Betty Farrell, CNM, MPH - ACQUIRE Project, EngenderHealth, Ghana, Uganda
September 2007
Betty L. Farrell serves as Senior Medical Associate for Integration with EngenderHealth. Ms. Farrell has broad national and international experience in midwifery education and practice, health personnel training, project administration and evaluation, as well as capacity-building with non-governmental organizations (NGOs). Ms. Farrell's education, training, and technical assistance have focused on family planning, optimal breastfeeding, and HIV, as well as other areas of reproductive health. As technical advisor with several domestic and international organizations, Ms. Farrell has provided technical assistance in Botswana, Cambodia, Ecuador, Egypt, Ghana, Jordan, Kenya, Malawi, Nigeria, Peru, Uganda, Zambia, and Zimbabwe. The HIV/SRH Integration site interviewed Betty about her experience with providing integrated services in Ghana and Uganda.
Can you give us a brief background of the program that deals with integration?
EngenderHealth was awarded the ACQUIRE project, which focused on increasing access to facility-based reproductive health (RH) and family planning (FP) services and also to support access to under-utilized methods. We also had a larger mandate to develop integration strategies to help increase access to FP. One of the areas we found that was sorely in need of support was RH needs among persons living with HIV (PLHIV). Because of that area of need, we actually were able to get funds for projects in two countries to look at what it takes to integrate FP services with antiretroviral (ARV) treatment services. As part of the ACQUIRE project, I developed a framework of integration which looks at the “what” and the “how” and then we applied the framework to the two pilots in Ghana and Uganda with stakeholder input. The Ghana pilot was first -- that was 2005-2006 -- and Uganda was 2006-2007. The focus was a bit different in that the Ghana experience was with two public sector facilities and the Uganda experience was with an NGO called TASO (The AIDS Support Organization). By and large, we have carried out the pilot, looked at the interventions and gotten a sense of how to best support the integration process.
Why Ghana and Uganda?
USAID originally suggested South Africa and Rwanda. When we suggested the project to the leadership in both of those countries, they noted that the programs on the ground were already overloaded and the staff on the ground were already stretched, so they respectively declined. In the first collaboration with Ghana (the replacement for Rwanda), we were asked to work with FHI so we would have a service delivery and a research team working on the implementation and monitoring and evaluation. Since the Rwandan opportunity was not available, the FHI team suggested Ghana since they were carrying out ARV programs there. So that’s where we went since the mission was interested and there was an infrastructure. FHI was already there and EngenderHealth had a few projects there. It made sense to pursue that avenue. As a replacement for South Africa, we chose Uganda because we were working there and our Uganda USAID Mission advisor had a keen interest in supporting FP and increasing access. When I proposed this pilot to her, she was keenly interested because there was a real absence of this service in the care and treatment in the country. So she was very interested in having this piloted there for possible scale up.
Did HIV prevalence rates also play a role in deciding where to try this?
Yes, I think it initially did since South Africa and Rwanda were first chosen and not the other two countries - the two other countries would be the next likely place to try the pilot.
Can you talk a little more about how that framework was developed?
Basically what I developed was a framework that looks at the background of persons living with HIV. Very often the focus of their care and treatment is the infection and preventing and managing opportunistic infections. Depending on the structure of the program, there is some linkage with social, legal, or quality of life resources. Very little has been done with the reproductive aspect of persons living with HIV. So we go through the background of that area of neglect. The document goes on to the definition of integration, the benefits and challenges to service sites, potential entry points where a person accessing health services may be able to receive information and be referred for FP information or HIV prevention information. We also talk about what integration might look like at a service site depending on the capacity to provide selective methods.
There is a chart that looks at a progressive range of offering methods. We include a discussion of operationalizing integration. What may be some of the policy and programmatic supports necessary for integration - what the service site would need and what the community component could be to support integration. We do a fair bit of looking at what the service delivery considerations need to be for integration, such as supervision, training, logistics, referral and record keeping. We look at some of the questions you may want to ask yourself when assessing the ability of your staff to take on additional services such as FP counseling, or possibly offering one or two methods or doing counseling and referral. We've included some examples from our activities in Ghana and Uganda and we have offered some forward thinking about sustainability -- what may be some of the considerations of sustainability. To support that we have appendices looking at what the possible integration tasks would be based on the cadre of persons working in the HIV care and treatment center. We look at some of the possible indicators. It’s a fairly comprehensive document that gives much food for thought.
Just to clarify the dates of the program -- Ghana you said was 2005-2006 and Uganda was 2006-2007? Is there any plan to carry that further?
We're getting ready to carry out the evaluation for the Uganda program. These are pilots so at this point once we finish the evaluation materials and present those we are not sure if they'll be additional funding for expansion. In the Uganda setting the organization we were working with -- TASO -- in general acknowledges the need for FP in their care and treatment portfolio and are interested in the evaluation to guide them to scale up. They are about 90 % externally funded, so this is part of something they want to take into consideration when they make their proposals or requests for funding. In Ghana, what the USAID mission there did was request that we look more at building PLWHIV networks to carry the information to their peers and the communities they serve. They also wanted us to work with facility-based providers to ensure that once people have received the information about family planning and the benefits to them, they are linked to the facility that has trained providers who are knowledgeable about the unique FP considerations of people with HIV and have the attitude to support PLWHIV to make informed decisions about their fertility.
Is TASO a community support group?
TASO is an AIDS Support group. It started out back when HIV/AIDS emerged in Uganda. It started out providing support to persons living with HIV and their families, and as the epidemic grew they became more active in providing support to people who tested positive as well as people who tested negative. They had what they called the post-test clubs. They’ve always been a people-responsive, grass roots organization that has been active in making sure the needs of PLWHIV were heard by the ministries and the government sector as well as providing support for people in the communities. They currently have 11 branches throughout the country and it has only been in the last three years that CDC (Centers for Disease Control and Prevention) has approached them to start offering ARVs. So it’s a different model in that it’s a community-focused organization that now has added the medical component -- the ARV therapy -- as opposed to other organizations, which are basically medical institutions offering ARVs and trying to provide the other components of care -- the more social service components of care.
In working with TASO, recognizing the FP needs of the HIV-positive clients, did the clients make any comments about this? How did they feel about this?
As part of the needs assessment, we had group discussions with a group of positive women, a group of positive men, and a group of discordant couples and they weighed in on what they saw, such as whether they thought it would be a value to add the services. The positive women felt it would be valuable to add the services because they may be in situations where their partners may refuse to use condoms, so if they want to avoid pregnancy they need other options. They were very comfortable at that TASO center and didn't necessarily want to go somewhere else for FP services -- especially when they disclose their HIV status.
The men in the group seemed a little more conflicted about FP in that they feel pressured by their clans to reproduce. If they haven’t disclosed their HIV status to their family, they feel "pressurized" by the family to have children. If they and their partners do discuss FP they feel more comfortable receiving services from a site where they have relationships with a counselor and with the staff rather than going somewhere else. The discordant couples tended to be older, so for them the issue around contraception is less urgent because they have had their children already. When we asked them about if they felt there was a particular way the service should be handled at the center, most felt that the FP services should have dedicated staff in a dedicated area so that clients needing the services would not have to wait through the general waiting area and go through the general registration process. When we worked with the supervisors there was discussion about how to triage the people when they were coming to register so that they would not get incorporated into the general pool of clients waiting for services and could get FP services directly. They could be directed to the FP clinic. That’s an activity in progress right now.
Who else was involved in deciding how to go about this program and deciding what approaches to take?
The concept paper was designed and approved by USAID. When the paper was approved we held meetings in country with the EngenderHealth representative and with the leadership of TASO and introduced the idea of the project and the approach. Since TASO had been doing some work with CDC on care and treatment they had only recently begun providing ART. They started in September 2004. They had begun to notice that more of their clients were becoming pregnant and the majority of those pregnancies were unintended so we came around at the right time when they had expressed a need for that type of intervention. Once we got their approval to proceed, they suggested a service delivery site within their network that they felt would be a good place to begin. They chose a site in the Eastern part of the country where the total fertility rate is higher than in any other part of Uganda and where they had an active ARV service, so they thought there would be a high volume of clients or potential clients for FP.
Once we got there, we used our stakeholder participatory approach to identify the needs of the community. The community is a large community -- it’s a community of potential users, users of the services, residents in the immediate community that are served by the facility, providers, counselors, managers, and representatives from the district health management team and the regional reproductive health coordinator. Those individuals were part of a large stakeholder meeting where we introduced the idea of RH needs for persons living with HIV and the rationale of offering FP as part of care and treatment
As a part of that discussion we got the sense of what they thought was going on in the services and in the communities for persons living with HIV. Based on what they thought was going on we did an assessment, interviews, and facility audit and reported back what we found. We identified the gaps between what they thought was going on and what they would like to see go on.We then worked with them to refine the approach outlined in the concept paper so it was relevant to their circumstances. So that is how we developed the action plans or the activities or the interventions that would be carried out under the pilot.
Was there any involvement of community support groups in Ghana?
They were not as active -- it was focused more on the two public sector hospitals and the FP clinics at the two hospitals as well as the ART clinics at those two hospitals. However, there was community representation during the needs assessment phase.
Were the ARV providers being trained in FP counseling or are we talking about separate providers?
When we refined the interventions, the TASO liaison told us there would be a need to train the counselors. Counselors do the most support and reinforcement of messages. We would also need to train the clinical providers, and we would need to train their trainers to keep this going. The center has a group of community nurses and a group of field officers who provide services and follow up in the field, and they also needed to be trained. Because our activity was a pilot and had limited funds, we needed to train a core of their trainers and from that core TASO identified members of the counselors, clinicians, field officers, and community nurses to be trained to provide the counseling and methods. This particular site also thought they could offer, in addition to the condoms they were already providing, combined oral contraceptives and Depo-Provera. For other methods they would refer the clients to the regional hospital, which basically is on the same compound where they have a building. The other resources in the community were the FP Association of Uganda and a couple of other sites, so they could offer the clients at least a list of other resources if the clients wanted an implant or a tubal ligation.
What about condoms?
Condoms are available and have been their staple, but it has been their staple in regards to infection prevention rather than contraception.
Were there situations of people going elsewhere and having negative experiences?
Yes. Fortunately we worked with the staff at the regional hospital FP clinics so that was an additional intervention. We had to get them updated as well so there wasn’t a conflict of information being provided. The nurse in charge was very supportive. We did an update with their staff, and a little referral slip was designed by TASO so that if a person was sent to that FP clinic, the staff there would give the referral slip to the client so when they came back for their ongoing monitoring at the treatment centers, there would be some documentation of the visit. One challenge that some clients had was when they were referred to the regional hospital for implants -- apparently the implants were very popular. If the provider at the hospital was very busy -- and there were a number of clients coming for the implants -- the client may not have gotten it on the day she appeared, so provider availability was a barrier. At one time the providers at TASO were interested in being trained in implants, but given the limitation of time and funding it was not possible to support that. But on a scale up, it would be advantageous to add that if the system could afford it.
Can you discuss if there were problems when implementing the pilot phase of this project? Any other obstacles?
One of the realities is the staff you are working with already carry out multiple tasks. So as they are trying to multi-task in their own scope of work, we are asking them to take on additional activities. Despite the fact that they want these services and want to be able to provide these services, it does take some adjustment and what we did was phase our interventions. We started with the –training of trainers, orienting their trainers and then followed it up a couple months later with training the service providers and counselors. Then we gave them a chance to start using what they were taught. Then three months later we came back and provided support to the supervisor, giving them supervision skills because many of them had risen to the ranks of supervisors without any training and basically were clinicians who were asked to supervise others while they also did the direct care function. We also worked with those supervisors and heads of departments to develop or refine an ongoing quality improvement mechanism that would help them define what they were doing, adjust what they were doing, and develop some problem solving skills at their own level. Then they would identify the problems beyond their capacity to resolve and have these communicated to their headquarters for support, so that helped.
The other challenges we had were getting TASO to access the FP commodities through the public sector system. What we were able to do is develop a relationship with the FP clinic of the regional hospital so they would put in the request for TASO as an interim solution while TASO got their staff oriented to the pull system and started making the requisitions directly.
The other challenge was record keeping. Since it is an HIV care and treatment center and their funders require record keeping, none of the record keepers addressed or tracked FP activities, so they had to develop a log book to capture FP statistics.
When we conducted the facilitated supervision, there emerged a number of issues related to the need for paying more attention to infection prevention. That was found to be a practice that needed to be corrected and supported. The way staff had arranged their physical structure for counseling violated privacy, so they took steps to improve auditory and physical privacy. They also needed to look at waiting time which was long so they came up with some solutions to reduce the waiting time. Part of it was the triaging and part of it was rearranging some of the activities that happened in the early part of the morning when clients first come so they're not sitting around waiting a long time in the morning before they are seen. So actually the pilot itself helped them look at their services in general and identify areas that were problematic and work on a solution. This was pretty helpful because then you weren’t adding another burden to a beleaguered system without dealing with some of the intrinsic problems.
When this initiative started was there staffing that you needed to set up in order to do this? How was this initiative staffed?
I worked with our regional HIV advisor who was based in Kenya and the two of us worked with our Uganda ACQUIRE staff, one of whom is an obstetrician/gynecologist and our technical manager for program activities in Uganda. We also have an FP/HIV coordinator, and between the four of us we got the initial activities started: the needs assessment, the materials development for training, trainers’ training, and subsequent technical assistance with the trainers for the training of counselors and the training of the service providers. Our staff in Uganda then provided the follow up in between these interventions. The TASO personnel identified one of their senior clinicians to be the liaison person, so he basically functions as the coordinator at TASO. There was communication between him and us. He also identified key people among the counselors who would be the point person to coordinate the counselor activities whenever we had to deal with issues related to counseling. He identified someone for the physician or the medical personnel, and he identified someone for the field officers and community nurses.
Regarding developing materials for the training, was everything developed new or did you repurpose existing resources?
What we did was pull together a number of resources. EngenderHealth had developed a training manuals on stigma and discrimination, which dealt with a lot of attitudinal issues. We have worked closely with FHI to develop a CD-ROM regarding contraception for couples and women that are HIV positive. It had the newest information on all of the methods, it was complete and comprehensive and talked about the FP needs of people with HIV, the rationale, the impact FP has on prevention, methods and their safety of use when one is HIV positive and the potential role of drug interactions, and some counseling points. EngenderHealth also developed a, FP-HIV integration training manual that was used in the Ghana pilot. When we got to Uganda we used that training document as a base. Since the Elizabeth Glaser Pediatric AIDS Foundation had worked with the Ministry of Health to develop a family planning-integrated preventing mother-to-child transmission counselor manual, the MOH asked us if we would also use that as a resource. When we completed the expanded FP-integrated training manual, we submitted it to a review panel that included MOH representatives from RH divisions and the AIDS control program, USAID mission, and colleagues in Uganda who were working in the area of HIV and FP. It is a two-week training that covers didactic content in the first week, and then it focuses exclusively on practical experience either in counseling or initiating and managing clients with methods during the second week.
If someone is a counselor and they are going to provide the FP counseling what kind of job aides do they have to help clients understand their options. What are they are expected to use in the service delivery setting?
In Ghana, we developed three tools. We developed a brochure for people who could read which basically had a cover page talking about FP needs of PLWHIV. It’s more speaking to the reader and each page has descriptive information, characteristics of the method and includes special considerations if you're HIV positive. So that’s a brochure that counselors can use to help support the counseling. We also worked on modifying a wall chart, more like a desk chart, that has all of the methods with special considerations if you’re HIV-positive. The third tool is a counseling flow chart that includes a kind of algorithm with the information to include. For example, if a person who is HIV positive is coming to you and they want to avoid a pregnancy, it helps you with what you need to discuss. Those that were developed in Ghana were introduced to the Uganda program and then they made minor adaptations since the content was accurate and updated. They just made some local adaptations since they may not have had some of the methods available in Ghana, such as the female condom.
What is going to be a methodology for conducting an evaluation?
It's going to include site visits, observations, pretty much a “before” and “after.” Since we did a needs assessment it will build on that. Looking at the differences in practice and service delivery, clients’ perception in providers’ function, providers’ perception, supervisors’ perception, and supervisors’ function.
What are some lessons learned from your programs and what do you see as the key for success?
One of the things we are looking at now with the evaluation is that we want to see to what degree supporting the service delivery systems was vital. Our hypothesis is that the service delivery systems have to be modified in order to make integration operational and lasting. Working with supervisors to support new practices, having a training system to ensure that staff are kept updated with new skills and knowledge, and strengthening a referral system are key. Also, finding a way to make the referral system real is crucial, particularly when you can't provide all of the methods at the ARV site.
For more information about the ACQUIRE project, see http://www.acquireproject.org/ .
References:
Contraception for women and couples with HIV. Family Health International, ACQUIRE Project. 2005.
http://tinyurl.com/2akrvy
Farrell, B. Family planning-integrated HIV services: A framework for integrating family planning and antiretroviral therapy services. New York, New York, EngenderHealth, ACQUIRE Project, 2007 Jun.
http://tinyurl.com/ynpn9a
Farrell, B. and Rajani, N. Integrating family planning with antiretroviral therapy services in Uganda. New York, New York, Engender Health, ACQUIRE Project, 2007.
http://tinyurl.com/yoxxx2
The AIDS Support Organization
Contact Information
Betty L. Farrell, CNM, MPH
Sr. Medical Associate, FP Integration, Engender Health
440 Ninth Avenue, 13th floor
New York, NY 10001
(212) 561-8035
Website for ACQUIRE project: http://www.acquireproject.org/