Day 8 - Introduction and Digest
Welcome to Day 8 of the online forum on “Client and Provider Perspectives on Integration of Family Planning Counseling and HIV/AIDS Services”.
Today we have a posting from Dr. James Shelton and comments from Dr. Irina Jacobson at Family Health International, Maureen Kwikiriza in Uganda and Konjit Kifetew in Ethiopia.
Dr. Shelton has been the Senior Medical Scientist in the Office of Population at USAID since 1994 and engages in a wide variety of technical, programmatic, and management issues. One of his main passions is the Maximizing Access and Quality (MAQ) initiative − a collaborative initiative between USAID and its Cooperating Agencies (CAs) designed to improve family planning/reproductive health service delivery throughout the developing world. He also authors "Contraceptive Pearls" a periodic e-mail to colleagues around the world on topic contraceptive issues. Dr. Shelton received his MPH with a major in Population Dynamics from Johns Hopkins University in 1972 and an MD in 1973 also from Johns Hopkins. In 1974, he joined the Epidemic Intelligence Service (EIS) at the Centers for Disease Control (CDC) where he gained additional training in family planning and reproductive epidemiology. He also completed a residency in Preventive Medicine at CDC and is Board Certified in Preventive Medicine.
Throughout the week, feel free to send questions or comments to Dr. Brown, 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 there are three ways to respond:
· simply click "reply" to this e-mail and post your comment,
· send your 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.
We look forward to rich and interesting discussions. Thanks for participating!
Best regards,
HCP and INFO Teams
The Provider Perspective: A few issues
With respect to the provider perspective, I just want to raise a few issues. The most important one relates to the fact that in these kinds of situations that integrate 2 (or more) services, we are asking providers to change what they do and generally it involves more work. For example in the context of providing ARVs, having the same worker or a different worker do FP counseling and hopefully also provide contraceptive methods clearly calls for more work and some additional expertise.
So one key question is “What’s in it for them.”
And another related question is how to motivate and equip them to do the different/increased work.
The general approaches could include:
· Finding out their perspectives on the potential changes in service including views on the need and importance for it.
· Training that includes both the mechanics of how to do the work, but also motivates.
· Standards and guidelines that support the provision of both
· Supervision that facilitates and motivates, and establishes a norm that this is central to the work
· Job Aids that facilitate the additional work
· Organization of the work to make it efficient for the provider
· Logistics systems that make the methods readily available
· Recognition and rewards for providers
· Creating an expectation among clients and the community that the additional services will be provided.
Appreciate the thought of those who have actually done this and others.
James D. Shelton
GH/PRH
USAID
Washington, D.C. 20523
202-712-0869
Comment from Irina Jacobson, Family Health International
Although not directly related to today's topic, I wanted to share some of the issues around integration that came out in provider interviews and focus group discussions during FHI rapid needs assessment in Kenya, March 2006s:
* When integrated services are adopted, it is important for all providers at the facility to be trained or at least sensitized to the changes in the delivery of services. Training a small number of providers and not providing orientation for their supervisors and in-charges, proved problematic for the implementation in several facilities. Concerns about how to train and deploy providers were frequently raised.
* Community members can and should be involved in the conceptualization of the integrated service package - since integration is being undertaken to better suit their needs, it's important to clarify what those needs are. Once established, the service package needs to be marketed to members of the community (e.g., promote FP/HIV services during CHW home visits, conduct health education sessions in clinic waiting areas).
* Similarly, service providers should be consulted (during the design of the program) about the feasibility of integrating services as they are ultimately responsible for ensuring that clients' needs are met. Providers can facilitate working out the kinks in the day-to-day logistics (e.g., record keeping, referrals, ensuring supplies, etc.).
* As family planning is offered in integrated settings, young people and couples are more frequently the target audience for the services, as such, providers need skills to counsel youth and couples.
* Some providers are struggling with how integration of services affects messages communicated to clients. For example, one concern that was raised is that VCT providers should be encouraging behavior change among clients, youth in particular, and offering contraception may appear to be encouraging pre-marital sex, which may be confusing to young clients. It seems like one of the challenges for HIV treatment and care providers is to accept that behavior change includes more than abstaining from sex, reducing number of partners, or using a condom. Adopting a contraceptive method other than condoms is also a positive behavior change that may improve the wellbeing of an HIV-infected individual.
* When added to an existing service, family planning should be built into the standard processes/procedures/approaches used by the providers when interacting with clients. If not well-integrated, providers may focus on one RH area (to the detriment of others) if they have pre-conceived ideas about what their core responsibilities are.
* Developing of a referral/tracking system to ensure that clients seeking services don't fall through the cracks. Providers who are only offering limited FP services expressed concern about not knowing whether their clients were able to have their needs met at referral sites. There was also concern that clients may be disappointed by having their hopes raised that they may be able to have their RH/FP needs met at a single site only to find that pills and condoms are the only methods offered.
* The ability to maintain confidentiality of a client's HIV status when referrals are used was a concern raised by number of respondents.
* Addressing the attitudes and motivation of providers - this concern was mentioned frequently. Suggestions for improving motivation include: monetary incentives for undertaking additional work load, targeted praise from supervisors, involving providers in program design.
* Make sure reporting forms are updated to allow supervisors and providers to track the services/commodities that they are offering/using.
* Ensure opportunities to explore (and practice) the "gold standard" of integrated care. Providers want to know how to integrate in their environment during their day-to-day interactions with clients - don't teach new knowledge and expect them to figure out how to integrate it into their daily practice.
* A need for training materials on FP and HIV was expressed as well as a need for various additional materials, including job aids/flow charts/checklists/booklets/posters for providers that can be used to guide CPI sessions in a manner that appropriately integrates family planning with whatever other RH services are being offered. Other materials mentioned include sensitization materials that can be used to orient administrators, managers, providers, community members to integrated services; pamphlets for clients that explain what services are offered and how they can best make use of integrated care services; fact sheets/charts that describes FP methods, to use in conjunction with demonstration trays of actual methods when providing client education about contraceptive methods; monitoring and evaluation tools for supervisors as well as a checklist that can be used by supervisors to assess the quality of care offered by providers.
* Lastly, something that was not addressed in the Kenya needs assessment, but came out very strongly in South Africa during conversations with HIV treatment and care providers: when it comes to clients with HIV, providers often question the concept of informed choice (there are also quite a few HIV providers who are not familiar with the concept). Some feel strongly that HIV+ clients should be using condoms because of their HIV status - and since protection from pregnancy is an added benefit of condom use, there is no need for them to counsel about, or for clients to consider, another FP method. Other providers tend to steer clients towards long-term/permanent FP methods. Both approaches disregard the client's right to informed choice - the approach providers perceive as the "most sensible," may be completely unrealistic or undesirable from the client's perspective. As a result, the client uses no method and is exposed to unnecessary risks. Thus there is a need to introduce, emphasize and support a concept of informed choice at every stage when integrating FP in HIV settings.
_________________________
Irina Yacobson, MD
Assistant Medical Director
Family Health International
PO Box 13950
Research Triangle Park, NC 27709 USA
Ph: 1-(919)-544-7040, ext. 431
Fax: 1-(919)-544-7261
Comment from Maureen Kwikiriza - Uganda
Greetings to all participants,
I work with one of the HIV/AIDS organisation in Uganda,which provides HIV/AIDS patients with care and treatment.
As regards Jonas' concern about a practical experience in intergrating HIV/AIDS with existing Reproductive Health services particularly in rural areas ,here is one. In Uganda whoever woman goes for Antenatal care, among other tests done which is a must, is HIV counselling and testing. If the client is positive, then she is considered for the PMTCT programme and again referred to the nearest HIV/AIDS service provider.This is working and helping women know their HIV serostatus before waiting to fall so sick as Dr Osur points it out. However one should know that initating such a service is a challenge as the clients tend to resist since there is still some stigma associated with HIV/AIDS positive people. This is where I agree with what Dr Osur that the government needs to come up with such policies and actually see to it that they are implemented.
I would also like to thank Dr Gina for the useful information about ARVS and Family Planning. However the main challenge I have experienced is that some clients on ARVS or while starting them claim to abstain from sex or assure the service provider how they do not wish to get pregnant, but only after a few months the same client is pregnant. And it seems like on starting ARVS the clients' libido increases.So how can we go about this, putting in mind also that in many African cultures open discussion about sex is still abominable?
Thanks so much, I am called Maureen.
Comment from Konjit Kifetew - Ethiopia
Dear Forum participatns
I would like to thank Dr. Gina Brown, who so eloquently described the factors of the integration of FP and HIV/AIDS, and issues to be considered in counseling. The integration of FP with HIV/AIDS will greatly reduce mother to child transmission and offer women with the PMTCT service. The community based distribution agents who are reaching rural families/women with FP and further refer clients for other methods of FP and other RH problems are resouces to be utilized in the integration of FP with HIV/AIDS. However they need to be trained, to offer women the information and the referral they need for VCT and PMTCT services. Community Based Agents have done great work in some areas in preventing harmful traditional practices, like early marriage and female genital mutiliation, they are the ones who fight the stigma and discrimination and the ones trusted by the community.
However the need of training nurses, midwives and other health workers as well as making available PMTCT services are a challenge, but then we do have the ground the bases for integration.
Finally I would like to hear program experiences, particularly in rural areas.
Thanks
Konjit Kifetew (Ethiopia)