Service Integration Expanding in Africa

Research shows need for integrated services.

Family Health Research: 2007, Vol. 1, Issue 1

Key Points Rigorous research is needed to evaluate impact and identify effective program models. Studies found substantial unmet need for family planning among HIV-infected women and couples. Service integration requires collaboration between family planning and HIV officials.

A growing number of health programs in sub-Saharan Africa are integrating some family planning and HIV services, and research suggests a pressing need for such services. Nevertheless, conclusive evidence that integrated services are effective is still lacking, agreed participants at a regional conference in Addis Ababa, Ethiopia, on October 9-10, 2006.

Organized by the Johns Hopkins Bloomberg School of Public Health and Addis Ababa University, the Linking Reproductive Health and Family Planning with HIV/AIDS Programs in Africa conference brought together more than 500 public health researchers, advocates, program managers, and policymakers from 20 countries to discuss 50 presentations.

One of several presentations about the impact of integrating services — on a randomized community trial conducted in Rakai, Uganda — found a small but statistically significant difference in hormonal contraceptive use between six intervention communities that received enhanced family planning services through an HIV surveillance program and six comparison communities (23 percent versus 20 percent contraceptive prevalence, respectively). Although no significant change in male condom use was observed in either the intervention or comparison communities, pregnancy rates were significantly lower in the intervention communities.¹

Other promising news came from studies in Kenya and South Africa, which concluded that integration did not compromise service quality (see Family Planning-VCT Integration in Kenya and Integrating VCT into Family Planning in South Africa). Meanwhile, the possible cost benefits of integrating services were underscored in assessments conducted in South Africa (see Integrating VCT into Family Planning in South Africa), Ethiopia, and the Ukraine. One study estimated that the HIV infections averted by integrating HIV prevention into maternal health programs would result in a savings of US$34 per dollar spent in Ethiopia and US$10 per dollar spent in the Ukraine.²

One rationale for integrating services — to address substantial unmet need for family planning services among all women, regardless of their HIV status — was bolstered by findings from studies among women and couples living with HIV, including those receiving antiretroviral therapy (ART).

• Contraceptive use decreased after HIV diagnosis among 460 Ethiopian ART clients, even though 55 percent of the women and 65 percent of the men said they did not want to have children.
• More than 60 percent of pregnancies among 235 women receiving HIV care and treatment in South Africa were unintended.

Most studies of integration, including those presented at the conference, have been inconclusive because they were cross-sectional or had methodological problems. Conference speakers called for more rigorous research to evaluate the impact of integrated services on both family planning and HIV services and to identify the best program models for various populations and situations.

Many speakers also pointed to the need for policies and organizational structures that support service integration. Several presentations highlighted changes in policies and guidelines to promote integrated services in Kenya that were achieved through close collaboration between the Ministry of Health's Department of Reproductive Health and the national AIDS program.³

References

1. Lutalo T, Namukwaya Z, Kimera E, et al. A community randomized trial of enhanced family planning effort in a Ugandan HIV Surveillance Program.
2. Perchal P, Collins L, Assefa, B, et al. Cost-effectiveness of integrating HIV prevention into maternal health programmes in Ethiopia and the Ukraine.
3. Solomon M, Ayisi R. Integrating reproductive health with HIV/AIDS services in Kenya: A Ministry of Health perspective; Askew I, Mullick S, Liambila W, et al. From global intentions to local realities: Adapting international guidelines on FP/RH and HIV/AIDS integration to national programs in Kenya; Rakwar J, Wilcher R. Policy considerations for effective and sustainable integration of family planning and HIV services.

All references are to presentations from the Linking Reproductive Health and Family Planning with HIV/AIDS Programs in Africa conference in Addis Ababa, Ethiopia, October 9-10, 2006.