Transcript Addressing the RH Needs of PLHIV: What do systems have to

Addressing the Family Planning Needs of
People Living with HIV
Betty Farrell, CNM, MPH
Laura Subramanian, MS
Grace Nagendi, MPhil
Charles Ngobi, MD
The ACQUIRE Project/
EngenderHealth
EOP Concurrent Session
September 17, 2008
Session Outline

Integrating family planning (FP) and HIV services:
definition, rationale and goals

Applications of ACQUIRE’s FP-HIV integration
approach

Lessons learned and recommendations for FP-HIV
integration programs
“More
Services
to
More
People
in
More
Places”
Increased Access, Quality and Use
• Service sites
readied
• Staff
performance
improved
• Training,
supervision,
referral,
and logistics
systems
strengthened
Supply
Increased availability
Quality
client-provider
interaction
Demand
Increased knowledge
+ acceptability
• Accurate
information
shared
• Image of
services
enhanced
• Communities
engaged
Advocacy
Improved policy + program environment
• Leadership and champions fostered
• Supportive service policies promoted
• Human and financial resources allocated
Fundamentals
of Care
Data for
Decision Making
Gender
Equity
Stakeholder
Participation
What is Integration?
“An approach in which health care providers use
opportunities to engage the client in addressing
her/his broader health and social needs than
those prompting the health encounter”
Why Integrate Family Planning with HIV
Services?


Increased availability of ART

16.5 million women of
reproductive age living with
HIV
Family planning helps HIV-positive women:
– avoid transmitting HIV to partners and children
– prevent unintended pregnancies and avoid stress of pregnancy
– plan desired pregnancies while minimizing HIV transmission risk

HIV clinic = key service point for people living with HIV
Goals of FP-HIV Integration

Comprehensive HIV services with family planning as
an integral component of care
– Family planning information specific to PLHIV
– Risk assessment and behavior change strategies
– Health monitoring
– Counseling and provision of family planning commodities
Choosing a Level of FP Integration
Level A
Level B
Level C
Provides all of the
following functions:
Provides all of Level
A functions plus:
Provides all of Level
B functions plus:
 Provides
 Provides oral
 Provides injectable
contraceptives* with
instructions for use and
caution to adhere to
daily, on-time pill
taking
hormones with
instructions for use and
caution to return on
schedule for re-injection
FP
information to clients
accessing ART services
 Performs risk/
intention assessment for
pregnancy or spacing
 Counsels on
FP
methods including
ability to prevent
HIV/STIs, dual
protection, potential
drug interactions and
availability/access
 Counsels on
 Counsels on
potential
drug interactions with
oral contraceptives
potential
drug interactions with
injectable methods
Level E
Provides all of
Level C functions
plus:
Provides all of
Level D functions
plus:
 Provides IUD
 Provides surgical
with
instructions for use,
including discussion
of new evidence for
safe use among HIV+
and those clinically
well on ARVs
contraceptive
methods with
instructions for selfcare and provides
follow-up
 Provides implants
 Provides follow-up or
 Provides follow-up or
Level D
refers for follow-up
with instructions for
use
refers for follow-up
 Provides follow-up
or refers for follow-up
 Provides condoms,
instructs/demonstrates
correct use
 Provides Emergency
Contraceptive Pills*
 Refers for methods not
offered on site
* If
facilities or programs providing Level A functions are not immediately prepared to
provide oral contraceptives for ongoing uses, they may provide emergency contraceptive
pills with referral for ongoing FP management. If the facility or program already provides
oral contraceptives (Level B), it can also offer emergency contraceptive pills.
ACQUIRE’s Approach to Integrating FP
and HIV Services
STEP 1*
STEP 2*
STEP 3
STEP 4
STEP 5
Identify/
refine level
of
integration
that can be
adopted
Assess
HIV
program’s
capacity
to support
FP**
Build or
strengthen
systems to
support
new
services
Identify
resources
to support
integration
Phase in FP
methods to
expand mix
within HIV
program’s
capacity
SYSTEMS
Supervision
Logistics
Referral
Training
RESOURCES
Partnerships
Capacity
* Steps 1 and 2 interchangeable
depending on stakeholders’ pre-existing
desires for level of integration
** Include orientation of stakeholders
to staff tasks and system functions
required to support levels of integration
ACQUIRE’s Integration Approach:
Ghana FP-ART Pilot
Needs Assessment
ART Provider
Trainings
April-June 2005
PNA at 2 sites  action plan
July-Dec 2005
FP-ART training curriculum
developed and field-tested
Jan/Feb 2006
32 providers trained to
counsel on FP and provide
pills and injectables
2 government hospitals
providing ART and FP
Job Aids and IEC
materials
Contraceptive chart
Counseling flow chart
Client brochure
Evaluation
May 2006
128 clients received FP
methods
Further attention needed to
clients’ fertility desires and
SD systems to support FP
Ghana FP-HIV Community Pilot:
“Family Planning for Healthy Living”
Peer Educator
Trainings
FP Provider Trainings
July/August 2007
Stigma reduction training &
CTU for 19 FP providers
July/August 2007
75 members from 43 PLHIV
support groups trained in FP
messaging and referral
PE-Provider
Partnerships
FP providers attended
monthly PLHIV support
groups
PLHIV support groups
in 4 regions
Job Aids and IEC
Materials
Contraceptive chart
Sample FP method card
Client brochure
Endline Assessment
April/May 2008
Increased FP knowledge of PLHIV
Expanded FP method mix
Persisting barriers to FP uptake
Ghana: Peer educators, providers and
clients as advocates for FP
Peer educators and Providers

Role models in the PLHIV
community

Advocates and partners for FP
Satisfied FP clients

“I feel confident that I
can prevent pregnancy
until I am ready to have
another child.”

“I am taking care of my
health.”
ACQUIRE’s Integration Approach:
Uganda TASO/Mbale Pilot
FP-ART Provider
Trainings
Needs Assessment
March/April 2006
July-Sep 2006
PNA  action plan
2 Stakeholder meetings
23 trainers and 15 ART
providers trained in FP (pills,
injectables, ECP)
Community
Outreach
16 referral providers
updated in FP
awareness sessions; 4 field
officers and 2 volunteers
trained in FP.
April 2007: 12 community
nurses trained in FP
FS/COPE®
Trainings
Feb 2007
Sep-Dec 2006: 33 FP
TASO/Mbale ART
center
Job Aids and IEC Materials
Contraceptive chart, counseling
flowchart, client brochure
Trainings for QI,
staff performance
and needs
TASO/Mbale: Stories of FP Advocates
ART Providers support FP for PLHIV

HIV-positive
mothers
adopt FP
“Family planning is
about people’s lives.
I don’t want PLHIV
to have unintended
pregnancies.”


Community
nurses talk
about FP and
address
myths
“We now encourage
others to come for family
planning. We share the
information we got from
TASO. Now clients are
learning to plan.”
TASO/Mbale Pilot:
Systems Challenges and Solutions
Training
Supervision
Recordkeeping
Infrastructure
Logistics
Referral
System Challenge: Training
What Would You Do?
TRAINING
Challenges
Staff do not ask
ART clients about
their fertility
desires or family
planning needs
Interventions
System Solution: Training
What TASO Did
TRAINING
Challenges
Interventions
Results
Staff do not ask
ART clients
about their
fertility desires
or family
planning needs
 Train
staff about clients’ FP
rights/needs via staff meetings, CME
 FP
 Train
staff to provide FP counseling
and methods
 FP
 Note
 FP
clients’ FP preferences in chart
providers discussing with
clients their fertility desires
included in health
talks
counseling part of
standard for care
method provision
carried out
 Observe
Develop
IEC materials/job aids
 Content
and quality of
FP counseling observed
System Challenge: Supervision
What Would You Do?
SUPERVISION
Challenges
Supervisors do not
give timely or
constructive
feedback on staff
performance in FP
Interventions
System Solution: Supervision
What TASO Did
SUPERVISION
Challenges
Interventions
Results
Supervisors do
not give timely
or constructive
feedback on
staff
performance in
FP
 FS
 Staff
training to practice
communication skills and
constructive feedback
oriented to giving and
receiving constructive feedback
 Supervisors
 COPE®
training to strengthen
capacity for monitoring quality
of FP services
providing timely,
supportive feedback on FP
activities with help of checklists
 Staff
 Performance
checklists to
support provision of objective
feedback including FP practices
acknowledge more
collaborative relationship with
supervisors and support in
problem-solving
TASO/Mbale Pilot: Evaluation

ART providers respect RH rights and fertility desires of
PLHIV

PLHIV satisfied to receive FP services from ART providers

Strengthened systems for training, supervision, logistics,
recordkeeping, referral, etc. to support FP

TASO/Mbale has provided FP to 605 clients (406 DMPA,
131 COC, and 68 referred for LAPMs)
Implementation differences:
Ghana and Uganda pilots
Ghana FP-ART pilot Uganda FP-ART pilot
 2 public
sector sites
 Multiple
project partners
with competing demands
 3-month
 3-day
implementation
update of trainers
and 5-day training of ART
and FP clinic providers
1
private sector site
1
dedicated project partner
 12-month implementation
 10-day
provider training
with practicum
 FP referral
staff updated
 Attention to
supervision,
QI, logistics, recordkeeping
 Community
outreach
Uganda Positive Prevention Project
Stakeholder engagement
Curriculum
Development
2006
PNA  action plan
Identified 4 liaisons from MoH
2007
Developed and field-tested
FP modules for HIV
counselor and peer educator
training curriculums
Strengthening HIV
Counselor training
(SCOT) Project
Job Aids and
IEC Materials
Contraceptive
chart
RH fact sheet
Client brochure
Reproductive Health Information for People Living with HIV and AIDS
Many people living with HIV (PHA) will want to space their births or prevent pregnancy,
however, availability of inaccurate information on use of family planning by PHA is often a
barrier to uptake of family planning services. This booklet is meant to provide answers to
frequently asked questions on use of family planning by PHA.
FREQUENTLY ASKED QUESTIONS
Q1
What is family planning (FP)?
A:
Family planning (FP) is the right of an individual or couple to decide without pressure
the number of children they want, when to have or stop having children.
Q2
Are all family planning methods safe to use if I have HIV?
A: Yes, most methods are safe to use if you are feeling well. Your health worker should guide
you on the most suitable method by discussing the available FP methods. Using your chosen FP
method with a condom will help protect you and your partner from infecting each other with
different strains of HIV and with STIs. However spermicides are not a suitable FP method
because they irritate the lining of the vagina making it easy for HIV transmission.
FP training
2007-2008
 Orientation, training TA and
post-training follow-up for 69
trainers from SCOT partners
 359 providers trained in FP
Q3
We are a discordant couple, can we use family planning?
A: Yes, you should use FP methods if you are a discordant couple and want to avoid a
pregnancy. Your health worker should discuss with you and guide you on the most suitable FP
method. In addition, you should use condoms correctly and consistently when you have sex to
protect the uninfected partner from HIV infection.
Q4
Do women with HIV experience different side effects or more side effects from family
planning than uninfected women?
A: No. Contraceptive side effects appear to be similar for women with HIV as for those without
the virus. The known contraceptive side effects appear similar for both HIV-positive and HIVnegative women.
Q5
Does family planning reduce the effectiveness of ART?
A: Currently, this is not known. It appears that contraceptives do not reduce the effectiveness of
currently available ARVs. So far there has not been any reported negative impact of Family
Planning on ART effectiveness.
Q6: Does ART reduce the effectiveness of pills and injections?
A: Some ARVs reduce effectiveness of some FP methods. In order to avoid unintended
pregnancy, all women using contraceptive pills should take care to start their next pack on time
and to avoid missing pills. Also the women using contraceptive injections should make sure
they get their next dose of injection at the next appointment date.
 213 community based peers
trained from 9 PLHIV groups
Positive Prevention: Advocates for FP
Providers

“People with HIV have the right
to have children. They deserve
choice, not chance.”
Clients

“Men need to seek family planning
if they love their family.”
Integrating FP and HIV Services:
Lessons Learned

FP-integrated HIV services are
acceptable, feasible and effective

Integration can be implemented at a
variety of levels

Holistic Supply-Demand-Advocacy
approach contributes to successful
sustained integrated services
ACQUIRE’s Integration Approach:
Lessons Learned

Supply: strengthening systems is key
– Counseling/clinical training in FP with practicum, post-training
follow-up, job aids/ IEC materials
– FS/COPE® to strengthen overall systems and supervision
– TA for using FP commodity supply system
– Accurate, organized records to track provision of FP counseling and
methods
– Strong referral linkages
– Assistance from volunteers to manage increased workload
ACQUIRE’s Integration Approach:
Lessons Learned (continued)

Demand: generate FP awareness and link HIVpositive clients with services
– Disseminate FP info through awareness sessions and campaigns
– Develop partnerships with peer educators and PLHIV groups

Advocacy: gain buy-in to create/maintain a
supportive environment for integration
– Collaborate with stakeholders, including community
– Orient donors to integration rationale and approach
– Engage senior health personnel in integration process
– Create fora for collaboration between FP and HIV leadership
– Develop supportive guidelines and policies for integration
Recommendations for FP-HIV Integration

5-step integration approach with SDA elements and
attention to systems strengthening
– Engage multiple levels of facility and MoH staff
– Consider LOE required for integration
– Implement comprehensive FP training + follow-up package
including addressing provider attitudes toward PLHIV
– Update referral site staff to strengthen linkages
– Partner with PLHIV communities as advocates for FP
– Assess site capacity for expanding FP method mix

Explore modifications to ACQUIRE integration approach
Acknowledgments

USAID – Mary Ann Abeyta-Behnke, Sereen Thaddeus, Peter
Wondergem

TASO – Drs. K. Mugisha & C. Ngobi; G. Ochieng; Center staff

Uganda MoH – Drs. Sentongo, Madra, Latigo, Esiru, Lukoda

Mbale Regional Hospital FP Unit – the late Sr. Tunde

ACQUIRE/Uganda – Dr. H. Kakande, G. Nagendi

QHP – O. Aglah, Drs. P. Preko and E. Bonku, P. Ampofo, R. Killian

OICI, CRS, SHARP and Ghana Health Service

ACQUIRE/NY – A. Kaniauskene, N. Johri, N. Russell, J. Wickstrom

Photo credits: N. Russell and TASO/Mbale
Featured Materials

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FP/HIV Integration Framework document (NY, June 2006)
ACQUIRING Knowledge: TASO/Mbale Project Brief (NY, 2007)
Evaluation of the TASO FP/ART Pilot (NY, August 2008)
Job Aids from Ghana and Uganda (2005, 2006)
Contraception for Women and Couples with HIV (FHI/ACQUIRE
product collaboration)
FP-HIV Integration Toolkit (FHI/ACQUIRE product collaboration)
Positive Prevention Family Planning Module #9 (from the tool
Positive Prevention Counseling: A training manual (Uganda, 2007)
Integrating Family Planning with HIV Care and Treatment Services:
A Training Curriculum for Providers & Counselors (Uganda, July
2006)
Ghana Peer Educator training manual: Family Planning for People
Living with HIV and AIDS, July 2007
Want to Know More?

Visit the ACQUIRE Project website:
www.acquireproject.org or email us at [email protected]

To learn more about TASO and their activities, visit
their website at www.tasouganda.org. For specific
information on TASO/Mbale, visit
http://www.tasouganda.org/mbl.php