Day 16 Digest (May 22, 2006)
This is the first e-mail for week 4 of the forum. Before starting, we would like to thank Anne Namwamba-Ntombela for serving as our expert for week 3 which focused on client perspectives. Many thanks as well to all the forum participants who shared their experiences and ideas.
Today’s digest includes:
- Dr. Young Mi Kim’s welcome and introduction to week #4 of the forum.
- Responses to last week’s discussion from Anupam Raizada and Janaki Sankaran – both working in India
- A short summary of Friday’s USAID Family Planning and Integration Working Group meeting in Washington DC
To participate in the discussion, you can:
- log into the forum website at http://my.ibpinitiative.org/Community.aspx?c=d1f835b2-0c72-420a-9ade-88186b49abe7 with the username and password you received.
ONLINE ARCHIVE
Postings are also archived at http://www.fpandhiv.org/videoconference/cpieventpage.php along with all the resources mentioned in previous postings. You do not need to know your username and password to read the postings on the web site. While you are there, please take a look at the web site as well. It was developed to bring together in one place all the relevant resources on integration of family planning and HIV/AIDS prevention and services.
Please send your responses to Dr. Kim or to any of the other postings, questions and discussions from previous weeks of the forum.
We look forward to more of these rich and interesting discussions. Thanks to everyone for participating and for sharing your questions, concerns, and experiences!
Best regards,
HCP and INFO Teams
Dr. Young Mi Kim
Week #4 will focus on discussion regarding future directions, including potential challenges and barriers, to the integration of FP counseling and HIV/AIDS Services. As our expert for this week, we bring back Dr. Young Mi Kim of Johns Hopkins. Dr. Kim also shared some thoughts on "dual protection" during the first week.
Dr. Young Mi Kim is Senior Advisor for Research and Evaluation at JHU/CCP and Senior Faculty Associate at the Johns Hopkins School of Public Health. She has worked over 15 years at CCP as an expert in quality of care and health communication research in developing countries such as Zimbabwe, Kenya, Tanzania, Nigeria, Ghana, Gambia, Ethiopia, Mexico, Peru, Bolivia, Cambodia and Indonesia. Dr. Kim is well renowned for her contribution to methodological advances in studying interpersonal communication between client and provider. She has over 15 articles published as a principle author in peer-reviewed journals, such as Health Communication, International Family Planning Perspectives. Her studies cover a very diverse client population, such as youth, couples, men and women in diverse service areas such as family planning, HIV/AIDS, general medicine.
Welcome to Week #4
Dear Forum Participants
On behalf of our team at Johns Hopkins University (HCP and INFO projects), we are very pleased to be able to contribute on advancing better counseling HIV positive clients on FP/RH needs in a humble way through this forum. We acknowledge the ideal situation is quite far away and a mountain of challenges lie ahead of us. Thank you very much for taking your interest and time to participate in the forum.
In the past 3 weeks, we not only shared our rich experiences, recommendations, researching findings and resource materials, but also our emotions in a way. Together we have experienced the sadness and pain of witnessing the reality of poor resources, overburdened providers, lack of structure and management support, lack of policy to meet client needs to be served well in HIV care/ treatment clinics whether they are pregnant, wish to have a child, or want to avoid pregnancy.
Some participants also voiced their frustrations. I felt very touched and hopeful by reading a exchange between Anne Ntombela (South Africa) and Dr. Asfawesen Yohannes (Ethiopia); recognizing a difficult position of service provider to do more to create convenience to clients and having a vision for today’s provider. I’d like to quote what Anne Ntombela beautifully responded, “We can not afford not to be multi skilled at this stage, it is necessary for the today’s provider to be able to “kill two birds with one stone,” especially when providing HIV and SRH counseling.”
During this last week of the online forum I’d like to invite you to discuss three particular aspects of the way forward: any additional recommendations, suggestions for future forums or discussions, and spin off small discussion groups.
1. Additional recommendations
Many of the recommendations that have come out in previous discussions, from service structural change to client education in community, are very insightful. We invite you to discuss any additional recommendations beyond or in addition to those. We also would like to hear some concrete and practical recommendations on what providers can use in their counseling and what clients can say with their providers.
How do clients need to bring up their needs and voice their concerns on FP/RH issues to the provider?
How do providers respond at their best to their clients within limited time and service?
Are there some technical contents giving need to be corrected?
2. Suggestions for future forum discussions
This year’s forum has been an experiment. Would you like to share any of your ideas and suggestions for a forum in the coming year? Are there topics which you would like us to continue to discuss? Do you have new topics to suggest related to FP/HIV client provider interaction? Do you have any suggestions or recommendations for the structure of the forum? In what ways can we extend this forum to reach service providers so that we can hear more of their voices and reach our discussions/suggestions to them?
3. Spin-off small discussion groups
Even though this online forum is officially ending, we hope to see spin-off small groups carrying on the dialogue. For that to happen, a motivated person needs to volunteer to facilitate the group discussion informally on a focused topic of her/his interest. Then, that person can solicit participants and exchange though regular e-mails. Alternatively, we can help you to create a community through the IBP gateway. We will not moderate that exchange as we do now. Small group discussions will be spontaneous, self-generated discussions among those who share a common interest on a specific topic.
I am personally interested in facilitating a small discussion group with colleagues who would like to exchange experiences, ideas and resource materials regarding research and intervention evaluation of FP/RH counseling/service integration into VCT, PMTCT and ART service settings. The purpose of the group will be to share measurement tools, strengths/weaknesses of research methods, findings, practical implications, and reference materials. There lack research evidences which can influence policy and practice in this area. This exchange and discussion can make the work of research and evaluation more effective, save money and time.
We look forward to having exciting exchange and discussion this week. Many thanks.
Young Mi Kim
Senior Research and Evaluation Advisor
JHU/HCP
COMMENTS - - Anupam Raizada – India
Dear Readers,
I am Dr. Anupam Raizada form India. I am a Medical doctor with Public Health background. I am working with CARE in India and implementing CARE-India's largest Program RACHNA (Reproductive and Child Health Nutrition and AIDS) in one of the most important state of India - Uttar Pradesh, as Regional Program Manager.
I was going through all the deliberations and comments posted on the forum till 14th day. I don't know whether I should raise this issue here or not as this forum is for 'integrating FP and HIV'. Yet, taking clue from 'Anne's' submission and deliberations from other participants I would like to raise the issue of 'Integration of antenatal care services with FP and HIV services'. This may not be the right forum to raise but the time is not wrong. Looking at data, we can say that HIV+ women are not far behind than HIV+ men in numbers. And many of these women are pregnant or may become pregnant in near future. Many of them still don't know about their HIV+ status. There are women like Anne who want to become pregnant despite their HIV+ status known to them. This certainly needs consideration of providing information (and may be services also) on antenatal care (ANC) along with HIV and FP counseling. Are our services and service providers equipped enough to provide ANC to HIV+ women?
The second issue is providing counseling to FP clients on HIV. FP counseling warrants presence of both spouses - for acceptance of the method and for increasing male participation as well. In India still at most of the places it is husband who decides for FP use. There is issue related to accepting HIV+ status in front of other half. The issue of negotiating males for condom use is linked to this. Use of FP method and HIV counseling is also linked with sexual behavior and STIs - the topics which are still taboo in many cultures and societies. And how much the counselor is equipped to deal with the situation?
Regarding situation of integration in India I would like to state that most of the govt. owned Voluntary Counseling and Testing Centers (VCTCs) are opened in Medical Colleges and District hospitals. In a way the HIV counseling, FP and ANC services are available within same area. But, there are issues related to different departments providing different services, visibility and quality of services, supplies and inter-departmental cooperation. Govt. of India has developed a paper for the integration of Ministry of Health and Family Welfare and National AIDS Control Organization but its actual implementation is still awaited – see http://www.mohfw.nic.in/Convergence plan between NACP and DOHFW.htm
Anne has provided a great exposure to the client side but, in the forum, I am yet to read similar account of issues and experiences from a counselor who was or is providing counseling on FP and HIV. S/he can provide details of the feelings and concerns of their clients which will certainly help us in developing such services and providing training to future service providers.
Thanks a lot.
Anupam.
Janaki Sankaran - India
I work in India and would like to share my experience in counseling training - mainly in the areas of HIV/AIDS and reproductive health.
I would like to begin by saying that an organization has to be willing to invest in counseling - at least in basic counseling skills. The initial training lasts 5 days (usually) and is experiential learning based - with a lot of role plays to learn the basic microcounseling skills of empathy, active listening, paraphrasing, and asking the right questions. Emphasis is also given to examining one's own attitudes and beliefs, and value systems and there is a bit on documentation, record keeping, and networking. Theoretical inputs are provided depending on the needs of the group - in my experience the group is usually strong in theory (including brilliant definitions of empathy!)
This has to be followed up with in-service training and ongoing capacity building - a day's session once in 4 to 6 weeks - where the group discusses the work done, the challenges faced, any difficult situations - the group is encouraged to look at how to handle such situations and learn from each other.
In my experience this ongoing training is what determines whether the group is able to build on the skills learned in the classroom the first time - if this is not provided then the group does not progress. Training and getting people to achieve a minimum level of competence takes time and patience - but the reward of seeing an empowered group of counselors who are willing to train others is well worth the time, the effort, and the money. This method has been used with groups with some experience, and with no experience (even just basic education) and has worked well.
Janaki Sankaran
Cochin, India
USAID Family Planning and Integration Working Group meeting
Some highlights of meeting on Friday, May 19, 2006
Friday’s meeting included two panels. The first was called “Voices of HIV Advocates” and included presentations by Promise Mthembu of the International Community of Women Living with HIV/AIDS and Bose Olotu from the Treatment Access Movement in Nigeria. Today we will share with you a summary of the presentation by Promise Mthembu.
Promised started by discussing the special needs and concerns of young women living with HIV/AIDS. These include:
A lack of recognition of young women living with HIV as sexual beings Lack of a safe space for them to express their reproductive needs, issues, and desires Lack of comprehensive FP services Their experiences of rape, violence, reproductive failures (abortion/miscarriage) and personal loss Their lowered self-esteem and fears Testing issues: young women are often the first to be tested Lack of access to gender-segregated STI treatment Lack of prophylactic treatments like pap smear Lack of sex education programs for young women living with HIV Unethical MTCT programs that reinforce the image of mothers as reproductive machines Force sterilizations and forced abortions
Promise asked how ‘voluntary’ some voluntary testing and counseling programs actually and discussed the tension between rights and epidemiology. She explained that disclosure is a double-edged sword and that young women don’t have adequate access to condom negotiation as a strategy or to female condoms.
Moving Forward: Promise argued that we should promote dialog between young women living with HIV/AIDS and service providers. We should support programs that promote human rights and gender equity. We should encourage more social and biomedical research on young women living with HIV/AIDS and their particular needs including fertility, STIs, cancer, vaginal infections, post-HIV physiology. Finally we should not refer young women to services for older people. We should create a safe space for HIV positive young women to access services.
Friday included a second session on latest developments. Dr. Saiqa Mullick of Population Council South Africa presented the results of a targeted evaluation on what improves the quality of integrated HIV and FP services. Dr. Joanne Mantell of Columbia University reported on a project to provide integrated reproductive health and HIV/AIDS care in Cape Town. Finally Dr. Heena Brahnbhaat of the Johns Hopkins Bloomberg School of Public Health reported on a study in Uganda that seems to indicate that pregnancy increases the risk of HIV acquisition in a biological way.
We hope to be able to share some of these presentations with forum participants in the future.
- send your comment to fphivintegration@ibp.wa-research.ch