Post on 01-Apr-2015
FP/HIV Integration
Translating Integration Goals into Practice in Asia
Caroline Francis, Associate DirectorFamily Health International/Cambodia
Reconvening Bangkok: 2007-2010 – Progress Made and Lessons Learned in Scaling Up FP-MNCH Best Practices in the Asia and Middle East Region, 6-11 March 2010
RECONVENING BANGKOK 6-11 March 2010
Presentation outline
1. What do we mean by “integration”?2. The need for FP/HIV messaging and
services in concentrated HIV epidemics in Asia
3. The challenges – vertical funding streams, policies, centers and programs; dismantling the message; capacity; and commodities
4. Pushing past the challenges – some practical examples of integration in practice and directions for future
RECONVENING BANGKOK 6-11 March 2010
What do we (broadly) mean by integration?
Integration =
combining different kinds of RH and HIV services/programs to: • Increase access to FP/RH/HIV, information, services and products• Improve health outcomes of clients (e.g. most at risk populations,
mothers and infants, PLHIV)• Contribute to HIV and FP goals (including United Nations
Millennium Development Goals)
RECONVENING BANGKOK 6-11 March 2010
Clients Seeking HIV-related Services
FP/HIV integration is important because -
Share common needs:
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 and vice versa
Clients Seeking FP Services
AND
RECONVENING BANGKOK 6-11 March 2010
FP/HIV integration is important because -
At the individual, community and societal levels
Protects right of women/people with HIV to determine #/spacing of children
Reduces unintended pregnancies and unsafe abortion
Improves maternal/infant health Prevents vertical transmission of
HIV
At a health services/systems level Makes better, more cost efficient use of resources
Systematizes commodities procurement processes
Reduces reporting/ records burden and makes more efficient use of client and provider time
RECONVENING BANGKOK 6-11 March 2010
While we know that integration is important, the problem is that . . .
Most of the practical examples are from
Africa, not from Asia
AND
The situation is different in Asia
RECONVENING BANGKOK 6-11 March 2010
Concentrated HIV epidemics are the norm in Asia
Source: UNAIDS
RECONVENING BANGKOK 6-11 March 2010
Asia has lower fertility rates and better overall contraceptive use than in Africa
FP use (%) TFR
Bangladesh 58 3
Cambodia 40 3
China 90 2
India 56 3
Indonesia 60 2
Lao PDR 32 3
Nepal 48 3
Pakistan 28 4
PNG 26 4
Viet Nam 79 2
RECONVENING BANGKOK 6-11 March 2010
Concentrated Asian HIV epidemics demand particular HIV prevention priorities
Maintain focus on condom/lubricant promotion and ensure access in all high risk contexts
Target new tools, messages and approaches to most at risk populations
Interrupt high-transmission networks reach people when they are newly affected and promote positive prevention
Scale up efforts among entertainment workers, male clients, MSM, IDU/DU and PLHIV to reach 60-80% of population
RECONVENING BANGKOK 6-11 March 2010
This means that our FP/HIV integration efforts in Asia can also be more targeted
Let’s take two target audiences from Cambodia with significant FP needs:
1. Female entertainment (sex) workers (EWs)
(n= 30,000+; HIV prevalence 14.7% among brothel-based workers)
2. People Living with HIV (PLHIV)
(n= c. 35,000 on ART)
RECONVENING BANGKOK 6-11 March 2010
In Cambodia, female entertainment workers use condoms as their primary FP method
PSI/Cambodia TRAC 2009
RECONVENING BANGKOK 6-11 March 2010
But it’s clear they have unmet FP needs ...
97%
63%
31%
0%
20%
40%
60%
80%
100%
Condom use at lastsex w/client
Condom use at lastsex w/SH
Had an abortion in last12 months
PSI/Cambodia TRAC 2009
RECONVENING BANGKOK 6-11 March 2010
In Cambodia, most of those with HIV are receiving treatment
45%
15%
40%OtherHIV+
(~23,500 adults)
ART(26,551 adults)
OI(8,987 adults)
In 2008, an estimated 59,000 out of 9.4 million adults* were living with HIV in Cambodia…
…this amounts to 0.6% HIV prevalence in the adult population…
…60% of these infected individuals are already receiving antiretroviral therapy (ART) or treatment for opportunistic infections…
Source: NCHADS*Persons aged ≥ 15 years (based on pre-2008 census estimates)
RECONVENING BANGKOK 6-11 March 2010
And sexual activity among those on ART increases over time (few report unprotected sex and multiple partners)
Sexually active in the past 6 months, by gender and duration of follow-up
43
52 55 57
79 82
91
23 25 26 2528
36
45
0
10
20
30
40
50
60
70
80
90
100
Enrollment 3 mth 6 mth 12 mth 18 mth 24 mth 30 mth
%MenWomen
Enhanced Patient-Based Longitudinal Assessment of PLHIV on ART (NCHADS and FHI 2008)
RECONVENING BANGKOK 6-11 March 2010
The first challenge we face: promoting dual methods for EWs and PLHIV
In HIV prevention, condoms have been promoted as THE FP method for prevention against STIs, HIV and unplanned pregnancy.
But it’s not enough. How can we support PLHIV and EWs to use condoms + an additional method without creating an onerous burden on users?
RECONVENING BANGKOK 6-11 March 2010
The second challenge we face: linking FP and HIV services for EWs and PLHIV
From funding streams, to policies, to institutions, to programs, to service delivery . . .
“It’s not my responsibility”
RECONVENING BANGKOK 6-11 March 2010
Cambodia’s HIV and FP Response in Action: The “Linked” Response for PMTCT
NMCHC NCHADS
Linked HCLinked HC
Satellite HC
OD RH
PHDNMCHC coordinator
Provincial AIDS officer (PAO)
STI Clinic
MaternityOI and ART
Service
VCCT
VCCT
ANC
ANC
FP/BS
FP/BS
FP/BS
PMTCT
PMTCT
RECONVENING BANGKOK 6-11 March 2010
FP referrals are almost nil, for both EWs and PLHIV
0
500
1000
1500
2000
2500
Month One Month Two Month Three
Total DSW andEW
Direct SexWorkers (DSW)
EntertainmentWorkers (EW)
Individualsreferred toVCCT
Individualsreferred toFamilyPlanning
Source: NCHADS 2008
Nu
mb
er o
f in
div
idu
als
Of 2000 EWs/DSWs in 2008 who sought gov’t STI consultations monthly, less than 50% referred to VCCT and almost none referred to FP
RECONVENING BANGKOK 6-11 March 2010
The third challenge we face: ensuring health provider capacity for FP/HIV messages, referrals or services
HIV health care providers and implementers in Cambodia have little training in FP, do not give consistent messages . . . and have little motivation to promote FP
(e.g. “I don’t know much about FP”; “condoms are all that’s needed”; “it’s not my job so what’s in it for me?”)
RECONVENING BANGKOK 6-11 March 2010
Pushing past the challenges for EWs: Promoting Dual Methods in HIV Prevention
FHI/Cambodia’s SMARTgirl program for EWs uses branding, targeted education and incentives to promote FP methods and service uptake
RECONVENING BANGKOK 6-11 March 2010
Promoting dual methods through SMARTgirl
1. Strengthening partnerships with FP service providers (e.g. MSIC, RHAC) and social marketing organizations (PSI) for referrals and products
2. Targeted communications stressing benefits of dual methods and responding to FP misconceptions/beliefs
3. Quarterly training to peer and outreach workers – using tools, making referrals, social marketing
4. Incentives for those who go and those who refer
THE RESULT – less than 10% service uptake after 6 months of intensive focus (we have much work still to do)
RECONVENING BANGKOK 6-11 March 2010
Pushing past the challenges for PLHIV – Adding FP to the “linked response”
NMCHC NCHADS
Linked HCLinked HC
Satellite HC
OD RH
PHDNMCHC coordinator
Provincial AIDS officer (PAO)
STI Clinic
MaternityOI and ART
Service
VCCT
VCCT
ANC
ANCFP/BS
FP/BS
PMTCT
PMTCTFP/BS
FP/BS
PPVCCT
RECONVENING BANGKOK 6-11 March 2010
Waiting room Doctors
Drug Dispensary
Drug Counselor
PatientsHome/ Community
Monthly visit
• Video spots• Posters/leafletson
PP and FP/RH
Prevention
PP messages • Pregnancy/FP RH/FP STI clinic
Systematic Referrals
NMCH NCHADS
• Key PP messages• Technical advice (pregnancy.)• STI screening • Refer to STI, FP
Psycho-Social and PP
Counseling
Key PP questions• Marriage/partner ?• FP/ baby ?• Last STI checking ?
Systematic Condom distribution
• Adherence• Drug interaction OC/ARV• Condom demonstration if needed
MMM
Triage
HBC
• PP messages• Referral to OI/ART, FP, STI
VCCTPost-test counseling
• Video spots• Posters• Education/information…
FP/RH
Pushing past the challenges for PLHIV – Adding FP to OI/ART sites
Referral or on site ?
RECONVENING BANGKOK 6-11 March 2010
Integration in concentrated epidemic settings: some final words1. Extensive “Point of care”/ “one stop” services may not be
needed, or even beneficial in concentrated epidemics. Instead find the openings!
2. There is unmet need for FP among most at risk populations, and condom use is not sufficient. Promotion of dual contraceptive use is key to FP/HIV integration efforts.
3. Capacity building on FP for PLHIV/MARPs is critical for both NMCH and HIV health care providers, and it may be useful to place FP service providers in HIV prevention, care and support services and vice versa (as per TB/HIV integration efforts in Cambodia)
RECONVENING BANGKOK 6-11 March 2010
Integration in concentrated epidemic settings: some final words
4. More M&E - We just don't have much in the way of evidence-based models of FP/HIV integration in concentrated epidemics. We need more data on the impact of FP/HIV integration efforts on key health outcomes, such as contraceptive uptake and continuation, prevention of unintended pregnancies, etc.
5. Countries/participants should take advantage of emerging opportunities under PEPFAR and the Global Health Initiative to do integration.
RECONVENING BANGKOK 6-11 March 2010
Acknowledgements
1. Rose Wilcher, Family Health International/NC2. Graham Neilsen, Family Health International/APRO3. Laurent Ferradini, Family Health International/Cambodia4. Gautam Bharat Raj, Family Health International/Cambodia5. Peter Cowley, Family Health International/Cambodia6. Somany Ngor, Family Health International/Cambodia7. Population Services International/Cambodia