Background
In recent years, there has been a growing international dialogue on the feasibil- ity and desirability of providing integrated FP and HIV services. The reasons for offering joint, complementary services are many. Adding family planning services to counseling and testing may provide an opportunity to reach populations that do not typically visit family planning clinics, such as the sexually active young and unmarried, men, and members of high-risk groups such as sex workers. Adding FP services to care and treatment protocols may facilitate the uptake of contraception
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by HIV-positive individuals, helping to maintain their health, plan safer pregnan- cies, and reduce the rate of mother-to-child transmission of HIV. Including HIV services, particularly counseling and testing, in FP services would allow earlier di- agnosis and referral to care and treatment.
A study conducted by FHI 360 with support from the US Agency for Internation- al Development (USAID) explored early integration efforts in five countries (Ethio- pia, Kenya, Rwanda, South Africa, and Uganda) to establish a baseline “snapshot”
to inform USAID and national programs in order to improve service integration.
Three models of integrated HIV and family planning services were included in the study: family planning in HIV counseling and testing (FP in HCT), family planning in HIV care and treatment services (FP in C&Tx), and HIV services (particularly HCT) into family planning (HCT in FP). This chapter uses some of the findings from one of these models, FP in HCT, to illustrate intervention points in which strategic health communication can be introduced to improve client screening and service delivery.
This research identified weaknesses in provider readiness to integrate services, knowledge, and attitudes in relation to the integration of these services. Moreover, the study showed discrepancies in provider perceptions of services offered and patient perceptions of services received. This gap poses a substantial risk in fully meeting client needs, despite performance protocols that encourage open commu- nication between provider and client, in regard to FP and HIV issues. This chapter addresses the need for improved communication behaviors by identifying and pro- posing opportunities to incorporate strategic communication (focused on integrated services) into provider behavior. A focus on strategic communication includes tech- niques to ready the providers and encourage their participation. It also includes sug- gestions of means to facilitate client advocacy and education as well as influence health-seeking behavior in order to nurture multiple trigger points for dialogue.
Project Findings
Across all countries, provider readiness, knowledge, and attitudes related to integra- tion of FP, HCT, and C&Tx services were shown to be important factors in patient care and experience. A considerable gap was also shown to exist between providers’
perception of care provided and patient perceptions of the same care, both across countries and services.
Provider Readiness Commonly accepted indicators of provider readiness include training in new service, supervision, and availability of job aids. Overall, clinical training was not common among HCT providers. Many of the HCT providers inter- viewed had not been trained to offer FP counseling or services, and they were unfa- miliar with integration guidelines. Adequate screening for FP needs seems unlikely, even in the “best” program sites. One program manager in South Africa explained,
“Nurses are proscriptive and they don’t counsel, and lay counselors are not train- ed in family planning.” A Kenyan AIDS official echoed concerns with provider
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readiness, “Every VCT (Voluntary Counseling and Testing) site stocks condoms, and after training they are supposed to have pills. But non-clinical officers are not confident to initiate.”
Most HCT providers lacked job aids to assist in delivering integrated services, most profoundly in Ethiopia. While many providers noted the availability of contra- ceptive samples to use in counseling clients, resources such as flip charts and check lists with FP information were generally scarce. Many providers met weekly with supervisors, but for some, such meetings were not perceived to improve service delivery but rather served to deliver supplies or arrange training. Regular contact with supervisors is an underutilized opportunity to strengthen and support HCT providers’ capacity for delivering integrated services.
Provider Knowledge and Attitudes HCT providers require unbiased attitudes and accurate knowledge of various contraceptive methods in order to effectively coun- sel clients. Lack of training and job aids may exacerbate knowledge gaps and biased attitudes and therefore perpetuate counseling weaknesses related to specific met- hods such as injectable contraceptives, oral contraceptive pills, and implants. Fur- thermore, due to high client load, providers may frequently have insufficient time to communicate vital information.
HCT providers overwhelmingly view condoms as the best contraceptive method for HIV-positive women (and give this message to their clients), while also coun- seling the use of other methods. Far fewer providers identified condoms as the best method for HIV-negative women, seemingly viewing condoms as a way to prevent transmission by infected women rather than as a way to protect HIV-negative wom- en from infection. This is particularly ironic and surprising considering condoms are the method most often associated with HCT services. This situation is further complicated in some contexts by the proliferation of advertisements and public ser- vice announcements that promote condoms solely for prevention of HIV and other sexually transmitted infections.
Few providers (with exception of those in South Africa) correctly defined “dual method” contraceptive use: using a condom with another contraceptive method.
Similarly, many providers were unable to correctly define the ability of condoms to offer “dual protection” (i.e., protection from pregnancy and sexually transmitted infections). While these findings may be related more to the comprehension of the providers of survey questions rather than their full understanding of dual protection or dual method use, providers need to recognize, appreciate, and clearly convey information on the multiple uses of condoms in the context of HIV/AIDS and fam- ily planning.
Opinions regarding whether integration improves services were mixed among providers in these countries. Positive aspects of integration included the conve- nience of providing information at one site and seeing more HCT clients seek FP services. Those with negative perceptions cited the lack of coordination between HIV and FP services.
Provider Reports of Services Offered Integrated services had already been intro- duced in the study sites yet results show limited evidence of actual delivery of
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integrated service. Less than two-thirds of providers reported referring clients for FP in the past week and with the exception of providers in South Africa, less than half reported having discussed contraception with clients on the day of the inter- view. This is a missed opportunity to share detailed information that could lead to uptake of services.
According to one program manager in Uganda, “family planning knocks them (counselors) off their track. VCT (voluntary counseling and testing) is highly script- ed, and it is an enormous step to look at individual needs.”
Client Reports of Services Received Screening clients for complementary service needs is the foundation of integrated services so multiple health concerns can be addressed in a single visit. In the context of a supportive, comfortable environment, screening questions to determine need for family planning typically follow a basic logic: Are you sexually active? Do you want to become pregnant? Are you cur- rently using contraception? Appropriate contraceptive methods should be discussed as needs are identified.
Client reports, however, reveal that at most 68 % were screened for sexual activ- ity. While providers may assume sexual activity in women seeking HCT services, on the presumption that the majority of those seeking testing are doing so because they may have been exposed to HIV through intercourse, women should still be asked about fertility desires. The data show, however, that screening for fertility desires and contraceptive use is not the norm.
In all but one country, South Africa, discussion of contraceptive methods other than condoms occurred in less than 40 % of client-provider interactions, begging the question of how integration of FP services changes the original counseling model if condom promotion is an integral component of HCT services.
Using client data, the unmet need for FP was estimated by using the proportion sexually active in the 3 months prior to the study, desire for children, and current contraceptive use. Unmet need varied across countries from a high of 46 % in South Africa to a low of 17 % in Ethiopia. Need varies for two reasons. Either very high percentages of women were pregnant (as some were tested during antenatal care visits) and intended the pregnancy (Ethiopia and Rwanda) and thus were not in need, or high percentages were using contraception (Kenya and Uganda).
Integrating family planning into counseling and HIV testing has clear benefits in theory, but presents significant challenges in practice. This case revealed a need for provider education and training (which may require reviewing and revising current methodologies as well as related policies and practices) as well as increased screen- ing and communication efforts at all levels and with all clients. Likewise, clients require educational information and resources to prepare them for interaction with providers. Clients must learn to be proactive in identifying and discussing their needs, concerns, and options in regard to family planning when receiving coun- seling and HIV testing services. Similar themes were echoed in each of the other two integrated models. Cross-national comparisons reveal numerous risk areas and service gaps but also opportunities for integrating and promoting strategic health communication.
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