1. Advancing the Integration of Family Planning and HIV Services from a Systems Perspective December 9, 2014

2. TIMETOPICSPEAKER/FACILITATOR 10 minutes Participants log in Instructions 10 minutes Welcome and opening remarks Nithya Mani, USAID 15 minutes Evidence for a health systems approach to integration: findings from the Integra Initiative Charlotte Warren, Population Council 15 minutes FP/HIV integration implementation: reflections from the field Mary Namubiru, EGPAF/Uganda 20 minutes New resources to support FP/HIV integration throughout the health system Tricia Petruney, FHI 360 20 minutes Q&A for the speakersAll participants

3. Opening Remarks Nithya Mani, USAID

4. Evidence for a health systems approach to integration: findings from the Integra Initiative Webinar: Advancing the Integration of FP and HIV Services from a Systems Perspective Charlotte Warren Susannah Mayhew and Richard Mutemwa 9th December 2014

5. What is the Integra Initiative?  Large operations research initiative (2008 – 2013)  Implemented in three countries in Africa:  Kenya, Swaziland, Malawi (start-up costing analysis only)  Managed by the International Planned Parenthood Federation (IPPF) in partnership with the London School of Hygiene and Tropical Medicine (lead on research) and Population Council (lead on intervention implementation)  Interventions involved staff training on integration and mentoring; research employed a program science approach to understanding and evaluating service provision and client experiences  Supported by the Bill & Melinda Gates Foundation

6. What gap did Integra seek to fill? Linkages: pre-Integra scenario Real commitment at global level to intensifying linkages between SRH & HIV at programmatic and policy levels. The rationale for doing so is clear but we needed to gather evidence on how to link HIV and SRH. The Cochrane Systematic Review conducted in 2007 showed a lack of evaluative studies on the benefits of linking HIV & SRH. Integra goal: To strengthen the evidence of the benefits and costs of a range of models for delivering integrated HIV and FP/PNC services in high and medium HIV prevalence settings for reducing HIV (& associated stigma) and unintended pregnancies.

7. 20092010 2011 2012 Health Facility Assessment time- series 2009-2012 (42 clinics) Community (HH) Survey Baseline 2009 N=2588 Community (HH) Survey Endline 2012 N = 3037 Client Flow time-series 2009-2012 N=9519 @ R0 Cohort studies 2010-2012 N=4763 @ R0 + 75 IDIs Costing Baseline 2009- 2010 (42 clinics) Costing Endline 2011-2012 (42 clinics) Integra Data Collection, Kenya & Swaziland Cohort IDIs with sub-sample of WLHIV 2010-2012 N=150

8. The challenge of ‘embedded’ research ‘Real’ setting: comparison facilities contaminated: by additional Govt/donor activities on integration by staff actions at individual facilities Implementation of intervention varied across facilities motivation, stock-outs, staff turnover etc. Degree of integration achieved & sustained at individual clinics varied and changed over time... As a result, we were not confident that the levels of integration achieved in intervention facilities would be significantly different from those in comparison facilities.

9. An Innovative Solution: The Integra Index Independent measure to account for actual degree of integration at each facility over time. Range of clinic-specific data available at different time-points = construct a multi-dimensional ‘Index’ to measure a continuum of achieved integration. Facility scores (n=42) are generated at multiple time-points and used to: 1) assess the extent of service integration achieved within facilities over time and understand what drives this; and 2) evaluate the impact of the level of facility integration on the behavioural and health status outcome indicators.

10. Building the Index of Integration Range of services = 1) ART 2) Cervical cancer screening 3) CD4 count services 4) HIV/AIDS testing services 5) STI treatment 6) FP 7) Postnatal care 8) ANC DimensionIndicator NameData Source Physical Integration Service availability within MCH/FP unit Service availability in facility Range services provided in each consultation room ART location and referral Periodic Activity Review Costing data (clinic registers) Client Flow tool Temporal integration Range of services accessed daily Client flow tool Provider Integration Range of services provided per clinical staff member Costing data (clinic registers) Functional Integration Range of services provided in one consultation Range of services provided in 1 visit Client flow tool

11. Exploring Functional Integration: The Capacity- Delivery gap Clinic A: High functional integration Clinic B: Poor functional integration Clinic B: Poor functional integration over time Clinic A: High functional integration over time Capacity- Delivery Gap

12. Importance of Proactive Staff Clinic A: High functional integration Clinic B: Poor functional integration Clinic A: Health Centre ServiceBaseline 2009 (TP1) Endline 2011 (TP5) FP2,4721,572 PITC1,385876 VCT-0 Ca Cx-68 Clinic B: sub-district hospital ServiceBaseline 2009 (TP1) Endline 2011 (TP5) FP2,4473,348 PITC250230 VCT275- Ca Cx2630 Source: Service statistics (economics)

13. Providers reported improvements in service efficiency and cost-benefits but also saw challenges from integration: Facility Integration level (endline): Reported issue: Low Integ. n=41 (%) High Int. n=87 (%) Combined n=128 (%) Occupational stress: No occupational stress Has not changed Has reduced Has increased 3 (7.3) 16 (39.0) 8 (19.5) 14 (34.1) 14 (16.1) 18 (20.7) 15 (17.2) 40 (46.0) 17 (13.3) 34 (26.6) 23 (18.0) 54 (42.2) Workload: Has not changed Has reduced Has increased 11 (26.8) 8 (19.5) 22 (53.7) 11 (12.6) 10 (11.5) 66 (75.9) 22 (17.2) 18 (14.1) 88 (68.8) Shortage of equipment/drugs11 (26.8)26 (29.9)37 (28.9) Shortage of room-space25 (61.0)41 (47.1)66 (51.6) Shortage of staff time22 (53.7)47 (54.0)69 (53.9) Lack of trained staff15 (36.6)23 (26.4)38 (29.7) Lack of clear policies & guidelines5 (12.2)6 (6.9)11 (8.6)**

14. “Ability to Cope”: Importance of People Systems software issues are critical to high functioning integration: Better Teamwork and communication: Nowadays we communicate…and that’s been really helpful I think. You don’t feel alone on the job. It never used to happen before. (Enrolled Nurse, Health Centre, Eastern Province, Kenya) Better job satisfaction and staff motivation …where there is no integration there is that boredom because of doing one thing and there is no change. In integration […] it keeps on rotating in your mind…and you enjoy the work. It boosts my morale, because the monotony is not there. (Enrolled Nurse, Hospital, Central Province)

15. Summary For SRH service integration Integra findings show that structural (including equipment and supplies) and training inputs are insufficient to achieving integrated service delivery. Mechanisms to enhance the motivation, communication and team-working of health workers is essential.

16. Thank you www.integrainitiative.org

17. Advancing the Integration of Family Planning and HIV Services from a Systems Perspective

18. Background  Integration of HIV and FP has been shown to improve sexual and reproductive health outcomes  FP is a proven strategy for reducing new pediatric HIV infections  FP has been perceived as a women issue with minimal male involvement, yet men are the decision makers  Observed stigma related to widows being sexually active affects uptake of FP for the HIV positive women

19. FP/HIV integration in Uganda  There is evidence of FP/HIV integration at various levels of service delivery.  The country has an RH/HIV integration strategy with other conducive policy guidelines  Good PMTCT service coverage  At national level, the planning for SRH/FP is under the RH division, community health department while HIV/PMTCT are under the AIDS control Program division, National disease control department.  At district level, the two are coordinated by the DHO

20. FP uptake by HIV positive women in the STAR SW supported districts

21. % of expected HIV positive women using modern FP Oct 13- Sept 14

22. Enablers of FP/HIV integration  HIV care clients have FP needs that have to be addressed (75% unmet need (Jhangri..2012). )  HIV/FP integration policy guidelines exist in many countries  Educational materials on FP/HIV integration are available for HW  Some FP methods can easily be provided in the HIV clinics eg condoms, oral contraceptives, health education

23. Enablers  There are opportunities to integrate FP in many HIV prevention services eg community mobilization, SMC, demand generation activities (6 tent activations), Health education

24. Hindrances to FP/HIV integration  Myths about FP  Stigma related to widows being sexually active  Family planning perceived to be a service for women  Low staffing levels at the health facilities especially HIV settings  Periodic stock out of family planning commodities especially injectables  Family planning registers do not capture clients receiving services as couples

25. Hindrances to FP/HIV integration  Capacity of health workers to offer long term family planning methods – training/infrastructure  Services not arranged to offer family services  Condoms known to be dispensed at various points and not captured / service uptake not monitored  A need and hope to have HIV negative babies reduces uptake of FP

26. Health system approach to FP/HIV integration  Human resource for Health  Medicines and technology  Service delivery  Information systems  Finance and funds  Governance

27. Governance  National policy guidelines supporting FP/HIV integration  Supportive supervision at various levels i.e. national, regional, district and site level

28. Human resources for health  Adequate number of service providers to offer services  Capacity of the health workers to offer LTFP methods  Accountability / ethical code/ supervision to ensure quality of services provided  Ownership of the program by the HIV care providers – justification for FP HIV positive clients  Remind HW that FP services are for both men and women (male involvements)

29. Service delivery  Recognize condoms as an FP method and not only for STI prevention  Streamline client flow in the HIV clinics to fully integrate FP  Space for service provision, examination of the clients/mothers, ensure confidentiality  Availability of a wide range of FP service methods including LTFP (vasectomy/BTL)

30. Medicines and supplies  Wide range of FP methods should be available at the service provision site  Client centered services- commodities should be supplied according to demand. Some communities prefer particular methods for various reasons  Timely and good quality forecasting and ordering for FP supplies- HIV service providers should be engaged in the forecasting of their needs  Ownership of the program by HIV care providers-

31. Information systems  There needs to be a systematic way of capturing family planning data in the HIV settings and HIV data in the family planning settings  Systematic monitoring of condom use as an FP method (dual protection)  Promotion of data use at all levels: service uptake data is key for logistic management, quality improvement, planning etc

32. Empower the community  Community should demand for the service  Demystify misconceptions on FP (widows not expected to take on FP)

33. Next steps  Commitment from governments to ensure regular supply of wide range of FP commodities  Invest in community sensitization and demand generation for FP services  Supervision and support to the service providers to ensure quality of services.  Improve staffing levels in the HIV clinics to take on other services like FP  Strengthen male involvement in FP – condoms as a FP method, increase uptake of vasectomy

34. NEW RESOURCES

37. A review of research findings, program experiences in the field, and technical guidance to identify and synthesize evidence pertaining to: the rationale for integrating FP and HIV services; facilitators of and barriers to successful integration; and the impact of integrated FP/HIV services.

39. Encourages supervisors, planners, service providers, and community-based personnel to consider opportunities for operationalizing the integration of family planning into the provision of ART services in a way that responds to and respects clients’ needs and desires. Includes: A hormonal contraceptive and ARVs interaction chart, safer conception resource, and extensive illustrative indicator tables for clients who desire conception, as well as for those wishing to avoid pregnancy.

40. Resources Preventive Technologies Agreement website: http://www.fhi360.org/projects/preventive-technologies-agreement-pta http://www.fhi360.org/projects/preventive-technologies-agreement-pta Integrating Family Planning into HIV Programs: Evidence-Based Practices – Prezi: https://prezi.com/mwk7mypyw9q7/integrating-family-planning- into-hiv-programs/https://prezi.com/mwk7mypyw9q7/integrating-family-planning- into-hiv-programs/ – Brief: http://www.fhi360.org/sites/default/files/media/documents/FP%20HI V%20Evidence%20Based%20Practices%202013.pdf http://www.fhi360.org/sites/default/files/media/documents/FP%20HI V%20Evidence%20Based%20Practices%202013.pdf Integrating Family Planning and Antiretroviral Therapy: A Client-Oriented Service Model: http://www.engenderhealth.org/files/pubs/family- planning/integrating-family-planning-antiretroviral-therapy-service- model.pdfhttp://www.engenderhealth.org/files/pubs/family- planning/integrating-family-planning-antiretroviral-therapy-service- model.pdf

41. Share your thoughts and questions! Please use the Q&A chat box to type in your questions for the guest experts or any general comments that you would like to share. If your question or comment is aimed at a particular guest expert, please indicate that.

42. THANK YOU! This webinar will soon be made available online, and we encourage you to share it with your colleagues who were unable to attend the live event. Please look for it on FHI 360’s You Tube channel! http://www.youtube.com/user/FHIVideo/videos If you have any follow up questions or comments please email Tricia Petruney at tpetruney@fhi360.orgtpetruney@fhi360.org