Integration of Counselling & Testing for HIV into FP services in Kenya

1. Integration of Counselling & Testing for HIV into FP services in Kenya Dr. Robert Ayisi: Deputy Head NASCOP, MOH Kenya Wilson Liambila: Population Council, Nairobi Presented at The XVII Inter-national AIDS conference 3-8 August 2008/Mexico City

2. Outline of Presentation Background Methodology Findings Lessons learnt Conclusion Way forward

3. BackgroundKenya • Population 34million (2005 KNBS) • CPR 39% • TFR 4.9 • FP unmet needs 24% • HIV prevalence 7.4% (KAIS 2007) • HIV prevalence among women 15-49years 9.2% (KAIS 2007) • Low VCT coverage 13% condom use 10%

4. Why Integrate HIV and RH Services Government policies support provision of integrated services (Kenya’s NHSSP 2005-2010, RH Policy 2007) Clients seeking RH&HIV share common needs Most clients seeking RH& HIV services are sexually active and fall within the reproductive age bracket (15-45) Are at risk of HIV infection or might be infected Need access to contraceptives need to know how HIV affects contraceptive options Clients Seeking HIV-related Services Clients Seeking RH Services AND

5. Study Objectives To develop and implement two models of integration (i.e. Testing and Referral) and evaluate the models in terms of: Feasibility of implementation, Acceptability to both clients and providers, Effect on the quality of FP services Effectiveness in increasing VCT uptake Incremental (Additional) Cost required 2. Disseminate and utilize results to create conditions for scale-up

6. Methodology - 1 Study design: Pre and post intervention design applied. Thus, measurements were conducted at both baseline and endline Participants were: FP clients and FP providers Sites: Central province: Nyeri - 9 facilities (low VCT availability initially) and Thika – 14 facilities (initially high VCT availability)

7. Methodology - 2 A health facility assessment of the readiness of facilities to offer counseling and testing for HIV within FP services conducted Data were collected through provider client observations (554 at baseline and 530 at endline) and client exit interviews (552 at baseline and 530) at end line Pre and post intervention FGDs with health providers and clients conducted

8. Models of Integration Two models of integration were piloted: The Referral Model: - Involved educating FP clients about VCT and referring those interested for testing and post testing counseling The Testing Model: - Involved Educating FP clients about VCT and offering them counseling and testing for HIV within the routine visits by FP providers as well as post-test counseling

9. Interventions Sensitization of Provincial and District teams Developing Training Materials Adaptation of Balanced Counselling Strategy (BCS) Plus Modified FP registers to allow routine collection of information on VCT services MOH supplied basic commodities e.g. test kits Training of Health Providers on FP updates, BCS & CT

10. Results Feasibility: Most facilities are ready to offer HIV/FP integrated services (About 70% had basic supplies, Equip, Appropriate Infrastructure) Integrated Approach Acceptable to Providers & clients:- -We do encourage clients to use dual protection and to know their HIV status” (Provider FGD) -(“It is better for my FP provider to test me and know my status)Client.

11. c) Quality of HIV Counseling Improved

12. d) Effectiveness: Uptake of HIV testing improved among FP Repeat clients (Who have ever had an HIV test)

13. e) Cost Analysis of the Testing Model Incremental cost per facility by level of care:  Hospital: Incremental cost per client tested ($ 5.60) Health Centre: Incremental cost per client tested ($ 9.2)  Dispensary: Incremental cost per client tested ($ 9.53) This includes planning, training, materials, and service delivery. Average Incremental Service Delivery cost per facility by level of care: Hospital: ($2,790) ; Health center ( ($1,156); Dispensary $548 Incremental service delivery Cost per FP client tested for HIV is $ 2.5 (This includes labour, test kits,other recurrent costs).

14. Lessons learnt Supportive service delivery guideline and MOH leadership is necessary Advocacy is key at various levels Build consensus among stakeholders Ensuring commodity security is important Clients are now demanding testing services due to increased knowledge. Reduction in stigma

15. Enabling factors Conducive Policy environment -NHSSP and the RH Policy Existence of a technical committee on integration Availability of suitable training materials Trained service providers Ready infrastructure Strong and willing partner support.

16. Challenges Human resource shortage Weak logistic mgt system for Commodities and supplies & Occasional stock-outs. Inadequate Equipment in some facilities Lack of space in some facilities has compromised confidentiality in counseling and testing. Clients exerting pressure on health providers to be tested within FP clinics

17. Conclusions Integration is feasible without compromising coverage or quality of existing FP services Provider Initiated C&T and HIV/FP integration is acceptable to both clients and providers Access, quality and uptake of HIV counseling and testing improved Use of the BCS+ tools facilitated integration

18. Way Forward Intensify National scale up of CT–FP services Ensure CT-FP service is captured in the National reporting tools Ensure that this approach is factored in the pre-service training curricula Supplies and Commodities need to be sustained

19. Acknowledgements Dr. Marsden Solomon-Regional RH Advisor FHI Division of Reproductive Health NASCOP PHMT including (PASCO) Central, Members of DHMT - Nyeri Members of the DHMT - Thika HMTs (PGH, Thika and Gatundu) Trainers USAID and PEPFAR –for financial support for the project activities.

20. No missed opportunities!!! Integrate FP with HIV Services Family Planning Services HIV Services