Peer mentoring: An effective strategy for integrating HIV and SRH services

Mentoring is an innovative approach to improving provider skills without compromising service delivery by harnessing the potential of existing providers. In Kenya, a peer-mentorship approach was designed and tested to improve service providers’ skills, knowledge, and capacity to provide high-quality integrated HIV and SRH services. A central component was to understand providers’ opinions on mentoring, so as to build a practical and sustainable mentorship model. The “Steps to Integration” series provides a guide on how to integrate HIV and SRH services based on findings from the Integra Initiative, managed by the International Planned Parenthood Federation in partnership with the London School of Hygiene & Tropical Medicine and the Population Council. Issue 2 of the series explores the peer-mentorship approach to providing high-quality integrated services. Conclusions: Mentorship was perceived to be a feasible method of training for capacity-building. The benefits of mentoring are particularly relevant for settings with moderate or high HIV prevalence and limited funding. If thoughtfully designed and implemented, mentoring has the potential to combat problems of staff shortages in an acceptable and cost-effective manner

SRH and HIV service integration and stigma

Stigma is frequently faced by people living with HIV and those who they are associated with, and is frequently followed by discrimination. The “Steps to Integration” series provides a guide on how to integrate HIV and SRH services based on findings from the Integra Initiative, managed by the International Planned Parenthood Federation in partnership with the London School of Hygiene & Tropical Medicine and the Population Council. Issue 3 of the series explores the experience of stigma among clients living with HIV in a variety of settings, both service-based (when seeking family planning, antenatal, and postnatal care services) and facility-based (when seeking services in different facility types). Recommendations: create practices that protect women’s confidentiality; strategize confidentiality policies and skilled management of the integration process; include psychosocial support unique to stand-alone facilities in integration program design; improve provider training regarding HIV client interaction; improve subtlety of labeling client records, ARV cards, and food distribution; either limit the number of providers who offer integrated services, or improve confidential record keeping

Integration of sexual and reproductive health and HIV services

In sub-Saharan Africa, there is a high rate of unintended pregnancy, particularly among HIV-positive women, and the majority of HIV infections are sexually transmitted or transmitted as a result of pregnancy, childbirth, and breastfeeding. Yet many health facilities do not provide integrated HIV and SRH services. Integration has the potential to increase access and uptake of health services, increase job satisfaction among providers, more effectively distribute facility workloads, and reduce facility costs. The Integra Initiative represents an effort to respond to the need for high-quality evidence on the feasibility, effectiveness, cost, and impact of different models for delivering integrated HIV and SRH services in settings with high and medium HIV prevalence in sub-Saharan Africa. The “Steps to Integration” series provides a guide on how to integrate HIV and SRH services based on findings from the Integra Initiative, managed by the International Planned Parenthood Federation in partnership with the London School of Hygiene & Tropical Medicine and the Population Council. Issue 1 of the series explores the integration of sexual and reproductive health and HIV services

The effect of integrating HIV services on quality of postnatal care

Addressing the postnatal needs of new mothers is a neglected area of care throughout sub-Saharan Africa. Unintended pregnancies during the first 12 months following delivery, and vertical transmission of HIV during labor and delivery, are some of the challenges faced by women during the extended postpartum period. Many women want to delay or avoid another pregnancy, but are not using a modern contraceptive method. Few developing countries ensure that mothers and newborns are assessed early and monitored during the initial six-week period as recommended by WHO, which contributes to discontinuity of services received during pregnancy and delivery and limits linkages to other key services, including family planning, HIV testing and counseling, and HIV care for women and infants. The “Steps to Integration” series provides a guide on how to integrate HIV and SRH services based on findings from the Integra Initiative, managed by the International Planned Parenthood Federation in partnership with the London School of Hygiene & Tropical Medicine and the Population Council. Issue 5 of the series focuses on the effect of integrating HIV services on quality of postnatal care in Kenya and Swaziland

Male utilization in integrated SRH and HIV services

Worldwide, men are less likely to seek sexual and reproductive health (SRH) and HIV services than women. This is due to the way in which SRH and HIV services are organized and promoted as well as rigid gender norms and harmful perceptions of what it means to be a man, with far reaching consequences on health and well-being. The “Steps to Integration” series provides a guide on how to integrate SRH and HIV services based on findings from the Integra Initiative, managed by International Planned Parenthood Federation in partnership with the London School of Hygiene & Tropical Medicine and the Population Council. Issue 8 of the series focuses on male utilization of integrated SRH and HIV services. Recommendations include: restructuring health facility reception areas and changing client flow to increase confidentiality and privacy; training health care workers on men’s sensitivities, needs, and preferences within SRH service provision, and recruiting more men to become health care providers; strengthening collaboration between traditional healers and health providers; and engaging the media to support male roles as capable household and community providers

Cost and technical efficiency of integrated HIV and SRH services in Kenya and Swaziland

Policymakers and researchers have long hypothesized the potential benefits of integrating HIV prevention, treatment, and care with sexual and reproductive health (SRH) services in settings with generalized HIV epidemics. In addition to improving health and social outcomes, integration of services holds the promise of increasing efficiency of service delivery and maximizing health care resources. Economic theory suggests several potential efficiency advantages at the service and programmatic levels. However, evidence on the unit cost and efficiency gains associated with integration remains scarce. The “Steps to Integration” series provides a guide on how to integrate HIV and SRH services based on findings from the Integra Initiative, managed by the International Planned Parenthood Federation in partnership with the London School of Hygiene & Tropical Medicine and the Population Council. Issue 4 of the series, focusing on cost and technical efficiency of integrated HIV and SRH services in Kenya and Swaziland, concludes that variability in unit costs and cost components for all services has the potential to reduce costs of delivery through better use of both human and capital resources

Contraceptive use and fertility intentions among women living with HIV in Kenya and Swaziland

At the end of 2013, an estimated 35 million people were living with HIV, and sub-Saharan Africa was disproportionately affected. With major efforts directed at expanding access to life-saving antiretroviral therapy in sub-Saharan Africa, many people are living longer with HIV, leading productive and sexually active lives. Unintended pregnancies and the potential of vertical transmission are some of the challenges faced by women living with HIV. Understanding the fertility preferences and reproductive decisions of these women is vital for informing efforts to enable them to achieve these desires effectively and safely. The “Steps to Integration” series provides a guide on how to integrate HIV and SRH services based on findings from the Integra Initiative, managed by the International Planned Parenthood Federation in partnership with the London School of Hygiene & Tropical Medicine and the Population Council. Issue 6 of the series focuses on contraceptive use and fertility intentions among women living with HIV in Kenya and Swaziland. Key message: facilities and providers need to offer a wider choice of FP methods and improve information and access to long-term methods for women living with HIV who do not want more children

Expanding young people\u27s access to integrated services in Malawi

In sub-Saharan Africa, uptake of sexual and reproductive health (SRH) services among young people remains low, placing millions of young people at risk of poor reproductive health outcomes and sexually transmitted infections, including HIV. The “Steps to Integration” series provides a guide on how to integrate HIV and SRH services based on findings from the Integra Initiative, managed by the International Planned Parenthood Federation in partnership with the London School of Hygiene & Tropical Medicine and the Population Council. Issue 7 of the series focuses on expanding young people’s access to integrated services in Malawi. Conclusions include: improving the quality of community-based compared with facility-based services shows more potential for expanding youth access to FP services, which may be important for increasing uptake of FP services in this population; it is important that outreach services are confidential, that FP providers are friendly and nonjudgmental, and that the supply of FP commodities is consistent and reliable

Does integration of HIV and SRH services achieve economies of scale and scope in practice? A cost function analysis of the Integra Initiative.

OBJECTIVE: Policy-makers have long argued about the potential efficiency gains and cost savings from integrating HIV and sexual reproductive health (SRH) services, particularly in resource-constrained settings with generalised HIV epidemics. However, until now, little empirical evidence exists on whether the hypothesised efficiency gains associated with such integration can be achieved in practice. METHODS: We estimated a quadratic cost function using data obtained from 40 health facilities, over a 2-year-period, in Kenya and Swaziland. The quadratic specification enables us to determine the existence of economies of scale and scope. FINDINGS: The empirical results reveal that at the current output levels, only HIV counselling and testing services are characterised by service-specific economies of scale. However, no overall economies of scale exist as all outputs are increased. The results also indicate cost complementarities between cervical cancer screening and HIV care; post-natal care and HIV care and family planning and sexually transmitted infection treatment combinations only. CONCLUSIONS: The results from this analysis reveal that contrary to expectation, efficiency gains from the integration of HIV and SRH services, if any, are likely to be modest. Efficiency gains are likely to be most achievable in settings that are currently delivering HIV and SRH services at a low scale with high levels of fixed costs. The presence of cost complementarities for only three service combinations implies that careful consideration of setting-specific clinical practices and the extent to which they can be combined should be made when deciding which services to integrate. TRIAL REGISTRATION NUMBER: NCT01694862

Family planning use and fertility desires among women living with HIV in Kenya.

BACKGROUND: Enabling women living with HIV to effectively plan whether and when to become pregnant is an essential right; effective prevention of unintended pregnancies is also critical to reduce maternal morbidity and mortality as well as vertical transmission of HIV. The objective of this study is to examine the use of family planning (FP) services by HIV-positive and HIV-negative women in Kenya and their ability to achieve their fertility desires. METHODS: Data are derived from a random sample of women seeking family planning services in public health facilities in Kenya who had declared their HIV status (1887 at baseline and 1224 at endline) and who participated in a longitudinal study (the INTEGRA Initiative) that measured the benefits/costs of integrating HIV and sexual/reproductive health services in public health facilities. The dependent variables were FP use in the last 12 months and fertility desires (whether a woman wants more children or not). The key independent variable was HIV status (positive and negative). Descriptive statistics and multivariate logistic regression analysis were used to describe the women's characteristics and to examine the relationship between FP use, fertility desires and HIV status. RESULTS: At baseline, 13 % of the women sampled were HIV-positive. A slightly higher proportion of HIV-positive women were significantly associated with the use of FP in the last 12 months and dual use of FP compared to HIV-negative women. Regardless of HIV status, short-acting contraceptives were the most commonly used FP methods. A higher proportion of HIV-positive women were more likely to be associated with unintended (both mistimed and unwanted) pregnancies and a desire not to have more children. After adjusting for confounding factors, the multivariate results showed that HIV-positive women were significantly more likely to be associated with dual use of FP (OR = 3.2; p < 0.05). Type of health facility, marital status and household wealth status were factors associated with FP use. Factors associated with fertility desires were age, education level and household wealth status. CONCLUSIONS: The findings highlight important gaps related to utilization of FP among WLHIV. Despite having a greater likelihood of reported use of FP, HIV-positive women were more likely to have had an unintended pregnancy compared to HIV-negative women. This calls for need to strengthen family planning services for WLHIV to ensure they have better access to a wide range of FP methods. There is need to encourage the use of long-acting reversible contraceptive (LARC) to reduce the risk of unintended pregnancy and prevention of vertical transmission of HIV. However, such policies should be based on respect for women's right to informed reproductive choice in the context of HIV/AIDS. TRIAL REGISTRATION: NCT01694862