1. Improving service provision:
Zelda Nhlabatsi
Executive Director,
Family Life Association Swaziland
Kathryn Church
London School of Hygiene & Tropical Medicine
experiences from an SRHR organisation in Swaziland

2. Family Life Association of Swaziland (FLAS)
Established in 1979
NGO indigenous to Swaziland
Member of International Planned Parenthood Federation (IPPF)
Focal areas
Delivery of Integrated sexual & reproductive health services (incl. HIV)
Youth-friendly services for year olds
Targeted stigma-free services for key pops
Advocacy
Demand creation

3. The Family Life Association Experience
Model 3
HIV Counselling and Testing, STI and ART
Youth Family Planning Services

4. Key interventions Introduction of ART
Infrastructural development/adjustments
Human resource
Trainings of service providers
Partnership development & strengthening
Housing and financial administration of local research (London School & Population Council)
Introduction of VIA (routine offer for all WLHIV)
Strengthening of youth activities
Youth centre equipment
Sport activities

5. What changed at FLAS as a result
New SRH and HIV services added to service list
Implants added to FP list
VIA (for cervical cancer), dry blood spot and CD4 count and TB screening added to the screening test list
HIV treatment, care and support added (ART initiation, adherence counselling, treatment and management of OIs etc)
Strengthened capacity of MA to provide quality integrated services:
Trainings, mentoring and continuous medical sessions (CMEs)
Infrastructural improvements
Outreach and demand generation activities (e.g. particularly among young people)
Strengthened partnerships for implementation
ICAP Swaziland
Mothers2mothers
Swaziland Action Group Against Abuse
Faith based organisations; Population Services International

6. Increase in number of clients reached

7. Increasing service uptake by males
Integration seemed to have a positive effect on the number of male clients accessing services.
HIV services

8. Innovativeness

9. Sustainability of interventions after Integra?
Capacity building and policy changes has enabled FLAS to continue service provision at same level
E.g. ART Initiation
Capacity building of partners at outreach and referral sites
Resource mobilisation
Factory workers: financing by employers
Donor support for youth activities

10. Swaziland Stigma Study - Design & methods
Cross-sectional study design to evaluate 4 models of care (N=611)
Mixed methods:
Exit survey of HIV clients (n=611) (male & female)
In-depth interviews with clients (n=22) and providers (n=16)
Manzini
This sub-study aimed to evaluate how different types of services (integrated and stand-alone) address the FP needs of PLHIV.
The 4 clinics all serve the same population, and ART is delivered free at each site, making this an interest comparative study of models of service delivery.
Of the 4 study clinics, 2 offer SRH services onsite in the same building; Clinic A is the most integrated site, where SRH and HIV services are available from the same provider in the same room. Clinic B has a full range of SRH services in the same building, and usually clients need to be internally referred for them. Clinic C, a hospital, offers ART outpatient services in a specialised building, though other SRH services are available in the main hospital building; and lastly Clinic D is a stand-alone HIV clinic which only offers HIV testing and ART services. (AT LEAST THIS IS HOW IT WAS AT TIME OF STUDY IN 2009/2010)
In the survey, we randomly sampled clients exiting the facilities, trying to get a representative sample of clients; this meant that we captured mostly women (nearly 80%), median age was 32, and most were attending for ART refills (65%) or ART user consultations (13%).
Clinic A
Clinic B
Clinic C
Clinic D
Most “stand-alone”
Most integrated

11. Stigma and Integrated Care
“[the nurses] announced that those who were there to get pills needed to go to Room 3...that was really bad because everyone was just sitting in the waiting room, and nobody was paying attention to what others were there for…then all of a sudden we have to get up because we’re the ones that have been called. People didn’t need to know…”
[Female, partially integrated site, HIV treatment client, Swaziland]
The Integra findings shows that integration of services does not automatically lead to a reduction in stigma. In some circumstances it can increase stigma for clients living with HIV depending on how the integrated services are delivered [read quote].
Data from client interviews

12. Findings from Swaziland indicate that all types of clinic can reduce stigma through:
Sensitive room labelling
Naming of clinic
Ensuring client HIV records are unidentifiable
Dispensing ART drugs either in private or without easy identification
Separating waiting areas of VCT and ART clients at HIV-only clinics

13. Key take home messages from Swaziland
Integration allows for a comprehensive package of care (widens scope)
Recognition of linkages with other non-clinical issues (social behaviour change communication; supportive legislation)
SRH and HIV programs can address socio-legal and cultural issues e.g. Stigma; gender inequality etc.
Partnerships are key
Maximise resources
Comparative advantage and referrals
Working with government is key for sustainability
National agenda

14. Key Take home messages from Swaziland
Integration of services does not automatically lead to a reduction in stigma.
All health facilities can reduce HIV-related stigma through a series of practical measures.
Continuous Training & capacity building of staff is essential
HIV integration (usually well funded) can strengthen SRH programs and systems.