Day 2 Introduction and Digest (May 2, 2006)
Welcome to Day 2 of the online forum on “Client and Provider Perspectives on Integration of Family Planning Counseling and HIV/AIDS Services”. Today’s posting is from Dr. Edward Bonku, Reproductive & Child Health Quality Assurance and Franchising Officer at Engenderhealth/Quality Health Partners (QHP) Project in Accra, Ghana. In this capacity, Dr. Bonku participates and contributes to cross-cutting activities including training and non-training interventions, facilitative supervision, equipment/renovations planning and procurements, application of problem-solving techniques (such as COPE and Whole-site training) and provider performance and systems monitoring, directed at the provision of quality RCH services at health facilities (in both public and private sectors) in 7 QHP project target regions of Ghana. Dr. Bonku received his MD from Lvov State Medical Institute in Ukraine and is completing a Master of Science in Public Health degree through the London School of Hygiene and Tropical Medicine.
Dr. Bonku summarizes the results of “FP/ART Integration in Ghana; Early Impressions and Interventions”. This information was originally presented by Ms. Olivia Aglah from Engenderhealth/ACQUIRE during the March videoconference (Powerpoint presentation).
Throughout the week, feel free to send questions or comments to Dr. Bonku, as well as submit your own experiences, findings or lessons learned on the topic of the week. Please refer to the submission instructions and guidelines you received last week on how to post comments/questions for the online forum. Remember that you can simply click "reply" to this e-mail and post your comment, or log into the forum with the username and password you received.
Tomorrow we will focus on the subject of “dual protection”. We look forward to rich and interesting discussions. Thanks for participating!
Best regards,
HCP and INFO Teams
TITLE: FP/ART Integration in Ghana; Early Impressions and Interventions
Presenters:
Olivia Aglah, ACQUIRE/Engenderhealth and Edward Bonku, Quality Health Partners/EngenderHealth.
Introduction:
The ACQUIRE/FHI project has embarked on a 15 month pilot project on the integration of family planning with antiretroviral treatment services since March 2005, in two hospitals that provide ART services to PLWHA in Ghana. The goal of the pilot is to gain practical experience and disseminate lessons learned from integrating FP counseling and methods provision into ART services. The pilot project included a preliminary performance needs assessment (PNA) and subsequent staff training. The key PNA findings included:
Clinics:
• FP needs of HIV positive women and men have been largely neglected.
• HIV positive women expressed the desire to have the provider discuss family planning during their consultation.
• Whereas HIV clinics were not providing FP services, Family planning clinics, on the other hand were more likely to routinely talk to clients about HIV and AIDS.
Systems:
• HIV and FP clinics lack integrated clinical guidelines/protocols and IEC materials.
• Formal referral systems were non-existent between HIV and FP clinics; service statistics and medical records lacked information on FP services provided to HIV positive women and men.
Staff:
• Staff recognized knowledge gaps in HIV and FP.
• The concepts of dual protection and dual method use were not understood (50% of HIV staff did not know what the terms meant).
• Supervisors demanded updates on facilitative supervision skills and the use of quality monitoring tools.
Intervention:
ACQUIRE/FHI used the results of the PNA in Ghana to design an intervention to train HIV service providers to offer FP counseling, provide short-term contraceptives (condoms, oral pills and injectables), and to refer HIV+ women receiving ART for long-term methods and other services not provided within the HIV clinic. In addition, the training emphasized the need for providers to recognize the rights of HIV+ individuals to realize their fertility desires, and aimed to reduce stigma and discrimination.
A 5-day training curriculum was developed based on the recently developed module, “Contraception for Women and Couples with HIV,” by FHI and EngenderHealth under the prior CTR cooperative agreement. Specifically, the following issues which were key for providers’ orientation and necessary for performing their integrated roles were achieved during the training.
• Describing the current HIV situation, especially among women, in sub Saharan Africa and Ghana.
• Explaining why family planning is an essential component of comprehensive care for HIV positive women and men.
• Discussing HIV positive clients’ reproductive health rights, including the right to make free, informed choices concerning the number, spacing and timing of their children.
• Identifying and addressing health workers’ attitudes against providing FP to HIV positive women and men
• Providing up-to-date information and counseling to clients on appropriate modern contraceptive methods for HIV positive women generally, and especially for women who are taking antiretroviral drugs;
• Counseling clients on ‘dual protection’ (against both HIV/STI infection/re-infection and undesired pregnancy), including dual method use;
• Identifying and addressing health workers biases against and reluctance to offer condoms, either alone or in combination with other contraceptive methods to clients, and especially to HIV positive women and men
• Addressing clients’ biases against and reluctance to use condoms either alone or in combination with other contraceptive methods;
• Developing clients’ skills in using male and female condoms and in negotiating condom use.
• Implementing service delivery changes to accommodate the expanded component within HIV care and treatment services.
Service Providers trained at the two facilities under the pilot include doctors, nurses and counselors who work at the HIV and Family Planning units.
ACQUIRE/FHI have also developed job aids and client information brochures on the FP needs of HIV+ persons under the project, for use at the service delivery areas. The job aids, Contraceptive Methods: Quick Reference Chart and Client-centered RH Counseling, are single-paged laminated sheets that are easily placed on the service provider’s desk-top, or hung on the wall. The former provides a snapshot of available family planning methods and their usability by HIV+ clients for easy reference and use during counseling sessions. The client-centered counseling chart on the other hand is an algorithm that enables providers to systematically explore clients’ reproductive health and HIV status and the related needs in counseling based on this. Both tools are being applied by trained providers in service delivery at the pilot health facilities. The client information brochure is currently being finalized after a pretest with PLWHA attending the ART clinics, where very insightful feedback was received from the client’s perspectives.
Experiences from implementing integrated services at the pilot facilities so far:
The incorporation of topics on FP needs and methods for PLWHA in the regular health talks organized for clients attending the HIV clinic at KBTH, has enabled clients to be informed and to better express their needs in FP where required, to service providers during consultation and counseling sessions.
HIV+ women who desire or express need for contraception receive counselling, and are provided male or female condoms in addition to oral contraceptives at the two ART sites. Long-term methods are only provided at the FP clinics at the hospitals for now, and can be accessed by HIV+ clients through referrals.
Referral modalities for HIV+ clients who need long-term FP methods were agreed to during the training of service providers in the integration program. The training equipped FP service providers to avoid stigmatizing clients and to observe issues of privacy and confidentiality. Related to this, referred clients from the HIV clinic for long-term family planning methods would carry along FP cards with necessary particulars such as history etc already done at the HIV clinic rather than bringing referral slips, which could advertise their HIV status.
Registers are available at HIV clinics for routine compilation of data on FP methods provided to clients, and FP clinics keep records on referred HIV+ clients in their usual registers to avoid stigmatization. However, all HIV+ clients’ FP cards are being kept at the HIV clinic for purposes of confidentiality.
Service Providers hold monthly meetings to discuss developments and issues related to implementation of integrated services and to identify ways for addressing them.
Discussion points:
1. In addition to health talks, how can HIV+ clients be better equipped to articulate their FP needs during their consultation?
2. What are some of the practical ways that provider stigma can be reduced?
Comments and Questions from Forum Participants
We need a community diagnosis for baseline data and situation analysis
Before we go to any community to integrate we need a community diagnosis for baseline data and situation analysis.
If you have any instrument for conducting the community diagnosis, I shall be grateful if you can send me one.
I want materials for structured interview, focus group discusion and observation.
DEOYE KOLAWOLE
PLOT 593 T CLOSE FESTAC TOWN
NIGERIA
Triggers for discussion of family planning?
Dear Dr. Reynolds:
In the Kenya study do you have any information about who and what triggers discussion of family planning? Did certain providers routinely raise family planning questions, while others hardly ever did? Or did clients initiate the discussion? Were there any particular circumstances that were likely to lead to discussion of family planning?
Ward Rinehart
Center for Communication Programs
Johns Hopkins Bloomberg School of Public Health
Making sure that FP is always brought up in VCT
On the question of how to introduce fertility and family planning discussions in VCT, I would suggest that one good strategy for making sure that family planning is always discussed would be to work to insure that there is a question (or several questions) about family planning, fertility, last period) included on the checklist that providers use when they do VCT screening. I wonder if anyone has experience trying to include these sorts of questions on screening checklists or routine forms?
Maybe we should not be asking ourselves what information providers need from clients to know whether they should spending time counseling on FP in VCT - but instead we should work toward making sure that FP is always brought up in VCT as part of a series of routine questions. Of course the issues and questions would be different for men and women, positive and negative people, youth and adults. I'd love to hear what other participants and Dr. Reynolds think of this approach.
Thank you!
Dr Arzum Ciloglu
US