Integration: Intersection for Reproductive Health and HIV Programs: the Kenyan Experience

1. Integration: Intersection for Reproductive Health and HIV Programs: the Kenyan Experience Family Health International Sponsored Satellite Session World AIDS Conference 2006 Toronto CANADA Dr. Joel Rakwar Family Health International

2. Outline • Background situation • Why integrate • Key operational questions • Integration program in Kenya

3. Young Women Disproportionately Affected 75% young women 25% young men HIV cases in sub-Saharan Africa among 15-24 year olds Source: UNAIDS, 2004.

4. HIV/AIDS Prevalence and Unmet Need Source: DHS, 1999-2003 (unmet need), PRB 2004 (HIV/AIDS)

5. RH Services Family Planning Services Clinic based Community based MCH Services ANC PNC CW HIV/AIDS services Prevention ABC PMTCT VCT Care and Support ART HBC OVC Components of RH & HIV Programs

6. Opportunities for Integrating HIV and RH Services Share common needs and concerns: • are often both sexually active and fertile • 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 AND Clients Seeking RH Services

7. Opportunities for Integrating HIV and RH services • HIV information and services not delivered in RH services and vice versa • Many people coming for HIV services may not come for RH/FP services and vice-versa even though they need them (e.g., men, adolescents) • RH services well established and patronized by large segment of sexually active female population • Massive expansion of HIV services provide opportunities linkages with RH/FP services • In many settings it is the same providers giving both services

8. RH Services Risk Assessment Pregnancy and complications STIs/HIV Cancers Counseling for behavioral change Prevention Health Seeking behaviors HIV/AIDS services Risk Assessment HIV and complications STIs/Pregnancy Counseling for behavioral change Prevention Health Seeking behaviors Opportunities for integration: Core Components of RH and HIV/AIDS services

9. Key Operational Questions • Is there potential demand for RH services among HIV/AIDS program clients and vice versa? • Is the provision of RH in HIV/AIDS programs acceptable to clients, providers and facility-in-charges? • Does the provision of RH in HIV/AIDS programs lead to better outcomes e.g., reduction in unmet need, reduction in unintended pregnancy?

10. The Kenya FP-VCT Integration Program • Key milestones • Assessment of feasibility, acceptability and potential demand, June 2002 • Found that FP into VCT was feasible, acceptable and there was potential demand among VCT clients • Development of Integration program • Formation of FP-VCT subcommittee of Ministry of Health • Formulation of national strategy on integration that defined integration as ‘incorporation of some or all of the different FP services into VCT and vice versa’ • Development of training manual and related training materials e.g., job aids for FP into VCT • Reverse integration of VCT into FP currently being developed along same lines

11. The Kenya FP-VCT Integration Program • Key Milestones • Development of Integration program (con/t) • 38 Trainers trained from all provinces in the country • 141 providers from 59 sites trained on provision of integrated services • Provincial sensitization meetings held for buy-in purposes • Modified the M&E tool of the MoH to capture integrated services using 3 indicators • Conducted operations research to evaluate the effect of interventions on offering of integrated services

12. Operations Research • Objectives • Determine the effectiveness and costs of adding FP services to VCT centers • Determine the effect of adding FP services on VCT quality of care • One group pre-, post-test design • Baseline data collection, June 2004 • Intervention (training of providers) • Follow-up data collection, April/May 2005 (CPIs) • Study sites: 14 VCT centers in Coast and Western

13. Provider Training • 14 facilities participated • Only 20 of the 60 VCT providers at these facilities, received the FP-VCT Integration training • < 2 providers per facility • Total of 689 Client-Provider Interactions observed

14. Results • 28% of the clients had unmet need defined as: • currently sexually active • do not desire a child in the next two years • are not currently on any contraceptive method

15. Trained providers more likely to discuss fertility issues Level of these discussions low Clients status not influencing discussions Smaller proportion of men asked about fertility issues than women Observations of Fertility and Family Planning Use Discussions by Provider FP-HIV Training

16. Observations of Family Planning Counselling by Provider Training

17. Observations of Condoms Discussions by Provider Training

18. Observations Of VCT Mean Session Length by Provider Training

19. Conclusions • Trained providers performed better than untrained in providing the integrated services • Providers not doing enough pregnancy risk screening and informed choice counselling • Providers should target their counselling to clients based on their characteristics e.g., HIV status, unintended pregnancy risk

20. Conclusions • Integration of contraception into VCT has potential of reducing unintended births (both HIV +ve and -ve) • Integration increases access to contraceptive services for VCT clients

21. Recommendations • Training needs strengthening to enable providers do adequate pregnancy risk screening and informed choice counselling • Providers should be assisted to target their counselling to their clients characteristics • Providers should be encouraged to target men with discussions about fertility issues • Further research needed to evaluate the impact of integrated FP-VCT services on RH outcomes e.g., contraceptive uptake

22. Thank you