Day 20 Digest
This is the final formal digest of postings. It will be followed by an e-mail that summarizes the forum and invites participants to complete a short online survey about the forum.
In today’s posting, we have comments from the following Forum participants:
- Abebe Shibru - Ethiopia
- Lynn Van Lith – USA
- Li Dongli - China
- Heather Bradley - USA
- Di Cooper – South Africa
Although the forum is officially ending today, this does not mean that all of us cannot continue to share information and experiences with the group. Any time you’d like to share something or have a question, you can send it by e-mail or go online to post it. We will continue to share news, resources and information with all of you as well.
Also, be sure to visit the www.fpandhiv.org website from time to time to keep up with new developments in integration.
Remember to continue to participate in discussions through this online community, you can either:
- Send your comment to fphivintegration@ibp.wa-research.ch
- 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
The official forum postings and links to all publications mentioned during the forum are also archived at http://www.fpandhiv.org/videoconference/cpieventpage.php along with all the resources mentioned in the forum, including the guide mentioned today. 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.
We look forward to continuing these discussions even after the official end of the forum today.
Thanks to everyone for participating and for sharing your questions, concerns, and experiences!
Best regards,
HCP and INFO Teams
Abebe Shibru – Ethiopia
Hi all really I'm enjoying the forum. I have the following to ask and share with the forum participants.
Stigma and discrimination is one of the hurdling factors in our PMTCT program here in Ethiopia. Particularly, we have noticed that provider stigma is the one which affects the quality of PMTCT service delivery.
Currently we are conducting ToT training for service providers on provider stigma so as to mainstream anti stigma activities in all process of service delivery. So, I want to hear anything about this from forum participants. But I want to share the research findings about provider stigma we did last year. Please contact me if u need it. I will send either the pp presentation or the soft copy for interested one.
The other issue I have is we are striving to integrate family planning service into PMTCT intervention both at IEC/BCC and service delivery levels. The providers are trained in this area in different time. But the outcome in the ground is not a such attractive. We are planning to assess why service integration are not happened as anticipated ? So I want to know if any forum participants could assist me from their experiences why such thing could happen?
Thanks
Abebe Shibru, Intrahealth International
PMTCT Team Leader
ashibru@intrahealth.org
Tel. 2511 6627480/81/82
Mobile: 251.911.40.85.83
P.O. Box 9658
Addis Ababa
Lynn Van Lith - USA
I particularly appreciated Abebe Shibru's submission yesterday in helping us take this rich discussion out of the clinic and reminding us how complex some of these issues are. Without support from fellow mothers or others affected by HIV/AIDS in the community, we end up relying on health care providers to do everything. Not only is this unreasonable given the demands on their time, but it is not the most effective way to provide all the support necessary.
I agree that it is essential to provide a support network for women and their partners and to recognize that many of the decisions HIV positive women make about their fertility desires and the like are made outside the clinic setting based on what is socially and culturally most relevant and acceptable to them and their families. Providing options and counseling in the clinical setting with additional support through peer mentoring and support groups as Abebe describes, reaches women and their partners based on an understanding of the many facets of their lives and the context in which they make decisions.
As the field of integration moves forward, I would be very interested to hear from others having success at the community level in providing support outside the clinic while doing so in tandem with it. Linking community support with services is key if we are to ensure success over the long term recognizing the resource constraints that exist at the service delivery setting while also appreciating the wealth of knowledge and experience in our communities.
Lynn Van Lith
HIV/AIDS Advisor
Health Communication Partnership
Li Dongli – China
Dear Dr. Louise Manning,
Thank you very much for posting my writing on the forum and the summary of you on my comments of yesterday .
I would like to tell you my view about the website of "Integrating HIV/AIDS into FP" of communication program in Johns Hopkins University, which your program emailed me maybe a couple of years ago. The information in it helped me a lot to know that family planning workers around the world are confronting similar problems when addressing HIV/AIDS while having very common approaches to solve. It enlarged my eye of views and greatly helped me to design my research and to conduct policy advococy. And that is the reason that I have recommended your website to many of my colleagues, including policy makers, researchers and media peoples.
I felt sorry for my way of talking in a somehow colletive way unconscienousely, instead of direct expressing personal views . Maybe owing to a kind of cultural difference: Chinese generally have less sense of individualism than the people of the West. However now I am in an international forum. Thank you very much for the reminding!
Best regards,
LI Dongli
Ph. D.
China Population and Development Research Center P. O. Box 2444, 100081 Beijing, China
Tel. 86-10-62570716
86-10-62172437
email: lidongli@readchina.com
Heather Bradley - USA
I would like to start out with some updated information about a conference in Addis Ababa on "Linking Reproductive Health and Family Planning with HIV/AIDS Programs in Africa." The conference will be sponsored by Addis Ababa University and the Bill and Melinda Gates Institute for Population and Reproductive Health and will be held October 9-10, 2006, at the UN Conference Center in Addis Ababa, Ethiopia. We will be posting a call for abstracts to www.jhsph.edu/gatesinstitute later this week, and limited travel awards are available for researchers from African countries. The conference will be the first international research meeting on this topic, and it will be timely for our community to hear preliminary or final results from many important studies that have recently begun. We hope to include a wide range of participants from research, program, community, policy and donor spheres. Please let me know if you would like to receive updates on this meeting, and I will add you to our mailing list.
Since one of the themes for this week is future directions, I am interested in hearing your ideas about future directions for research on family planning and HIV service integration - either through the forum or e-mail. Your ideas will help us to narrow the focus for the Addis meeting and will inform the conference themes.
We are launching a study on integrating family planning into VCT services in Ethiopian public sector facilities next month. Through literature reviews and instrument development for this study, I have been struck by how little we know about implementing provider-level service integration. Active integration - in which providers proactively discuss a range of reproductive health services with clients and then either deliver or refer for these services - is probably necessary for clients to realize the full benefits of family planning and HIV service integration. My read of the current literature is that most providers understand the rationale for service integration and agree that it should be implemented. From the work that has been done thus far, their attitudes toward integration are relatively positive, but they are still not proactively offering integrated services, in some cases even after training.
As others have stated on this forum, cross-service training for providers can be expensive and time-consuming. Operationally speaking, what is the best strategy for helping to ensure training funds and time are well spent and can effect sustainable change? Is the underlying need for more health resources - including additional staff, equipment, commodities and space - so dire that even training, job aides and empowerment will not enable providers to proactively offer multiple services? Or could providers' time and tasks be effectively re-allocated to facilitate integrated service delivery?
While it is important for researchers to try to identify and measure structural barriers (such as the need for more staff, commodities and space) to provider-level family planning and HIV integration in their work, it is quite difficult to measure. One good example is FHI's (Heidi Reynolds) work in Kenya, in which they conducted feasibility analysis based on providers' time and work responsibilities. We are currently working on how to measure these factors in our Ethiopia study, from both client and provider perspectives. I would be very interested in hearing how others are dealing with these underlying, but important, structural determinants of family planning and HIV integration efficacy.
Heather Bradley, Researcher
Bill and Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health hbradley@jhsph.edu
Di Cooper – South Africa
Dear all
I have really enjoyed these forum discussions – it has been a greatly enriching experience hearing what others are doing and we can learn much from each other.
The questions posed for this week’s forum by Dr Kim were:
-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?
There have been interesting contributions around this the whole week.
I would like to share once again some of the findings of qualitative research colleagues and I in the Women’s Health Research Unit at the University of Cape Town have been conducting around the Reproductive choices, health needs and service provision for HIV+ individuals, related to this topic. To recap on the information I gave earlier in the forum: We conducted 60 individual in depth interviews with HIV+ women and men and with 26 health care providers, NGO key informants and Western Cape Provincial Policy-makers. Research was conducted at 2 health centres in Cape Town. We are currently conducting a survey with 470 HIV+ women and men and with 70 health care providers.
Some women & men were firm in their desire not to have children, fearing infecting a partner or baby; anxious about children becoming orphans or about progression of their illness while pregnant. Others wished to have children despite their HIV-infected status. In common with uninfected individuals: felt children were normative in family formation; brought happiness. They also felt that having children was a sign of ‘normality’; gave meaning to life; represented hope Also: wish to leave ‘something of themselves behind’ There was a strong wish to have ‘at least one child’ among those with no children. Married women and those anticipating marriage, faced particularly strong family & sometimes partner pressures to reproduce. Those on ART experienced overwhelmingly positive effects on their health and although the provision of ART is still in its early stages in S.A, some felt being on ART would alter attitudes to childbearing, saying: "I often hear…people talking about this within the support groups... People who resisted having children because of their failing health are now considering having children...now that their health has improved through the use of ARVs" (woman on ART)
Most women and men had not discussed reproductive intentions with providers because anticipated negative reactions. Men more likely to feel provider attitudes would be supportive or neutral. Those on ART tended to feel that health care provider attitudes would be more sympathetic to their reproductive choices. There were high levels of satisfaction with HIV care & treatment services. However, while in counseling sessions they were free to talk, their were barriers to discussion about sexuality and having children and reproductive health needs. Men in particular had little knowledge of reproductive health
services. Clients were generally in favour of integration of HIV care and reproductive health services saying for example: "What I can say is…that maybe they could mix all the folders and be the one colour...You see if you’re carrying that folder [at the general service not for HIV care], they sit there with their eyes wide open and you can see, yhoo! This one is like this! “; “I mean it would have been better if they were to combine the contraception side...doesn’t have to go to the outside to get contraception… That will help to prevent people getting pregnant at a wrong time [women, focus group discussions]. Providers also felt that they did not have the training and skills to know how to tackle reproductive health issues and childbearing with HIV+ clients and there was no explicit enough policy in South Africa to guide them. Our preliminary findings from the quantitative study shows once again very little discussion between HIV+ clients and providers about reproductive health issues except for encouraging condom use. Yet client interviews express a great desire to discuss such issues with providers, especially counselors. Both women and men seemed to know that abortion was legal in South Africa although men in particular were reluctant to use this avenue. Both had extremely poor knowledge of Emergency Contraception but having obtained the information during the interview, expressed a keenness to use it if they or their partner had an unintended pregnancy.
Policy makers, NGO representing those with HIV+ and public sector health care providers in the W.Cape have shown a strong interest in developing specific and overt policy that can help ensure reproductive choice. In addition we are in discussions to develop counselling and health service interventions to improve reproductive counselling and reproductive service delivery to HIV-positive individuals. We would like to move
towards further development of an enhanced client counseling intervention together with colleagues at the HIV Center at Columbia University, drawing on what others have produced, training health care providers and testing and evaluating this in the South African context. Providers feel that despite their time constraints if they could have a counselling tool to deal with these issues more adequately it would bring individual and public health benefit and save them time in the future from clients with unwanted pregnancies or who do not access the adequate services for preventing vertical transmission while pregnant or do not seek counseling on how to minimize risk of infection to an uninfected partner etc.
Lastly we would be very keen to join the 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 as suggested by Dr Young Mi Kim from JHU/HCP
--
Dr Di Cooper
Women's Health Research Unit
School of Public Health & Family Medicine
University of Cape Town
Anzio Road 7925
Observatory
Cape Town
South Africa
Tel: 27-21-406 6528
Fax: 27-21-448 8151
email: dic@cormack.uct.ac.za
http://www.publichealth.uct.ac.za