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INTEGRATING Sexual & Reproductive Health and HIV Services. OVERVIEW & REVIEW OF EVIDENCE Susannah Mayhew, Kathryn Church, Manuela Colombini Acknowledgements: Aagje Papineau-Salm, Lydia Mungherera, Ron MacInnis. Background.

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integrating sexual reproductive health and hiv services
INTEGRATING Sexual & Reproductive Health and HIV Services


Susannah Mayhew, Kathryn Church,

Manuela Colombini

Acknowledgements: Aagje Papineau-Salm,

Lydia Mungherera, Ron MacInnis

varying definitions and understandings of integration
Varying definitions and understandings of integration
  • Bundling of services e.g. IMCI (Becker et al., 1997)
  • Functional vs organisational (WHO, 1996; Lush et al., 2001; Fleishchman, 2006)
  • Active (provider-driven) vs responsive (client-driven) (Maharaj & Cleland, 2005)
  • Provider-level vs facility-level integration (Fleishchman, 2006)
  • Linkages (IPPF, WHO, UNFPA, etc.)
  • Are we integrating services, or are we simply adding in interventions?
  • Most importantly: what is being integrated with what?

SRH Care

HIV Care

Service Reality

  • FP/RH services
  • FP counselling (new and repeat users)
  • EC provision
  • Pregnancy testing
  • Abortion services (where legal)
  • HIV Prevention
  • HIV testing and counselling
  • Male circumcision
  • STI treatment

How do these fit into a PHC context?

  • HIV care (pre ART)
  • Screening for TB and other OIs
  • Clinical staging (with CD4s)
  • Psycho-social support
  • OI Prophylaxis
  • Clinical monitoring and restaging
  • Positive prevention


  • MCH services
  • ANC
  • PNC
  • Newborn and child health
  • Sexual health services
  • STI/HIV prevention (condom promotion, dual protection)
  • STI screening, diagnosis & treatment
  • Pap smears
  • Sexual health counselling
  • Refer out:
  • Delivery care
  • Specialised STI treatment
  • Infertility treatment
  • Cervical cancer treatment
  • Refer out:
  • TB care?
  • Home-based care
  • Specialised care for OIs
  • Palliative Care
  • ART
  • ART adherence counselling
  • ART provision & monitoring
  • Psychosocial support
  • Positive prevention
1 integration into srh services

Recent review on impact of integrating HIV & STI services into FP contexts (Church & Mayhew 2008):

1. Integration into SRH services
  • Clients generally satisfied to received broader package of care
  • Increased access to STI/HIV services BUT persistence of missed opportunities
  • Mixed results on reaching men and youth
  • Evidence of reducing stigma, but also concerns over privacy and confidentiality, and poor treatment of PLWH
  • Many provider-related constraints identified, but also some preferences for integrated care
  • Weak evidence of impact on health outcomes
  • Difficulty in evaluating an integrated model; lack of controls & experimental designs
  • Little evidence on cost effectiveness/cost benefits
2 srh needs of plwh
2. SRH needs of PLWH
  • Multiple studies in sub-Saharan Africa have found PLWH (in either PMTCT, pre ART or on ART contexts) have high unmet needs for SRH care (Cooper et al, 2009; Heys et al 2009; Homsy et al 2009; Meyer et al, 2007; Stringer et al, 2009).
  • Both supply- and demand-side factors influence demand for FP for PLWH
  • High baseline unmet needs for family planning in many high prevalence settings

“there was no planning whatsoever with any of them, it would happen by accident, and it’s like I woke up and I had 13 children and couldn’t do anything about it” (male client, ART clinic Swaziland, INTEGRA project)


  • Impact of promoting long-term FP methods in HIV settings; impact on condom use in PLWH: are we doing any harm & should dual protection be a priority?
evidence from programmes on meeting srh needs of plwh
Evidence from programmes on meeting SRH needs of PLWH
  • Limited robust evidence on integration of SRH into HIV care contexts
  • Studies suggest integration can increase FP counselling or uptake through:
    • Referral models: Chabikuli, 2009 (Nigeria); suggest integrating FP into HIV care
    • Onsite delivery: Bradley et al, 2008 (Ethiopia), ACQUIRE, 2008 (Uganda); King et al 1995 (Rwanda); Mark, 2007; Peck et al 2003 (Haiti)
  • Mixed evidence on impact of integration: most studies record little or no impact on service uptake or health outcomes.
  • Limited individual programme data on costs; much aggregate data on cost-effectiveness of FP as an HIV prevention intervention (Reynolds; Stover; Halperin)
what model of service delivery best meets srh needs of plwh the integra project
What model of service delivery best meets SRH needs of PLWH? The Integra project

I haven’t told anyone [about my status] I only tell those that I find at the clinic when I go collect my pills, they talk about their situations and I also find myself sharing mine, but when it comes to my family, its still a challenge. (female client ) facility-level integrated site

Qualitative interviews with 15 providers and 22 clients at 4 HIV clinics

HIV client exit survey (cross-sectional) with 611 HIV patients

  • Integrated clinics not better at meeting SRH needs
  • Integrated clinics not less stigmatising for HIV patients
  • HIV clients satisfied at both types of services; reasons for choice = proximity, provider friendliness, referred or recommended
3 hiv provider attitudes to integration
3. HIV Provider attitudes to integration
  • Some providers see benefits to integration but many studies demonstrate common provider-level and health systems challenges
  • Even where providers were trained on SRH, many still lack knowledge on dual protection, and on appropriate contraceptive choices for PLWH
  • In some settings, providers fear HIV infection within clinics which has implications for offering more clinical FP methods.
  • Providers often assign ‘blame’ to clients for poor FP uptake/continuity
  • Useful strategies at provider level: provider/clinic participation in needs assessment before integration activities: opportunity to promote buy-in

(ACQUIRE Project, 2008; Adamchak, 2007; Hayford, 2009)

4 pmtct services and a continuum of care for pregnant women with hiv

Factors affecting uptake of and adherence to PMTCT services:

    • Health systems factors; Socio-cultural factors (community level); Individual factors (of HIV+ mothers)
  • Programmes with high rates of adherence offered:
    • same-day test results and knowledge on ARV benefits for HIV prevention, supported partner involvement, and gave the nevirapine tablet at post-test counseling (at first visit) (Spensley et al, 2010; Nassali et al, 2009; Temmerman et al., 2003)
  • Limited data on continuity of HIV/AIDS care to mothers and babies after delivery
  • High drop out rates of PMTCT post-partum care (Bwirire et al, 2008; Chinkonde et al, 2008)
  • Limited postpartum linkage of HIV mothers to HIV/AIDS care
  • Implications of shift from single dose NVP to triple therapy
  • Impact of PMTCT on mother + long-term survival rates
4. PMTCT services and a continuum of care for pregnant women with HIV
challenges in srh hiv integration programme experiences
Challenges in SRH-HIV integration: Programme experiences

Definition: what do we mean by integrated services? Is a good referral system sufficient? Should 1 person do it all? What are ‘linkages’ ?

Differing service configurations: differ from clinic to clinic, town to town, region to region, country to country : how to formulate policy advice?

Health systems challenges: staffing shortages; health worker management systems (rotation); space constraints; logistics systems derived from vertical programmes; management & supervision; weak referral systems

Cultural challenges: client expectations; provider attitudes and expectations; cultures of practice within medical systems (task-orientation and specialism culture); challenges shifting to client-centred care

Technical challenges: skills training – how much can multi-purpose health workers be expected to learn or do?

Donors and funding streams: national & international policies may necessarily still be disease-specific, but leads to separate training, skills specialisation, and programme activities in clinics

research gaps
Research gaps
  • Cost-effectiveness data on integrated vs stand-alone services
  • Impact data on health outcomes
  • Detailed assessments of process in intervention studies (WHY does integration work well in some settings and not others?)
  • Impact of integration in reducing HIV-related stigma
  • Is there a demand for integrated services, and how are clients currently accessing care?
    • What kinds of SRH services do PLWH want? Which types of services best meet their SRH needs?
  • Integration into primary care: what are the implications? How to integrate HIV into other PHC services such as child welfare?
  • Associations between pregnancy and HIV
conceptual research challenges
Conceptual & Research Challenges
  • ‘Integration’ has no consistent definition and there are as many variations as clinics
  • Separating out treatment and prevention programmes: what different service configurations belong together?
    • VCT & dual protection in FP/ANC/PNC clinics
    • PMTCT in ANC clinics
    • ART and FP/SRH in HIV clinics
  • Isolation of the integration effect from other programmatic activities/interventions virtually impossible
  • Complex structure of health services & programmes inhibits measurement of specific models

IPPF, LSHTM and Population Council-NairobiAssessing the benefits & costs of different models of integration of HIV and SRH services in Swaziland, Kenya and Malawi 2008-2012. Aims: (a) determine the benefits of different integrated models; (b) determine the impact of different integrated services on changes in HIV risk-behaviour; HIV related stigma and unintended pregnancies; (c) establish the efficiency& cost-effectiveness of using different operational models for delivering integrated services; (d) ensure utilization of research findings by policy and program decision makers through extensive stakeholder or