1. Integration of HIV and Nutrition Services – Action and Measurement Barbara Engelsmann, Sweden Chiruka, Charity Zvandaziva, Fitsum Assefa, Diana Patel Abstract No MOAE0102 Session Title: Integrated HIV, Health and Human Development Programs 20 th International AIDS Conference Melbourne, Australia 20-25 July 2014

2. What is Integration? Integration means different things to different people:  Integration of type of services  Integration referring to service delivery points  Integration of services over time  Integration of vertical levels of service  Integration at policy/management level WHO definition: “The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system.”

3. Why Integration?  Resource constraints – available resources have to be used as efficiently as possible  Rise of single disease funding or population group specific programs  Different disease goals based on common service delivery resources  Client oriented, closer to the goal of universal access  For smaller programs integration might be survival

4. Why NOT Integration?  Risk of reduced quality of service provision  Challenges to showcase achievements  AIDS exceptionalism – “it is important to regard HIV/AIDS services as a special case which needs to be well-resourced, expanded quickly and protected from the inefficiencies of the broader health system”

5. Integration of HIV (PMTCT/ped. HIV) and Nutrition (IYCF/CMAM) services IYCF CMAM PMTCT Pediatric HIV Mutual dependence of HIV and nutrition services Yet Largely vertical implementation of their programs to date Potential to maximise on different entry points for service provision PILOT PROGRAM to integrate service delivery for HIV and nutrition WHERE: Three country program (in Zimbabwe, Malawi and Mozambique) SUPPORT: Funded by DFATD through UNICEF WHEN: Over three years (July 2011 to June 2014)

6. In Zimbabwe: 32 sites in two rural districts (Marondera and Hwedza) Implementation: by the Organization for Public Health Interventions and Development (OPHID) trust in Zimbabwe linked to/leveraged by existing PMTCT program

7. Integration - Activities At national/provincial level Stimulation of policy dialogue at national level Sensitization at provincial level At service delivery level Skills building Encouragement of bi-directional linkages and referral systems Supervision and mentoring Development of job-aides At community level Mobilization of Voluntary community cadres Traditional leaders Mother-baby support groups At outreach level Capacity building of outreach teams Training and sensitization of village health workers

8. Integration - Monitoring & Evaluation  To monitor the delivery of service integration specific integration indicators were defined measuring the concurrent provision of HIV and nutrition services at different service delivery points  Examples:  % of children with SAM receiving HIV testing  % of children in pediatric ART program screened for SAM

9. Indicator 1: % PMTCT clients with children under 2 years of age receiving at least 2 IYCF counselling sessions Indicator 2: % HIV exposed infants attending DPT3 immunization who are exclusively breastfed Indicator 3: % children in pediatric ART program screened for SAM

10. Indicator 4: % children with SAM receiving HIV-testing Indicator 5: % of HIV positive children at CMAM enrolling on ART

11. Integration – Success Baseline integrated service delivery Program interventions to promote service integrations Recording of indicators to define and prompt integrated service delivery Integration now measurable Outcome: Integrated service provision increased

12. Integration – Challenges Action Challenges:  In particular at higher level Monitoring and Evaluation Challenges:  Information required for integration indicators originating from different source registers (CMAM register, ART register, EPI register) at different service delivery points over a period of time  Enumerators and denominators were not always routinely available as part of the national M&E system eg IYCF counseling provided, currently breastfeeding

13. Integration – Recommendations  Support of integration efforts at national level (even if different departments are involved)  More attention to national routine M&E tools to include measures for integration and set targets for integration indicators Next Steps:  Impact analysis  Cost-effectiveness analysis

14. Acknowledgements President’s Emergency Plan for AIDS Relief through USAID under the terms of Families and Communities for Elimination of Pediatric HIV in Zimbabwe (AID-613-A-12-00003) Disclaimer “This study was made possible by the generous support of UNICEF and the American people through the U.S President’s Emergency Plan on AIDS relief (PEPFAR) and United States Agency for International Development (USAID). The contents are the responsibility of OPHID and do not necessarily reflect the views of UNICEF, DFATD, PEPFAR, USAID or the United States Government” UNICEF HQ, regional and country office And many more…. Zimbabwe Ministry of Health and Child Care Department of Foreign Affairs, Trade and Development Canada