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Addressing the Family Planning Needs of People Living with HIV

Addressing the Family Planning Needs of People Living with HIV. Betty Farrell, CNM, MPH Laura Subramanian, MS Grace Nagendi, MPhil Charles Ngobi, MD The ACQUIRE Project/ EngenderHealth EOP Concurrent Session September 17, 2008. Session Outline.

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Addressing the Family Planning Needs of People Living with HIV

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  1. Addressing the Family Planning Needs of People Living with HIV Betty Farrell, CNM, MPH Laura Subramanian, MS Grace Nagendi, MPhil Charles Ngobi, MD The ACQUIRE Project/ EngenderHealth EOP Concurrent Session September 17, 2008

  2. Session Outline • Integrating family planning (FP) and HIV services: definition, rationale and goals • Applications of ACQUIRE’s FP-HIV integration approach • Lessons learned and recommendations for FP-HIV integration programs

  3. “More More More Services People Places” to in Increased Access, Quality and Use Supply Demand Advocacy • Service sites readied • Staff performance improved • Training, supervision, referral, and logistics systems strengthened • Accurate • information • shared • Image of services enhanced • Communities engaged Quality client-provider interaction Increased knowledge + acceptability Increased availability Improved policy + program environment • Leadership and champions fostered • Supportive service policies promoted • Human and financial resources allocated Fundamentalsof Care Data for Decision Making StakeholderParticipation Gender Equity

  4. What is Integration? “An approach in which health care providers use opportunities to engage the client in addressing her/his broader health and social needs than those prompting the health encounter”

  5. Why Integrate Family Planning with HIV Services? • Increased availability of ART • 16.5 million women of reproductive age living with HIV • Family planning helps HIV-positive women: • avoid transmitting HIV to partners and children • prevent unintended pregnancies and avoid stress of pregnancy • plan desired pregnancies while minimizing HIV transmission risk • HIV clinic = key service point for people living with HIV

  6. Goals of FP-HIV Integration • Comprehensive HIV services with family planning as an integral component of care • Family planning information specific to PLHIV • Risk assessment and behavior change strategies • Health monitoring • Counseling and provision of family planning commodities

  7. Choosing a Level of FP Integration * If facilities or programs providing Level A functions are not immediately prepared to provide oral contraceptives for ongoing uses, they may provide emergency contraceptive pills with referral for ongoing FP management. If the facility or program already provides oral contraceptives (Level B), it can also offer emergency contraceptive pills.

  8. ACQUIRE’s Approach to Integrating FP and HIV Services STEP 1* STEP 2* STEP 3 STEP 4 STEP 5 Identify/ refine level of integration that can be adopted Assess HIV program’s capacity to support FP** Build or strengthen systems to support new services Identify resources to support integration Phase in FP methods to expand mix within HIV program’s capacity SYSTEMS Supervision Logistics Referral Training RESOURCES Partnerships Capacity * Steps 1 and 2 interchangeable depending onstakeholders’ pre-existing desires for level of integration ** Include orientation of stakeholders to staff tasks and system functions required tosupport levels of integration

  9. ACQUIRE’s Integration Approach:Ghana FP-ART Pilot Needs Assessment April-June 2005 PNA at 2 sites  action plan ART Provider Trainings July-Dec 2005 FP-ART training curriculum developed and field-tested Jan/Feb 2006 32 providers trained to counsel on FP and provide pills and injectables 2 government hospitals providing ART and FP Evaluation May 2006 128 clients received FP methods Further attention needed to clients’ fertility desires and SD systems to support FP Job Aids and IEC materials Contraceptive chart Counseling flow chart Client brochure

  10. Ghana FP-HIV Community Pilot:“Family Planning for Healthy Living” Peer Educator Trainings July/August 2007 75 members from 43 PLHIV support groups trained in FP messaging and referral FP Provider Trainings July/August 2007 Stigma reduction training & CTU for 19 FP providers PE-Provider Partnerships FP providers attended monthly PLHIV support groups PLHIV support groups in 4 regions Endline Assessment April/May 2008 Increased FP knowledge of PLHIV Expanded FP method mix Persisting barriers to FP uptake Job Aids and IEC Materials Contraceptive chart Sample FP method card Client brochure

  11. “I feel confident that I can prevent pregnancy until I am ready to have another child.” “I am taking care of my health.” Ghana: Peer educators, providers and clients as advocates for FP Peer educators and Providers Satisfied FP clients • Role models in the PLHIV community • Advocates and partners for FP

  12. ACQUIRE’s Integration Approach:Uganda TASO/Mbale Pilot FP-ART Provider Trainings July-Sep 2006 23 trainers and 15 ART providers trained in FP (pills, injectables, ECP) 16 referral providers updated in FP Needs Assessment March/April 2006 PNA  action plan 2 Stakeholder meetings Community Outreach Sep-Dec 2006: 33 FP awareness sessions; 4 field officers and 2 volunteers trained in FP. April 2007: 12 community nurses trained in FP FS/COPE® Trainings Feb 2007 Trainings for QI, staff performance and needs TASO/Mbale ART center Job Aids and IEC Materials Contraceptive chart, counseling flowchart, client brochure

  13. TASO/Mbale: Stories of FP Advocates ART Providers support FP for PLHIV • “Family planning is about people’s lives. I don’t want PLHIV to have unintended pregnancies.” • Community nurses talk about FP and address myths • “We now encourage others to come for family planning. We share the information we got from TASO. Now clients are learning to plan.” HIV-positive mothers adopt FP

  14. TASO/Mbale Pilot: Systems Challenges and Solutions Record- keeping Training Supervision Infrastructure Logistics Referral

  15. System Challenge: TrainingWhat Would You Do?

  16. System Solution: TrainingWhat TASO Did

  17. System Challenge: SupervisionWhat Would You Do?

  18. System Solution: Supervision What TASO Did

  19. TASO/Mbale Pilot: Evaluation • ART providers respect RH rights and fertility desires of PLHIV • PLHIV satisfied to receive FP services from ART providers • Strengthened systems for training, supervision, logistics, recordkeeping, referral, etc. to support FP • TASO/Mbale has provided FP to 605 clients (406 DMPA, 131 COC, and 68 referred for LAPMs)

  20. Implementation differences:Ghana and Uganda pilots

  21. Uganda Positive Prevention Project ositive revention Stakeholder engagement 2006 PNA  action plan Identified 4 liaisons from MoH Curriculum Development 2007 Developed and field-tested FP modules for HIV counselor and peer educator training curriculums Strengthening HIV Counselor training (SCOT) Project • FP training • 2007-2008 • Orientation, training TA and post-training follow-up for 69 trainers from SCOT partners • 359 providers trained in FP • 213 community based peers trained from 9 PLHIV groups Job Aids and IEC Materials Contraceptive chart RH fact sheet Client brochure

  22. Positive Prevention: Advocates for FP Providers • “People with HIV have the right to have children. They deserve choice, not chance.” Clients • “Men need to seek family planning if they love their family.”

  23. Integrating FP and HIV Services:Lessons Learned • FP-integrated HIV services are acceptable, feasible and effective • Integration can be implemented at a variety of levels • Holistic Supply-Demand-Advocacy approach contributes to successful sustained integrated services

  24. ACQUIRE’s Integration Approach: Lessons Learned • Supply: strengthening systems is key • Counseling/clinical training in FP with practicum, post-training follow-up, job aids/ IEC materials • FS/COPE® to strengthen overall systems and supervision • TA for using FP commodity supply system • Accurate, organized records to track provision of FP counseling and methods • Strong referral linkages • Assistance from volunteers to manage increased workload

  25. ACQUIRE’s Integration Approach: Lessons Learned (continued) • Demand: generate FP awareness and link HIV-positive clients with services • Disseminate FP info through awareness sessions and campaigns • Develop partnerships with peer educators and PLHIV groups • Advocacy: gain buy-in to create/maintain a supportive environment for integration • Collaborate with stakeholders, including community • Orient donors to integration rationale and approach • Engage senior health personnel in integration process • Create fora for collaboration between FP and HIV leadership • Develop supportive guidelines and policies for integration

  26. Recommendations for FP-HIV Integration • 5-step integration approach with SDA elements and attention to systems strengthening • Engage multiple levels of facility and MoH staff • Consider LOE required for integration • Implement comprehensive FP training + follow-up package including addressing provider attitudes toward PLHIV • Update referral site staff to strengthen linkages • Partner with PLHIV communities as advocates for FP • Assess site capacity for expanding FP method mix • Explore modifications to ACQUIRE integration approach

  27. Acknowledgments • USAID – Mary Ann Abeyta-Behnke, Sereen Thaddeus, Peter Wondergem • TASO – Drs. K. Mugisha & C. Ngobi; G. Ochieng; Center staff • Uganda MoH – Drs. Sentongo, Madra, Latigo, Esiru, Lukoda • Mbale Regional Hospital FP Unit – the late Sr. Tunde • ACQUIRE/Uganda – Dr. H. Kakande, G. Nagendi • QHP – O. Aglah, Drs. P. Preko and E. Bonku, P. Ampofo, R. Killian • OICI, CRS, SHARP and Ghana Health Service • ACQUIRE/NY – A. Kaniauskene, N. Johri, N. Russell, J. Wickstrom • Photo credits: N. Russell and TASO/Mbale

  28. Featured Materials • FP/HIV Integration Framework document (NY, June 2006) • ACQUIRING Knowledge: TASO/Mbale Project Brief (NY, 2007) • Evaluation of the TASO FP/ART Pilot (NY, August 2008) • Job Aids from Ghana and Uganda (2005, 2006) • Contraception for Women and Couples with HIV (FHI/ACQUIRE product collaboration) • FP-HIV Integration Toolkit (FHI/ACQUIRE product collaboration) • Positive Prevention Family Planning Module #9 (from the tool Positive Prevention Counseling: A training manual (Uganda, 2007) • Integrating Family Planning with HIV Care and Treatment Services: A Training Curriculum for Providers & Counselors (Uganda, July 2006) • Ghana Peer Educator training manual: Family Planning for People Living with HIV and AIDS, July 2007

  29. Want to Know More? • Visit the ACQUIRE Project website: www.acquireproject.org or email us at info-acquire@acquireproject.org • To learn more about TASO and their activities, visit their website at www.tasouganda.org. For specific information on TASO/Mbale, visit http://www.tasouganda.org/mbl.php

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