|
Research |
||||||||||
Case Studies |
|
||||||||||
Uganda: Integrating Family Planning into VCTIf you visit the impoverished neighborhood of Kisenyi in Kampala, Uganda, near the largest public transportation hub in the country and the biggest outdoor market in the city, you may be able to catch a glimpse of the new headquarters of the AIDS Information Centre (AIC). From the outside of the building, however, you will not be able to appreciate just how much the organization has evolved in recent years. Opened in 1990 as a single site offering only HIV voluntary counseling and testing (VCT), the AIC now offers VCT integrated with multiple reproductive health services to thousands of clients each year at six main sites in Uganda. Receiving about 250 clients daily at these sites, the AIC is now one of the largest nongovernmental providers of VCT services in the country. First provided at the main Kampala facility in 1993, family planning services have been offered at branches in the cities of Jinja, Mbarara, and Mbale since 1995. Jane Harriet Namwebya, a VCT technical officer at FHI, had the opportunity to observe the integration process. Having worked in various positions at the AIC from 1992 to 1998 and then as executive director until 2001, she recounts some of the obstacles to integration and how they were overcome. "There was initial resistance from the VCT counselors regarding time constraints," says Namwebya. "Many thought that by integrating services, including family planning, counseling sessions would become much longer. But this was addressed through training." Reproductive health volunteers also assist counselors to help ease the burden of providing multiple services. For each client, a typical visit to the AIC includes pretest counseling, HIV testing, HIV prevention counseling, delivery of test results obtained on-site, and post-test counseling, all in a single visit lasting from 45 to 90 minutes. Counselors mention the AIC's family planning services in both pretest and HIV prevention counseling, where they also demonstrate correct condom use. During post-test counseling, counselors offer free condoms and advice on how to negotiate condom use. The reproductive health volunteers are also in the waiting room throughout the day, providing family planning information, identifying particular family planning needs, and referring clients to counselors who can meet those needs.
Another barrier to integration — that many of the counselors did not have medical backgrounds — was resolved by creating an internal referral system. "Nonmedical counselors would assess the reproductive health needs of clients and then refer them to counselors who had medical backgrounds to provide further services," says Namwebya. (All counselors at the AIC are trained to provide condoms, spermicides, and oral contraceptives. If clients request other methods, such as injectables or intrauterine devices, they are referred to counselors who are also nurses.) The impact of integration on AIC clients' reproductive health has not been assessed. But data from the AIC indicate that condoms are the most popular contraceptive method, with almost a third of family planning clients using condoms plus another, more effective method for dual protection against unintended pregnancy and HIV infection.1 Demand for family planning has increased over time, and approximately 8 percent of clients at the four main sites offering family planning services accessed those services in 2002.2 Other services that have been integrated into the AIC include syphilis testing, management of sexually transmitted infections, tuberculosis education, post-test support services for anyone who has had an HIV test, services targeting youth, and community outreach activities. Namwebya admits that, for convenience, health care services often have focused on only one aspect of a client's health needs at a time. "But," she says, "in reality, each individual's health needs are truly interconnected. So health care services should be integrated to reflect this." — Kerry Wright Aradhya References
Cambodia: Clients Find Everything They Need in One PlaceThe year was 1996. HIV incidence was clearly rising in Cambodia, but in Phnom Penh only one group — the Pasteur Institute — provided voluntary counseling and testing (VCT) for HIV. Incidence of HIV was mainly rising among people at high risk of infection. Yet, ominously, between 30 percent and 40 percent of clients (mainly married women) served at that time by the two-year-old Reproductive Health Association of Cambodia (RHAC) had reproductive tract infections (RTIs) or sexually transmitted infections (STIs). Such infections are, in themselves, risk factors for HIV infection. Furthermore, the same sexual behaviors that put people at risk for RTIs and STIs also put them at risk for HIV. RHAC, an International Planned Parenthood Federation affiliate primarily supported by the U.S. Agency for International Development (USAID), was quick to act. That year, it sent staff to Thailand to learn to do HIV/AIDS counseling. It also began drawing blood samples for clients wanting to know their HIV status and sending samples to the Pasteur Institute for testing. The following year, RHAC conducted a study of the feasibility of performing HIV testing at its own clinics. Staff reactions were mixed. "One-third of staff expressed doubts, but their professional expertise told them that the chances of serving AIDS patients would keep rising," recalls Dr. Var Chivorn, associate executive director of RHAC. Client reactions were more favorable: Most welcomed the introduction of HIV services into a package of existing services that included family planning, diagnosis and treatment of RTIs/STIs, pregnancy care, and counseling about and treatment of minor gynecological problems. Overall, the study suggested that RHAC clinics should provide HIV testing. But the cost per test — at that time limited to the ELISA technique — was simply too high for RHAC. Then, in 2002, a breakthrough occurred: Rapid test methods, suitable for clinics where the volume of testing was too low to efficiently use the ELISA machine, became available. RHAC then moved forward to introduce HIV counseling and testing services, supported by the United Nations Children's Fund (UNICEF), into its six USAID-funded clinics.
VCT service guidelines for use by clinic staff and counselors were established. Informational materials were developed for staff use and for display in waiting rooms. HIV educational services via media and hot lines were created. More staff were added to busy clinics. Counselors were hired and trained. Nurses and midwives were trained to provide information about AIDS. Issues of HIV acquisition risks and post-exposure prophylaxis were addressed to reassure staff that they ran little risk of being infected. Alert systems in clinic rooms addressed provider fears that they might be in danger if clients became violent in reaction to a positive test. To better serve clients testing HIV-positive, links with home-based care teams, locations offering antiretroviral drug therapy, and the national tuberculosis center were established. The next year, RHAC clinics provided VCT services to 13 percent (14,208) of their clients, of whom about 7 percent (some 995) were found to be HIV-infected. More than 100 infected clients needing additional services were referred either to home-based care teams or to tuberculosis centers. Early concerns about the cost of providing HIV testing are no longer an issue. While a testing fee of U.S. $1 can be waived if a client cannot pay, the RHAC has found that "most clients are happy and able to pay this fee," says Dr. Chivorn. "RHAC has proved that, regardless of the fee, clients come for testing because the service is of good quality." Similarly, fears that offering VCT services would be stigmatizing and scare away family planning and other clients were laid to rest. "We do not see any decline in family planning or other clients. In fact, clients in the clinics are increasing," says Dr. Chivorn. About 13 percent of clients now are men, most of whom come for STI services. RHAC has also trained staff to serve adolescents. "Overall, clients have been happy to find everything they need in one place," says Dr. Chivorn. "This has strengthened RHAC's resolve to further integrate services, which now also include early detection of cervical cancer, premarital counseling, and support to rape victims. And, this year, child health services are being added." — Kim Best Zimbabwe: 'I Have the Knowledge and Skills to Help'In Zimbabwe, Hebron Gotora's workday officially ends at 4:30 p.m., but it is often later than 6:00 p.m. when he navigates his bicycle down the bumpy dirt road to his home in the community of Chihota. His dedication and pride as a community-based distributor (CBD) of contraceptives for the Zimbabwe National Family Planning Council (ZNFPC) is evident. Seemingly everywhere, people seek him out for advice. Gotora has been a CBD worker for nearly a decade, taking family health services beyond clinic walls to the doorsteps of people in the community. But his job was recently expanded to include the more holistic approach of providing information about HIV/AIDS, sexually transmitted infections (STIs), HIV voluntary counseling and testing (VCT), referrals to VCT services, access to prevention of mother-to-child transmission services, and much more. "With my new role, I feel renewed," Gotora, 39, and a father of three, said in a recent interview with the Advance Africa project, supported by the U.S. Agency for International Development (USAID). "Now I can assist many people."
Advance Africa, a consortium of six organizations that includes FHI and seeks to increase family planning and reproductive health services in sub-Saharan Africa, began working with the ZNFPC in 2001 to integrate HIV/AIDS services into the jobs of CBD workers. The initiative followed an extensive ZNFPC review of the existing CBD program that considered ways of expanding CBD workers' roles to address the AIDS crisis in the country. Such expansion was natural since CBD workers were already reaching people of reproductive age. The expanded CBD program, which targeted adolescents, men, and low-parity women, was piloted in eight districts and has since been expanded to 16 districts. USAID and Advance Africa continue to provide financial and technical support. Initial districts were chosen based on proximity to VCT centers (so clients could make the trip within a day), availability of CBD workers, and proximity to ZNFPC provincial offices for support and supervision. VCT services in Zimbabwe are still largely urban based. CBD workers serve in rural areas, but few have problems making referrals because "clients are already asking them about HIV," says Premila Bartlett of FHI, who is country director for Advance Africa in Zimbabwe. The main challenges are the scarcity of VCT centers and travel difficulties that many clients face due to the country's economic decline. Before CBD workers were trained for their expanded role, ZNFPC reviewed, streamlined, and revised CBD responsibilities and guidelines. Advance Africa provided technical assistance to ZNFPC to develop a curriculum. Subsequent training at headquarters and the provincial level targeted leaders of CBD groups, CBD workers, and volunteer depot holders (who work from home to provide information and resupply clients). To date, 19 CBD supervisors, 141 CBD workers, and 379 depot holders have been trained. Although the project has not been evaluated, Advance Africa is working with ZNFPC to develop improved monitoring and evaluation systems and to assess the cost and cost-effectiveness of expanded service delivery, among other things. Anecdotal evidence suggests that trained CBD workers and depot holders have embraced the provision of information beyond family planning. And initial analyses of the expanded program have been encouraging. Between 2001 and 2003, CBD referrals for VCT rose from 121 to 840, and referrals for STI and HIV/AIDS care rose from 202 to 499. The number of people receiving HIV/AIDS information and behavior change messages through group meetings rose 10-fold, from some 3,000 to more than 30,000. The impact of HIV/AIDS activities has also been measured in terms of the distribution of condoms: some 725,000 male and female condoms in 2003, compared to about 175,000 in 2001. Meanwhile, access to family planning has increased and quality has improved, as providers have been retrained about contraceptive methods and now spend more time with clients. Distribution of oral contraceptives increased from about 53,000 in 2001 to more than 360,000 in 2003. However, lack of funding has prohibited growth of the expanded program to a proposed 58 districts in Zimbabwe, says Bartlett. Similarly, economic factors have compromised the strength of Zimbabwe's well-respected CBD program as a whole. Since the 1980s, Zimbabwe's network of about 800 salaried male and female CBD workers has shrunk to an estimated 550. Another concern is that CBD workers as a group are aging. Some find it difficult to ride a bike long distances and may not be "the most appropriate" people to reach youth, a goal of the expanded program, says Bartlett. Nevertheless, "the CBDs are generally happy with their roles and find that they are now more relevant to the needs of their communities," she says. Gotora continues to reach out with his expanded message anywhere he can — churches, businesses, agricultural shows, clubs, and even roadside meetings in villages or at his own home. He says he considers his job nothing short of an honor. "Now I can communicate and discuss with everyone, whereas in the past, we talked only about family planning and to women alone," Gotora said recently. "Women, men, and youth, many of them school-leavers, seek my services and advice on their different health and reproductive concerns. And I have the knowledge and skills to help." — Pamela Babcock Jamaica: System-Wide Integration of ServicesMost integrated delivery of family planning and HIV services is limited to pilot projects in one or a few health facilities. Little is known about how to integrate these services throughout a health care system. But a study in Jamaica seeks to identify changes needed to make family planning and HIV service integration a reality system-wide. Conducted by the Jamaican Ministry of Health (MOH) and the Washington, DC-based POLICY Project of the Futures Group among 100 health care providers, program managers, policy-makers, and potential clients, the study will determine the feasibility and potential cost of integrating family planning and HIV services in the rural parish (district) of Portland and the urban area of St. Ann's Bay. "We are asking, 'What policies, regulations, and guidelines need to change to actually institutionalize integration?'" explains Dr. Karen Hardee, research director for the POLICY Project.
The MOH has identified service integration as a priority to better meet the reproductive health needs of Jamaicans. Offering HIV prevention counseling and diagnosis and treatment of curable sexually transmitted infections (STIs) at family planning and maternal and child health facilities and through outreach is considered a good way to improve women's access to these services. It would also offer opportunities to provide comprehensive reproductive health services for youth and to attract male clients who could receive counseling about family planning and HIV/STI risk reduction, as well as STI treatment.1 Reaching Jamaican women and youth is particularly important because they are at higher risk of infection with HIV and other STIs than are Jamaican men. HIV prevalence among Jamaican adults is relatively low, at 1.2 percent.2 But rising levels of HIV infection among women have narrowed the ratio of male-to-female AIDS cases: In the 1980s, that ratio was 6 to 1; in 2001, it was 1.6 to 1. Women now account for 40 percent of all AIDS cases reported since the epidemic began, and girls ages 10 to 19 years are two and a half times more likely than teenage boys to be infected with HIV.3 In one study in the capital, Kingston, 27 percent of female family planning clients with no STI symptoms were found to have an STI.4 And half of reported cases of gonorrhea occur among Jamaican youth ages 15 to 19 years.5 The feasibility study began with workshops that brought together national, regional, and parish-level health officials; nongovernmental organization staff; and public and private health care providers to develop a plan for service integration in Portland and St. Ann's Bay. The plan outlines 20 possible strategies for combining family planning and HIV services and improving access to integrated services. The proposed strategies address training, screening, access, referral, outreach, patient education, management information systems, and treatment. They range from training all providers in a more integrated approach to counseling and service delivery, to hiring additional staff at specific facilities. Local research organizations carried out four feasibility studies of these strategies. They conducted interviews and focus group discussions with providers to assess their willingness and ability to provide integrated services. They gauged clients' reactions and perceptions of stigma through focus group discussions. Finally, they analyzed operational constraints to service integration and identified the cost per STI treated for each strategy in the proposed plan. Data collection ended in April 2004. Once the data have been analyzed, the MOH and the POLICY Project will use the findings to plan how to remove operational barriers to family planning and HIV integration in Portland and St. Ann's Bay. The experience with integrated services in these parishes will, in turn, guide decisions about integrating services throughout the country. — Kathleen Henry Shears References
|
|||||||||||
 |
|||||||||||
