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

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 10-24 year olds Targeted stigma-free services for key pops Advocacy Demand creation

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

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

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

Increase in number of clients reached

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

Innovativeness

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

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

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

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

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

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.

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