Jennifer Mason, Senior Advisor for FP/HIV Integration for USAID's Office of Population and Reproductive Health describes the agency's approach to integrating family planning services with HIV health services and provides country examples of integration practices.
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The Nuts and Bolts of FP/HIV Integration: Promising Practices and Technical Considerations Christian Connections for International Health Conference Sunday, June 22, 2014 Jennifer Mason USAID Office of Population and Reproductive Health
Transcript
The Nuts and Bolts of FP/HIV Integration: Promising Practices and Technical
Considerations
Christian Connections for International Health Conference Sunday, June 22, 2014
Jennifer Mason
USAID Office of Population and Reproductive Health
Overview of Presentation
• USG Rationale and Guiding Principles for FP/HIV • FP/HIV integration approaches and models • Programming considerations for specific populations • Country examples • Promising practices • Technical Considerations • Resources
Why Support FP/HIV Integration?
FP/HIV Integration assists the US Government to: • Meet clients’ rights and needs for comprehensive health services
o Access to a full range of FP services and information is critical for individuals to exercise their reproductive health rights.
o USG is committed to meeting the reproductive health needs of PLHIV and those at risk of HIV.
o Ensure PLHIV have access to family planning counseling and services and safe pregnancy counseling through the integration of FP services into all PEPFAR prevention, care, and treatment programs.
• Achieve global FP, HIV and MCH objectives • Leverage USG comparative advantages in FP and HIV • Practice good public health by using evidence based approaches to
achieve improved health outcomes through FP and HIV platforms
Presenter
Presentation Notes
The integration of health programs is a priority for the USG as outlined in the US Global Health Initiative. Integration of FP/HIV will help countries reach goals for global initiatives, including the Millennium Development Goals, creating an AIDS Free Generation, FP 2020 and Ending Preventable Maternal and Child Deaths. Reaching these goals requires new ways of doing business and accelerated programmatic approaches to reach more beneficiaries in a more efficient manner. More on client rights and needs for integrated services on next slide. Better utilizing the expertise of USG agencies, including comparable advantages, through collaboration and knowledge sharing is one way doing business differently, more effectively, and hopefully, more efficiently. Capitalizing on PEPFAR’s renewed engagement in integration and leveraging PEPFAR resources. USG has experience and resources in both technical areas and is a global leader on smart integration of health programming. USG is largest bilateral donor in HIV and has had huge impact on global HIV evidence base, programming and practices. USAID is largest FP bilateral donor and has helped to achieve fantastic FP outcomes through a platform based on voluntarism and informed choice. Implementing effective program practices - and accelerating those practices when we have the opportunity - reduces death and disability and save lives
1. HIV-positive individuals should be provided with information on, and be able to exercise voluntary choices about their health, including their reproductive health.
2. The USG, including PEPFAR, supports a person‘s right to choose, as a matter of principle, the number, timing, and spacing of their children, as well as use of family planning methods, regardless of HIV/AIDS status.
3. Family planning use should always be a choice, made freely and voluntarily, independent of the person‘s HIV status.
4. The decision to use or not to use family planning should be free of any discrimination, stigma, coercion, duress, or deceit and informed by accurate, comprehensible information and access to a variety of methods.
5. Access to and provision of health services, including antiretroviral treatment, for an HIV-positive person should never be conditioned on that person's choice to accept or reject any other service, such as family planning (other than what may be necessary to ensure the safe use of antiretroviral treatment).
6. HIV-positive women who wish to have children should have access to safe and non-judgmental pregnancy counseling services.
Guiding Principles for USG FP/HIV Programs
Presenter
Presentation Notes
All HIV and family planning programs supported by USG foreign assistance funds are subject to legislative and policy requirements outlined by the US Congress. These requirements state that the choice to accept a family planning method should be completely voluntary; free of coercion, duress, or stigmatization; and informed by accurate, comprehensible information. In addition, the provision of health services, including antiretroviral treatment, should never be conditioned on acceptance of a family planning method.
USG Interagency Activities
• Established the USG Interagency FP/HIV Task Force
• 2013-2014 PEPFAR FP/HIV Acceleration Initiative o $25M for five countries: Malawi,
Nigeria, Tanzania, Uganda, Zambia o $1.97M for headquarters country
support and evaluation activities • Develop technical resources and
programming guidance and tools • Provides technical assistance to USAID,
CDC and DoD FP/HIV programs
Presenter
Presentation Notes
One-time funding to jump-start FP/HIV activities Encouraged conversations and strategic thinking across USG platforms Operations research to examine different models for integrating FP and HIV service delivery; comparing efficiencies in providing FP services Costing of PMTCT Prong 2, collaboration with IATT Translations and dissemination of USG FP policy and legislative compliance materials Technical assistance for country programs implementing Acceleration Funding In order to strengthen coordination and programming, five countries (Malawi, Nigeria, Tanzania, Uganda, and Zambia) were selected for additional resources and targeted technical assistance. Countries were selected using the following criteria: (i) significant PEPFAR investments; (ii) significant USAID FP investments; (iii) high HIV prevalence AND high unmet need for FP services. The selected countries were asked to: Submit proposals to expand and strengthen FP/HIV integration within PEPFAR platforms. Countries were asked to include activities that can be done at no-cost, marginal cost, and additional cost. All three categories must be included in the proposals. Indicate how they will coordinate with key USG, national and global stakeholders, including to ensure FP commodity security. Have access to an additional $5 million per country in funding to implement activities that will incur extra costs. Examples of proposed country activities include: Community-based comprehensive mobile health services for key populations Integration of HIV and FP logistics systems Capacity building of FP providers to conduct HIV counseling and testing Training of HIV service providers to provide comprehensive FP counseling and services Strengthening FP services in health facilities with PMTCT programs Revising and strengthening HIV/AIDS and FP guidelines for implementation Interagency coordination (FSN position)
FP/HIV integration approaches and models
• FP/HIV integration service delivery platforms include • HIV • Family Planning • Maternal Child Health
• Models of integrated FP and HIV services: o Co-located services at the same service delivery point - one
provider (e.g. HIV provider counsels and provides FP methods) o Referrals within same health facility - multiple providers (e.g.
internal referral system within same service delivery site) o External referral network between health facilities
• Health Systems Strengthening • Supply chain, training, enabling environment activities
• Social Behavior Change Communication • Community engagement and demand generation
Presenter
Presentation Notes
As noted in the PEPFAR Blueprint, we are optimizing PEPFAR as a platform to incorporate and integrate other essential health services for women, including the integration of HIV and voluntary FP services, aimed at safeguarding the rights of individuals living with HIV in reproductive decisions. PEPFAR supports integration both ways –FP into HIV sites and HIV into FP sites, all for an HIV purpose. USAID’s FP/RH program and PEPFAR have supported integrated HIV and FP services as part of care and treatment for PLHIV, as well as through antenatal care and MCH care platforms, including PMTCT. Now we can really leverage PEPFAR resources for this. Effective and efficient integration of HIV and FP services makes use of diverse entry points and improves comprehensive care for clients. Strategic integration decisions require consideration of the country-specific context, especially the country’s HIV epidemic and its modern contraceptive prevalence rate. Specifics such as HIV incidence and prevalence, unmet need for FP, numbers of people served and cost-effectiveness are important factors to consider when making programmatic choices about integration. The use of multiple service delivery entry points to offer FP services—including through HIV prevention, care, and treatment programs—can have a great impact on the ability of PLHIV and those at risk of HIV to realize their reproductive rights, provide support for meeting women’s fertility choices, and increase the voluntary use of contraception to prevent unintended pregnancies. Such barriers include gender inequality, social norms, and stigma and discrimination. For example, people living with and affected by HIV may refrain from seeking FP services or safe pregnancy counseling for fear of experiencing stigma and discrimination. Furthermore, experience has shown that men’s dominance in reproductive health decision-making, and cultural expectations that encourage high fertility can lead to poor uptake of FP services by both HIV-positive and HIV-negative women. To address this issue, U.S. government-supported programs encourage constructive male participation and couples counseling within family planning services so that both partners can make shared decisions around future childbearing and contraception. Consider structural and institutional barriers that prevent women from accessing services�
Health Systems Strengthening
Health Systems Strengthening
Community engagement
Community engagement
PMTCT Option B+
FP MCH
HIV/AIDS
FP services
ART HCT
Prevention
HBC
VMCC
Safe pregnancy services
Programming for Specific Populations
• Women of reproductive age • PLHIV • Other women at risk of HIV
• Key populations • Sex workers • Female drug users
• Youth • Couples
• Sero discordant couples
• Male engagement
USAID/Uganda
(Below) Marie Stopes Uganda (MSU) and EGPAF coordinate their activities to provide FP to HIV clients at public health centers.
(Above) Women and men attend group counseling together to receive healthy behavior messages, including FP and VMMC.
Presenter
Presentation Notes
While STAR-SW does not implement HIV/FP integrated activities itself, it does coordinate its technical assistance with those provided by MSU to ensure that clients being served by STAR-SW have access to LARC-PMs. STAR-SW and MSU also cross-promote and coordinate each other’s services schedule and advertising campaigns to further advertise the health services being provided by their organizations. Theoretically, ART nurses are trained to provide FP; however, many still refer their HIV-positive clients to the FP nurse (often within the same compound). This results in HIV-positive women having to queue twice to receive HIV and FP services. Due to lack of documentation of FP referrals and the lack of FP uptake data collected by HIV HMIS systems, HIV partners are unable to track and respond to the uptake of FP of their clients.
USAID/Ethiopia
(Below) PEPFAR-supported HIV NGO clinic providing FP services in Addis Ababa, including to ~200 sex workers that live near the clinic.
USAID/Tanzania
Comprehensive group counseling at Marie Stopes Tanzania mobile clinical outreach site, includes HCT services
(Above) Mobile outreach to rural communities by nurse midwives through bajajis
Presenter
Presentation Notes
MST outreach goes to rural communities – usually a health facility to provide a full range of FP methods, including a public sector doctor to perform tubal ligations. Outreach teams consist of 4-5 staff including providers, nurses, driver, counselor, etc who travel to different sites each day. Pictures shows a group counseling session engaging a group of ~40 women on FP methods. This is followed by individual counseling and provision of an FP method of the woman’s choice. Clients are provided with the contact details for the team leader and health facility in case of complication. Demand generation prior to arrival of outreach team
USAID/South Africa
One-stop shop integrated FP and HIV services in primary and community health centers
Presenter
Presentation Notes
Integrated ARV site with one provider – usually ART counselor or doctor provides counseling on FP and service provision, client sees one provider for all her health needs FP methods available include: pills, injectables (method of choice for most women), IUDs available more recently (referred at some PHCs) and implants will be rolled out in early December. Voluntary sterilization (tubal ligation) is available on site at PHCs and CHCs. CHCs also offer safe abortion services within the legal context. Some sites offer delivery services, opportunity for post partum FP provision If a client is HIV-negative and in need of FP – she can go directly to an FP provider at the same site and doesn’t have to wait in ART queue. Some site offer group counseling while clients are waiting, all offer individual counseling, dual protection messages are included.
USAID/Lesotho
Community based HIV activities with FP integration through village health workers
Presenter
Presentation Notes
Visited a faith based hospital that offered one stop services for FP and HIV integration as well as a separate FP and MCH unit within the complex. Injectables were method of choice here as well. Pharmacy had good stock Also visited a PSI VCT center which provides referrals for FP services. Potential to include more information on FP method at this center. Center will also be looking at offering STI services soon. Visited a community health center that offered broad based health services – vaccinations, out patient services, ANC, HIV testing, ARV services and FP services on day per week. Health center has pills, injectables and condoms available, referrals for IUDs and implants. A community group – mothers to mothers comes for the center for group counseling and community support sessions which include messages on FP. Have over 300 ART patients. Community village health workers go into nearby community to provide health talks and often do extensive follow up services from the community health center. They try to combat stigma and help with psychosocial support.
USAID/Zambia
Co-location of VMMC, VCT, and FP services
USAID/Nepal
FP integration for female sex workers in HIV drop in centers
Community-based FP education linked to Radio Listeners Group
FP integration in home based care for PLHIV
Promising Practices Promising practices for improving FP and HIV outcomes • “One-stop shop” service delivery • Dedicated FP providers in HIV sites • Facilitated referrals • Sensitizing FP providers to PLHIV and Key Population needs • Integrated community health outreach
• HIV CHWs delivering ART and FP • FP CBDs providing VCT
• Community based activities • Demand generation for FP integrated with HIV communication efforts • FP integration into home based care for PLHIV
• Integrating FP services into existing Key Populations platforms • Training HIV providers to act as FP Champions
Promising Practices (3) • Integration of FP into PMTCT settings
• FP education in ANC sites • Provision of post partum family planning for PLHIV • Utilizing Option B+ platform to maximize window of opportunities for
FP counseling and method provision
• Integration of FP into HIV treatment settings • Provision of FP services, including methods • Designated FP provider model for high volume sites
• Integration of FP into VMMC settings • Sensitizing males to FP • Leverage resources to expand FP information and counseling
• Supply Chain • Integrating FP and HIV supply chains systems and LMIS
• Monitoring and Evaluation • Integrating FP indicators into HIV HMIS to capture achievements and
have better FP data on PLHIV
Technical Considerations
• No “one-size fits all” approach; country context important • FP services in an FP/HIV integrated site should be of the same
quality as in a traditional FP/RH services. • Provision of FP methods is not the always the best approach;
consider referrals • Ensure programmatic activities are in line with USG compliance
requirements • QUALITY OF CARE! • Ensuring method mix (especially LARCs) • Informed choice for PLHIV
• Strengthen post partum FP within PMTCT • Ensure that FP is part of the key population prevention and
continuum of care package
Presenter
Presentation Notes
High unmet need and limited access through traditional sites
Technical Considerations (2)
• Safe pregnancy services for PLHIV – counseling and care services should be part of comprehensive FP/HIV integration package
• Consider FP integration in design and roll out of Option B+ • VMMC – is VMMC a good integration platform? • Consider HC-HIV issues • Consider the costs of integrated services • Ensure availability of FP commodities in HIV settings as needed • Track FP outcomes in HIV sites
Presenter
Presentation Notes
Training, monitoring, supervision, equipment, additional staff, time, effort Consider using FP outcome indicator in HIV HMIS
FP/HIV Resources
Technical Brief: Hormonal Contraception and HIV http://www.usaid.gov/sites/default/files/documents/1864/hormonal-contraception-and-HIV.pdf
Integrating FP into HIV Programs: Evidence-Based Practices
FP/HIV Resources • USAID Knowledge for Health (K4Health) FP/HIV Integration Toolkit
https://www.k4health.org/toolkits/fphivintegration • From Roots to Results: Evidenced Based Practices for Integrating FP into HIV
http://prezi.com/mwk7mypyw9q7/integrating-family-planning-into-hiv-programs/ • The Balanced Counseling Strategy Plus (BCS+): A Toolkit for FP Service Providers
Working in High HIV/STI Prevalence Settings: http://www.k4health.org/toolkits/sdm/balanced-counseling-strategy-toolkit-family-planning-service-providers
• Reproductive Choices and Family Planning for People Living with HIV: a counseling tool developed by the World Health Organization to help health care workers counsel women and men living with HIV and their partners on sexual and reproductive choices and family planning. http://apps.who.int/iris/bitstream/10665/43609/1/9241595132_eng.pdf
