintended pregnancy and HIV transmission. Implementing change These potential benefits of integrating family planning services into VCT services are apparent, and international support for such integration is growing. A recent analysis of family planning content in 12 international VCT and PMTCT guidelines produced between 1997 and 2003 found that all but one explicitly address family planning, with the focus on providing information about contraceptives or referring clients to family planning services.1 Despite this progress, the idea of such integration is still relatively new, and, generally, implementation is just beginning. The potential for its success is illustrated by the AIDS Information Centre in Uganda, which integrated family planning services into its VCT services in 1993 and now offers them at multiple sites throughout the country (see Uganda: Integrating Family Planning into VCT). Now, other countries are exploring whether and how such integration will be effective in their particular settings. In Kenya, for example, a large collaborative effort to develop and implement a national strategy to integrate family planning into VCT services is well under way. Kenya is a promising setting for integration because its Ministry of Health (MOH) already has an ambitious program to expand VCT services. Nearly 300 VCT centers have been registered, and Kenya is one of few countries to have developed country-specific VCT guidelines. The government also recognizes the benefits of family planning; Kenya was identified in the recent analysis as one of six countries to mention family planning in its VCT guidelines.2 "This governmental support has been a major first step toward integration," says Dr. Ndugga Maggwa, regional director of FHI's Institute for Family Health in East and Southern Africa, who is helping facilitate the integration process in Kenya. Progress continued, said Dr. Maggwa, with formative research to identify opportunities and challenges for integration. The Kenya MOH's National AIDS and STD Control Programme (NASCOP) and Division of Reproductive Health, with technical assistance from FHI and partners, gathered information from 20 VCT centers throughout Kenya in June of 2002.3 Data from 20 VCT supervisors, 41 counselors, and 84 clients suggested that integration was acceptable but that only some of the centers were ready to implement it. Researchers noted that more counseling to describe the benefits of condoms, to increase the use of modern contraceptives, and to promote dual protection was needed. And though the majority of counselors had clinical training, an assessment of their contraceptive knowledge suggested that some were not prepared to provide contraceptive methods. Furthermore, only 10 percent of observed client-counselor interactions included a referral for family planning services.
Overall, counselor training backgrounds, referral mechanisms, and contraceptive supply needs varied among VCT centers. The researchers concluded that decisions on whether and how much to integrate need to be made at the facility level, and this finding later became the basis of the national integration strategy. To develop a strategy that would not compromise existing VCT services, NASCOP created a task force of diverse VCT and family planning experts. Together, these experts identified four potential levels of integration, each contingent on available resources at particular facilities (see Adding Family Planning to Existing VCT: Levels of Integration in Kenya). The national integration strategy recommends that all VCT centers achieve at least the first level, which — in addition to the traditional VCT services — includes the provision of basic pregnancy risk assessment and counseling services and the availability of contraceptive pills and condoms on-site. The fourth level, in which all contraceptive methods are available on-site, is viewed as a long-term goal since it would require enormous additional resources for most centers.4 The task force recently presented the strategy to a VCT committee within NASCOP, and the MOH gave its approval. "I would recommend a similar process for other countries as well," says Margaret Gitau, a program officer at NASCOP and chairman of the task force. "There is more ownership this way, and the final products are accepted by all, as all become involved in the whole process." On behalf of NASCOP and the MOH — and as task force facilitator — FHI is already working with task force members AMKENI (a national service delivery project led by EngenderHealth) and JHPIEGO (an international public health organization) to implement the first level of integration, as outlined in the strategy, into 20 proposed VCT centers in two provinces in Kenya. Results from operations research to determine the effectiveness and costs of implementation are expected in 2005. Demonstrating impact In general, whether integration of services has a measurable impact on improving reproductive health remains unknown, and research to generate clear evidence of benefits is greatly needed. But the potential for positive impact of offering family planning services to VCT clients has been demonstrated in a VCT center in Port-au-Prince, Haiti. The VCT center was established in 1985 by the Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), a nongovernmental organization that works with the Haitian MOH to provide free HIV services in Port-au-Prince. The center gradually integrated other services, such as care for AIDS and tuberculosis patients and management of sexually transmitted infections (STIs). And, in 1993, it finally added family planning services. In collaboration with researchers from Cornell University and Vanderbilt University, GHESKIO subsequently evaluated the experiences of the VCT center from 1985 to 2000.5 Data showed that demand for services, in general, increased more than 60-fold, from 142 clients in 1985 to 8,757 clients in 1999. The percentages of reproductive-age women, adolescents, symptom-free clients, and self-referred clients attending the center also increased after integration began. Determining which services contributed most to this increase in client demand was not possible, but family planning services were well received. In 1999 alone, 19 percent of some 6,700 VCT clients began using contraceptives and then returned to the center for at least three family planning visits. Seventy percent of these new contraceptive users chose condoms alone, and the remaining 30 percent (all women) chose oral contraceptives, injectables, or vaginal sponges, either alone or with condoms for dual protection against both pregnancy and HIV infection. A separate study conducted from March 1999 to November 2001 showed that after an additional intervention to introduce family planning services into the STI and HIV clinic within GHESKIO, 16 percent of some 3,000 HIV-infected women attending the clinic began using contraceptives.6
"When we screen women for HIV, we inevitably also find reproductive health needs, so it makes sense to provide these services on-site," says Dr. Daniel Fitzgerald, an investigator of the original study and a Cornell University assistant professor who has assisted with service provision in Haiti. Further, "many women who initially come for reproductive health services end up being tested for HIV. Women know they can receive a package of quality primary care services at the center, and they are willing to come." Integrating multiple services into VCT makes sense in Haiti, which has the highest prevalence of HIV outside of sub-Saharan Africa and is fighting a tuberculosis epidemic. HIV-positive Haitians have also faced intense social stigmatization in recent years. But "if thousands of people come for HIV testing, then they must believe the benefits of VCT and integrated services outweigh the risk of stigmatization," report Dr. Fitzgerald and other authors of the original study. As in Kenya, efforts to integrate services in Haiti have enjoyed the support of the government. Dr. Fitzgerald says that the MOH is working with GHESKIO and partners to increase the number of sites that offer VCT and integrated services. With assistance from the Global Fund to Fight AIDS, Tuberculosis and Malaria and from PEPFAR, they established 20 new centers throughout Haiti in 2003 and plan to create 15 more by the end of 2004.
A similar effort to integrate multiple reproductive health services into VCT services is ongoing in Zimbabwe. In 2002, the New Start network — managed by U.S.-based Population Services International (PSI) on behalf of the Zimbabwean government and funded by the U.S. Agency for International Development (USAID) mission in Zimbabwe — began offering family planning and other reproductive health services (including STI screening and treatment) at its busiest stand-alone VCT center in the country. This new package of services, known as New Start Plus, is now available at four of 18 New Start VCT sites, and at least 10 percent of New Start Plus clients request and receive family planning services, says Shannon England, a VCT program development manager at PSI. PSI is also working to integrate VCT into family planning services, as is the Kenyan government, but these efforts are not as well developed as those doing the reverse: integrating family planning into VCT. "We need to be thinking about integrating both ways because each way presents different opportunities," says Dr. Maggwa of Kenya. "But, it may be most prudent at this time to think about integrating family planning into VCT, especially since the infrastructure for VCT services is being developed and reinforced right now," he says. — Kerry Wright Aradhya References
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