FP/RH and HIV/AIDS(VCT/PMTCT) Integration: Advance Africa’s experience

2. FP/RH and HIV/AIDS(VCT/PMTCT) Integration:Advance Africa’s experience Kwaku Yeboah MB,CHB; MPH Arlington, November 18, 2004

3. Outline of presentation • Overview of RH/HIV/AIDS Integration • RH/HIV challenge • Definition/Why integrate? • Levels/models of integration • Advance Africa’s experience • Way forward

4. The Reproductive Health Challenge • Enormous task in tackling unmet needs of RH in developing world • Over 120 million women have unmet need for FP • 350 million women lack access to full range of contraceptive methods • 120,000 HIV + women get pregnant each year • # of young people 10-24 yrs increased by 50% in 30 yrs • Between 1994 and 2015, 3 billion people will enter reproductive years • 500,000 women die a year from pregnancy related causes

5. CPR remains low and unmet need is high for most countries in Sub Saharan Africa

6. Both Unmet Contraceptive need and Adult HIV Prevalence are high

7. HIV/AIDS Challenge • 40 million people worldwide; approx.70% in SSA • 14,000 new daily infections ( mainly through sexual contact) {UNAIDS} • Women and young people especially vulnerable • 50% new infections in 15-24 yr olds • 50% new infections among women • Annually 1.8 million infected pregnant women deliver approx 600,000 infected infants (UNICEF)

8. Effect of unmet need and high HIV prevalence • Estimated 20 million women living with HIV • 25% of women with an unmet need for contraception • Therefore an estimated 5 million HIV positive women are in need of contraception

9. Integration defined • “arrangement for the provision of multiple but related services concurrently during a same visit” • Provider of one service actively encourages clients to use other services during the same visit

10. Why Integrate RH and HIV/AIDS Programmes? • FP and HIV/AIDS services are both elements of reproductive health care, aimed at improving reproductive health of individuals. • FP is a key strategy in reducing vertical transmission of HIV. • To maximize use of scarce financial and human resources, and respond to client needs by offering services to meet multiple needs of clients

11. Why integrate? (2) • Both have similar socio cultural determinants • Both programmes serve essentially same target groups. • Both rely on effective prevention. • Both promote responsible sexual behavior among others. • Both require and use similar medical/health skills and /or facilities. • Both address sensitive sexuality issues

12. Levels of integration • Policy • Provides framework and enabling environment • Programmatic • Gives the clear direction of the “how”( reduce missed opportunities) • Service delivery • Institutional arrangements/ community involvement and participation

13. Models of integration • High integration • Services in same physical location • Services in same institution but different physical locations • Low integration • Services in different institutions but linked by pre arranged mechanism

14. Prevention of Mother to Child Transmission Strategy (UNAIDS/WHO) Prevention of HIV in women, especially young women Prevention of unintended pregnancies in HIV-infected women Prevention of transmission from an HIV-infected woman to her infant Support for mother and family Phase 1 Phase 2 Phase 3 Phase 4

15. Prevention of unintended pregnancies among HIV + women. How? • Meet unmet need for contraception • Bring services closer to HIV + women • VCT, PMTCT, ARV treatment programmes, HBC • Address special needs of HIV + women currently using FP

16. What did Advance Africa do? • Development of strategy • Advocacy for integration • Assessment of sites for demonstration projects • Participatory planning • Capacity building • Supervision • M&E

17. Strategy • Work with already existing VCT/PMTCT/PMTCT Plus programs • Chelston clinic • MOH, Mozambique • 3 Mission hospitals in Zimbabwe • Use already existing service delivery arrangements • Harness community mobilization for demand generation

18. Advocacy • “Why FP matters” developed • Personal contacts with appropriate authorities in demonstration sites • Advocacy seminar in Harare – Sept 2003 • Targeted heads and key staff of demonstration hospitals • USAID, MOHCW,ZNFPC,PSI,EGPAF etc • About 65 participants involved

19. Assessment of sites • Objective was to determine current status of RH/FP and HIV/AIDS as it relates to: • Access – service delivery arrangement and cost • Quality – numbers trained in FP and when, any refresher training, equipment, method mix etc • Demand for services – community mobilization • Sustainability – ownership, partnerships, collaboration

20. Participatory planning • What to do • Target groups • How to undertake these without disruption of services • Time line • Indicators • Product: detailed plan for each site

21. Capacity building • Development of curriculum • Focus on special contraceptive needs for HIV + women, dual protection and WHO medical eligibility criteria. • HR – training needs assessment in Zimbabwe • Training – 5days theory to be followed up with clinical practice • 16 trainees from 3 hospitals in Zimbabwe • 28 trainees from 10 provinces in Mozambique • 25 trainees from Chelston and 4 surrounding clinics • Technical supervision planned for trainees

22. Capacity building-2 • Commodity security • Reviewed current system and added additional resources for additional quantities of contraceptives to ensure wider method mix • Data management • Orientation of relevant staff in data entry and analysis • Provision of PC to facilitate data management • Community outreach strengthening • Resources for more outreach • Additional depot holders recruited in Zimbabwe

23. Results – Howard Hospital (October 2004)

24. Results – Gutu Mission Hospital (October 2004)

25. Results – Chelston Clinic, Lusaka (October 2004)

26. Method Mix by HIV status ( all 3 sites) Condoms are both male and female

27. Lessons learnt • Advocacy seminar sought to clarify the concept of integration • Participatory planning allowed the hospitals to identify the best ways of implementing the integration • Trainees have developed confidence in providing FP for HIV + women • Clear guidelines on reporting enhanced data collection • Community component very crucial

28. Challenges to integration • Policy issues( e.g restriction on certain service provision by certain categories of HCWs) • May create additional burden on providers • May meet resistance by service providers • Existing parallel programmes may resist integration • Continuous availability of RH commodities • Community perceptions/commitment

29. What is the future for AAs integration efforts? • All resources will be widely disseminated as part of the close out of the project • A thorough write up of the experience with all relevant documentation will be made available to integration working group for dissemination • Specific best practices will be documented

30. Conclusion • Integrating FP/RH and HIV/AIDS programmes have great benefits to providers and clients • Political will, commitment and change in orientation is required to ensure that integration happens • Challenges are inevitable but can be overcome • Integrating FP/RH and HIV/AIDS services is feasible in spite of HR and financial constraints.