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FP/HIV Integration Translating Integration Goals into Practice in Asia Caroline Francis, Associate Director Family Health International/Cambodia Reconvening.

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Presentation on theme: "FP/HIV Integration Translating Integration Goals into Practice in Asia Caroline Francis, Associate Director Family Health International/Cambodia Reconvening."— Presentation transcript:

1 FP/HIV Integration Translating Integration Goals into Practice in Asia Caroline Francis, Associate Director Family Health International/Cambodia Reconvening Bangkok: – Progress Made and Lessons Learned in Scaling Up FP-MNCH Best Practices in the Asia and Middle East Region, 6-11 March 2010

2 RECONVENING BANGKOK 6-11 March 2010 Presentation outline 1.What do we mean by “integration”? 2.The need for FP/HIV messaging and services in concentrated HIV epidemics in Asia 3.The challenges – vertical funding streams, policies, centers and programs; dismantling the message; capacity; and commodities 4.Pushing past the challenges – some practical examples of integration in practice and directions for future

3 RECONVENING BANGKOK 6-11 March 2010 What do we (broadly) mean by integration? Integration = combining different kinds of RH and HIV services/programs to: Increase access to FP/RH/HIV, information, services and products Improve health outcomes of clients (e.g. most at risk populations, mothers and infants, PLHIV) Contribute to HIV and FP goals (including United Nations Millennium Development Goals)

4 RECONVENING BANGKOK 6-11 March 2010 Clients Seeking HIV-related Services FP/HIV integration is important because - Share common needs:  often both sexually active and fertile  are at risk of HIV infection or might be infected  need access to contraceptives  need to know how HIV affects contraceptive options and vice versa Clients Seeking FP Services AND

5 RECONVENING BANGKOK 6-11 March 2010 FP/HIV integration is important because - At the individual, community and societal levels  Protects right of women/people with HIV to determine #/spacing of children  Reduces unintended pregnancies and unsafe abortion  Improves maternal/infant health  Prevents vertical transmission of HIV At a health services/systems level  Makes better, more cost efficient use of resources  Systematizes commodities procurement processes  Reduces reporting/ records burden and makes more efficient use of client and provider time

6 RECONVENING BANGKOK 6-11 March 2010 While we know that integration is important, the problem is that... Most of the practical examples are from Africa, not from Asia AND The situation is different in Asia

7 RECONVENING BANGKOK 6-11 March 2010 Concentrated HIV epidemics are the norm in Asia Source: UNAIDS

8 RECONVENING BANGKOK 6-11 March 2010 Asia has lower fertility rates and better overall contraceptive use than in Africa FP use (%)TFR Bangladesh583 Cambodia403 China902 India563 Indonesia602 Lao PDR323 Nepal483 Pakistan284 PNG264 Viet Nam792

9 RECONVENING BANGKOK 6-11 March 2010 Concentrated Asian HIV epidemics demand particular HIV prevention priorities  Maintain focus on condom/lubricant promotion and ensure access in all high risk contexts  Target new tools, messages and approaches to most at risk populations  Interrupt high-transmission networks reach people when they are newly affected and promote positive prevention  Scale up efforts among entertainment workers, male clients, MSM, IDU/DU and PLHIV to reach 60-80% of population

10 RECONVENING BANGKOK 6-11 March 2010 This means that our FP/HIV integration efforts in Asia can also be more targeted Let’s take two target audiences from Cambodia with significant FP needs: 1. Female entertainment (sex) workers (EWs) (n= 30,000+; HIV prevalence 14.7% among brothel-based workers) 2. People Living with HIV (PLHIV) (n= c. 35,000 on ART)

11 RECONVENING BANGKOK 6-11 March 2010 In Cambodia, female entertainment workers use condoms as their primary FP method PSI/Cambodia TRAC 2009

12 RECONVENING BANGKOK 6-11 March 2010 But it’s clear they have unmet FP needs... PSI/Cambodia TRAC 2009

13 RECONVENING BANGKOK 6-11 March 2010 In Cambodia, most of those with HIV are receiving treatment Other HIV+ (~23,500 adults) ART (26,551 adults) OI (8,987 adults) In 2008, an estimated 59,000 out of 9.4 million adults* were living with HIV in Cambodia… …this amounts to 0.6% HIV prevalence in the adult population… …60% of these infected individuals are already receiving antiretroviral therapy (ART) or treatment for opportunistic infections… Source: NCHADS * Persons aged ≥ 15 years (based on pre-2008 census estimates)

14 RECONVENING BANGKOK 6-11 March 2010 And sexual activity among those on ART increases over time (few report unprotected sex and multiple partners) Sexually active in the past 6 months, by gender and duration of follow-up Enrollment3 mth6 mth12 mth18 mth24 mth30 mth % Men Women Enhanced Patient-Based Longitudinal Assessment of PLHIV on ART (NCHADS and FHI 2008)

15 RECONVENING BANGKOK 6-11 March 2010 The first challenge we face: promoting dual methods for EWs and PLHIV In HIV prevention, condoms have been promoted as THE FP method for prevention against STIs, HIV and unplanned pregnancy. But it’s not enough. How can we support PLHIV and EWs to use condoms + an additional method without creating an onerous burden on users?

16 RECONVENING BANGKOK 6-11 March 2010 The second challenge we face: linking FP and HIV services for EWs and PLHIV From funding streams, to policies, to institutions, to programs, to service delivery... “It’s not my responsibility”

17 RECONVENING BANGKOK 6-11 March 2010 Cambodia’s HIV and FP Response in Action: The “Linked” Response for PMTCT NMCHC NCHADS Linked HC Satellite HC OD RH PHD NMCHC coordinator Provincial AIDS officer (PAO) STI Clinic Maternity OI and ART Service VCCT ANC FP/BS PMTCT

18 RECONVENING BANGKOK 6-11 March 2010 FP referrals are almost nil, for both EWs and PLHIV Source: NCHADS 2008 Number of individuals Of 2000 EWs/DSWs in 2008 who sought gov’t STI consultations monthly, less than 50% referred to VCCT and almost none referred to FP

19 RECONVENING BANGKOK 6-11 March 2010 The third challenge we face: ensuring health provider capacity for FP/HIV messages, referrals or services HIV health care providers and implementers in Cambodia have little training in FP, do not give consistent messages... and have little motivation to promote FP (e.g. “I don’t know much about FP”; “condoms are all that’s needed”; “it’s not my job so what’s in it for me?”)

20 RECONVENING BANGKOK 6-11 March 2010 Pushing past the challenges for EWs: Promoting Dual Methods in HIV Prevention FHI/Cambodia’s SMARTgirl program for EWs uses branding, targeted education and incentives to promote FP methods and service uptake

21 RECONVENING BANGKOK 6-11 March 2010 Promoting dual methods through SMARTgirl 1. Strengthening partnerships with FP service providers (e.g. MSIC, RHAC) and social marketing organizations (PSI) for referrals and products 2.Targeted communications stressing benefits of dual methods and responding to FP misconceptions/beliefs 3.Quarterly training to peer and outreach workers – using tools, making referrals, social marketing 4.Incentives for those who go and those who refer THE RESULT – less than 10% service uptake after 6 months of intensive focus (we have much work still to do)

22 RECONVENING BANGKOK 6-11 March 2010 Pushing past the challenges for PLHIV – Adding FP to the “linked response” NMCHC NCHADS Linked HC Satellite HC OD RH PHD NMCHC coordinator Provincial AIDS officer (PAO) STI Clinic Maternity OI and ART Service VCCT ANC FP/BS PMTCT FP/BS PP VCCT

23 RECONVENING BANGKOK 6-11 March 2010 Waiting roomDoctors Drug Dispensary Drug Counselor Patients Home/ Community Monthly visit Video spots Posters/leaflets on PP and FP/RH Prevention PP messages Pregnancy/FP RH/FP STI clinic Systematic Referrals NMCH NCHADS Key PP messages Technical advice (pregnancy.) STI screening Refer to STI, FP Psycho-Social and PP Counseling Key PP questions Marriage/partner ? FP/ baby ? Last STI checking ? Systematic Condom distribution Adherence Drug interaction OC/ARV Condom demonstration if needed MMM Triage HBC PP messages Referral to OI/ART, FP, STI VCCT Post-test counseling Video spots Posters Education/information… FP/RH Pushing past the challenges for PLHIV – Adding FP to OI/ART sites Referral or on site ?

24 RECONVENING BANGKOK 6-11 March 2010 Integration in concentrated epidemic settings: some final words 1.Extensive “Point of care”/ “one stop” services may not be needed, or even beneficial in concentrated epidemics. Instead find the openings! 2.There is unmet need for FP among most at risk populations, and condom use is not sufficient. Promotion of dual contraceptive use is key to FP/HIV integration efforts. 3.Capacity building on FP for PLHIV/MARPs is critical for both NMCH and HIV health care providers, and it may be useful to place FP service providers in HIV prevention, care and support services and vice versa (as per TB/HIV integration efforts in Cambodia)

25 RECONVENING BANGKOK 6-11 March 2010 Integration in concentrated epidemic settings: some final words 4.More M&E - We just don't have much in the way of evidence-based models of FP/HIV integration in concentrated epidemics. We need more data on the impact of FP/HIV integration efforts on key health outcomes, such as contraceptive uptake and continuation, prevention of unintended pregnancies, etc. 5. Countries/participants should take advantage of emerging opportunities under PEPFAR and the Global Health Initiative to do integration.

26 RECONVENING BANGKOK 6-11 March 2010 Acknowledgements 1.Rose Wilcher, Family Health International/NC 2.Graham Neilsen, Family Health International/APRO 3.Laurent Ferradini, Family Health International/Cambodia 4.Gautam Bharat Raj, Family Health International/Cambodia 5.Peter Cowley, Family Health International/Cambodia 6.Somany Ngor, Family Health International/Cambodia 7.Population Services International/Cambodia


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