Zubaida Abubakar
Zubaida is currently the reproductive health/PMTCT officer for FHI/Nigeria. She joined FHI/Nigeria in 2007 as the palliative care officer for the Federal Capital Territory's zonal office, before assuming her current role. She holds an undergraduate degree in biology from Brandeis University, a medical degree from the Royal College of Surgeons in Ireland, and a master of science in public health from the London School of Hygiene and Tropical Medicine. Following clinical practice in obstetrics and gynecology in Ireland and Nigeria, Zubaida joined IPAS-Nigeria, where she worked as the training and service delivery improvement coordinator. At IPAS, she was responsible for building capacity in post-abortion care, post-partum family planning, and facilitative supervision skills.

Usman Gwarzo
Usman is FHI/Nigeria's senior advisor on reproductive health and PMTCT. He Joined FHI/Nigeria in 2005.  Usman is a graduate of Ahmadu Bello University and Zaria medical school.  He is an associate fellow of the national postgraduate medical college and fellow of the West African college of physicians .  He has over 10 years of field experience in Nigeria, and specializes in issues realted to  care and support .  His career has focused on increasing the capacity of government agencies and NGOs to deliver HIV/AIDS and reproductive health services. Usman has guided various agencies and organizations in behavior change communication, maternal and child health quality service delivery innovations, and integration of family planning and HIV. He had an additional postgraduate training in administration

Christoph Hamelmann
Christoph became FHI/Nigeria country director in May 2007. Christoph began as a consultant in family medicine and earned his doctorate in molecular immunology and parasitology. He holds various postgraduate degrees and certificates, among them in molecular biology, infectious diseases epidemiology, health systems management, and economics. Christoph has served as the senior public health adviser for various governments and civil society organizations; prior to joining FHI in 2006, he assisted the South African Ministry of Health in its planning and implementation of the largest comprehensive HIV and AIDS program worldwide. He was the founder and director of the International Kumasi Centre for Collaborative Research in Ghana.

Mohammed Dada Ibrahim
Mohammed joined FHI/Nigeria in 2004 as director of medical services. A physician with over 25 years of experience managing clinical and health projects, he has built and supervised an effective team of experts in Nigeria. Under his leadership, FHI pioneered the implementation of HIV/AIDS care and support in secondary health facilities in Nigeria. Prior to joining FHI, Mohammed served as CEDPA's deputy country director for Nigeria. Mohammed graduated from Ahmadu Bello University, and has an MSc from the University of London. He had additional training in health project management from the Harvard School of Public Health.

Hadiza Khamofu
Hadiza became FHI/Nigeria's associate director of medical services in December 2007 after a brief period as senior medical services advisor. She specializes in family medicine and is a fellow of the National Post-Graduate Medical College. Hadiza also holds a master's degree from the Liverpool School of Tropical Medicine. She has numerous certificates in vaccine development and clinical trials, domestic violence, and evidence-based medicine and research. Prior to joining FHI/Nigeria, she held positions in public and private health sectors, and was a consultant on various health related projects.

The HIV/SRH Integration site interviewed Zubaida, Usman, Christoph, Mohammed and Hadiza about Family Health International provision of integrated services in Nigeria.

Can you provide background information on the HIV/AIDS and sexual and reproductive health situation in your country?

HIV/AIDS reached epidemic level during the last five years, with prevalence of 5.8 and 5.0 percent recorded in 2001 and 2003 sentinel surveys.  Currently, the trend is reversing, with the latest sentinel survey showing prevalence of 4.4 percent. Initially HIV was highly stigmatized, but with increased awareness and access to care, stigma is decreasing. The reproductive health situation is not encouraging, as there is very high maternal and infant mortality, low contraceptive uptake, high unmet needs of modern family planning methods, and a high fertility rate

Please tell me about a project /program experience integrating HIV/AIDS and sexual and reproductive health services.

Through the Global HIV/AIDS Initiative Nigeria (GHAIN) project, Family Health International piloted the first HIV-RH integration in Nigeria in the two states of Federal Capital Territory (FCT) and Lagos.  The project integrated FP counseling into HIV counseling and testing, strengthened the family planning component of PMTCT and address the family planning needs of ART clients

The project initially targeted uniformed servicemen but was later expanded to non-uniformed men. There were many challenges common to all new projects, including resistance to change, perception of added workload by care providers, the need to work with many partners with different goals and deliverables, and issues with commodity security. The experience of the pilot integration project built our capacity to expand to many other project sites. Overall that the pilot project resulted in increased quality of care due to synergy and wraparound services as well as leveraging of resources.

How did you decide on the approach to take?

As the GHAIN project was primarily an HIV program, it was not a difficult decision: FHI rode on existing HIV services structures to integrate the reproductive health services. That made the integration easier for us.

What were the dates of the project/program?

The project started in 2005 and is ongoing. Current funding for the project ends in 2009.

What was the problem you were responding to when you developed the program?

We were addressing the reproductive health needs of HIV-positive clients and strengthening the second prong of preventing mother-to-child transmission. We were also preventing unintended pregnancies and using the opportunity to increase uptake of family planning.

Who was involved in the discussion and decision-making on the approach to take to address the problem?

Most activities are facility based but our work takes place under agreements signed with relevant government ministries. Discussions and decision-making are usually done with the policymakers at the ministerial level and with facility managers. For community-based programs, our general approach involves community mobilization, stakeholders' meetings, and consensus-building.

Did you involve the community in developing the program?

FHI's care model is called HAST (HIV/AIDS, STI, RH, and TB). It involves local governance authorities and the communities in both planning and implementation.

How did you work with the district health office in setting up the program, for example, in strengthening systems and services?

The HAST model is a district-level health system strengthening project. All the stakeholders in HIV, STI, RH and TB are involved, and their capacity to deliver quality services continues to be strengthened.

How do the providers and clients feel about the integrated activity?

Some providers look at the integration as an opportunity to increase their capacity. However, others may look at it as an added burden.

What obstacles did you encounter from a program standpoint and how did you address them?

A key challenge is working with other partners who may have different deliverables. We were able to respond to this by synchronizing our tools to serve the purpose of partnership.

Did you make adjustments to your approach as you went along? Please describe.

When we started the integration activities, we were limited to only the uniformed servicemen but later we made some adjustments to the cooperative agreement with USAID. This allowed us to extend the service to the general population.

Did you have need for special resources to implement your approach (e.g., funding, staffing, supplies, and consultants)?

We received funding from USAID under the Population Fund.  With this funding staff was recruited, and tools were developed and produced. We needed consultant services during the development of the training modules, and consultants also facilitated trainings for service providers.

How did the project team decide on a system to balance work activities (e.g., addition of new activities with existing activities for the purpose of integration)?

We recruited technical staff and made changes to job descriptions to increase support to the level needed for successful integration.

Were there systems you developed to manage integrated services, such as client follow-up or special complicated cases?

We strengthened the referral tracking and follow up system to ensure clients were retained in care.
This was done through provision of referral forms and directories.   Our HIV prevention strategy also includes prevention among positives, which limits incidence of complicated cases.

Was training needed to be able to offer integrated services?

The FHI team developed a three-day training module to build the capacity of relevant service providers on the RH-HIV integration. This training is mandatory for all sites where FHI intends to integrate services.

How did you evaluate the success of your activity?

The referral and uptake of family planning methods was high among the clients of HIV services. We were able to achieve over 10,000 couple-year protections (CYP) [1] from the two pilot states. The capacity of healthcare workers was strengthened, and routine counseling is now provided to clients on family planning methods, with high uptake of dual methods.

Do you have reports or tools related to the project? Could you tell us the URLs or provide electronic files?

Yes, these are available on request. Contact ugwarzo@ghain.org.

Contact information

Christoph Hamelmann, GHAIN Chief of Party
GHAIN National Office
Plot 1073-A1
Godab Plaza, J.S. Tarka Street
Area 3, P.M.B. 44, Garki
Abuja, Nigeria

[1] According to International Federation of Planned Parenthood, a couple-protection year is "A measure representing the total number of years of contraceptive protection provided by a method, for one couple, for one year." (http://www.ippf.org/en/Resources/Glossary.htm?g=C)