FP and HIV/AIDS Integration Forum: “Client and Provider Perspectives on Integration of Family Planning Counseling and HIV/AIDS Services”

Day 3 Digest (May 3, 2006)

Response to questions and comments from Dr. Heidi Reynolds

I'd like to take the opportunity to thank you for the comments that were made the first day. I have tried to respond to these comments below, but these have also raised new questions. The issues raised are important and our community would benefit from your experiences. I look forward to your comments.

Deoye Kolawoe suggested a community diagnosis for baseline data and situation analysis before integration occurs. Not only is baseline and post-intervention data helpful to know if the intervention is effective, but data collected prior to the intervention can inform the intervention. Before any actual integration occurred in Kenya, an assessment was conducted in VCT centers to understand whether integration of family planning into VCT would be feasible and acceptable and if there was potential demand among clients. The report is available through the www.fpandhiv.org website (or directly: http://pdf.dec.org/pdf_docs/PNADA521.pdf). The results of the report will give you an idea of some of the topics and data collection techniques. Who else has integration assessment/situation analysis or community diagnosis resources or results? I'd also be interested to know what information you think would be important to gather during the community diagnosis or situation analysis that is needed to inform integration activities.

Ward Rinehart's question about who in VCT raises the fertility/family planning issue and what is are the circumstances that lead to FP discussion gets at the heart of integration. Integration of FP services into VCT means much more than tacking family planning services on to the end of a VCT session. Because HIV risk screening overlaps with unintended pregnancy risk screening (e.g., unprotected sex) and because the messages for HIV prevention are also pregnancy prevention (e.g., condom counseling), providers should capitalize on those opportunities to offer the dual messages wherever they arise. Ideally, VCT providers would get information from the client about his/her fertility desires and family planning use then target family planning services for clients at risk of unintended pregnancy (i.e., those sexually active clients who are not using a method of contraception but not desiring to get pregnant
in the near future).

In our research we found that providers were discussing fertility and family planning with women more than men. HIV status did not appear to influence the likelihood of fertility or family planning discussions. We did not find that providers were using the fertility information from their clients to target family planning services to those at risk of unintended pregnancy. Providers said they preferred to raise fertility and family planning issues before the HIV test, while clients preferred family planning information after the post-HIV test counseling period. We need more information to understand what will help providers
routinely raise fertility desire questions and use this to targeting family planning discussions.

Someone (see comment from Arzum Ciloglu in yesterday’s digest) made an important suggestion that a checklist or some similar tool may be helpful to remind providers to raise fertility and family planning issues with their clients. One technique that we plan to use in Kenya is adding some family planning indictors to the monitoring and evaluation form. This will have the dual advantage of serving as a reminder to providers and it will also help evaluate integration activities. In Kenya providers fill out a "client card" for M&E purposes. We have proposed three indicators for this form. They are: Does the client want children in the next two years (yes/no)? Is the client/client's partner using condoms or other contraceptive method to prevent pregnancy (yes/no)? What contraceptive method was provided? (multiple responses possible). As you well know, choosing indicators is always a struggle because there are many more indicators than are feasible to collect regularly. What indicators do you suggest should be prioritized to monitor FP into VCT integration? Also, do people feel that a checklist (independent of any M&E form) is needed? What elements should be on the checklist?

A comment posted on the Knowledge Gateway by Arzum Ciloglu (see first comment below) stated that the facility environment providers work in influences their ability to apply newly gained FP-VCT integration knowledge and skills. She suggests that this demonstrates the need for 'whole site' and onsite training programs. In particular in the Kenya experience, it was noted that there was still a need to orient facility supervisors and managers to integration so that they can support trained providers. While providers were able to find solutions to facility-specific questions around record keeping and requisitioning contraceptive supplies, some providers were not able to implement the intervention at all because their managers had
not been fully oriented.

Finally, I'd like to note that some of the results I've cited here were not presented during the March videoconference, but these results will be available soon in report form.

Heidi Reynolds

Comments and Questions from Forum Participants

Thank you, Dr. Reynolds, for sharing your experiences in Kenya. I believe that this example shows that training, by itself, is often not the answer to a programmatic need. Whereas training is usually a necessary component, there are other elements that must to be in place for us to be able to see the "results" from the training. One example, is the environments in which providers work. The powerpoint from the videoconference states that either 1-2 providers were trained from each site. Although the policy environment and MOH structure may be supportive, the individual facility environment may not have been supportive enough when the providers returned to their work for them to be able to apply their newly gained knowledge and skills. I believe this further highlights the need for whole site and onsite training programs.

G. Arzum Ciloglu, MPH, DrPH
Senior Program Officer
Center for Communication Programs
Johns Hopkins Bloomberg School of Public Health
111 Market Place Suite 310
Baltimore, MD 21202

The project in Ghana sounds very interesting and I look forward to learning
more.

I am interested to hear advice about a similar situation. What happens when
FP counselling and the provision of contraceptives is already integrated
into the clinical setting which is treating HIV-positive women with HAART
and many still become pregnant (often times unintentionally)? Do we known
enough about the factors which influence reproductive decisions or lack of
decision-making? How can the health care system help to address these
factors (social, cultural, economic)??

Michelle Schaan
Botswana

Dear Dr. Bonku,
Thank you for your presentation. I have a couple of questions. From your study –

1. What would you say were the root causes of provider stigma? (I think that knowing what the causes are would help program managers design interventions to address the issue more effectively).
2. Did HIV+ clients prefer to have both FP & HIV services at the same site?
3. Could you please shed some more light on how you dealt with issues of confidentiality?
Thank you.
Marian Amoa,
USA

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