Addressing the Family Planning Needs of People Living with HIV

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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

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Session Outline

• Integrating family planning (FP) and HIV
  services definition, rationale and goals
• Applications of ACQUIREs FP-HIV integration
  approach
• Lessons learned and recommendations for FP-HIV
  integration programs

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• Service sites readied
• Staff performance improved
• Training, supervision, referral, and
  logistics systems strengthened

• Accurate
• information
• shared
• Image of services enhanced
• Communities engaged

Quality client-provider interaction
Increased knowledge acceptability
Increased availability
Improved policy program environment

• Leadership and champions fostered
• Supportive service policies promoted
• Human and financial resources allocated

Fundamentalsof Care
StakeholderParticipation
Data for Decision Making
Gender Equity
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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

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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

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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

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Choosing a Level of FP Integration
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.
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ACQUIREs 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 programs 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
programs 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
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ACQUIREs Integration ApproachGhana FP-ART
Pilot
Needs Assessment April-June 2005 PNA at 2 sites ?
action plan
ART Provider Trainings 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
Evaluation May 2006 128 clients received FP
methods Further attention needed to clients
fertility desires and SD systems to support FP
Job Aids and IEC materials Contraceptive
chart Counseling flow chart Client brochure
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Ghana FP-HIV Community PilotFamily Planning
for Healthy Living
FP Provider Trainings July/August 2007 Stigma
reduction training CTU for 19 FP providers
Peer Educator Trainings 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
Endline Assessment April/May 2008 Increased FP
knowledge of PLHIV Expanded FP method
mix Persisting barriers to FP uptake
Job Aids and IEC Materials Contraceptive
chart Sample FP method card Client brochure
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Ghana Peer educators, providers and clients as
advocates for FP
Peer educators and Providers
Satisfied FP clients

• Role models in the PLHIV community
• Advocates and partners for FP

• I feel confident that I can prevent pregnancy
  until I am ready to have another child.
• I am taking care of my health.

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ACQUIREs Integration ApproachUganda TASO/Mbale
Pilot

• FP-ART Provider Trainings
• July-Sep 2006
• 23 trainers and 15 ART providers trained in FP
  (pills, injectables, ECP)
• 16 referral providers updated in FP

Needs Assessment March/April 2006 PNA ? action
plan 2 Stakeholder meetings
Community Outreach Sep-Dec 2006 33 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 Trainings for QI,
staff performance and needs
TASO/Mbale ART center
Job Aids and IEC Materials Contraceptive chart,
counseling flowchart, client brochure
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TASO/Mbale Stories of FP Advocates
ART Providers support FP for PLHIV

• Community nurses talk about FP and address myths

• Family planning is about peoples lives. I dont
  want PLHIV to have unintended pregnancies.

• We now encourage others to come for family
  planning. We share the information we got from
  TASO. Now clients are learning to plan.

HIV-positive mothers adopt FP
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TASO/Mbale Pilot Systems Challenges and
Solutions
Record- keeping
Training
Supervision
Infrastructure
Logistics
Referral
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System Challenge TrainingWhat Would You Do?
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System Solution TrainingWhat TASO Did
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System Challenge SupervisionWhat Would You Do?
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System Solution Supervision What TASO Did
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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)

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Implementation differencesGhana and Uganda
pilots
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Uganda Positive Prevention Project
Stakeholder engagement 2006 PNA ? action
plan Identified 4 liaisons from MoH

• Curriculum Development
• 2007
• Developed and field-tested FP modules for HIV
  counselor and peer educator training curriculums

Strengthening HIV Counselor training (SCOT)
Project

• FP training
• 2007-2008
• Orientation, training TA and post-training
  follow-up for 69 trainers from SCOT partners
• 359 providers trained in FP
• 213 community based peers
• trained from 9 PLHIV groups

Job Aids and IEC Materials Contraceptive chart RH
fact sheet Client brochure
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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.

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Integrating FP and HIV ServicesLessons 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

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ACQUIREs 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

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ACQUIREs Integration Approach Lessons Learned
(continued)

• Demand generate FP awareness and link
  HIV-positive 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

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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

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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

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Featured Materials

• 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

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Want to Know More?

• Visit the ACQUIRE Project website
  www.acquireproject.org or email us at
  info-acquire_at_acquireproject.org
• 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